In this paper we present a contemporary understanding of "nursing informatics" and relate it to applications in three specific contexts, hospitals, community health, and home dwelling, to illustrate achievements that contribute to the overall schema of health informatics.
We identified literature through database searches in MEDLINE, EMBASE, CINAHL, and the Cochrane Library. Database searching was complemented by one author search and hand searches in six relevant journals. The literature review helped in conceptual clarification and elaborate on use that are supported by applications in different settings.
Conceptual clarification of nursing data, information and knowledge has been expanded to include wisdom. Information systems and support for nursing practice benefits from conceptual clarification of nursing data, information, knowledge, and wisdom. We introduce three examples of information systems and point out core issues for information integration and practice development.
Exploring interplays of data, information, knowledge, and wisdom, nursing informatics takes a practice turn, accommodating to processes of application design and deployment for purposeful use by nurses in different settings. Collaborative efforts will be key to further achievements that support task shifting, mobility, and ubiquitous health care.
Nursing Informatics; Knowledge; Health Information Systems; Personal Health Records; eHealth
This paper discusses a definition of the content of the computerized nursing data base developed by the Nursing Department for the Clinical Center Medical Information System at the National Institutes of Health in Bethesda, Maryland. The author describes the theoretical framework for the content and presents a model to describe the organization of the nursing data components in relation to the process of nursing care delivery. Nursing documentation requirements of Nurse Practice Acts, American Nurses Association Standards of Practice and the Joint Commission on Accreditation of Hospitals are also addressed as they relate to this data base. The advantages and disadvantages of such an approach to computerized documentation are discussed.
A prequisite to designing computer-aided information systems to support nurse decision making is to identify the kinds of decisions nurses make and to specify the data and the knowledge required to make those decisions. Perrow's (1970) models of organizational technologies, which consider the variability of stimuli and the nature of search procedures for deciding what to do about the stimuli, offer a useful approach to analyzing nurse decision making. Different assumptions about stimuli and search procedures result in different models of nursing, each with its own requirements for a knowledge base and a data base. Professional standards of nursing practice generally assume that clients are unique and therefore treat the stimuli with which nurses deal are highly varied. Existing nursing information systems, however, have been designed as though the stimuli had little variability. Nurses involved in developing the next generation of computer systems will need to identify appropriate models of nursing and to specify the data bases as knowledge bases accordingly.
Translating guidelines into nursing practice remains a considerable challenge. Until now, little attention has been paid to which interventions are used in practice to implement guidelines on changing clinical nursing practice. This cross-sectional study determined the current ranges and rates of implementation-related interventions in Austria, Germany, and The Netherlands and explored possible differences between these countries. An online questionnaire based on the conceptual framework of implementation interventions (professional, organizational, financial, and regulatory) from the Cochrane Effective Practice and Organization of Care (EPOC) data collection checklist was used to gather data from nursing homes and hospitals. Provision of written materials is the most frequently used professional implementation intervention (85%), whereas changes in the patient record system rank foremost among organisational interventions (78%). Financial incentives for nurses are rarely used. More interventions were used in Austria and Germany than in The Netherlands (20.3/20.2/17.3). Professional interventions are used more frequently in Germany and financial interventions more frequently in The Netherlands. Implementation efforts focus mainly on professional and organisational interventions. Nurse managers and other responsible personnel should direct their focus to a broader array of implementation interventions using the four different categories of EPOC's conceptual framework.
A prototype program of doctoral study has been developed at the University of Maryland School of Nursing to prepare students with nursing expertise in the conceptualization and research of computer based information systems in hospitals, industry and other health care organizations. The graduate will be prepared to design effective nursing information systems; create innovative information technology; conduct research regarding integration of technology with nursing practice, administration, and education; and develop theoretical, practice, and evaluation models for nursing informatics.
