Implications for Nursing (Academia, Research, Clinical Practice)
Health leaders from various disciplines are committed to ensuring health
professionals, particularly nurses, are equipped with tools necessary to best perform and support the activities of nurses as knowledge workers thus improving their environment. Besides the rapid introduction of clinical information systems into nurses' work flow, and their limited input in its selection, design, and system implementation a particular
problem affecting nursing and health care systems is the growing nursing shortage. The nursing shortage is huge burden to health care organizations because care quality is a function of its quantity (Simpson, 2007). This premise is supported by research by Aiken et al (2002), which shows that reduced nursing staffing is associated with longer hospital stays and increased morbidity and mortality. The HRSA projected that the nursing shortage will exceed 1 million nurses by 2010 (ACCN, 2006). Therefore, health care organizations must optimize the existing nursing workforce to ensure quality patient care amid shortages.
Technology has been touted to aid clinicians in making clinical decisions. Crossing the Quality Chasm highlights the potential of technology—software that integrates information on the characteristics of individual patients with a computerized knowledge base for the purpose of generating patient-specific assessments or
these systems are often implemented and evaluated with respect to physician practice, hospital operations and ancillary departments (i.e. laboratory, radiology, etc) rather than nursing (Ball & Bierstock, 2007; IOM, 2004). Moreover, there's a discrepancy between new technologies deployment and the integration into nursing basic education of the skills needed to support nurses' work. Although, nursing informatics (NI) has been recognized as a specialty since 1992 by the American Nursing Association, fewer than 50% of accredited nursing schools offered graduate or undergraduate programs with NI specific courses (National Advisory Council on Nurse Education and Practice
[NACNEP], 1997). NACNEP further purports, of those schools who did offered NI courses, some only covered basic computer literacy, without nursing-specific NI courses.
Nursing informatics is “a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice” (ANA, 2007). This specialty supports patients, nurses, and other providers in their decision-making in all roles and settings. ANA go on to state that this support is accomplished through the use of information structures, information processes, and IT. According to Windsor (2006), few differences exist in the goals of nursing and nursing informatics. Nursing informatics exists to support the highest possible quality of care, and the core service of nursing is patient care (Turner, 2002). However, informatics belongs to the specialists (Hebert, 2000).
Furthermore, because of the rapid introduction of clinical information systems into nurses' work, many stakeholders are being faced with a need to define informatics competencies for nurses.
Informatics knowledge and skills range from how to use a clinical application or knowledge about basic technology terms to more advanced concepts surrounding nursing structured languages (i.e., NANDA, NIC, NOC) or evaluating the impact of a clinical system on practice (Staggers et al, 2002). Because there is a lack of informatics
knowledge and skills among nurses as well as other health professionals in work settings (Barnett, 1995; Carter & Axford, 1993; Ngin & Simms, 1996; Staggers, et al., 2002; Staggers, Gassert, & Skiba, 2000), and in academia (AACN, 1997; McCannon &
O’Neal, 2003; Smith, 2006; Staggers et al, 2002; Staggers et al, 2000), healthcare leaders must address this discrepancy through needs assessment prior to and during
implementation, at job entry, and in nursing education programs (ANA, 2007).
The American Association of Colleges of Nursing (ACCN) introduced guidelines pertaining to nurses’ education and information technologies role in health care, while AMIA examined informatics education by all health professionals (Staggers et al, 2000). Both organizations contend that there is a need for research-based, informatics
competencies to guide curricular development in formal academia. Staggers et al (2002) created and validate a research-based master list of informatics competencies for nurses by differentiating these competencies across all levels of practice. An expert panel was formed to define initial competencies for each level of nursing. These definitions for levels of nurses include: beginning nurses (level 1), experienced nurses (level 2), informatics specialists (level 3), and informatics innovators (level 4).
Beginning nurses (Level 1) have fundamental information management and computer technology skills and use existing information systems and available
their domain of interest (e.g., public health, education, administration). These nurses are highly skilled in using information management and computer technology skills to support their major area of practice. They see relationships among data elements, and make judgments based on trends and patterns within these data.
Informatics specialists (Level 3) are registered nurses who possess additional knowledge and skills specific to information management and computer technology. They focus on information needs for the practice of nursing, which includes education, administration, research and clinical practice. In their practice, informatics specialists use the tools of critical thinking, process skills, data management skills (includes identifying, acquiring, preserving, retrieving, aggregating, analyzing, and transmitting data), systems development life cycle, and computer skills. Informatics innovators (Level 4) are
educationally prepared to conduct informatics research and to generate informatics theory. Innovators function with an ongoing healthy skepticism of existing data management practices and are creative in developing solutions. Innovators possess a sophisticated level of understanding and skills in information management and computer technology. They understand the interdependence of systems, disciplines, and outcomes, and can finesse situations to maximize outcomes.
