Canadian Journal of Nursing Informatics

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This article was written on 20 Jun 2020, and is filled under Current Issue, Volume 15 2020, Volume 15 No 2.

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The History of Technology and Innovation in Nursing

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Angeline Agustin, BA – Soc & IR
Simran Bhatti, BSc – HSc
Jenessa Bourne, BSc – PE – Kin
Lauren Holmes, BA – Eng
Hedy Hughes, BSc – Geo
Adrian Ng, BA – Psych
Natasha Raju, BSc HC Admin
Emily Shea, BA – Psych
The History of Technology and Innovation in Nursing

Abstract

Nurses are natural innovators in the healthcare field. Consistently, they have access to evidence, knowledge, and resources to effect positive changes around them. The purpose of this paper is to explore the history of technology and innovation in nursing, with a focus on the cultures surrounding both topics. Through researching a variety of primary and secondary sources regarding aspects of technology and innovation in nursing, we are better able to understand the role that nurses play in the development and implementation of new technologies and the role of nurses as innovators in their field. This role of nurses, as innovators and mechanisms for change, is essential in understanding the role of the nurse as an advocate. Furthermore, by understanding the history of these topics one can more easily promote a culture of innovation and development moving forward in an industry that is constantly changing. The findings of this paper suggest that nurses are able to recognize gaps in the care they provide. This knowledge combined with their desire to improve care to their clients encourages nurses to act as innovators. Assisting with new technologies, procedures, or policies, nurses are at the forefront of change in the healthcare system. Moreover, this paper argues that the role of nurses themselves can be considered an innovation and suggests that more research is needed into this.

Introduction

Health is the maintenance of homeostasis in our bodies and is considered to be a state free of injury or illness (Oxford English Dictionary, 2019). By maintaining one’s health, a person is able to live their life day to day without health-related struggles. As such, there is great value placed on health, with an increasing demand for money to be spent on ways to improve or maintain it. However, maintaining health is not always a task that can be completed alone, and it is for this reason that the healthcare industry exists. In healthcare, nurses have the essential role of providing care to their clients. This task is not always an easy one, as there are many hurdles in healthcare that impede a nurse’s ability to provide care to their clients. These hurdles may be logistical, financial, technological, psychological, educational and/or cultural in nature (International Council of Nurses (ICN), 2009; Krick et al., 2019; Power, 2013; Rhoads, 2017; Sanko, 2017). In order to overcome these hurdles, nurses become natural innovators through advocating for changes in the healthcare system and by conducting research in order to develop more effective measures of care. In this study, we will explore some of the many instances of innovation and technology in the nursing field as early as the 1900s all the way to the present. Through exploring the history of nursing in innovation and technology, we hope to provide more insight into how to better promote innovation in nursing today.

Background Literature Review

Definition and Significance

The health care system is constantly changing. With the burden and demands of disease and the challenge and pressure to do more with fewer resources, nurses are required to innovate and find new information and ways to improve health promotion, disease prevention, and ways of care (ICN, 2009). Global workforce shortages, high cost, and high-tech solutions are just a few of the drivers for innovation in the developing world (ICN, 2009). The definition of innovation has changed and developed over many years. Many terms regarding this topic are used interchangeably; innovativeness, innovative behaviour and innovative work behaviour (Asurakkody & Shin, 2018) are all regarded the same in the literature. The awareness of the importance of innovation has also changed as it has been implemented in nursing education and as nurses are constantly questioning the effectiveness of their services (ICN, 2009). Innovation is important to address a need or a gap in service or technology and is important in nursing to improve client care outcomes and costs (ICN, 2009). Innovation can be defined as “the process of developing new approaches, technologies, and ways of working. It can apply to tools and technologies and processes, or to the way an organization or an individual behaves, works, or acts” (ICN, 2009, p. 3).

