Practice Application

Submitted by:
Ompad, Samuel Jr. G.
Gomonit, Zarah Kay S.
Solon, Emily
Co, Elaine R.

Historical Perspectives
More than 50 years ago, Florence Nightingale spoke about the critical importance of nursing
informatics in patient care. Decision making must be based upon the use of accurate data, she said.
The nursing pioneer also spoke of frustration from the difficulties of extracting such critical patientrelated data from hospital records. It was more than a century after Florence Nightingales era that
computers made their appearance on the hospital landscape.
Late 1950s to the mid 1960s
The first hospital information system arrived, although these systems focused primarily on
processing financial and administrative information.
1965
The American Hospital Association conferences for hospital administrators signaled the
emerging move toward more clinical adaptations of such systems in healthcare.
1970s
The advent of the silicon chip allowed the focus to shift from one large supercomputer to
smaller personal computers that could be adapted for many different applications throughout
the hospital system.
1980s
The computer was being used for diverse hospital functions such as radiology, pharmacy, and
laboratories. At this time, there emerged a strong drive within healthcare to understand how
clinicians would use the new tools to advance practice.
1990s
Expanded uses of computers evolved as nurses in keeping with the traditions begun 100 years
before by Florence Nightingale, used computers to improve patient care and conduct research
by analyzing patient trends, variability in practice, and outcomes of care. Nursing informatics
at this time was characterized by concerns about accessibility, compatibility, and overall
integration of informatics efforts within nursing practice and the entire healthcare system.
Snyder- Halpern and Chervany (2000) suggest that success with informatics is not only foundational
but also key to survival in the modern day healthcare industry.
Carty (2001) described the contemporary system of healthcare as new terrain that is no longer
confined to hollowed halls of brick and mortar institutions. Instead, it has become a point and click
system with leveled boundaries that promotes unfettered public access to healthcare information and
untraditional communication between providers and patients. It is in this new point and click system
that contemporary nurses, in order to practice their profession, must build new competencies that
reflect the digital era of healthcare.
Zytkowski (2003) explained that such competencies are needed because nursing informatics is
foundational to all areas of nursing practice.

Nursing Informatics: An Evolving Definition

One view of the changing nature of technology use in nursing practice can be seen through the
evolving definition of nursing informatics. According to the ANA (2001), since 1980, nursing informatics
has been defined broadly either with a focus on the technologic aspects, on the concepts of nurses
interacting with technology to produce greater knowledge, or on the role of nurses who specialized in
developing applications of technology to nursing practice.
1989
Graves and Corcoran set forth what had become the most widely accepted definition of
nursing informatics as a combination of nursing science, information science, and computer
science to manage and process nursing data, information, and knowledge to support the
practice of nursing and delivery of nursing care.
1992
ANAs Council on Computer Application in Nursing published a new definition of nursing
informatics wherein the expanding role of the informatics nurse specialist was incorporated.
A specialty that integrates nursing science, computer science, and information science in
indentifying, collecting, processing and managing data and information to support nursing

