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The Practice Specialty of Nursing Informatics
ABSTRACT
Nursing informatics is an established nursing specialty. All nurses employ information technologies and solutions in their practice. Informatics nurses are key persons in the design, development, implementation, and evaluation of these technologies and solutions and in the development and enhancement of the specialty’s body of knowledge.
This chapter addresses pertinent concepts, definitions, and interrelationships of nursing, nursing informatics, and healthcare informatics. The evolution of definitions for nursing informatics is presented. The recognition of nursing informatics as a distinct nursing specialty is discussed. Select models and theories of nursing informatics and supporting sciences are described. The identification of various sets of nursing informatics competencies is explained. A collection of international and national organizations of interest to informatics nurses is presented. This chapter also addresses components of the scope of practice and the standards of practice and professional performance for nursing informatics.
INTRODUCTION
Decision-making is an integral part of daily life. Good decisions require accurate and accessible data as well as skill in processing information. At the heart of nursing informatics [NI] is the goal of providing nurses with the data, information, and support for information processing to make effective nursing practice decisions in clinical care, research, education, administration, and policy development. Generation of knowledge and the application of wisdom also occur.
INFORMATICS NURSE/INFORMATICS NURSE SPECIALIST
An informatics nurse [IN] is a registered nurse who has an interest or experience in nursing informatics. Informatics nurse specialists [INSs] are registered nurses prepared at the graduate level [master’s degree or higher] in nursing informatics, informatics, or an informaticsrelated field. An INS functions as a graduate-levelprepared specialty nurse.
Foundational Documents Guide Nursing Informatics Practice
Nursing informatics practice and the development of this specialty have been guided by several foundational documents. These documents are listed in Table 16.1 and described in this section.
TABLE 16.1. Foundational Documents
In 2001, the American Nurses Association [ANA] published the Code of Ethics for Nurses with Interpretive Statements, a complete revision of previous ethics provisions and interpretive statements that guide all nurses in practice, be it in the domains of clinical care, education, administration, or research. Nurses working in the informatics specialty are professionally bound to follow these provisions. Terms such as decision-making, comprehension, information, knowledge, shared goals, outcomes, privacy, confidentiality, disclosure, policies, protocols, evaluation, judgment, standards, and factual documentation abound throughout the explanatory language of the interpretive statements [American Nurses Association, 2001a]. Although cited in the 2015 Nursing Informatics: Scope and Standards of Practice, Second Edition, that resource has been replaced with the contemporary 2015 Code of Ethics for Nurses with Interpretive Statements document that is available at: www.nursingworld.org/practice-policy/nursingexcellence/ethics/code-of-ethics-for-nurses/.
ANA’s Nursing: Scope and Standards of Practice, Second Edition [2010], referenced in the Nursing Informatics: Scope and Standards of Practice, Second Edition [American Nurses Association, 2015c], reinforced the recognition of nursing as a cognitive profession and provided the definition of nursing: “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” [p. 9]. The exemplary competencies accompanying each of the 16 Standards of Professional Nursing Practice comprised of Standards of Practice and Standards of Professional Performance, reflected the specific knowledge, skills, abilities, and judgment capabilities expected of registered nurses at that time. The standards included data, information, and knowledge management activities as core work for all nurses. This cognitive work began with the critical-thinking and decision-making components of the nursing process that occur before nursing action can begin [American Nurses Association, 2010]. Consult Nursing: Scope and Standards of Practice, Third Edition [American Nurses Association, 2015b] for the contemporary definition of nursing and revised standards of nursing practice and professional performance.
The nursing process provides a delineated pathway and process for decision-making. Assessment, or data collection and information processing, begins the nursing process. Diagnosis or problem definition, the second step, reflects the interpretation of the data and information gathered during assessment. Outcomes identification is the third step, followed by planning as the fourth step. Implementation of a plan is the fifth step. The final component of the nursing process is evaluation. The nursing process is often presented as a simplistic linear process with evaluation listed as the last step. However, the nursing process really is very iterative, includes numerous feedback loops, and incorporates evaluation activities throughout the sequencing. For example, evaluation of a plan’s implementation may prompt further assessment, a new diagnosis or problem definition, and decision-making about new outcomes and related plans.
