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Future of Nursing
How the nursing profession should adapt for a digital future, richard g booth.
1 Arthur Labatt Family School of Nursing, Western University, London, Canada
Gillian Strudwick
2 Centre for Addiction and Mental Health, Toronto, Canada
Susan McBride
3 School of Nursing, Texas Tech University Health Sciences Center, Lubbock, USA
Siobhán O’Connor
4 School of Health in Social Science, University of Edinburgh, Edinburgh, UK
Ana Laura Solano López
5 University of Costa Rica, San José, Costa Rica
Transformation into a digitally enabled profession will maximize the benefits to patient care, write Richard Booth and colleagues
Digital technologies increasingly affect nursing globally. Examples include the growing presence of artificial intelligence (AI) and robotic systems; society’s reliance on mobile, internet, and social media; and increasing dependence on telehealth and other virtual models of care, particularly in response to the covid-19 pandemic.
Despite substantial advances to date, challenges in nursing’s use of digital technology persist. A perennial concern is that nurses have generally not kept pace with rapid changes in digital technologies and their impact on society. This limits the potential benefits they bring to nursing practice and patient care. To respond to these challenges and prepare for the future, nursing must begin immediate transformation into a digitally enabled profession that can respond to the complex global challenges facing health systems and society.
Many exemplars show how digital technologies already bring benefit to nursing practice and education. 1 For instance, telehealth programs where nurses provide daily monitoring, coaching, and triage of patients with several chronic diseases have helped reduce emergency department admissions. 2 Mobile devices, in particular smartphones and health applications, are enabling nurses to offer remote advice on pain management to adolescent patients with cancer 3 4 and supplement aspects of nursing education by providing innovative pedagogical solutions for content delivery and remote learning opportunities. 5
The development and application to nursing of systems based on AI are still in their infancy. But preliminary evidence suggests virtual chatbots could play a part in streamlining communication with patients, and robots could increase the emotional and social support patients receive from nurses, while acknowledging inherent challenges such as data privacy, ethics, and cost effectiveness. 6
Challenges persist
Digital technologies may, however, be viewed as a distraction from, or an unwelcome intrusion into, the hands-on caring role and therapeutic relationships that nurses have with patients and families. 7 This purported incompatibility with traditional nursing ideals, such as compassionate care, may explain some nurses’ reluctance to adopt digital approaches to healthcare. 8 9 In addition, nursing’s history was as structurally subordinate to other healthcare disciplines, 10 and the profession is still cementing its relationship and leadership in health systems.
The specialty of nursing informatics has long advocated for the integration of technology to support the profession, but it has comparatively few practitioners globally. Nursing informaticians are predominantly based in the United States, where the discipline seems to have originated, but many other countries and regions are expanding their digital nursing workforce and involvement with informatics. 11 12
Slow progress in some areas has been due to a lack of leadership and investment that supports nurses to champion and lead digital health initiatives. Globally, uncertainty remains regarding the next steps the nursing profession should take to increase and optimize its use of digital technology. This challenge is exacerbated by the global diversity of the profession, including unequal access to resources such as technological infrastructure maturity and expertise. Huge differences exist among countries and regions of the world in terms of the digitalization of healthcare processes, access to internet connectivity, and transparency of health information processes.
Selected technologies: benefits and challenges
The nursing literature contains many analyses of digital technologies used to support or extend the profession, including practice (eg, hospital information systems, electronic health records, monitoring systems, decision support, telehealth); education (eg, e-Learning, virtual reality, serious games); and, rehabilitative and personalized healthcare approaches (eg, assistive devices sensors, ambient assisted living). 1 T able 1 summarizes the potential benefits, challenges, and implications of emerging innovations to practice.
Benefits, challenges, and implications of selected digital technologies in nursing
The table is not exhaustive, but the diversity of topics researched shows the profession recognizes the value and challenges of digital technologies. Given the evidence, for the profession to make further progress we recommend five areas for focused and immediate action. These recommendations should be qualified in light of regional context and professional background owing to global heterogeneity in nursing and the inclusion of digital technologies into healthcare.
Reform nursing education
We must urgently create educational opportunities at undergraduate and graduate levels in informatics, digital health, co-design, implementation science, and data science. 39 These should include opportunities to work with and learn from computing, engineering, and other interdisciplinary colleagues. For instance, nursing will need a critical mass of practitioners who understand how to use data science to inform the creation of nursing knowledge to support practice. 40 These practitioners will also need savviness and courage to lead the development of new models of patient care enabled by digital technologies. 41 42
Determining how, where, and why technology like AI should be used to support practice is of immediate interest and a growing competency requirement in health sciences and informatics education. 43 Nursing education should evolve its competencies and curriculums proactively for the increasing use of digital technologies in all areas of practice 39 while incorporating novel pedagogical approaches—for example, immersive technologies such as virtual and augmented reality—to deliver aspects of simulation based education. 44 45
Recently, the American Association of Colleges of Nursing released core competencies for nursing education, explicitly identifying informatics, social media, and emergent technologies and their impact on decision making and quality as critical to professional practice. 46
Build nursing leadership in digital health
All levels of nursing leadership must advocate more actively for, and invest resources in, a profession that is both complemented and extended by digital technology. The profession needs to evolve its use of digital technology by continuing to champion and support nurses to become knowledgeable in, and generate new scientific knowledge on, data analytics, virtual models of care, and the co-design of digital solutions with patients, differences across contexts and regions permitting.