practice, administration, education, and research; and to expand nursing knowledge. The
purpose of nursing informatics is to analyze information requirements; design, implement and
evaluate information systems and data structures that support nursing, and identify and apply
computer technologies to nursing.
1994
The ANA again revised this definition by replacing specifics about the systems life cycle with a
more general description of nursing informatics which suggested that:
Nursing informatics supports the practice of nursing specialties in all sites and settings
whether at the basic or advanced levels. The practice includes the development of
applications, tools, processes and structures that assist nurses with management of data in
taking care of patients or in supporting their practice of nursing.
Although these definitions reflect various aspects of computer use in nursing, they did not
acknowledge and incorporate what the ANA describes as the phenomena of nursing- the nurse,
patient, health, and the environment- in combination with the other critical elements which are
relevant to nursing informatics: data; information; knowledge; nursing science, information science
and computer science; decision making; information technology; information structures; and
information management and communication. These diverse elements are involved in the dynamic
process by which nurses use computers to make sound database and content- specific decisions
about patient care.
2001
ANA suggested that historical definitions underemphasized the role of the patient in
informatics and participatory decision making, neglected the importance of both context and
information and communication, and focused too narrowly on data and information within
nurses decision making. Thus, ANA Scope and Standards of Nursing informatics offered the
newest definition.
Nursing informatics is a specialty that integrated nursing science, computer science, and
information science to manage and communicate data, information, and knowledge in nursing
practice. Nursing informatics facilitates the integration of data, information and knowledge to
support patients, nurses and other providers in their decision making in all roles and settings.
This support is accomplished through the use if information structures, information processes
and information technology.
The goal of nursing informatics, said the ANA, is to:
Improve the health of populations, communities, families, and individuals by optimizing
information management and communication. This includes using in the direct provision of
care; establishing administrative systems; managing and delivering educational experiences;
supporting life-long learning, and supporting nursing research.
This description of nursing informatics reflects the key tenets of contemporary nursing
informatics which, as identifies by the ANA, include:
Clinical and non-clinical aspects of practice
Importance of human factors in decision making
Focus on delivering the right information to the right person at the right time
Central emphasis on the improvement of the equality of patient care, welfare of the
health care sonsumer, and patient outcomes
Importance of collaboration with other areas within health informatics
1997
The National Advisory Council on Nursing Education and Practice differentiated nursing
informatics from the broader category of healthcare informatics. They suggested that the
general field of health care informatics included:
Identifying information to collect and process
Creating databases
Developing user-friendly data entry and retrieval screens
Educating users to work with and maximize available information resources
Installing and maintaining hospital information system
Developing distance education and telehealth system for information exchange
Further, the council suggested that nursing augmented health informatics by:
Bringing specific values and beliefs
Bringing a specific practice base that produces unique knowledge
Focusing attention on specific phenomenon
Providing a unique language and word context
2001
A similar theme within the contemporary literature on nursing informatics was set forth by the
ANA standards. The ANA stated, Nursing informatics is a distinct area of specialty practice
within nursing- it has a unique body of knowledge, formal preparation within the specialty, and
identifiable techniques and methods. Although nursing informatics shares many elements and
commonalities with other informatics specialties, there are unique dimensions of informatics
used by nursing in practice today.

Meadows (2002)- According to him, voices arises from nurses as they participate in a process of using
clinical information system to analyze data and information; exploring and understand the
informational and cognitive foundations specific to nursing; developing nursing wisdom; and then
applying this to affect patient care.
Abbot (2003)- The greatest struggle in nursing informatics is in the representation of nursing in a
language that a computer can use. Nurses in general have not understood what is as stake with this
nursing naming fame for computerized medical record system. This lack of understanding has been
costly to nursing as a whole.

Nursing Documentation
In the beginning of the first decade of the new century, nursing documentation rests at an
interesting and challenging intersection of history and technology
1986 ANA House of Delegates passed a resolution to promote the development of computerized
nursing information systems (NIS) in nursing services
1989 Steering Committee on Databases to support Clinical Nursing Practice was established
1992 ANA House of Delegates passed another resolution
1998 Steering Committee on databases to support Clinical Nursing Practice was renamed the
Committee for Nursing Practice Information Infrastructure
Simpson (2003) echoed the chorus of concerns from others in the nursing literature about the
standardized structures for the computerized documentation of nursing.
There are now 13 standardized languages at the turn of the century which speak what nurses do.

Care Planning
The computer based patient record facilitates the automation of nursing care planning
process.
The ability to electronically record, integrate, and analyze data and information enables nurses to
quickly move to the synthesis of nursing knowledge and the development of nursing wisdom, which
they can then apply to patient care (Meadows, 2002)

Decision Making with Administrative Data

The desirability of cost containment in healthcare was the driving force behind the
development of CLASSICA, a new Norwegian decision support focused on financial management,
resource allocation, activity planning, and budgetary monitoring and control.
The core components of this system contain a wealth of data about patient flow and activity,
staffing, the cost of nursing care at the nursing unit level, and relationships between costs and
services.
The goal of improved resource management with a model like the CLASSICA system can only
be realized when implementation of the system is paired with parallel financial management training
for the nurse managers.

