By Kennedie Lentz Maidment, RN BScN MSN

Citation: Lentz Maidment, K.  (2024). Making Tech-Savviness Mandatory in Canadian Nursing. Canadian Journal of Nursing Informatics, 19(1).  https://cjni.net/journal/?p=12749

Abstract

The Canadian healthcare system is in crisis and nurses’ ability to use technology is part of this crisis. With the need to have patient information widely available quickly, technology must be integrated into nursing work. However, the lack of basic informatics competency among Canadian nurses is allowing the integration of any new technology into practice to be incredibly difficult or even fail. The Romanow report (2002) foreshadowed these needs for technology yet was ignored. Now, in the current day, the need is still pertinent while continued integration failures and the failure of efficient and effective patient care occur. These failures can be improved and throughout this paper, solutions are explored to improve the current Canadian healthcare system. These include the options of education reform for pre and post licensure nurses, the full use of existing nursing informaticians, and the enforcement of existing Canadian nursing informatics competencies. Theories of change and innovation diffusion prove that this process may not be quick but can aid in the current healthcare climate crisis. They are a necessary hurdle to tackle to improve Canadian healthcare sustainability.

Keywords: Nursing Informatics, Technology Integration, EHR, Education Reform, Informaticians, Informatics Competency.

Background

Canadian nurses’ ability to use technology impacts healthcare innovation and sustainability. Over twenty years ago, the Romanow report (2002) provided recommendations for the future of Canadian healthcare to remain sustainable. The main recommendation was the inclusion of technology into healthcare. The goal of that recommendation was two-fold; to increase the efficiency and effectiveness of care, and to bring experts closer to patients to achieve this (Romanow, 2002). Many of the recommendations spoke to the need to change documentation practices to electronic ones and share more information wider and faster. Now, 22 years later there has been some uptake, but not enough to sustain the current system that is failing to keep up to the needs of Canadians.

Currently, nursing varies in it’s use of technology both in programs and devices, as well as in depth of technology use in practice (Chipps et al., 2022). Some of this variance has to do with the level of care area (Chipps et al., 2022). For example, a tertiary care area will have more need to communicate within itself to provide effective and efficient patient care and therefore may use an electronic health record (EHR). Whereas a rural remote nursing clinic may only have a basic computer system for scheduling appointments, or a glucometer for measuring blood glucoses, but not full electronic records for ease of translative communication or virtual healthcare assistance from remote experts. As well, the technology in current nursing practice differs vastly by jurisdiction (Ting et al., 2021). Due to the inability of these multiple systems to share an interface, there is lack of portability of information even within tech-savvy areas (Egbert et al., 2019).

Nurses serve as the largest population of healthcare staff in Canada (McGonigle et al., 2014). However, nurses are partially causing this slow down of technology integration and therefore system sustainability due to a lack of competency consistency with basic informatics. Given the need to deliver healthcare faster, wider, and with more complexity than ever before, nursing is falling behind in efficiency and effectiveness of care. A greater focus on nursing informatics is needed to sustain the current Canadian healthcare system and all nurses need a basic informatics competency level upon entering the profession. This paper will explore the barriers keeping this competency from being obtained and suggest bridging strategies for the future. 

What is Nursing Informatics?

Recognized as a specialty in 1992 in the United States (yet to be in Canada but supported by the Canadian Nurses’ Association [CNA]), nursing informatics is evolving and expanding to serve in many patient care areas (Graves & Corcoran, 1996).Informatics is defined as “the science of processing data for storage and retrieval; information science” (Staggers & Thompson, 2002, p. 3). When nursing is applied to that definition it becomes the science of storing and retrieving nursing information (Hannah et al., 2006). This in turn translates practically into the communication of nursing work and patient or population status information for storage, reporting or quality improvement (Staggers & Thomspon, 2002). While it may not always be visible, many if not most patient-care nursing experiences do encounter technology or data storage for the purposes of interpretation and reporting by nursing leaders and informatics specialists in the future (Staggers & Thompson, 2002). The practice of nursing informatics is expanding into many fields of practice including specialty areas such as critical care, public health, and maternity (Chipps et al., 2021). However, it has a place in every aspect of nursing and needs to be included for future healthcare system sustainability (Ting et al., 2021).