Innovation to practice

The ICN (2019) stated that the process of applying innovation to practice requires knowledge, persuasion, decision implementation, and confirmation. It is said that for an innovation to stick, it has to be of relative advantage and not too complex. An innovation that is simple and easy to apply and use will be adopted more easily. It has to have the ability to be trialed as well as have observability, which is the ease with which potential users will see results/outcomes. Lastly, for an innovation to stick it requires reinvention, which is the extent to which it can be tweaked for different environments (ICN, 2019). To facilitate an environment of innovation, one must start from the top. Leaders and management must embrace and model innovation and cultivate a culture of innovation (Melnyk & Davidson, 2009). They must set out a clear vision and communicate the goal to set the culture. This allows for individuals (positive deviants) to launch creative solutions to complex problems. Students and employees need to know that failures are part of this process so that innovation will be promoted (Asurakkody & Shin, 2018).

History of innovation

Many of the healthcare advances made by nurses were developed and perfected during World War One, where nurses had to manage hundreds of clients with minimal resources and work quickly in dangerous and stressful situations (Power, 2013). Nurses learned the importance of quickly addressing head, chest, and abdominal wounds and developed the concept of treating certain wounds immediately. These nurses began to understand the variety of repercussions from head injuries. They developed antiseptic cleansing techniques for infections, and they began to understand shell shock. World War One nurses also learned how to develop empathy for wounded soldiers and while this skill was not lacking pre-World War One, this innovation allowed for empathy to become a critical part of the accepted nurse role. Further, the nurses of World War One pressed for the development of plastic surgery, physical therapy, and occupational therapy for the people who were disabled by shells, bullets, and chemical warfare. These innovations alone changed healthcare for the people of that time. Finally, they also learned the skill of how to act fast and problem solve with good judgement and intelligence. As time progressed, the habits and procedures of nursing practice grew and developed. New innovations regarding treatments, specific care and healing procedures expanded and advanced alongside other medical fields. Nurses, together with other members of the health team, continue to push and develop the boundaries of what is known and practiced in the healthcare environment.

Innovation in medicine has greatly increased over the past century, but innovation in wound care has been relatively slow (Harding, 2015). According to Harding (2015), the practice of dressing wounds with gauze dates back to Egyptian times and yet was the best practice in wound dressing well into the early 20th century. It was not until the mid to late 20th century, 1950-1970, that there were any further advances to wound management. These advances included using tulle gras instead of gauze, the development of moist wound healing versus a dry approach, and the use of antimicrobials and biological dressings (Harding, 2015). Within thirty years, huge advancements in this field were made with more to come in the 1980s. Negative pressure wound therapy (NPWT) was developed, a process that works to remove infectious materials, promote “perfusion and granulation tissue formation” (p. 12), and to reduce edema through “controlled subatmospheric pressure” (p.11-12). Another medical innovation for wound care was skin grafts to help with wound closure (Harding, 2015). Technological breakthroughs have resulted in a better understanding of pathogenic factors and a strict adherence to standards of care, which means there is new hope for solving the problem of impaired healing.

In addition to wound care, there have been countless other innovations and discoveries made to healthcare with the help of nurses. Innovations in medication administration include automated dispensing, automatic medication packages, and the location of medication dispensing carts in relation to medication administration and have all led to fewer errors in medication administration overall (Baril, Gascon, & Brouillette, 2014). Baril et al. (2014) suggested that before these advances, the long number of steps in the medication use process was a source of potential error and that transcription of orders was another cause of error. With these innovations in medication administration, nurses are better able to care for their clients and deliver higher quality of care. As well, innovations in cardiac nursing equipment include total artificial heart (TAH), left ventricular assist devices (LVADs), enhanced external counterpulsation (EECP) therapy, and implantable cardioverter defibrillators (Hudson, 2007). Hudson (2007) also listed innovations in cardiac nursing technology which included implantable cardioverter defibrillators (UCDs), cardiac resynchronization therapy (CRT), percutaneously placed clips for mitral regurgitation, impedance cardiography (ICH), and imaging technologies. The invention and implementation of these devices have been essential in the development of cardiac medicine as we know it today. While nurses may not have been at the forefront of developing these technologies, by adopting these new technologies and procedures as best practices and by continuing to question if they are in fact best practices, nurses play a critical role in the success of these developments in the healthcare system. Without these additional roles, as questioners of technology and innovation and adopters of change, improvements in medicine could be much slower to progress.