Decision Making with Expert Systems

The term clinical decision support system (CDSS) includes an array of computer based
applications that assist healthcare clinicians in the day to day work of patient care. These may
include programs that involve programs that involve artificial intelligence.
Expert systems, also known as knowledge based systems, process knowledge while
conventional software process data.
Two types of AI - expert systems and machine learning have been used to aid decisionmaking in nursing. Expert systems solve problems by trial and error rather than using algorithms such
as those used in convention programming. Machine learning systems have been as a branch of AI
concerned with construction of programs that learn from experience.
Nursing documentation systems that incorporate expert systems and AI offer nurses a valuable
resource the ability to improve clinical decision making at the point of care in real time. This labor
saving feature substitutes retrospectives and labor intensive analysis with trend analysis.
The use of decision support system yields direct benefits for patient and for the entire
healthcare industry in the form of reduced healthcare expenses from saved labor costs and fewer
adverse events.
Lyons and Richardson point out that a CDSS may contain either synchronous or asynchronous
alerting systems. Synchronous alerting occurs when an order entry is entered into a computerized
order entry system. Order processing takes place under the watchful surveillance of an inference
engine that acts when predetermined conditions are met. Asynchronous alerting provides clinicians
with important but delayed feedback which is gleaned as the expert system combs through multiple
databases. This type of system has advantages in that it can send messages via a number of
modalities to specific individual clinicians or multiple clinicians. An additional advantage of
asynchronous alerting is its capacity to detect adverse events that occur over time.
Kosko has also suggested that innovations in what he calls fuzzy thinking concepts without
exact border and computer technology which mimics the organization of neutral networks used by

our brains as an operating platform will bring new and even more revolutionary systems to healthcare.
These will include synchronous language translation systems and even more expert diagnostic
systems.

Outcome Management
A look at outcomes management provides a powerful illustration of how nurses use informatics
in daily practice to evaluate the relationship between patient goal attainment and nursing
interventions. Since 1898, there has been an emphasis on outcomes management in
healthcare as a result of new legislation and the efforts of the Joint Commission on
Accreditation of Healthcare Organizations. From a theoretical standpoint, outcomes are viewed
as beneficial in healthcare while the implementation of appropriate nursing interventions are
viewed as quality patient care. (Larrabee,1996; Mize Bentley, and Hubbard, 1991). The
outcomes of healthcare, i.e., both the short- and long-term results of a treatment or clinical
approach, should be monitored so that the nursing profession and the healthcare industry can
determine and implement the best practices in healthcare (Aller, 1996; Wojner and Kite-Powell,
1997). Outcomes can include factors such as increased client satisfaction, decreased hospital
admissions and ER visits, decreased costs and acuity of hospital stay, decreased morbidity and
mortality, minimized hospital revenue loss, increased job satisfaction for nurses, and
decreased job stress. Martin (1999) and Martin and Scheet (1995) have written extensively
about the 20 year development of the Omaha system, with its problem rating scheme for
outcomes. The outcomes capability of the system serves as a method for documentation and
as a guide for nursing practice. The rating system was designed to measure problem-specific
knowledge, behaviour, and status throughout the time of service.
Problem Rating Scale for Outcomes: The Omaha System

Concepts
Knowledge:
Ability of the client to
remember and interpret
information

No knowledge Minimal
knowledge

Behavior:
Not
Observable responses, actions, appropriate
or activities of the client fitting behavior
the occasion or purpose
Status:
Condition of the client in
relation to objective and
subjective defining
characteristics

Rarely
appropriate
behavior

Extreme signs/ Severe signs/

symptoms
symptoms

Basic knowledge

Adequate
knowledge

Superior
knowledge

Inconsistently
appropriate
behavior

Usually
appropriate
behavior

Consistently
appropriate
behavior

Moderate signs/
symptoms

Minimal signs/ No signs/

symptoms
symptoms

Martin stated: when establishing the initial ratings for client problems, the nurse creates an
independent data baseline, capturing the condition and circumstances of a client at a given
point in time. This admission baseline is used to compare and contrast the clients condition
and circumstances with ratings completed at later intervals and at client dismissal. The
comparison or change in ratings over time can be used to assess client progress in relation to
nursing intervention and thus judge the effectiveness of the plan of care.
Data are used both for individual care planning and for aggregate analysis. Such analyses are
used to interface with other components of an instructions informatic systems, and to
evaluate the impact of patient care services, meet accreditation requirements, complete
reports for third party payers, plan new programs, and ultimately advance progress in nursing.