Who Does this Work?

Nurses who specialize and/or work in informatics are referred to as informaticians (Rojas & Seckman, 2014). They may be nurses of varied backgrounds that either have formal education or a vested interest in the subject that complete informatics work (Rojas & Seckman, 2014). The job title of informaticians varies as per the care area they service but includes the selection, design, and training of new technology being integrated into practice (Hannah et al., 2006). As imagined, this work includes a lot of change management in which many informaticians are also educated in (Hannah et al., 2006). Stakeholder feedback and evaluation is also a large part of informatics work with regard to new technologies and their successful integration into nursing work (Rojas & Seckman, 2014). With both the technical education and nursing background, informaticians are heavily relied on to problem-solve technological issues as well as smooth transitions into practice (Egbert et al., 2019). Who knows best how a nurse works? A nurse. An informatician bridges the gap between the information technology (I.T.) world, and that of nursing practice for the smooth integration and use of one in the other (Rojas & Seckman, 2014).

From another lens, the job duties of an informatician with well-integrated technology, is the monitoring and reporting of data that technology can collect (Hailegebreal et al., 2022). For example, a critical care informatician may gather monthly statistics on how frequently patients are being turned while on ventilators and compare that to how many sacral ulcers are reported that month. They can then report that information once gathered and organized to the nursing staff and encourage better patient outcomes with more frequent turning intervention. Those better patient outcome suggestions may include a change to the policy on turning unconscious patients or may warn about ineffective products resulting in new institutional purchasing to improve patient care.  

How Does Nursing Informatics Impact Patient Care?  

Nursing informaticians can serve in many faceted roles in the betterment of patient care. Data gathering and reporting is one such example as explained above, but these steps of data gathering and reporting may be repeated for multiple quality improvement sessions until the quality reaches a certain consistent care level and is maintained (Hailegebreal et al., 2022). Another good example would be the monitoring of Central-Line Associated Bloodstream Infections (CLABSI). An informatician’s job would be to assess the nursing documentation and extrapolate the necessary data including how many central lines exist in the area of interest. They would also gather information about documented line care. Finally, they could compare this to the number of CLABSI reported through other interdisciplinary team members’ documentation. By gathering, interpreting, and reporting this data several improvements can occur. On the local level, those would include the awareness and conscious attention given to central line cleaning and best practices. On a grander scale though, this may influence a product choice for cleaning and maintenance or policy development for the care of central lines. All the choices made not only ease the way nurses provide care to be the most effective and efficient, but also to improve patient outcomes (Elliott et al., 2018).

When it comes to the integration of new technology though, there is a different lens applied to how informaticians impact patient care. By integrating technology into nursing practice in a successful manner, patient information can be more readily available to remote providers, and best service the patient’s needs (Hannah, 2007). As well, patients can access care more efficiently with the experts in follow up care (Hannah, 2007). Overall, this decreases the burden on the healthcare system’s wait times, reducing travel for the patient and duplicate test ordering (Ting et al., 2021). New technologies are also allowing for an improvement in health literacy for the lay person (Kaur & Rawat, 2015). By increasing their own access to health information such as laboratory results sooner, people can ask questions, learn about their health, and begin to take some ownership over it, again decreasing the burden on the healthcare system with unnecessary visits (Kaur & Rawat, 2015). This is not to say that the goal of technology integration is to eliminate healthcare visits, but instead empower the patient to make an informed decision about what designates an emergent or urgent visit (Kaur & Rawat, 2015).  

What are the Drawbacks of Informatics?

As is the case with any field of healthcare, informatics is not the perfect solution to all problems. The concerns with it range from the informaticians appreciation for current nursing workload and workflows, to the fear of device or program failure with loss of information (Reid et al., 2023). Even the niche devices or programs chosen that do not interface with other healthcare professional’s systems may still pose a large barrier for patients to access care instead of bridging access concerns (Kleib & Nagle, 2023). All these concerns do not only impact nursing staff, but also patients and other interdisciplinary team members. These concerns may leave gaps large enough to negatively affect longitudinal care (Hughes et al., 2014).