The Robert Wood Johnson Foundation funded the Quality and Safety Education for Nurses (QSEN) project to prepare future nurses with the knowledge, skills and
attitudes to improve the quality and safety of health care systems in which they will work. This project, spearheaded by Dr. Linda Cronenwett, Dean and Professor at the University of North Carolina at Chapel Hill, is supported by a national core faculty and advisory board (Smith, 2006). Phase one (1) of this project has built and expanded upon IOM’s
(2003) recommendations to “identify and define” six core competencies for incorporation into pre-licensure nursing students' curricula. These core competencies include: patient- centered care, evidence-based practice, teamwork and collaboration, safety, quality improvement, and informatics.
A national electronic survey was administered by the QSEN staff to selected associate degree in nursing and Bachelor of Science in nursing programs to determine the state of nursing curricula. Pedagogical strategies were developed by QSEN to help convey these competencies into curricula and practice (Cronenwett et al., 2007). In the following year, QSEN was funded for phase two (2), which was expanded to include advanced practice students and clinicians. The QSEN collaborative could be useful for understanding staff nurse informatics needs as well as needs of those entering the profession.
The Technology Informatics Guiding Educational Reform (TIGER) is working to “enable practicing nurses and nursing students to fully engage in the unfolding of the digital electronic era in healthcare” (TIGER, 2006). The purpose of this initiative is to identify information/knowledge management best practices and effective technology capabilities for nurses. TIGER’s platform, like QSEN, is built on the Institute of Medicine’s premise in Health Professions Education: A Bridge to Quality (2003) that incorporating informatics into health care practice is a core competency for all health professionals.
Implications for health care organizations
Hopefully, this discussion will provide guidance to health care organizations and professionals struggling to keep pace with the rapid introduction of clinical information
systems into nurses' work environment. “Successful organizations must foster innovation and master the art of change or they'll become candidates for extinction” (Robbins, 2005; p. 23). Fostering change requires empowering employees by placing them in charge of what they do (i.e., shared governance, magnet designation). According to Robbins (2005), the only way this can be accomplished is by relinquishing control by executives, so that employees can learn to take responsibility for their work and make appropriate decisions. The lack of control over nursing practice or inability to make decisions based on one’s knowledge because of a system based on rigid hierarchical rules has been shown in the literature as one of many reasons for nurse dissatisfaction.
Magnet designation is shown in the literature to positively enhance the nursing practice environment (Friese, 2005). In fact, Magnet hospitals were identified as being more successful in attracting and retaining nurses in comparison to non-magnet hospitals (Aiken & Patrician, 2000). Autonomy and control over nursing practice (Havens & Aiken, 1999), good relationships with physicians, flexible scheduling, strong nursing leadership, participative management, and professional development (Stovie, 1984), are cited as the characteristics of a practice environment in Magnet organizations. McClure, Poulin, Stovie & Wandelt (1983) found that Magnet hospitals had low nursing turnover rates even during times of nursing shortage.
Along with magnet designation to enhance the nursing practice environment, promote professional development and improve nurse satisfaction, healthcare
organizations must seek to strengthen ongoing assistance in knowledge and skill acquisition. The overwhelming expansion of clinical knowledge, medications, medical equipment, and new technologies continues unabated (IOM, 2004), and likely provides
ongoing benefits to patients (Bates et. al., 2001). However, with this rapid expansion of knowledge come risks to patient safety. “Today, no one clinician can retain all the information necessary for sound, evidence-based practice; no unaided human being can read, recall, and act effectively on the volume of clinically relevant scientific literature” (IOM, 2001a: p. 25). IOM's premise has implications for the work environment of nurses and patient safety. Therefore, health care organizations must seek to improve patient safety as well as satisfaction of nurses by assessing the culture of the nursing organization and transforming it into one of a “learning organization" (Holden, 2006; IOM, 2004).
A learning organization is an organization “skilled at creating, acquiring, and transferring knowledge, and at modifying its behavior to reflect new knowledge and insight” (Garvin, 1993: p. 80), and allowing its workers “slack” to “unleash their genius, reinvent health care, and fix health care from the inside out” (Kerfoot, 2007; p. 61).
Senge, Kleiner, Roberts, Ross & Smith (1994) described the components of a learning organization as: systems thinking, personal mastery, mental models, team learning and shared vision. Systems thinking require the entire organization, not just the nursing department, to support and embrace change. The entire organization must be able to see that each part of the system has an effect on the whole. Personal mastery involves the development of the person as a constantly evolving and improving individual and professional. Benner's (1984) stages in describing the professional evolution of a nurse (novice, advanced beginner, competent, proficient, and expert) would be a prime example of personal mastery.
