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Nursing Informatics: A Key to Improving Nursing Practice by Prof Ajibade B. L
Date Posted: 15/Sep/2017
Informatics are essential for nursing practice, and are critical to providing safe and effective patient care. This paper on nursing Informatics, a key to improving nursing practice was presented at the 17th Scientific Conference/General Meeting by the body of Heads of Nursing Services Department and principals of School in Federal Institutions hosted by the Department of nursing Services, Federal Medical Centre, Keffi. The Diffusion of Innovation theory by Rogers served as the theoretical framework for the write-up. The paper discussed the concepts of nursing informatics, nursing practice, definition of nursing, who is a nurse?, Roles of nurses in informatics, nursing informatics competencies, the importance of nurse in informatics functioning, the impact of nursing informatics on the health care system, impact of nursing informatics on the nursing profession and creating a supportive environment for nursing informatics in Nigeria. It was concluded that nursing informatics attempts to manage the explosion of ever increasing medical information by managing and communicating information in order to promote knowledge in nursing practice for quality care.
Technology in health care is increasingly becoming an integral part of health care delivery system and is declared by strategist as a means whereby sustained improvement in healthcare outcomes may be attained1. 
The healthcare delivery environment is dramatically changing and nursing has found itself in the midst of these revolutionary changes. Health care providers are expected to provide safe, competent care in a highly technical and digital environment. Today’s nursing requires nurses to be constantly aware of new developments, new medications, and new technologies among others2. Nursing practice encompasses a health care discipline derived from the concept that nurses are care providers who design, manage, and coordinate care, and are member of a profession. 
Nurses are required to collect, store, and retrieve data and information, in order to synthesize and use wisdom to guide nursing care critically important to handling data and information, effective communication must be exercised at the professionals’ level in order to achieve safe patient care3. 
A new major theme in this new healthcare arena is the use of information systems and technologies to improve the quality and safety of patient care4. Nursing practice is continuously changing, and the need for appropriate competencies to address specific areas of nursing are essential to the provision of safe and effective care5. 
Among the most important components of patient care are communication, clinical decision making, and patient safety. The practice of nursing is based on the collection, storage, retrieval and use of data, information and knowledge. Nurse must be competent in these areas in order to provide safe and effective patient care. Often times, technologies are used in practice to help with the management of information and clinical decision making. The development, implementation and use of technology is integral to the practice of nursing6. However, the use of technology in practice creates new educational needs for nurses in regards to possessing knowledge, behavior, and skill for practice. It is important that nursing professionals and other healthcare providers are educated and competent in the proper use of technology as it applies to the various disciplines in healthcare. 
To be competent is to possess specific behaviours, knowledge, skills, and capacity within defined areas7,8,9. Nurse especially, must possess competence in nursing to practice safe and effective care. A critical areas of nursing competencies is that of nursing informatics which can be explained as possessing the appropriate knowledge, behavior, and skills required for nurses to collect, store, retrieve, and process information. In order for nurses to effectively manage patient care, they must understand how to appropriately manage information thus possessing informatics competencies is instrumental to practicing as a professional nurse .
Concept of Nursing Informatics
Nursing informatics emerged over the last 20 years to assist nurses fully use information technology to improve the delivery of care10. Nursing informatics is a specialty that integrates nursing sciences, computer science and information and knowledge in nursing practice11. Nursing informatics facilitates the integration of data, information and knowledge to support patients, nurses and other health- care  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. This definition is a product of review of other definitions and the most acceptable of all definitions. The American Nurses Association Nursing Informatics Scope and Standards also adopted this definition in 200812. Factors inherent in this definition is that nursing informatics is a multidisciplinary science practice  and secondly, the definition clarify that nursing informatics is not and synonymous with the generic term informatics, it is specific to nursing and nursing practice because of the inclusion of the nursing sciences domain. Nursing informatics is not just about computers but rather the core elements derived from computers involving data, information, knowledge and how best to structure nursing documentation systems to ensure that the output will meet the needs of patient care and nursing science13.     
Nursing informatics is defined as a “Science and practice which integrates nursing, it information and knowledge, and their management, with information and communication technologies to promote the health of people, families and communities worldwide14.