The first problem is the potential gap in realistic practice representation given by informaticians who have not participated in the workflows of the nurses they are representing when planning or evaluating an informatics change over time (Reid et al., 2023). Although professional standards would indicate that nurses should be keeping current on best practices, participating in the these changes and how much time it consumes is lost on some informaticians leading to a level of technology use not realistic for frontline nurses (Reid et al., 2023). For example, when planning medication administration electronically, an informatician who has not practiced medication administration or sought out the stakeholder engagement of those who have, the level of detail may be too great and medication administration may become more time consuming than is feasible for front line nurses. A large complaint identified in the literature is the increased time spent in front of a screen inputting or extrapolating data, and the decreased time available to be spent with a patient (Hughes et al., 2014). This high level of what is called technostress (defined as the overwhelm of different technologies in practice) may lead to corner-cutting and errors being made at the patient’s expense (Hughes et al., 2014).

Another drawback of informatics is the reliance on consistently available technology that will not falter (Hughes, et al., 2014). Many technologies require scheduled maintenance that take the system into “downtime” for users and render it unavailable (Hughes et al., 2014). When this is a scheduled occurrence, procedures put into place allow for care to resume as normal and reduce any patient care differences; however, should a device fail or unexpectedly need maintenance, there can be a struggle to step into downtime procedures (Kleib & Nagle, 2023). A large concern would be the potential loss of patient information gathered in the time leading up to the failure and the potential that it cannot be recovered. Even worse would be the security of that information should the system have been broken into (Kleib & Nagle, 2023). Without a competency in basic informatics, many nurses panic at this point and may experience technostress that leads to worse patient outcomes and overall care (Hughes et al., 2014).

A final concern for informatics practice in this paper is the lack of ability for some systems to interface with others. There is a lack of consistency in Canada with which healthcare technologies are adopted which leads to unequal and at time inequitable resources available to nurses and patients (Lo et al., 2021). For example, a tertiary care center’s EHR may not interface with that of a smaller community centre, allowing for gaps in communication of care that happens for a patient transferred from one to the other. While this is not a new concern from that of a paper-based records system, it is important to note that a digital focus does not correct all problems (Lo et al., 2021). Again, without a basic understanding of informatics, this also poses a large challenge for patient care transfers between institutions (Ting et al., 2021).  

Theoretical Underpinnings

Prior to assessing the barriers of implementing informatics into mainstream nursing care, two theories need to be closely paired for pattern monitoring and solutions on how to advance. Those two theories are the Kurt Lewin Change Theory and the Thery of Innovation Diffusion (Burnes, 2004; Wani & Ali, 2015). While both relate to change, the Kurt Lewin Change Theory relates to both hard system change issues and soft system change solutions (Burnes, 2004). However, the Theory of Innovation Diffusion sets realistic timelines and expectations for the soft-system changes that will occur and remind those leading change of the make up of the people experiencing it (Wani & Ali, 2015).

As a quick overview, the Kurt Lewin change theory encompasses three streps: unfreeze, change, refreeze (Burnes, 2004). From the outside it may look simple and reconcile with the processes that hard systems methodology requires to create and manage change and structure (Burnes, 2004). The operation is examined for change, and the change is planned in the unfreeze step, it is implemented in the change step and the system reaches equilibrium in the refreeze step (Burnes, 2004). To examine this theory from a soft systems methodology though, the three simple steps uncover a lot of detailed needs that are required for a successful change to take place. In terms of implementing technology into nursing practice, this includes the observation of current nursing practice and documentation, the needs of technology to make it successful, the needs of the staff to learn the technology, the time required to train the users and implement the change, and the creation of evaluation tools to discover if the change is successful (Burnes, 2004).

Nursing informaticians and nurses with basic informatics competencies would help this process greatly as not only would it make the unfreezing easier with stakeholder engagement and decrease training needs but would also help to ease the burden and time for equilibrium to be reached in the refreeze stage (Burnes, 2004). As well, basic informatics competencies would help decrease the technostress observed by researchers in nurses undergoing technology implementation into their work allowing for the second theoretical underpinning to be applied with more ease.  