A task force appointed by the American Board of Neuroscience Nursing conducted a role delineation study to define current practice in neuroscience nursing. The results were used to validate the content matrix for future Certified Neuroscience Registered Nurse (CNRN) examinations. The study employed a survey design for which the Nursing Intervention Classification taxonomy was the guiding theoretical framework. The eligible sample include all current CNRNs and all members of the American Association of Neuroscience Nursing. An invitation to participate in an online survey was successfully emailed to 2,462 neuroscience nurses; the survey was completed by 477 respondents. They rated the performance and importance of 175 neuroscience nursing activities. On the basis of data analysis conducted by Schroeder Measurement Technologies, Inc., the task force recommended revisions to the CNRN examination matrix to reflect current practice in neuroscience nursing.
Nurses prepare knowledge representations, or summaries of patient clinical data, each shift. These knowledge representations serve multiple purposes, including support of working memory, workload organization and prioritization, critical thinking, and reflection. This summary is integral to internal knowledge representations, working memory, and decision-making. Study of this nurse knowledge representation resulted in development of a taxonomy of knowledge representations necessary to nursing practice.
This paper describes the methods used to elicit the knowledge representations and structures necessary for the work of clinical nurses, described the development of a taxonomy of this knowledge representation, and discusses translation of this methodology to the cognitive artifacts of other disciplines. Understanding the development and purpose of practitioner’s knowledge representations provides important direction to informaticists seeking to create information technology alternatives. The outcome of this paper is to suggest a process template for transition of cognitive artifacts to an information system.
Radiotherapy (RT) units are high-tech nursing environments. In Sweden, RT registered nurses (RNs) provide and manage RT in close collaboration with other professional groups, as well as providing nursing care for patients with cancer. Communication demands on these RNs are thus particularly complex. In this study, we aimed to better understand problems, strengths and change needs related to professional communication with and within the RT department, as a basis for developing a situation-specific intervention.
Focus groups discussions (FGDs) were conducted with different professional (RNs, assistant nurses, physicians, engineers and physicists) and user stakeholders. Transcripts of the FGDs were inductively analyzed by a team of researchers, to generate clinically relevant and useful data.
These findings give insight into RT safety climate and are presented under three major headings: Conceptualization of professional domains; Organization and leadership issues; and Communication forms, strategies and processes. The impact of existing hierarchies, including how they are conceptualized and acted out in practice, was noted throughout these data. Despite other differences, participating professionals agreed about communication problems related to RT, i.e. a lack of systems and processes for information transfer, unclear role differentiation, a sense of mutual disrespect, and ad hoc communication taking place ‘on the fly’. While all professional groups recognized extensive communication problems, none acknowledged the potential negative effects on patient safety or care described in the FGD with patient representatives. While RNs often initially denied the existence of a hierarchy, they placed themselves on a hierarchy in their descriptions, describing their own role as passive, with a sense of powerlessness. Potential safety hazards described in the FGDs include not reporting medical errors and silently ignoring or actively opposing new guidelines and regulations.
There is a risk that RNs who view themselves as disenfranchised within an organization will act with passive resistance to change, rather than as change promoters. As interventions to strengthen teams cannot be stronger than the weakest link, RNs may need support in the transition “from silence to voice” in order to take a position of full professional responsibility in a multi-professional health care team.
The development of nursing knowledge should give structure and form to the practice of nursing. The development of Nursing Process Theory resulted from early nursing observations and inferences from nursing practice that resulted in formal data accumulation processes, mutual correspondence between nurses and patients, and exchange of information. The development of the nursing process discipline helped to substantiate the need for professional nursing services. The shifts towards examining the links between processes and outcomes, professional accountability, and classification of distinct nursing functions have influenced the development of information systems. The Nurse—Patient Trajectory Framework described in this paper may be used to show the relationships between the virtual information system and the real world that it affects. The framework is visualized along two separate and distinct nurse and patient trajectories.
Nursing Informatics; Information Systems; Nursing Process
To explore the role of genetic association studies in risk assessment for common complex diseases.