Innovation has advanced technology and ways of caring in a variety of nursing specialties. The advancement of telephones and cameras have greatly improved quality of service in nursing and the level of comfort and support experienced by clients. In neonatal intensive care, web-cameras are used so that parents can have virtual presence with their baby, which reduces anxiety and stress, and helps decrease travel expenses for parents (Rhoads, 2017). In the United States, nurse specialists often make telephone calls to follow-up on infants with lung disease in rural areas, so that families would not have to travel for care (ICN, 2019). In South Africa, nurses have used mobile phones to support individuals living with HIV/AIDS and to improve their client’s adherence to antiretroviral therapy (Kayaa, Turan, & Aydinb, 2015). The technological advancements in nursing have changed the experience of care worldwide. Without many of these technologies and without the motivation of nurses to implement positive changes to their industry, care as we know it would be drastically different.

Study trends & future studies

According to Krick et al. (2019) the top three most researched study trends related to technological innovation were information and communication technologies (ICT), robots, and sensors. ICT includes technologies that provide or document information that is important for improving interpersonal communication such as electronic health records (EHR)/Electronic Medical Records (EMR), Hospital/Care Institution Information Systems (HIS) or monitoring technologies (Krick et al., 2019). Robots provide assistance which may be physical, psychological, social, organizational, security-related, educational, or therapeutic in nature. Sensors measure behaviour, movement, falls, and other parameters, and may help to control other devices such as alarm systems or pumps (Krick et al., 2019). The areas that have not been studied as much, and could be a potential area for future study, are virtual reality technologies (VR) which are able to create a virtual world, tracking technologies intended to locate people or objects, and serious games intended for learning purposes or to improve personal dependence (Krick et al., 2019). Jeon and Park (2015) also touched upon the growing use of electronics by clients to aid in their care. Electronics such as computers, phones and tablets help clients manage their symptoms and conditions through web-based interventions. With the above interventions in addition to automated messaging systems to remind the client of upcoming appointments and treatments, as well as scheduled times for medication, there has been an overall increase in positive client outcomes (Jeon & Park, 2015). Although there are positive effects that can be seen with using tech-based interventions, there has not been a side-by-side comparison of web-based and mobile based interventions. A study on this can determine which has the better outcomes and determine the efficiency of both.

Education

Simulation as a teaching technology has been a huge advancement since the mid-1930s for teaching or practicing technical and non-technical skills using high and low technology simulator mannequins designed to depict humans (Sanko, 2017). Nursing informatics is a specialized area of study for the improvement of client care through information, technology, and communication (Chauvette & Paul, 2016). It is continually evolving as new information, technologies and communications emerge and are incorporated into undergraduate curriculum in some nursing programs (Chauvette & Paul, 2016). A common problem in today’s nursing education is that there are more students in relation to faculty. This means that there is limited time that the students are exposed to clients. With simulation methods, students are able to actively learn as clinical settings are realistically simulated and errors are discussed immediately (Medley & Horne, 2005). The use of high-fidelity simulation helps to foster learning outside of ordinary situations; students are able to hear out of range vitals instead of the normal ranges they would be likely to hear when practicing with student peers. In order to facilitate the use of simulation in nursing education, Medley and Horne (2015) suggested that the role of faculty in nursing programs be addressed. Faculty are the main drivers of using simulation in the classroom, much like management and leaders are the main drivers for innovation in change in the workplace.

Nursing Informatics

With the world revolving around technology in modern times, the topic of nursing informatics is important. As mentioned above with education, nursing informatics is a continuously evolving field. Nurses use the data from technology and analyze, interpret and evaluate them to promote best care (Chauvette & Paul, 2016). There are many different definitions for nursing informatics, many of which relate to the use of computers in different nursing domains whether it be in practice, administration, education or research (Chauvette & Paul, 2016). In Canada, there are numerous informatics innovations that nurses are able to apply to their practice. An example of such an innovation is electronic medical records (EMRs), which are commonplace in much of the nursing sphere and allow for charting to be done electronically, using digital information. In addition, the encouragement by managers or health authorities to use digital health methods (e-prescribing, telehealth, remote patient monitoring) is seen as adding to the improvement of the overall health of Canadians. The adoption of technology in health care is moving in a direction that all nurses, including entry level nurses, are required to have strong ICT skills in order to provide safe quality nursing care in the 21st century health care system (Chauvette & Paul, 2016).