The collection of data about the healthcare consumer, client, patient, management, education, or research situation is guided by a nurse’s knowledge base built on formal and informal educational preparation, evidence and research, and previous experiences. In healthcare, as in most areas of our lives, data, information, knowledge, and wisdom [DIKW] are growing at astronomical rates and demand increasing reliance on computer and information systems for collection, storage, organization and management, analysis, and dissemination. For example, in clinical nursing practice, consider the significant expansion in the amount and types of data that must be collected for legal, regulatory, quality, and other reasons. DIKW might include understanding of the following:
• Genetic profiles, related to specific healthcare consumer health conditions
• Information and knowledge about the healthcare environment and services, including data related to:
• Standardized nursing terminologies and their capacity to contribute to codification, quantification, and evaluation of delivery of nursing care services [see Chapter 8, “Standardized Nursing Terminologies” for more detailed discussion]
Collecting data in a systematic, thoughtful way, organizing data for efficient and accurate transformation into information, and documenting thinking, decisions, and actions are critical to successful nursing practice. Nursing informatics is the nursing specialty that endeavors to make the collection, management, and dissemination of data, information, and knowledge—to support decisionmaking—easier for the practitioner and healthcare consumer, regardless of the domain and setting.
INFORMATICS AND HEALTHCARE INFORMATICS
Informatics is a science that combines a domain science, computer science, information science, and cognitive science. Thus, it is a multidisciplinary science drawing from varied theories and knowledge applications. Healthcare informatics may be defined as “the integration of healthcare sciences, computer science, information science, and cognitive science to assist in the management of healthcare information” [Saba & McCormick, 2015, p. 232]. Healthcare informatics is a subset of informatics, as is nursing informatics. Imagine a large umbrella named informatics comprised of many panels. Each panel represents a different domain science, one of which is healthcare informatics. The healthcare informatics panel could be comprised of many stripes depicting the composite of nursing informatics, dental informatics, public health informatics, etc.
Because healthcare informatics is a relatively young addition to the informatics umbrella, you may see other terms that seem to be synonyms for this same area, such as medical or health informatics. Medical informatics historically was used in Europe and the United States as the preferred term for healthcare informatics but now is evolving to be more clearly realized as a subset of healthcare informatics. Similarly, health informatics may reference informatics used in educating healthcare consumers and/or the general public. As healthcare informatics evolves, so will the clarity in definition of terms and associated scopes of practice.
Healthcare informatics addresses the study and management of healthcare information. A model of overlapping discrete circles could depict the integrated content most often considered representative of the multiple and diverse aspects of healthcare informatics. Healthcare informatics would be the largest encompassing circle surrounding smaller intersecting circles. These aspects include specific content areas such as information retrieval, ethics, security, decision support, patient care, project management including electronic health record [EHR] implementations, system life cycle [SLC] as a subcomponent of project management, evaluation, human– computer interaction [HCI] or user experience, standards, connected health/telehealth, healthcare information systems, imaging, knowledge representation, education, and information retrieval.
Nursing Informatics
Nursing informatics [NI], as a subset of healthcare informatics, shares common areas of science with other health professions and, therefore, easily supports interprofessional education, practice, and research focused on healthcare informatics. Nursing informatics also includes unique components, such as standardized nursing terminologies, that address the special information needs for the nursing profession and healthcare consumers. Nurses practice interprofessionally as well as independently when engaged in clinical and administrative nursing practice. Nursing informatics reflects this duality as well, moving through the continuum of integration and separation as situations and needs demand.
In 1985, Kathryn Hannah proposed a definition that nursing informatics is the use of information technologies in relation to any nursing functions and actions of nurses [Hannah, 1985]. In their classic article on the science of nursing informatics, Graves and Corcoran presented a more complex definition of nursing informatics. Nursing informatics is a combination of computer science, information science, and nursing science designed to assist in the management and processing of nursing data, information, and knowledge to support the practice of nursing and the delivery of nursing care [Graves & Corcoran, 1989].
With the development of the first scope of practice statement for nursing informatics, ANA modified the Graves and Corcoran definition to identify nursing informatics as the specialty that integrates nursing science, computer science, and information science in identifying, collecting, processing, and managing data and information to support nursing practice, administration, education, research, and the expansion of nursing knowledge [American Nurses Association, 1994]. The explication of the accompanying first standards of practice for NI followed in 1995 with ANA’s publication of the Standards of Practice for Nursing Informatics [American Nurses Association, 1995].