An introduction to the types of genetic association studies is followed by a discussion of their potential use in risk assessment for age-related macular degeneration and type 2 diabetes mellitus. The benefits and limitations of this burgeoning technology are explored and related to nursing practice and scholarship.
Nurses in practice must be prepared to assist clients with decisions about seeking and interpreting results from genetic association studies and nurse researchers must apply current guidelines for conducting robust studies and applying the results of such studies in clinical practice.
Data collected from genetic association studies will increasingly be used to identify novel prevention and treatment strategies for many complex diseases. An understanding of the principles that underlie this new science is essential for nurses in all areas of clinical practice as they design, test, and implement appropriate intervention and prevention strategies based on genetic association studies.
genetic association studies; genomics; nursing; genetic markers; risk assessment
Nurses are challenged to find and use reliable, credible information to support clinical decision-making and to meet expectations for evidence-based nursing practice. This project targeted practicing public health and school nurses, teaching them how to access and critically evaluate web-based information resources for frontline practice. Health sciences librarians partnered with nursing faculty to develop two participatory workshops to teach skills in searching for and evaluating web-based consumer and professional practice resources. The first workshop reviewed reliable, credible consumer web-resources appropriate to use with clients, using published criteria to evaluate website credibility. In the second workshop, nurses were taught how to retrieve and evaluate health-related research from professional databases to support evidence-based nursing practice. Evaluation data indicated nurses most valued knowing about the array of reliable, credible web-based health information resources, learning how to evaluate website credibility, and understanding how to find and apply professional research literature to their own practice.
information literacy; evidence-based practice; public health nurses; school nurses
The Canadian Health Outcomes for Better Information and Care (C-HOBIC) project introduced systematic use of standardized clinical nursing terminology for patient assessments. Implemented so far in three Canadian provinces, C-HOBIC comprises an innovative model for large-scale capture of standardized nursing-sensitive clinical outcomes data within electronic health records (EHRs). To support this activity, nursing assessment and outcomes concepts were mapped to the International Classification for Nursing Practice (ICNP®). By comparing serial data on a patient across multiple time points, the C-HOBIC model can generate nursing-sensitive patient outcome reports. A principle benefit of the C-HOBIC model is that it provides nurses with information critical to planning for and evaluating patient care. Inclusion of nursing information in either provincial databases or EHRs in three Canadian provinces promotes continuity of patient care across sectors of the healthcare systems in those provinces and also facilitates aggregation and analysis by administrators and policy makers. The C-HOBIC model provides standardized, consistent, interoperable clinical information that reflects nursing practice throughout the Canadian healthcare System.
Adolescent dating abuse is not specifically described by any current nursing theory, and this paper presents discussion of some existing theories that could inform a nursing theory of adolescent dating abuse. To account for the effects of gender, this discussion is limited to young women.
Adolescent dating abuse is an important and understudied international issue for nursing. Theoretical frameworks can support development of nursing scholarship for such issues. No single theory yet exists within nursing to explain the experiences and health ramifications of dating abuse among young women.
A summary table of theories is provided. Literature was gathered via database search and bibliographic snowballing from reference lists of relevant articles. Included literature dates from 1982 through 2010.
Theories of relationship formation and function are discussed, including attachment, investment, feminist and gender role conflict theories. Betrayal trauma theory is considered as a mechanism of injury following an abusive dating experience.
IMPLICATIONS FOR NURSING
Gender, relationship, and adolescence combine in a complex developmental moment for young women. To improve nursing care for those at risk for or in the throes of abusive relationships, it is critical to develop specific nursing approaches to understanding these relationships.
Existing theories related to relationship and traumatic experiences can be combined in the development of a nursing theory of adolescent dating abuse among young women.