The foundation of nursing informatics is based on the concepts of data information and knowledge. Data are discrete observations that are interpreted, organized or structured. Information is data that has been interpreted, organized or structured to provide meaning to the data, for instance, age, number of home visits, blood pressure, diseases, and weight among others. Nursing informatics has the purpose and the potential to support and improve the care of patients and communities through the collection, management, and communication of information about and for the patient. Nursing informatics can assist in making the contributions of nursing visible in the medical record and assist the nurse by providing decision support tools. Nurses are presented with an increasing array and complexity of information that they are expected to synthesize and incorporate into their patient care decisions. More information does not necessarily result in better care unless it is thoughtfully analyzed, organized and presented in ways that are meaningful to nurses and their practice13. 
The goal of nursing informatics is to improve the health of populations, communities, families and individuals by optimizing information, management and communication. This includes the use of information and technology in the direct provision of care, in establishing effective administrative systems, in managing and delivery educational experiences, in supporting lifelong learning and in supporting nursing research11.
Historical perspective
In 1857, Florence nightingale compiled and processed data in an effort to advocate for appropriate nursing and medical protocols. However, in more recent history, nurses have been involved in informatics since the 1960s15. Nurse utilized computer-readable punch cards to check-off their observations of patient as early as 1965. The data from this card were then read into computers at San Jose Hospital, which then served as an electronic record of patient care. In 1966, nurses at the institute of Living in Hartford used similar technology to document patient statuses.  In this case nurses used machine readable bubble sheet similar to Scranton technology that can read penciled markings. The term ‘marking informatics’ was not actually coined until 1980 by Scholes and Barbar16. Thereafter, in 1992, the American Nurses Association17 approved nursing, informatics as a recognized specialty. Since the mid 1990s, nursing informatics has virtually ‘exploded’ as a discipline. The USA began certifying nurses in informatics competencies in the early 1990s. This occurred concurrently with the development of the internet and desktop computing advances18. In Canada, concern about the effectiveness and efficiency of the Canadian healthcare systems beginning in the mid 1980s, led to a growing recognition of health informatics19. As the need for better information with which to manage the healthcare system became an increasing consistent theme and a national priority in Canada, the Canadian Institute for Health Information (CHI) was established. Its mandate is to provide ‘essential data and analysis on Canada’s health system and the health of Canadians(CHII, 2008).10
Nursing informatics evolved as nurses participated in the early initiatives in hospital information system adoption in various agencies across the nation. As these systems improved, specialized nursing components and even free standing nursing information system began to spring up. Early systems were primarily imported from other countries especially USA. By the late 1980s, most hospitals had at least a rudimentary information system that required nurses to enter common data such as admission profiles and basic care requirements like diet, medications and treatments into a computer as part of their routine duties6,2,5.
Concept Of Nursing Practice
Having elucidated on the concept of nursing informatics and  historical   basis of nursing informatics, let us now deliberate on the concept of nursing practice. Nursing as an integral part of the health care system, encompasses the promotion of health, prevention of illness, and care of physically ill, mentally ill, and disabled people of all ages in all health care and other community settings. Within this broad spectrum of healthcare, the phenomena of particular concern to nurses are individual family, and group ‘reponses to actual or potential health problemms17”.
These human responses range broadly from health restoring reactions to an individual episode of illness to the development of policy in promoting the long-term health of population. The unique function of nurses in caring for individuals, sick or well, is to assess their responses to their health status and to assess them in the performance of those activities contributing to health or recovery or to dignified death that they would perform unaided if they had the necessary strength, will or knowledge and to do this in such a way as to help them gain full or partial independence as rapidly as possible20. Within the total health care environment, nurses share with other health professionals and those in other sectors of public service functions of planning, implementation, and evaluation to ensure the adequacy of the health system for promoting health preventing illness and caring for ill and disabled people21. 
From the afore mentioned concept, it is crystal cleared that nursing practice is eclectic in nature and it is very wide in orientation. Therefore, nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well in all settings. Nursing includes the promotion of health prevention of illness and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles23. 
The above definition of nursing has clearly shown the necessity of information management as being associated with nursing, therefore use of nursing informatics has become imperative in nursing practice.