In 2000, the ANA convened an expert panel to review and revise the scope and standards of nursing informatics practice. That group’s work included an extensive examination of the evolving healthcare and nursing environments and culminated in the publication of the Scope and Standards of Nursing Informatics Practice [American Nurses Association, 2001b]. This professional document included an expanded definition of nursing informatics that was then slightly revised in the 2008 Nursing Informatics: Scope and Standards of Practice to include wisdom:
Nursing informatics [NI] is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. NI supports consumers, patients, nurses, and other providers in their decision-making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology. [American Nurses Association, 2008, p. 1]
Then, in 2015, ANA’s second edition of Nursing Informatics: Scope and Standards of Practice presented an updated definition:
Nursing informatics [NI] is a specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice. NI supports nurses, consumers, patients, the interprofessional healthcare team, and other stakeholders in their decision-making in all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes, and information technology. [American Nurses Association, 2015c, pp. 1–2]
ANA has convened an expert group to review and revise the 2015 Nursing Informatics: Scope and Standards of Practice, Second Edition, which may result in further refinement of the current definition. Nursing: Scope and Standards of Practice, Third Edition, [American Nurses Association, 2015b] and the Code of Ethics for Nurses with Interpretive Statements [American Nurses Association, 2015a] will inform that discussion and development effort. These multiple definitions illustrate the dynamic, developing nature of this evolving nursing specialty. Development of different definitions and a healthy debate on those definitions promotes validation of key elements and concepts. A willingness to continue exploring possible definitions can prevent premature conceptual closure, which may lead to errors in synthesis and knowledge development.
Nursing Informatics as a Specialty
Characteristics of a nursing specialty include differentiated practice, a well-derived knowledge base, a defined research program, organizational representation, educational programs, and a credentialing mechanism. In early 1992, ANA recognized nursing informatics as a specialty in nursing with a distinct body of knowledge. Unique among the healthcare professions, this designation as a specialty provided official recognition that nursing informatics is indeed a part of nursing and that it has a distinct scope of practice.
The core phenomena of nursing are the nurse, person, health, and environment. Nursing informatics focuses on the information of nursing needed to address these core phenomena. Within this focus are the metastructures or overarching concepts of nursing informatics: data, information, knowledge, and wisdom. It is this special focus on the information of nursing that differentiates nursing informatics from other nursing specialties.
Nursing informatics is represented in international, national, regional, and local organizations. For example, there is a nursing informatics working group in the American Medical Informatics Association [AMIA] and in the International Medical Informatics Association [IMIA]. Nursing informatics is part of the clinical section of the Healthcare Information and Management Systems Society [HIMSS]. There are additional organizations such as the American Nursing Informatics Association [ANIA] and the American Academy of Nursing [AAN] Informatics and Technology Expert Panel [ITEP].
Increasingly, nursing school curricula include content, and sometimes complete courses, on information technologies in healthcare and nursing. In 1989, the University of Maryland established the first graduate program in nursing informatics. The University of Utah followed in 1990. Now there are several established in-person and online programs for graduate work as well as doctoral programs in nursing informatics.
Certifications That Support the NI Specialty
Following the publication of the first nursing informatics scope of practice and standards documents, the American Nurses Credentialing Center [ANCC] established a certification process and examination in 1995 to recognize those nurses with basic nursing informatics specialty competencies. The ANCC has used scholarship in nursing-informatics competencies and its own role-delineation studies to develop and maintain the nursing-informatics certification examination. The ANCC-designated NI contentexpert panel has oversight responsibility for the content of this examination and considers the current informatics environment and research when defining the testcontent outline. Application details and the test-content outline are available at www.nursingworld.org/our-certifications/informatics-nurse/.
Information for the HIMSS Certified Professional in Health Information and Management Systems [CPHIMS] and Certified Associate in Health Information and Management Systems [CAHIMS] certifications are available at www.himss.org/health-it-certification.
Other Certification Programs That Support the NI Role. As noted by McGonigle and Mastrian [2015], NI roles include those of project manager, consultant, educator, researcher, product developer, decision support/outcomes manager, advocate/policy developer, clinical analyst/system specialist, and entrepreneur. For example, the certification for:
Project manager is the Project Management Professional [PMP], supported by the Project Management Institute: www.pmi.org/certifications/types/project-management-pmp
Nurse Executive and Nurse Executive-Advanced [NE & NE-A]:
www.nursingworld.org/our-certifications/nurse-executive-advanced
Nurse Educator–Certified Nurse Educator [CNE]: www.nln.org/Certification-for-NurseEducators/cne.