As new technology evolves and the entire profession develops, even the expert can become a novice with respect to a new procedure or skill (Holden, 2006). Mental
models encourage abstract thinking in order to make sense of the organization, the nursing unit, or the problem by framing it and then re-framing the situation to improve or redirect efforts. “Mental models, combined with the respect for individual and
professional opinion, encourage input to improve the organization as a whole.” (Holden, 2006; p. 36). Team learning represents not only the ability of a unit to move forward as a unit but also suspending the paradigm of “us versus them” to a “we” paradigm
throughout the organization. Shared vision is a collective moving of an entire group towards a joint goal.
Creating a learning organization is without its challenges. Delong & Fahey (2000) found that organizational culture was an impediment to creating a learning organization. In order to create a learning environment, IOM (2003) recommends that health care organizations should assess existing knowledge culture within an
organization; freeing up employee time for thinking, learning, and training; and aligning incentives to reinforce and facilitate uptake of knowledge management practices. Moreover, adapting to people who are different is another challenge facing health care organizations.
In Robbins's Organizational Behavior, the term used to describe this challenge is workforce diversity. Workforce diversity means that “organizations are becoming a more heterogeneous mix of people in terms of gender, age, race, ethnicity, and sexual
orientation.” (p. 17). Traditionally, it has been assumed that people who are different would automatically want to assimilate into an organization. However, it has been shown that employees do not easily relinquish their cultural values, lifestyle preferences, and differences when they come to work. Therefore, recognizing value differences is vital to
embracing diversity thereby improving quality and productivity especially during shortages.
Recommendations for future research
This paper demonstrates a need for nurse researchers and health leaders to examine all facets of nurses' work environment from the introduction of clinical information systems to their decision-making when selecting, designing, and implementing these systems. Nurses must view these systems favorably. As stated previously, a negative perception of a new system can lead to unintentional
documentation and/or patient care errors through work-a-rounds or worse, system abandonment (Englebardt & Nelson, 2002). In essence, these systems must “make sense” to nurses, as well as be a fit into their practice. In addition, nurses must be
involved at every level of a system's life cycle. Moreover, human factors associated with system implementation must not be overlooked nor saved for last. Human factors include usability, ergonomics, scenario-based testing, and other strategies to truly support the practice environment. Healthcare organizations are knowledge driven environments. Therefore, nurses must be proficient and competent to effectively manage large amounts of data to support their practice.
The conceptualization of nurse readiness (NIRM), in particular its knowledge sub-component could assess the need for further training and communicative initiatives to expand on the benefits of technological innovations into their environment. The NIRS is still an incipient assessment tool and needs to be further developed through future studies. Further enhancements and validation efforts of nurse readiness assessment tools will allow nursing leaders to effectively assess and identify issues related to technology
implementation. Over 50% of CIS implementations fail. Therefore, research examining whether the assessment of informatics competencies and user acceptance of CIS by nurses in work settings could possibly decrease implementation failures. Moreover, the creation, then testing of research-based competencies in nursing could ensure the use of IT to its full potential by equipping these users with the knowledge, skills, attitudes and informatics competencies needed to support safe patient care.
Future studies may combine survey methodology with structured interviews or conduct a Delphi study with a panel of experts to validate surveys. A mixed-mode survey that uses the Internet and paper may also help the response rate. However, proven
methods found to improve response rates are frequent visits or reminders from
researchers. The survey could also be replicated in multiple environments and at multiple phases within the SDLC. Longitudinal studies over time would be helpful to compare survey results at different points throughout the SDLC. For instance, survey results may change after a new technological system has been fully implemented and results may vary according to elements of successful or failed implementation.
In addition to longitudinal studies, scenario-based testing could aid health care leaders to identify new paths to failures. Also, with scenario-based testing, workplace performance trade-offs related to time and production pressures can be identified. “Human-computer interaction (HCI) deficiencies and mismatches between systems design and the structure of work create the potential for new paths to system failures” (Rogers et. al., 2005: p. 365). Therefore, this methodology may impact human performance thereby improving patient safety.
Multidisciplinary focus in clinical information systems (CIS) implementation is shown in the literature (Hilz, 2000; Staggers et al, 2000). However, as “new systems affect larger, more heterogeneous groups of people and more organizational areas, the major challenges to systems success often become more behavioral than technical” (Lorenzi & Riley, 2000: p. 116). Specialists in the area of organizational behavior and human factors engineering could “reconsider how work would be done and an
organization structured if it were starting over in the approach called process
reengineering.” (Robbins; p. 20). The term reengineering comes from the process of taking apart an electronic product and designing a better version. In organizations, process reengineering entails rethinking and redesigning the processes by which the organization creates value and does work, ridding itself of operations that have become antiquated (Hammer & Champy, 1993). The extensive literature within this paper shows that nurses are not really viewed as end users in CIS implementations. Therefore, it will take leaders in all facets of healthcare, especially nurses to alter this misperception to mitigate system failures.
CHAPTER 6