Going back to the memory lane and for the purpose of this discourse, who is a nurse?. A nurse is a person who has completed a programme of basic, generalized nursing education and is authorized by the appropriate regulatory authority (in Nigeria, N & MCN) to practice nursing in his or her country. Basic nursing education is a formally recognized programme of study providing a broad and sound foundation in the behavioural, life, and nursing sciences for the general practice of nursing for a leadership role, and for post-basic education for specialty or advanced nursing practice. The nurse is prepared and authorized:
*To engage in the general scope of nursing practice including the promotion of health, prevention of illness, and people  of all ages and in all health care and other community settings
*To carry out health care teaching
*To participate fully as a member of healthcare team
*To supervise and terrain nursing and healthcare team
*To be involved in research
Theoretical Framework
Since we have all agreed that nursing is a science, its therefore imperative to have a theoretical basis for any write up on discourse in nursing. Therefore, the theory adopted for this discourse is the Diffusion of Innovation Theory.
Rogers Innovation diffusion Theory is one of the most popular theories for studying adoption of information technologies (IT) and understanding how IT innovations spread within and between communities. According to the theory, innovation is an idea, process, or technology that is perceived as new or unfamiliar to individuals within a particular area or social system. Diffusion is the process by which the information about the innovation flows from one person to another over time within the social system. There are four (4) main determinants of success of an IT innovation communication channels, the attributes of the innovation, the characteristics of the adopters, and the social system. The communication channels refer to the medium through which people obtain the information about the innovation and perceive its usefulness. It involves both mass media and interpersonal communication17. 
The attributes of an innovation include five (5) users perceived qualities:- relative advantages, compatibility ,Complexity, triability and observability. Relative advantage is the degree to which the user perceives the benefit or improvements upon the existing technology by adopting an innovation (with this discourse, how do we as nurses perceive the benefit of nursing informatics? Do we see it as a step in improving the nursing practice? If the answer is yes, then this discourse will later mention the roles of nurses in nursing informatics.) The second attribute is the compatibility captures. The extent to which an innovation can integrate or co-exit  with existing values, past experience and the needs of potential adopters, the greater its prospects for diffusion and adoption. In the case of informatics, the filing systems of nursing care rendered will be reduced and the information can easily be retrieved from the computer thereby saving time while carrying out our nursing care. The third attribute is the complexity measures the degree to which an innovation is perceived to be difficult to understand, implemented or used. An innovation that is the less complex is more likely to be rapidly accepted by end users since the nursing informatics has now been introduced into the nursing programme curriculum, the complexity that may be assumed to be involved should have reduced. Equally there are now periodic continuing education programmes to make practicing nurses to be computer literate  for  the purpose of developing knowledge on the use of computers in the care of patients. The fourth attribute is Trialabilty which is the ability of an innovation to be put on trial without total commitment and with minimal investment. An innovation with higher trialability is more likely to be adopted by individuals. The last attributes is observability which is the extent to which the benefit of an innovation are visible to potential adopters. Only when the results are perceived as beneficial, will an innovation be adopted, hence the organization of this type of conferences on nursing informatics. Rogers went further to characterize the individuals of a social system into five groups based on their attitudes toward an innovation: innovators, early adopters, earlier majority, later majority and laggards. The first group of adopters comprises 16% of the population in a social system. The next two groups, which account for 68% of the population of the social system, are earlier and later majority adopters. The last 16% of individuals in the social system are called Laggards. They are the strongest resisters to the adoption of an innovation and most likely they tend to become non-adopters because of their limited resources and lack of awareness or knowledge of innovations.  As social system is a set of interrelated units engaged in joint problem solving to accomplish a common goals. It constitutes a boundary within which the diffusion of innovations takes place. Rogers suggests that the structure of a social system affects the individuals’ attitude toward the innovation, and consequently, the rate of adoption of innovations. This discourse demonstrated that Rogers, innovation theory is useful for conceptualization of technology (Nursing Informatics) adoption in the context of e-health. Therefore, this theory was used in this presentation to explain the nursing informatics as an innovation in nursing practice, and that some nurse will be resilient in accepting the innovation, as early as possible, majority will be delayed in their acceptance of nursing informatics while others will resist the acceptance of nursing informatics because of their lack of awareness. 