Sources

Primary Sources & Secondary Sources

Data collection is a critical part of research analysis and involves two types of data. Primary data sources are those which are being collected for the first time by the researcher through direct efforts and experience (Surbhi, 2017). Primary data can also be referred to as raw data, as it is collected specifically for a research problem. Primary data is data collected in real time and includes such collection methods as surveys, observations, experiments, questionnaires, and interviews. Primary data can also be previously collected but is done so by the initial writer/researcher/theorist; secondary is often done by third parties who interpret primary sources. Alternatively, secondary data are sources which have previously been collected. This type of data is typically readily available and is easy to access which makes it both cost and time effective for research studies. Secondary data sources are often in the form of books, websites, journal articles, and government publications. Based on the topic of this research study, secondary data sources were primarily used as they were readily available. The majority of the main literature review articles used for this project were secondary in nature and the majority of them consisted of journal articles based on data collected from existing, large databases. Of the two primary data sources utilized for this project one was used within the main literature review and the other was categorized as an additional resource. These primary sources consisted of first-hand data collection on innovative processes used in the nursing field. The first article, titled “Impact of Technological Innovation on a Nursing Home Performance and on the Medication-use Process Safety” (Baril et al., 2014), focused on determining what causes medication processing errors within nursing homes through work measurement surveys. The second article, titled “Improving Healthcare through Nursing Innovation” (Rhoades, 2017), discussed the results obtained from using cameras in neonatal units in hospitals to improve hospital experiences for new mothers. Overall, the data sources used for this historical research project were adequate and aided in defining the history of technology and innovation within the nursing profession.

Evaluation of Authenticity and Accuracy of Source Materials

Innovation begins with a good idea. It refers to the process of turning an idea into something that can be used, something that can be achieved and ultimately bring about better health care and disease prevention. According to the International Council of Nurses (2009), innovation in nursing is extremely important for improving health, describing and avoiding risk factors, and developing quality care and treatment methods. With the recent advances of technology in the healthcare system, we have seen an improvement in monitoring and managing diseases. These advances in medical equipment and technology have become an important factor in changing clinical practice. Clients expect to receive the most effective care based on the best available evidence. For this to be successful, extensive scrutiny of the evidence-based research is important to provide the most effective care available. The sources chosen for this paper have been carefully selected and verified to ensure the consistency and reliability of our paper.

LoBiondo-Wood et al. (2018) mentioned that peer reviewed journals are the preferred mode of communicating the most recent theory or results of research. The articles chosen for this paper have all been peer reviewed which indicates the reliability of the documents. Peer-reviewed journals are required to be reviewed by experts in the same field and are examined for accuracy and scientific rigour. Rigour ensures the study is conducted to enhance the quality, believability, and trustworthiness of the findings (LoBiondo-Wood et al., 2018). The authors of all the articles discussed were affiliated with the same field of interest. This shows that the authors are knowledgeable in the field of health care and have expertise in various specialities. The studies are also current and were all within a ten-year period. LoBiondo-Wood et al. (2018) mentioned that peer reviewed journals are the preferred mode of communicating the most recent theory or results of a research study and should be one’s first choice when looking for theoretical, clinical, or research articles.

The validity and reliability of the studies discussed in this paper, which all relate to similar concepts, allows for an advancement in evidence-informed practice in this field. The variety of articles yield the same results on repeated measures, allowing for consistency throughout. The researchers used comparable instruments in different articles to describe how innovations in the healthcare field has improved the quality of health and social care. For example, ICN (2009) created a mobile library that allowed nurses to administer evidence-based health care to individuals in developing countries. From the use of this innovation, nurses working in developing countries were provided with resources and tools to ensure their clients are receiving current and up-to-date health care information. Furthermore, a neonatal intensive care unit in the USA created the Angel-Eye Web-Camera System, which provides live streaming video feed to clients’ families and the health care team (Rhoads, 2017). This innovation allowed parents to be comforted by being virtually present with their neonate and allowed the health care team to provide appropriate care without any unwanted disturbance of the neonate during a fragile time in their life. As mentioned by LoBiondo-Wood et al. (2018), consistency is the main measure of reliability. With the use of these innovations, the significant improvements in the health of patients, populations, and health systems have been repeatedly outlined in each article.