Adolescent health; gender; nursing theory; violence; feminist research; theory-practice gap
End-of-life nursing encompasses many aspects of care: pain and symptom management, culturally sensitive practices, assisting patients and their families through the death and dying process, and ethical decisionmaking. Advocacy has been identified as a key core competency for the professional nurse, yet the literature reveals relevant barriers to acquiring this skill. Challenges exist, such as limitations in nursing school curricula on the death and dying process, particularly in multicultural settings; differing policies and practices in healthcare systems; and various interpretations of end-of-life legal language. Patricia Benner's conceptual model of advocacy behaviors in end-of-life nursing provides the framework in which nurses can become effective patient advocates. Developing active listening and effective communication skills can enhance the nurse-patient trust relationship and create a healing environment.
Advance directives; advocacy; comfort measures; dignity; end-of-life care; stages of grief
The PEN&PAD model for clinical record systems has been successfully used for medical records in both General Practice and hospital-based care. This paper describes experiences of using the model for developing computer-based nursing records. Results from this work show that there are some problems with directly applying the model to the nursing domain. Whilst the main purpose of the nursing record is to document and communicate a patient's care, it has several other, possibly incompatible, roles. Furthermore, the structure and content of the information contained within the nursing record is heavily influenced by the need for the nursing profession to visibly demonstrate the philosophical frameworks underlying their work. By providing new insights into the professional background of nursing records, this work has highlighted the need for nurses to clarify and make explicit, their uses of information, and also provided them with some tools to assist in this task.
Building upon the foundation of the Structured Narrative electronic health record (EHR) model, we applied theory-based (combined Technology Acceptance Model and Task-Technology Fit Model) and user-centered methods to explore nurses’ perceptions of functional requirements for an electronic nursing documentation system, design user interface screens reflective of the nurses’ perspectives, and assess nurses’ perceptions of the usability of the prototype user interface screens. The methods resulted in user interface screens that were perceived to be easy to use, potentially useful, and well-matched to nursing documentation tasks associated with Nursing Admission Assessment, Blood Administration, and Nursing Discharge Summary. The methods applied in this research may serve as a guide for others wishing to implement user-centered processes to develop or extend EHR systems. In addition, some of the insights obtained in this study may be informative to the development of safe and efficient user interface screens for nursing document templates in EHRs.
Electronic Nursing Documentation; User Interface; Functional Requirements; Nursing Documentation Templates; User-Centered Approach; Clinical Document Architecture; Document Ontology; Technology Acceptance Model; Task-Technology Fit model
Effective cancer pain management requires accurate knowledge, attitudes, and assessment skills. The purpose of this study was to obtain information about the knowledge and attitudes of nurses concerning cancer pain management with the use Health Belief Model (HBM) as conceptual framework.
Materials and Methods:
The study was a descriptive survey and included 98 randomly selected nurses from Alzahra hospital, Isfahan, Iran. A self-administered questionnaire which was designed on the basis of HBM was used to collect the data. Knowledge, attitudes, and HBM constructs regarding cancer pain were the main research variables. The obtained data were analyzed by SPSS (version11.5) using descriptive statistics, independent t–test, and Pearson correlation at the significant level of α=0.05.
Ninety-eight nurses aged 38.7 ± 7.04 years were studied in this survey. From the 10 pain knowledge questions assessed, the mean number of correctly answered question was 61.2 (SD=16.5), with a range of 30–100. There was a direct correlation between knowledge and attitude of nurses with HBM constructs except for perceived barriers and perceived threat. Among the HBM constructs, the highest score was related to self-efficacy with mean score of 87.2 (SD=16.4).
The findings support the concern of inadequate knowledge and attitudes in relation to cancer pain management. We believe that basic and continuing education programs may improve the knowledge level of nursing about pain management.
Attitude; cancer; Health Belief Model; knowledge; nurse; pain management
Objectives: This research was conducted to provide new insights on clinical nurses' and nursing students' current use of health resources and libraries and deterrents to their retrieval of electronic clinical information, exploring implications from these findings for health sciences librarians.
Methods: Questionnaires, interviews, and observations were used to collect data from twenty-five nursing students and twenty-five clinical nurses.