The Theory of Innovation Diffusion looks at soft systems methodologies of change in how they relate to the timeliness of change acceptance by end users (Wani & Ali, 2015). Soft systems methodologies of change look at how those affected by the change can be successfully led through it (Wani & Ali, 2015). It’s not just “X (paper-based systems)” becomes “Y (digital-based systems)”, it includes that “X” affects “A (nurses)” so to get to “Y”, “A” will need training, support, and evaluation for the change from “X” to “Y” to be successful.

What is currently known is that 30% of all users experiencing change will fall into the category of early adopters (Wani & Ali, 2015). Another 30% will fall into the laggards or late adopter category (Wani & Ali, 2015). Immediately, this means that there will be an anticipated balance of those who respond well to the change and those who do not. While there are no defined timelines to each of these groups adapting to change, it will depend on the size of the change and the energy given to the training, thus we do know that these will be the first and last groups to adopt it, respectively (Wani & Ali, 2015). How does this specifically relate to the necessary work in building informatics competencies in nursing? Simply put, it means that there is significant work and patience needed to be given to the staff that now require these new competencies as we know that although 1/3 will take the change in stride and adapt quickly, 1/3 will do the opposite and fight the change for as long as they can (Wani & Ali, 2015). Mentorship about the change that can be appreciated for practice and competence to understand that appreciation will help nurses adjust, although it will remain a long and time-consuming process to uproot the practice of the largest profession in healthcare.

Current Concerns

The largest concerns affecting nursing and patient care in Canada, are two-fold: that of the choice in technology and that of its integration (O’Connor & LaRue, 2021). Like what was discussed in the drawbacks of informatics, the current concerns of what is chosen and how it is implemented serve to be the largest areas of technostress for those enduring them both because of as well as despite informatics and informaticians (Hughes et al., 2014). While both concerns pose their own issues, they are compounded by the lack of informatics competencies possessed by Canadian nurses (Hughes et al., 2014). Should informatics competencies be present in all Canadian nurses, the higher engagement in the pre-work for the selection of technology as well as the quality of the integration strategies would hopefully eliminate these concerns (O’Connor & LaRue, 2021). Please keep this in mind while reading this section.

The Technology

Without an appreciation for basics informatics, nurses are struggling to juggle the sheer volume of differing technology used during their work (Mollart, 2021). On any given day there are multiple different technologies that any nurse may face and need to work around or with to provide patient care (Malane et al., 2019). For example, in a large tertiary center an acute care nurse may find him/her/them self encountering a digital attendance system, EHR, glucometer, medication dispensing unit, bedside monitor or vitals machine, laboratory and microbiology reporting systems, scheduling systems, medical imaging equipment and interdisciplinary team messaging systems just to name a few. That is eight different pieces of technology with different functions that, if not thought of from an informatics competency lens just sit as eight different sets of steps that stand between the nurse and providing care to their patients (Malane et al., 2019). Of course, that is still a lot of technology to deal with, and informatics competencies would help bridge the stress of it all, but at times the informatician’s lack of cohesiveness in selecting, designing, and testing the technology also serves a large barrier (Raghunathan et al., 2022).  As well, the differing technologies rarely interface together, causing unnecessary duplicate work for the nurse (Foster & Sethares, 2017). The lack of understanding of nursing workflow is a large reason that many technologies fail by taking nurses away from their patients, inducing technostress, and ultimately leading the way to poorer patient care and outcomes (McGonigle et al., 2014) Even if technologies do interface, the understanding of how or why it is done may be lost on some nurses who instead engage in duplicating work by inputting information into multiple pieces of the EHR (Hannah, 2007).

The lack of awareness of the gap in informatics technology by nursing leadership is also to blame for these issues (Shin et al., 2019). The selection of advanced technology that requires delicate use or intricate training may induce technostress in the nurse who struggles to navigate the software or even to type/input data (Ting et al., 2021). Instead, prior to the selection of a device or program to integrate, a nursing leader and/or informatician should have a firm grasp on the level of informatics practice their staff nurses are confident and competent to handle (Chipps et al., 2022). It is once this level of realistic understanding is achieved that proper integration planning can take place and a realistic timeline for successful integration may be set (Chipps et al., 2022).