In a 2000 study, Johnson and Nolan reviewed three systems that can be used for managing
patient outcome data: traditional manual data entry, automated data entry scanning system,
and a handheld device. Their findings suggest that in this period, when entire institutions are
searching for integrated options for efficient and effective outcomes management, they may
be wise to use interim approaches that integrate handheld devices with traditional data entry
scanning systems.
According to Simpson (2003b), in order to effectively monitor outcomes, an organization must
adapt one of the key tenets of CQI and TQM make quality decisions up front so there are
quality outcome data at the end. Despite their limitations, information systems are still the
best solutions for collecting, aggregating and creating information from data (p355). Simpson
concluded: with outcome measurement, nursing can become visible. The operative word here
is can without nursing specific taxonomies and nomenclatures, there can be no nursingspecific measures. And the result of that is continued invisibility. (p355)

Healthcare Collaboration
Collaboration with other members of the healthcare team has always been a critical
component of nursing. Advances in technology, however, have changed the ways in which
members of interdisciplinary healthcare teams are and will be communicating with each other
in the digital world of healthcare in new millennium. As Alpay and Russell (2002) have
suggested, the use of IT is part of the development and delivery of health services (p136).
As primary caregivers at the bedside, nurses typically carry out the nursing process by
interacting in person, writing or telephone with a wide variety of healthcare professionals to
share information and decision-making focused on improving patient care outcomes. Typically
these interactions include sharing of information, networking, consulting, and supporting. As
Miller and Carlton suggested in 1998, this communication is communication in constant
change sparked by the growing availability of telecommunication applications that allow both
asynchronous and synchronous interaction.
Miller and Carltons predictions that future healthcare practitioners such as nurses would be
active participants in collaboratively matching the wide range of telecommunications tools to
the health care application need have become the reality for many healthcare systems in the
first years of the new century.

Standards for Practice

The new standards (ANA, 2001) built on the previous scope and standards of practice published by the ANA
Task Force to Develop Measurement Criteria for Standards for Nursing Informatics (ANA, 1995). They have documented
the evolving definition of nursing informatics that parallels the rapid evolution of informatics in healthcare. The new
standards repeatedly emphasize the central role that information plays in the practice of nursing and the importance
of all nurses, beyond those who specialize in nursing informatics to develop their skills in managing and
communicating information. Nurses outside nursing informatics are focused on the content of information while nurse
specialists in information for decision-making by nurses. It also describes that emphasis lies in nurses focus on using
information technology and application rather than the focus of nursing informatics specialists who seeks to optimize
structures, applications and technology for use in patient care settings.

The foci of nursing

vs. nursing
informatics metastructures,
concepts and tools

NURSING

NURSING.

INFORMATICS

Nurses, patients,
health,
environment

Nursing data,
information and
knowledge

Content of Information

Design structure and

presentation of information
for nurses decision making

Using information
applications and
technology

Optimizing information structures,

applications and technology for use
in managing and communicating
data, information and knowledge

Informatics Competencies: Beginning to Experience

In then new 2001 standards of practice, the ANA makes a definitive statement about informatics competencies needed
in the nursing practice today. It stated, Informatics competencies are needed by all nurses whether or not they
specialize in nursing informatics. As nursing settings become ubiquitous computing environments, all nurses must be
both information and computer literate.

Scope and Depth of Competencies

Computer literacy skills

These are the basic computer skills needed to use a word processor, access a database, create a spreadsheet,
communicate with e-mails and interact with clinical documentation systems.

Information literacy skills

These include the ability to recognize the need for information and the skill to access evaluate and interpret
information correctly. According to the Association of Colleges and Research Libraries (ACRL), information
literacy includes determining the extent of information needed, accessing that information efficiently and
effectively, evaluating the information and its sources critically, incorporating the information into ones own
knowledge base, using information to accomplish a designated purpose, understanding the economic, legal
and social issues involved with the use of information and ultimately using information in ethical and legal
ways.
General information skills
These basic skills are required for all nurses but are not sufficient for specialists: identifying, collecting and
recording data relevant to the nursing care of the patients, analyzing and interpreting patient and nursing
information, using applications of informatics as an integral part of the nursing process and implementing
institutional and public policies regarding privacy, confidentiality and security information.