Roles Of Nurses In Informatics
According to Hersher18, Several current and future roles for nurses in informatics include:
User Liaison: A nurse in this role is involved in the installation of a computer information system and interfaces with the system vendor, the user and management of health care institutions
Product Manger: The nurse in this role is responsible for constantly updating a current product and keeping abreast of new developments in the field. They develop applications like decision support system nurse staffing system, scheduling system, bedside information and handling terminal cases
Clinical Systems Initiator: In this role the nurses work with the vendor who sold the computer systems to the healthcare institution. She/he helps train users of the system, serves as liaison between the healthcare institution and the vendor and works closely with the system coordinator for the healthcare institutions
Other roles of nurses in informatics could be inform of chief information officer, nursing informatics consultants, network administrator, data repository specialist, nursing informatics project manager, nursing informatics educator, clinical information liaison and nursing online programmers 23,6
In Nigeria, nursing informatics is a new specialty and therefore should cover major sectors of the health care system where nurse are working, these include the clinical, administrative, research and nursing education areas. These four areas interrelate to deliver evidence based nursing practice. The relevance of nurses in the four (4) areas are as highlighted below:-
Clinical practice
Provides a work schedule to remind staff of planned nursing actions
Electronic medical records and computer base patient record
Monitoring of devices that record vital signs and other measurement directly into the client/patient records.
Computer generated nursing care plan and critical pathway 
Automatic billing for supplies and procedures or procedures with nursing documentation
Reminders and prompts that appear during documentation to ensure comprehensive charting
Nursing Administration / Management
Automated staff scheduling
E-mail for improved communication among departments
Cost analysis and finding trends for budget proposals
Quality assurance and outcome analysis
Nursing Education
Computerized record keeping
Computerized assisted instruction
Interactive video technology (Telenursing)
Distance learning web based courses and degree programmes
 Teaching and presentations
Nursing Research
Computerized literature searching
Retrieval of evidence based nursing practice
The adoption of standardized language related to nursing terminologies
The ability to find data derived from large population groups statistical software
Adoption of Epi-info analysis
Use of knowledge based internet
Nursing Informatics Competencies
Nursing informatics has developed into a mandatory focus for all registered nurses on a global scale. Now, in the twenty-first century, official organizations, schools, and continuing education which help prepare nurses for engaging in informatics related practice are springing up all over the world especially in technologically advanced nations. There is however a growing need for practicing registered nurses, nurse educators, nurse researchers, nurse administrators and mangers to ensure that the expected competencies in informatics are met. Nurses certified in nursing informatics are skilled in the analysis, design, and implementation of information systems that support nursing in a variety of healthcare setting, functions as translators between nurse clinical and information technology personnel and ensure that information systems capture clinical nursing information.
Globe16 identify three levels of competencies as beginner entry or user level, intermediate or modifier level and advanced or innovator level of competency. Each of the three competency levels include both knowledge and skill required to use information and communication technologies to enter, retrieve and manipulate data; interpreter and organized data into information to affect nursing practice, and combine information to contribute for knowledge development in nursing. The expertise of these competencies is a continuum and include:
Technical competencies
Utility competencies
Leadership competencies
The Impact Of Nursing Informatics On The Health Care System
According to McGonigles and Mastrian,25 nursing informatics impacts the healthcare systems and the nursing profession in many ways, which includes:
Nursing informatics digitizes paper charting into interpretative electric charting hence decreasing documentation time which relieves nursing from writing on and handling of papers thus creating a paperless environment
Nursing informatics eliminates ambiguous of information, redundancy and tedious process of documentation
Nursing informatics reduce turnaround time. The turnaround time starts from the time a request is made to the time it is fully accomplished. For example, laboratory results can be sent directly to the nurses’ station with the use of an e-mail, so there is more time available to client care.