The Integration Strategies

Without basic informatics competencies, nurses need intensive training on some of the larger scale technology changes that are being implemented (Raghunathan et al., 2023). The strategies of slow and thoughtful inclusion of small pieces of technology in practice to help ease the technostress burden simply do not exist (Foster & Sethares, 2017). Instead, a rushed approach to train all users on a very large technological change to their practice such as adopting a new EHR, leads to failed implementation of technology that could have indeed improved the working lives of staff and quality of patient care (Smailes et al., 2019). As aforementioned throughout this paper, there are multiple reasons why these implementations are not effective nor successful including the lack of informaticians work throughout the selection, design and training stages, the lack of stakeholder engagement from the staff that will be affected by the change, the rushed training or lack of exhaustive training, and the lack of support throughout the change period (Seo et al., 2019; Shin et al., 2018). Should basic informatics competencies already exist and be upheld in Canadian nurses, the training needs for further implementations would be less, but also the engagement from nurses and their drive to change for the betterment of patient care would also support more meaningful training and implementation (Foster & Sethares, 2017). This engagement would not only communicate the need for support with more strength but could also increase the number of nurses willing to help to provide support to their own colleagues.

The Way Forward

While it will not be simple nor quick, the suggestions to improve the informatics competencies of Canadian nurses and therefore help sustain the Canadian healthcare system include the following four recommendations. The first is the betterment and enforcement of Canadian nursing informatics competencies. The second and third would be the education reform of both pre-service and in-service nurses. Finally, building on the prior three suggestions, nurses with competencies can increase the effectiveness of informaticians with stronger engagement in informatics work and the ability to provide appropriate feedback during change planning.

The existing nursing informatics competencies as developed and published by the Canadian Association of Schools of Nursing (CASN) and endorsed by the CNA serve to aid both students and nurse educators in developing teaching and evaluation methods to ensure the overarching goal of “[using] information and communication technologies to support information synthesis in accordance with professional and regulatory standards in the delivery of patient/client care” (CASN, 2012, p. 5). Through it’s flexible and open guidelines, nurse educators have the freedom to engage students with technology in nursing practice however they wish (Harerimana et al., 2022). However, that poses a problem of lack of specificity in competencies upon graduation. In training areas that use an EHR, that ability to use the EHR for daily documentation may be deemed competent, whereas an area without a full EHR may deem the ability to use a glucometer, or AED competent in informatics by simply engaging in technology.

More specific language is needed in the competencies to increase the equivalence of practice across Canadian nurse graduates (Shin et al., 2019).  Also, the enforcement of the competencies is lacking amongst these now-practicing nurses (Ting et al., 2021) With varying technologies in work settings, and varied regulatory standards in each jurisdiction, the definition of competence becomes difficult to ascertain, let alone enforce (Harerimana et al., 2022). The way forward through this issue would be more detailed competencies and an agreement for all jurisdictions on those details (Ravert et al., 2020). For example, the competency indicator that reads, “Advocates for the use of current and innovative information and communication technologies that support the delivery of safe, quality care” (p. 13) could be more detailed to include the use of an EHR or applicable technology and the ability to educate patients on their use/how to access for their own health literacy (CASN, 2012). This is just one example but it shows how future education reform could also become more easily structured.

Second and thirdly as they will need to occur simultaneously to allow for fulsome mentoring and smooth transitions into practice are pre-service education reform and in-service training reform to include and support informatics competencies achievement (Ravert et al., 2020; Thompson & Skiba, 2008). If the informatics competencies is focused on the hard systems methodological thinking about how to enforce change (by simply implementing and enforcing it for quality improvement and change management), these two suggestions are the soft systems pairing. If we want to achieve the change, this is how it will need to be done for each person to achieve the goal successfully (Thompson & Skiba, 2008). Firstly, pre-service education reform would need to include basic informatics training integrated into pre-licensure nursing education (Reid et al., 2022). By interacting with technology more in spaces such as laboratory and simulation settings, students have the safe and unrushed training space to learn not only how healthcare technology works but also grasp the understanding of why and how the information becomes important to informaticians, nurses and patients (Reid et al., 2022). One of the largest drawbacks of this solution is the required engagement of pre-licensure nursing educators who may be removed from frontline practice and are unaware or uneducated themselves on the impact that technology has made to practice (Bove & Sauer, 2023). The balance of having educators keep up with the innovation in practice as well as their teaching workloads will be a challenge to achieve, but it is necessary moving forward (Bove & Sauer, 2023). Once these students have the training they need in their school environments, they will also need mentors who carry these competencies in their practice to learn from as they build their own practice as new graduates (Raghunathan et al., 2023).