Results: Nursing students and clinical nurses were most likely to rely on colleagues and books for medical information, while other resources they frequently cited included personal digital assistants, electronic journals and books, and drug representatives. Significantly more nursing students than clinical nurses used online databases, including CINAHL and PubMed, to locate health information, and nursing students were more likely than clinical nurses to report performing a database search at least one to five times a week.
Conclusions and Recommendations: Nursing students made more use of all available resources and were better trained than clinical nurses, but both groups lacked database-searching skills. Participants were eager for more patient care information, more database training, and better computer skills; therefore, health sciences librarians have the opportunity to meet the nurses' information needs and improve nurses' clinical information-seeking behavior.
The American Nurses' Association has set eight Standards of Nursing Practice related to the nursing process. Computer-aided information systems intended to facilitate the nursing process must be designed to promote adherence to these professional standards. For each of the eight standards, the paper tells how a hypothetical expert system could help nurses to meet the standard. A prototype of such an expert system is being developed. The paper describes issues in conceptualizing clinical decision-making and developing decision strategies for the prototype system. The process of developing the prototype system is described.
Careful hand hygiene (HH) is the single most important factor in preventing the transmission of infections to patients, but compliance is difficult to achieve and maintain. A lack of understanding of the processes involved in changing staff behaviour may contribute to the failure to achieve success. The purpose of this study was to identify nurses’ and administrators’ perceived barriers and facilitators to current HH practices and the implementation of a new electronic monitoring technology for HH.
Ten key informant interviews (three administrators and seven nurses) were conducted to explore barriers and facilitators related to HH and the impact of the new technology on outcomes. The semi structured interviews were based on the Theoretical Domains Framework by Michie et al. and conducted prior to intervention implementation. Data were explored using an inductive qualitative analysis approach. Data between administrators and nurses were compared.
In 9 of the 12 domains, nurses and administrators differed in their responses. Administrators believed that nurses have insufficient knowledge and skills to perform HH, whereas the nurses were confident they had the required knowledge and skills. Nurses focused on immediate consequences, whereas administrators highlighted long-term outcomes of the system. Nurses concentrated foremost on their personal safety and their families’ safety as a source of motivation to perform HH, whereas administrators identified professional commitment, incentives, and goal setting. Administrators stated that the staff do not have the decision processes in place to judge whether HH is necessary or not. They also highlighted the positive aspects of teams as a social influence, whereas nurses were not interested in group conformity or being compared to others. Nurses described the importance of individual feedback and self-monitoring in order to increase their performance, whereas administrators reported different views.
This study highlights the benefits of using a structured approach based on psychological theory to inform an implementation plan for a behavior change intervention. This work is an essential step towards systematically identifying factors affecting nurses’ behaviour associated with HH.
Hand hygiene; Knowledge translation; Compliance; Behaviour change; Electronic monitoring
In Canada, workforce shortages in the health care sector constrain the ability of the health care system to meet the needs of its population and of its health care professionals. This issue is of particular importance in peripheral regions of Quebec, where significant inequalities in workforce distribution between regions has lead to acute nursing shortages and increased workloads. Information and communication technologies (ICTs) are innovative solutions that can be used to develop strategies to optimise the use of available resources and to design new nursing work practices. However, current knowledge is still limited about the real impact of ICTs on nursing recruitment and retention. Our aim is to better understand how work practice reorganization, supported by ICTs, and particularly by telehealth, may influence professional, educational, and organizational factors relating to Quebec nurses, notably those working in peripheral regions.
First, we will conduct a descriptive study on the issue of nursing recruitment. Stratified sampling will be used to select approximately twenty innovative projects relating to the reorganization of work practices based upon ICTs. Semi-structured interviews with key informants will determine professional, educational, and organizational recruitment factors. The results will be used to create a questionnaire which, using a convenience sampling method, will be mailed to 600 third year students and recent graduates of two Quebec university nursing faculties. Descriptive, correlation, and hierarchical regression analyses will be performed to identify factors influencing nursing graduates' intentions to practice in peripheral regions. Secondly, we will conduct five case studies pertaining to the issue of nursing retention. Five ICT projects in semi-urban, rural, and isolated regions have been identified. Qualitative data will be collected through field observation and approximately fifty semi-structured interviews with key stakeholders.