Data Analysis

With health care constantly evolving, the history of technology and innovation in nursing is very important. The health care system and its workers are always looking for better ways to help improve patient care outcomes and costs in the health care system (ICN, 2009). The information in the research was gathered through peer-review journals from the same field of interest. The data was analyzed in four phases which are history of innovation, study trends and future studies, education, and nursing informatics.

The history of innovation includes five types of innovations in nursing. Innovation in nursing developed during and after World War One. During this time period, nurses learned how to address head, chest, and abdominal wounds and developed antiseptic cleansing techniques. As time progressed after World War One, nursing innovations and technology improved for better quality of care for clients. Innovation in wound care has slowly developed. There have been great advancements since the Egyptian times such as negative pressure wound therapy and skin grafts to help with wound closures (Harding, 2015) discussed earlier in this paper. These examples help to show the difference in speed that some innovations are developed and advanced, some occurring at a much slower rather than others. Innovation in medication administration involves technology and is constantly improving, which has led to fewer errors in administration. Technology and innovation in cardiac nursing equipment has advanced greatly, which has improved client outcomes following a cardiac incident and allowed for improved client results and ability to determine any cardiac related problems. The technology is considered to be safe, it ensures quality options, cost containment, and control over practice standards is maintained (Hudson, 2007). Innovation of technology such as telephones and cameras have also greatly improved. Neonatal intensive care units utilize web-cameras to improve not only the care they give but also the experience of families. As well, nurses use telephones or video calling to communicate with family in regard to their infants.

Information and communication technologies (ICT), robots, and sensors are the three most researched study trends in regard to technological innovations. These three innovations continue to advance and improve. However, it is noted that there has not been a side by side comparison of web-based and mobile based intervention. In nursing, the education of new nurses has advanced significantly since World War One. Innovations such as simulation teaching technology provides active learning since the simulation mannequins are so realistic. This provides students with better opportunities to learn and a greater chance of become exceptional nurses in the future. The use of technology in nursing education also promotes a culture of innovation and technology in new nurses. This is a culture that they can then bring with them to their new units, and further advance the science of nursing in their careers. Nursing informatics is also important in the health care field. It is highly likely that within the next ten years, the health care system in Canada will be largely, if not entirely, electronic. Nurses today are required to have ICT skills in order to provide safe quality nursing care – this will be unquestionably essential as Canada moves further into the digital age.

The research team analyzed data through peer-reviewed journal articles. Several articles were analyzed for the history of technology and innovation in nursing. The data collected and analyzed was based on the innovation and technology that were important and the most advanced since World War One. The research team categorized the data into themes to better show the scope of this broad topic. Looking at the concepts of innovation and technology in the field of nursing through a variety of lenses, the researchers were able to compile a general theory regarding the topic. The lenses that were considered for this paper were: significance, innovation to practice, a history of innovation, current study trends and suggested future studies, education, and nursing informatics.

Discussion

Nursing is a fast paced, constantly changing field where the ability to be innovative is highly important. By being primary providers of hands-on care in many health care settings, nurses are directly exposed to resource requirements and development, as well as the evidence and knowledge required to advance the healthcare field. Nursing innovations include the advancements made in understanding head injuries during the first World War, along with wound care and shell shock, and numerous others (Power, 2013). Nurses have also been innovative in using technological developments for health care delivery, such as using the telephone to provide follow-up care and to deliver care to less developed areas (Kayaa, Turan, & Aydinb, 2015; ICN, 2019). Nurses provide innovation in education delivery by constantly incorporating new technology and research into the field through nursing informatics (Chauvette & Paul, 2016). Some of the innovations incorporated through the nursing informatics area of study are electronic health records (EHR), e-prescribing, remote patient monitoring, and telehealth as previously mentioned. From the understanding of war time wound care to the utilization of technology for global nursing, nurses have always been forefront innovators. The results of this historical analysis support the notion that nurses are natural innovators in the healthcare field, making them vitally important to the field’s development.