Within, the general nursing category, nurses who are most experienced must be highly skilled in information
management and communication. According to Staggers, Gassert and Curran, these nurses should be able to see
relationships among data elements, make judgments based on trends and patterns within the data, use current
informatics solutions and also collaborate with the informatics nurse specialists. In addition, experienced nurses must
be able to use system applications to manage data, information and knowledge within their particular specialty area,
participate as a content expert to evaluate information and assist others in developing information structures and
systems to support the area of practice, actively participate in efforts to improve information management and
communication, promote the integrity and access to information related to confidentiality, legality, ethical and security
issues, and serve as a leader in incorporating innovations and informatics concepts into their area of specialty.
Kerfoot (2000) made a strong case for positioning technical intelligence (IQ) as a core competency for leaders.
He described technical IQ as not only knowing about specific functioning of technology but also the interrelatedness
between the technology, people and systems that interact with this technology and how this translates into
outcomes.

Problem Solving as an Organizing Framework

According to the ANA (2001), the informatics nurse specialist moves beyond the foundational competencies and into a
practice specialty in which there are organized and recognized standards of practice and performance standards.
These standards include six major areas that mirror the traditional nursing process. They suggests that this problemsolving framework supports all facets of informatics practice, including those without technology and all areas of
nursing practice.

ASSESSMENT

DIAGNOSIS

Nursing
informatics
standards of
practice: The
problem
solving
framework

IDENTIFICATION
OF OUTCOME

PLANNING

IMPLEMENTATIO
N

EVALUATION

Assessment. It involves using data, information and knowledge to clarify the presenting issue or problem.
This process focuses on collecting data with different methodologies such as structured system and workflow analysis,
and from a variety of sources such as stakeholders who are close to the problem.
Diagnosis and Identification of Outcome. This calls for identifying and evaluating possible solutions to
information issues. This includes developing functional and technical specifications based on identified needs,
designing new models for informatics solutions, considering costs and return on investment of informatics solutions,
identifying measurable outcomes and terminal objectives and advocating for informatics solutions with key
stakeholders.
Planning. This includes all activities related to the identification of an appropriate informatics solution and
planning for its application. It is in this stage that the informatics specialist skillfully matches the capabilities and
limitations of hardware and software.
Implementation. In this process the informatics specialist acts as a process consultant and project manager
for all interventions and activities related to the informatics application.
Evaluation. This sets forth criteria to be used as the efficiency and effectiveness of decisions, plans, activities
and applications are evaluated. This ongoing process serves as a means of not only evaluating the structure, process
and outcome of the informatics solution, but also the net effects of the informatics solution on nursing practice.

Information Technology and the Actual Work of Nurses

At the beginning of the new century, much was written about the reality that information technology had become
important in the delivery of contemporary healthcare. A federal report on proposed strategies to build a national
health infrastructure emphasized the need for all healthcare providers to be skilled in using technology for decisionmaking, while other reports expressed concerns that the healthcare industry was lagging behind other industries in
implementing information systems. Depiction of nursing profession in the twenty-first century that computer
technology needed to be part of professional nursing practice which was later on confirmed by the ANA 2001 when the
revised Scope and Standards of Nursing Informatics Practice was published.

A Pattern of Underutilization
There are number of approaches for exploring the use and importance of information technology in nursing practice
applications. These include directly documenting the actual use of information technology tools and more indirectly,
through assessing specific information technology content areas taught in nursing schools.
Surveys were conducted and were designed to determine the perceived current and future uses of information
technology by practicing nurses, specific information technology knowledge and computing skills currently being
taught in American nursing schools and the extent to which faculty members were prepared to teach this knowledge
and these skills. The researchers concluded that the nurses had a high level of awareness of potential uses for IT and
they had concerns about the lack of computer training to harness this potential. The ability to use IT was affected by
the lack of practical knowledge in basic computer skills and lack of available knowledge about the adaptability of the
software.
Underutilization has also been noted in other sectors of the industry as well. Thus, it appears that the successful
integration of automated information systems in healthcare is seen as both a goal to be attained and as a survival
strategy in the regulated healthcare environment of today.