Nursing informatics impacts quality and cost of health care
Optimize information  management and communication among healthcare providers
Impacts Of Nursing Informatics On The Nursing Profession
Computer information systems prevent nurses from making medication errors
Computer order entry systems help nurses to interpret  prescriptions from physician in the management of a patient
There is better collaboration and sharing of patient information with other healthcare providers
Nursing perform better assessment and monitoring of patient disease and ailments
Helps nurses utilize research to provide evidence based care
Help nurses work faster, smarter and more competent
Creating A Supportive Environment For Nursing Informatics In Nigeria
Nurse Leadership
Leaders in nursing must play the role of advocates for nursing informatics. Advocacy is about influencing people, polices, practices, structures and systems in order to bring about change28. In advocating for nursing informatics, nurse leaders need to communicate early and concisely and to structure their message to fit both the situation and the intended audience (the intended audience could be nursing students or practicing nurses). Leaders should be comfortable in communicating in verbal, written, and electronic formats. Nurse leaders as advocates must be able to influence others to action. Influence is the ability to alter or sway an individual’ or groups’ thoughts, beliefs, or actions30; it is essential to the advocacy process. Influence is built on competence, credibility, and trustworthiness hence all nurse leaders in education, administration and even in practice should be computer literate and have basic competencies of nursing informatics for them to influence others5. Lastly, nurse leaders must establish positive, collaborative relationships with others to garner the support necessary to address the issue of nursing informatics. Collaboration is working with other individuals or groups for example doctors, laboratory technicians, and administrators etc to achieve a common goal31. Successful collaboration requires careful communication with the groups involved in the process, seeking input when appropriate, and providing ongoing reports related to progress on achieving the goal33.
The Nursing and Midwifery Council of Nigeria (NMCN)
This is the governing body of nursing in Nigeria which also has a part to play in making polices and developing a national informatics agenda for Nursing Education and practice that are geared towards improving nurses’ use of information and technology. These includes: An agenda to educate nursing students and practicing nurses in core informatics content, this can be done by ensuring that all nursing schools have well equipped and functional computer rooms with internet facilities that will help nursing students be competent in the use of computers and in the sourcing of information that will help improve patient care; enhancing nursing practice and education through informatics projects and support for increased nursing preparation in informatics through the use of collaborative programmes among public and private organizations (National nursing Informatics discussion paper, 2007)26.
Nursing education in Nigeria takes cognizance of the National Policy in developing sound educational principles which are essential to the preparation of nurses to function independently and/or as members of interdisciplinary and intersectoral teams. Hence there are so many programmes in the nursing education in Nigeria starting from the basic nursing programme, degree programmes (full time and part time), distant learning programmes, Open University few universities (like OAU, Ife, LAUTECH, Ogbmoso, ABU). Strategies for providing nursing informatics education within these programmes include; integrating nursing informatics into the curriculum or as programmes, make nursing informatics a specialty or elective for graduate programmes, have nursing informatics certificate program in formal continuing education for practicing nurses and could be a non credit/informal continuing education programme for nurse33. The need to adopt a culture in nursing that promotes acceptance and use of information technology has been identified as an important parallel initiative to establishing nursing informatics competencies and educational strategies, hence strategies for achieving nursing informatics competencies in the workplace include in-service training, internet ready modules for teaching and learning purposes, free access to online resources, and opportunities for continuing education.
Education units of hospitals should ensure a continuing education programme that includes training of nurses on the use of computers, their application programmes and sourcing information for research and application to patient care purposes5. Nurses need consistent training to feel comfortable with the use of information technology in their everyday practice. With the advent of computer technology use in nursing, the need for data to be analyzed and interpreted to become usable information in practice escalates with each passing year. In order to work with data, process information and derive knowledge, nurses must be able to apply synthesis and application to their practice. Therefore informatics competencies need to be developed in all three levels of expertise through basic and continuing nursing education programs4.
Nurses spend a significant proportion of their time on information related activities as part of clinical decision making in order to lead, co-ordinate and support the delivery of safe, effective, person centered care. In order to provide high quality care for patients, nurses need up-to-date, accurate, relevant information about the person and access to the latest evidence or best practice at the point of care delivery3. Hence, research in nursing is necessary for the development of nursing practice since nursing informatics is a new specialty. It is important that research be carried out on nursing informatics being applied in the nursing practice in Nigeria.
Nursing informatics attempts to manage the explosion of ever increasing medial information by managing and communicating information in order to promote knowledge in nursing practice for quality care. The ultimate goal of nursing informatics is to use technology to bring critical information to the point of care to increase efficiency and make healthcare safer and more effective. To provide for the advancement of nursing informatics as a specialty practicing nurses nursing students, nurse leaders and even the NANMM the Nursing And Midwifery Council of Nigeria must be committed to continuing education and professional development. Voluntary certification, self-governance; involvement in influencing healthcare polices and active participation in research efforts are required to contribute to the body of nursing informatics knowledge. However, much work is still needed to educate nurse on informatics competencies so that technology can be embraced as a tool in everyday practice
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