1. Practice Application
Chapter 20

2. Historical Perspectives
More than 150 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 patient-related data from hospital records.
The first hospital information systems arrived in late 1950’s to the mid 1960’s, although these systems focused primarily on processing financial and administrative information. In 1965, the American Hospital Association conferences for hospital administrators signaled the emerging move toward more clinical adaptations of such systems in healthcare. In the 1970’s, 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. By the 1980’s, the computer was being used for diverse hospital functions such as radiology, pharmacy, and laboratories. At this time, these emerged “ a strong drive within healthcare to understand how clinicians would use the new tools to advance practice”.

3. 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. The chapter specifically focuses on the degree to which technology has truly worked for nurses as they have collectively strived to assure that the voice of nursing- the unique language and contributions of nurses and the nursing process- is integrated into the field of healthcare informatics, and that computers are fully utilized in nursing practice to improve patient care.

4. Nursing Informatics: An Evolving Definition
According to the ANA, since 1980, nursing informatics has been defined broadly either with a focus on the technologic aspects, on the concept 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. In 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 the delivery of care”. A specialty that integrates nursing science, computer science, information science in identifying, 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 identifying and apply computer technologies to nursing.

5. Elements that are relevant to nursing informatics:
DATA, or the discrete entities that are described objectively without interpretations ;
INFORMATION, or data that are interpreted, organized or structured ;
KNOWLEDGE, or information that is synthesized so that relationships can be identified and formalized ;
NURSING SCIENCE, information and computer science ;
DECISION-MAKING, or the process of choosing among alternatives ;
INFORMATION TECHNOLOGY, which includes computer hardware, software, communication and network technologies derived primarily from computer science ;
INFORMATION STRUCTURE, which organize data, information, and knowledge for processing by computers ; and,
INFORMATION MANAGEMENT AND COMMUNICATION

6. Nursing informatics is a specialty that integrates 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 supports is accomplished through the use of information structures, information processes and information technology.
The goal of nursing informatics said ANA, is to improve the health of populations communities, families, and individuals by optimizing information management and communication. This includes using technology in the direct provision of care ; establishing administrative systems ; managing and delivering educational experience ; supporting life-long learning, and supporting nursing research

7. Informatics Competencies : Beginning to Experienced
ANA 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”.
Three Major Domains
Computer literacy skills : these are the basics computer skills needed to use a word processor ; access a database ; create a spreadsheet ; communicate with ; 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.
General informatics competencies : 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 patients ; analyzing and interpreting patient and nursing information.

8. Although competencies in informatics are critical for all nurses in practice, Kerfoot (2000) made a strong case for positioning technical intelligence (IQ) as a core competency for leaders. Kerfoot 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 “.

9. Problem Solving as an Organizing Framework
ANA suggests that this “ problem-solving framework supports all facets of informatics practice, including those without technology and all areas of nursing practice “.
The first standard assessment involves using data, information, and knowledge to clarify the presenting issue or problem. This process focuses on collecting data on different methodologies such as structured system and workflow analysis, and from a variety of source such as stakeholders who are close to the problem.
The second standard calls for identifying and evaluating possible solutions to information issues.
The third standard includes all activities related to the identification of an appropriate informatics solution and planning for its application.
Implementation is the fourth standard in which the informatics specialist acts as process consultant and project manager for all interventions an activities related to the informatics application.
Finally, the sixth standard sets forth criteria to be used as efficiency and effectiveness of decisions, plans, activities, and applications are evaluated.

10. 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 ( U.S. Department of Health and Human Services, 2001 ) on proposed strategies to build a national health infrastructure emphasized the need for all healthcare providers to be skilled in using technology for decision-making, while other reports expressed concerns that the healthcare industry was lagging behind other industries in implementing information systems.

11. Pattern of Underutilization
There are number of approaches for exploring the use and importance of information technology in nursing practice application. 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. The conducted a survey and showed and concluded that there were many gaps in information technology. Underutilization has also been noted in other sectors of the healthcare industry as well.

12. Nursing Documentation
Although this chapter focused on specific practice application, it would be incomplete without mention of the challenges, which lie in the area of nursing documentation, or the official recording of the essential applications of nursing practice. Nursing documentation in the patient record has become more complex as nursing practice has expanded to encompass care to critically ill and specialty patients, and as technologic advances have become standard of care in practice. In 1986, the ANA House of Delegates passed a resolution to promote the development of computerized nursing information systems in nursing services.

13. Care Planning
The computer-based patient record facilitates the automation of the nursing care planning process. The benefits and the challenges of integrating computerized systems with care planning have been extensively reported in the literature during the last decade. This research has focused on a wide range of topics related to the impact of computers on various aspects of nursing care such as contact time with patients, accuracy of documentation, charting time, transcription and medication errors, and communication between nurses and other healthcare professionals within a hospital.

14. Decision-making with Expert Systems
Broadly defined, the term clinical decision support system 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 include artificial intelligence (AI) expert systems, also known as knowledge-based systems, process knowledge while conventional software process data. expert systems solve problems by trial and error rather than using algorithms such as those used in convention programming. a successful expert system has the potential to capture and preserve expertise only if the procedural knowledge of experts can be articulated. A decision support or expert system can therefore guide, facilitate, and strengthen nursing decisions at the point of care. This might involve, detection and prevention of untoward clinical events such as drug interactions, errors, or omissions,, as well as trends in patient symptoms. Ultimately, the use of decision support system yields direct benefits for patients- prevention of suffering, symptoms, and death.

15. Outcomes 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.

16. Discharge Planning
Discharge care planning systems provide for continuity of care from the home to the hospital and back to the community, another care facility, an outpatient department, or the home. A typical discharge plan includes five components:
Summary of the admission assessments
Summary of the learning needs that the patient had at discharge
Multidisciplinary plan including problems still unresolved and outcomes not met during hospitalization
Medication and procedures that the patient must continue
Summary of selected patient outcomes that a multidisciplinary team desired as minimal criteria for the patient to have achieved during hospitalization

17. Healthcare Collaboration
Collaborations with the other member of the healthcare team has always been a critical component of nursing. 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.

18. Progress in Practice
The inevitable integration of computers into nursing practice has been accompanied by speculation, controversy, and research on the benefits, barriers, and real potential for improving clinical practice and giving nurses a voice in the development of healthcare policy. Analysis of nursing research provides evidence of Kurzxweil’s predictions about the accelerating transformation in computer technology. In the 1990’s, a major focus of informatics research in nursing was the comparison of nursing documentation at the nursing station. As these and other researchers studied factors such as ergonomic design, ease of use, elimination of redundant data, system support, availability and currency of data, and access to expert systems, there were some prescient voices in the nursing community who offered insights for the future that have now become a reality. Patterson had also predicted in 1995 that nursing homes would be “going electric” because the managed care environment was requiring electronic billing and patient records.. In 1996, Kasper had noted that personal digital assistant (PDA) technology offered portability, accessibility, and accuracy with a mobile medical record, which provided instant access to current patient charts in a wide variety of practice settings.

19. This allowed for patient records to be recorded instantly from remote settings and when nurses were at home and on call. With PDA’s, nurses and other healthcare providers could complete a patient record, send a prescription to a pharmacy, order follow-up clinical procedures, collect billing information, and access vast amounts of medical information. Yet, the excitement about advances in technology is tempered by concerns within the profession, as described earlier in this chapter, about patterns which show nurses’ underutilization of technology and problems with standardization of computer languages.