This idea of reforming in-service education to build the current working nurses’ competencies in informatics is not light, but necessary work (Foster & Sethares, 2017). Engaging nurses in learning that impacts the future of their work again may not be fast and will need to be made equitable to every specialty, but overall will increase the uptake and quality of feedback received during new technology implementation (Egbert et al., 2019). A nursing workforce that can support new graduates to build their practice that includes technology mentoring allows for lesser technostress in both groups, making transitions to practice smoother (Hughes et al., 2014). This education reform may include the slow uptake of basic computer skills, including typing and will eventually increase in complexity to include the navigation of an EHR for data extrapolation to better patient care (Egbert et al., 2019).

Finally, once there is a deeper competency achieved in informatics practice, front line nurses can be brought in at earlier stages of informatics work to be members of the team in selecting, designing, training, and evaluating new technology to be integrated into practice (McGonigle et al., 2014). This is not to say that nurses with informatics competency will want to leave the frontline and join informatics as an entire job title. However, being able to provide quality feedback with a more wholesome appreciation for what the change could mean for their practice benefits all who are involved in the change process when implementing new technology as well as reporting the data gathered for quality improvement. Whether new graduate or seasoned nurse, the feedback will allow the informaticians who gather it to do more with it. An informatician working with a group of nurses who have basic competencies can work more efficiently without needing to provide detailed education for what feedback they need, how their job is done and why. They can also work with an interdisciplinary team more effectively to improve their data reporting results or their adjustments to a new technology (Rojas & Seckman, 2014).

Conclusion

Upon close literature review, achieving nursing informatics competency is not an outrageous ask for Canadian nurses. However, it is certainly not a quick or easy solution to the problems of the entire health care system. With the needs of the system to deliver more information faster and wider than ever before, technology needs to become a part of practice to achieve the necessary sustainability to continue delivering adequate patient care. While nursing informaticians have existed since the late 1990’s and provide guidance and support on the integration of technology into practice, they cannot work effectively with nurses who do not understand nor appreciate their work (Rojas & Seckman, 2014; Graves & Corcoran, 1996).

Currently, the integration of technology is failing due to this gap of knowledge that the few informaticians currently working cannot bridge themselves while maintaining their workload. In fact, the time spent explaining their jobs or teaching the basics of technology that could be a basic competency of graduate nurses entering the nursing workforce diminishes the job entirely. As well, technology integration is failing due to the inability of informaticians to adequately grasp what is already demanded of nurses in their daily work (Chipps et al., 2022). Instead of designing technology that will meet nursing workflow and ease their work, the technology integrated is creating duplication of work and inducing technostress (Egbert et al., 2019). This is the exact opposite of the Romanow report’s (2002) goals of bringing healthcare experts closer together virtually to create more efficient and effective care outcomes.

The current Canadian nursing informatics competencies need more direct language and stronger enforcement to achieve the needs of nurses, informaticians, and patients (CASN, 2012). Through education reform and stronger stakeholder engagement in new technology integrations, the work can be achieved. It may not be quick, and the innovation diffusion curve will still prove there to be laggards in acceptance of anything new, but the lasting impacts of an equal informatics competency enforced for all Canadian nurses will improve not only quality patient care, but nursing workload as well (Bove & Sauer, 2023). The world will always need nurses, technology will not replace them, but the world needs the two to come together for the betterment of all.  

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Author Bio

Kennedie Lentz Maidment, RN BScN MSN

Kennedie is a registered nurse in Kamloops, BC. After graduating with a BScN from Thompson Rivers University in 2017, Kennedie started her career in critical care, spending 5 years there before transitioning into a clinical practice educator role in digital health assisting in the implementation of the hospital’s EHR. Currently, Kennedie is expanding her skills in out-patient care at her hospital’s Infectious Diseases Clinic. She has just completed a master’s degree at Athabasca University. Outside of work, Kennedie and her husband Chris enjoy cheering on their local hockey team, hiking the beautiful alpines of the province, and travelling with their most recent adventures including Italy and Alaska.