For future research, technology innovations in virtual reality and their incorporation into nursing should be explored, in addition to the use of tracking technology and educational game development for students (Krick et al., 2019). Another suggestion for future research is client use of personal technology devices in health care maintenance, as technology use for daily tasks is becoming more and more prevalent (Jeon & Park, 2015). This will likely become essential as children and young adults who have been raised around mobile technology age enter the workforce and healthcare system. Further, nurse education methods should be researched. In 2017 in Canada, the number of regulated nurses with an active licence (Canadian Institute for Health Information, 2017) to practice was 425,757. In British Columbia alone, the number of new nurses entering the work force annually between 2007 and 2016 was on average 1,481 (CIHI, 2017). While these numbers may seem small overall compared to the size of the healthcare industry’s workforce, Canada is a country with an aging population. Nurses who graduate between 2020 to 2040 will largely takeover the workforce, bringing with them a new culture of nursing. If educators are leaders responsible for encouraging innovation and technological advancements, then it is essential that research is done on how to foster an attitude of innovation in student nurses and prepare them further for their future roles as not only client advocates but as innovators in their fields as well.

The findings of this paper also suggest that the role of nurses is an ever changing one and that part of the innovation that nurses provide is to create new parameters for their role within the healthcare system. By pushing the boundaries of what they as nurses are responsible for, they widen the parameters of their role. The role of nurses in Canada has long been one of advocacy and change. From the building of the first hospitals in Eastern Canada (The Canadian Encyclopedia, 2019) to present day, nurses have been on the forefront of change. The possibilities of further research into the concept of nurses as innovators of the healthcare system have already been outlined in this paper, but further research into the concept of nurses as innovation themselves should be conducted. This concept opens many questions into the effect that being thought of as advocates, innovators, and adopters/creators of technology has on nurses as individuals. What stress does this add to their already long list of tasks? In a field where nurses are already largely overworked, lacking in resources, and under-funded what effect does the added pressure of being mechanisms of change have on nurses (Wranik et al., 2017)? A common thread throughout this paper has been the essential role that nurses play in not only client centered care but in the progression of healthcare as well. Without understanding the effects that this culture and trend has on nurses as a group and as individuals, there is potential for negative effects to emerge.

Conclusion

In reviewing the many examples of innovation in nursing through a historical lens, it is apparent that innovation often begins with nurses who are able to recognize the disparity between the care they are giving to their clients and the care they envision being able to give. It is this desire to do better that in part drives the need for change in the nursing field. Regardless of working conditions, nurses have been able to innovate and promote the discovery and use of new technologies in their fields. As the researchers have discovered with the examples given by the advancements made during World War One, nurses are often willing to put themselves at risk in order to provide the best care possible to their clients and in order to make advancements for the sake of future clients (Power, 2013). When innovation is combined with new technologies the effects can be very far reaching. The use of telephones, online resources, and other innovations in one country can spread to more remote or isolated areas, which ensures that people with less access to community services or resources do not receive less care than those in urban locations. The spread of technologies and innovation allows for new possibilities in the care that nurses are able to give to communities. It has also been discussed that innovation does not necessarily mean inventing new technology, it can be the reinvention of an already existing technology (ICN, 2009). Regardless of the type of innovation or technology, it is the culture of both that is essential for proper implementation and exploration in the field. It is the responsibility of leaders and management to cultivate an innovative culture in the workplace (Melnyk & Davidson, 2009). With the right support and working environment the nursing field will be able to see many more advances and breakthroughs. More research into this concept is necessary however, to ensure that nurses as innovators are able to thrive and to ensure that technological advancements can continue to be both explored and well-implemented.

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ABOUT THE AUTHORS

This paper was collaboratively done by eight Critical Inquiry: Qualitative Research students in the Fall of 2019 during their course work in the BSN-AE Nursing Program at Kwantlen Polytechnic University in British Columbia, Canada.

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