Data from both parts of this research project will be jointly analysed using triangulation of researchers, theoretical approaches, methods, and results. Continuous exchanges with decision makers and periodic knowledge transfer activities are planned to facilitate the dissemination and utilization of research results in policies regarding the nursing recruitment and retention.
Information has become a capital good and is focused on
outcomes. Clinical guidelines are being developed to standardize care for
populations, but patient preferences also need to be known when planning
individualized care. Information technologies can be used to retrieve both
types of information. The concern is that nurses are not adequately prepared
to manage information using technology. This paper presents five strategic
directions recommended by the National Advisory Council on Nurse Education and
Practice (Department of Health and Human Services, Division of Nursing) to
enhance nurses' preparation to use and develop information technology. The
recommendations are 1) to include core informatics content in nursing
curricula, 2) to prepare nurses with specialized skills in informatics, 3) to
enhance nursing practice and education through informatics projects, 4) to
prepare nursing faculty in informatics, and 5) to increase collaborative
efforts in nursing informatics. The potential impact of these strategic
directions on patients is discussed.
At New England Deaconess Hospital (NEDH), identifying nursing diagnoses and collaborative problems treated during the patient's hospitalization and saving this information as part of the computerized core clinical data base is essential to a professional practice model for the delivery of nursing care. Providing the patient with concise, easy-to-read discharge instructions and referral agencies with consistent information about the patient's functional status and directions for patient care are important components of delivering high quality patient care. ODISY (the On-line Deaconess Information System) facilitates an automated nursing discharge summary function in addition to an automated medical discharge summary, interdepartmental communication via order entry and results reporting, and other user designed functions that support patient care. Utilization of this function strengthens the multidisciplinary discharge care planning process, increases patient satisfaction, facilitates the identification of nursing diagnoses and collaborative problems treated by nurses and physicians, saves a significant amount of nursing time in the preparation of discharge information, and enables the hospital to meet Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards and state regulations for discharge planning.
To identify barriers to and facilitators of the diffusion of clinical practice guidelines (CPGs) and clinical protocols in nursing homes (NHs).
Four randomly selected community nursing homes.
NH staff, including physicians, nurse practitioners, administrative staff, nurses, and certified nursing assistants (CNAs).
Interviews (n = 35) probed the use of CPGs and clinical protocols. Qualitative analysis using Rogers’ Diffusion of Innovation stages-of-change model was conducted to produce a conceptual and thematic description.
None of the NHs systematically adopted CPGs, and only three of 35 providers were familiar with CPGs. Confusion with other documents and regulations was common. The most frequently cited barriers were provider concerns that CPGs were ‘‘checklists’’ to replace clinical judgment, perceived conflict with resident and family goals, limited facility resources, lack of communication between providers and across shifts, facility policies that overwhelm or conflict with CPGs, and Health Insurance Portability and Accountability Act regulations interpreted to limit CNA access to clinical information. Facilitators included incorporating CPG recommendations into training materials, standing orders, customizable data collection forms, and regulatory reporting activities.
Clinicians and researchers wishing to increase CPG use in NHs should consider these barriers and facilitators in their quality improvement and intervention development processes.
clinical practice guidelines; nursing facilities; qualitative research
Despite the fact that nursing informatics is entering its third decade as a specialty within nursing, many definitions still exist to describe the field. This paper offers a rationale for a definition for nursing informatics and a critical analysis of past definitions. An organizing framework of technology-oriented, conceptual, and role-oriented definitions is used to critique these definitions. Subsequently, a revised definition is proposed. This evolutionary definition integrates critical concepts from past work and adds components that are currently missing—patients, information communication, information structures, and decision making. A separate role specification for informatics nurse specialists is provided.