Advancement of leadership competencies in existing informatics technologies, such as clinical decision support systems, electronic health records, and mobile technologies, is also essential: these kinds of systems will undoubtedly come with increasing levels of AI functionality. Possessing a critical mass of nursing leaders who understand the intended and unintended consequences as well as opportunities of these kinds of technologies is vital to ensure the quality and safety of nursing.
The increasing presence and recognition of the importance of chief nursing informatics officers is a step in the right direction. 47 Further, providing opportunities for nurses of all specialties to contribute to the development and implementation of digital health policies, locally and nationally, could increase future use of digital technologies in nursing.
Investigate artificial intelligence in nursing practice
The influence of AI on human decision making and labor are areas in need of immediate inquiry to support nursing practice for the next decade and beyond. AI technologies could provide the profession with huge benefits in data analytics and advanced clinical decision support.
Although many of the purported potential benefits of AI (eg, improved patient outcomes, streamlined workflow, improved efficiency) have yet to be fully shown in nursing research, 6 it is inevitable that AI technologies will be used more regularly to support and extend nurses’ cognitive, decision making, and potentially labor functions. 15
These opportunities bring new and dynamic practice considerations for nursing and interprofessional expertise. One example relates to the potential automation of inequity and injustice within systems and decision support tools containing AI 48 49 : self-evolving algorithms in systems sometimes unintentionally reinforce systemic inequities found in society.
Increased use of AI also brings novel policy, regulatory, legal, and ethical implications to the fore. The nursing profession must examine its role, processes, and knowledge against emerging ethical frameworks that explore the opportunities and risks that AI and similar innovations bring, while advocating for patient involvement in AI development and application. Floridi and colleagues offer tenets regarding AI development and the ethical considerations in using such innovations in their call to develop AI technology that “secures people’s trust, serves the public interest, and strengthens shared social responsibility.” 50 They also advocate that as guiding principles, AI should be used to enhance human agency, increase societal capacities, cultivate societal cohesion, and enable human self-realization, with an emphasis on instilling and reinforcing human dignity. 50 Further research, funding, and thought leadership in this domain are needed to help support the development of new practice policy, regulatory frameworks, and ethical guidelines to guide nursing practice.
Re-envision nurse-patient relationships
The profession must reframe how nurses interact with and care for patients in a digital world. The sheer variety of “do-it-yourself” health and wellness applications (eg, personalized genetic testing services, virtual mental health support), mobile and social media applications (eg, mHealth, wearables, online communities of practice) and other virtual healthcare (eg, telemedicine, virtual consultations) options available to consumers is impressive.
All this may seem antithetical toward the traditionally espoused nursing role—therapeutic relationships in physical interactions—but patients are increasingly empowered, connected to the internet, and demanding personalized or self-management healthcare models that fit their busy and varied lifestyles.
To maximize its impact on patient care, the profession should continue to develop virtual care modalities that exploit internet and mobile technology, drawing on its experiences with telehealth and remote models of care. 51 These care models might also be extended through virtual or augmented reality technologies or integrated with assisted living or “smart home” systems, 52 and potentially other precision and personalized healthcare solutions that leverage genomic and other biometric data.
Care approaches, interpretations of privacy, and technological interoperability functionalities should be co-designed among the interprofessional healthcare team, patients, and carers 53 and available where patients want them, ideally in both physical and digital realms. Deeper discussions and scientific research regarding access, cost, electronic resource use or wastage, and equity implications of the increasing digitalization of nurse-patient relationships will also need to be thoroughly explored.
Embrace digital practice
The profession requires a cultural shift. Its membership and leadership must demand the evolution of digital systems better to meet contemporary and emerging needs.
Too often, technology to support nursing is poorly configured, resourced, or not upgraded to respond to practice and societal trends. Nurses still commonly use practice systems that are lacking basic usability (eg, contributing to alert fatigue, reinforcing disruptive workflow processes) or generate added documentation burdens because of poor configuration and optimization. 54
There is huge variation globally in access to, integration of, and sustainability of digital technology. 55 56 57 Solutions vary and are context specific. Renewed awareness of digital technology’s use brought about by the covid-19 pandemic offers an impetus for change that nurses should embrace.
Tasks undertaken by nurses that do not add enough value to patient care present opportunities for partial or full divestment, 58 and may be better integrated into future technology enabled processes or delivered by other care providers.
The profession should revisit cultural interpretations of how technology such as drones, robots, and other AI enabled systems can be considered complementary to nursing practice and process, rather than as competition or adversaries. Collaboration with technology developers, providers, and patients will be essential to ensure success.
Although some outdated nursing activities and processes made redundant or less relevant will likely be missed by some in the profession, digital technology provides opportunities to support new models of care and approaches to nursing practice. We must not allow cultural and historical interpretations of nursing to upend or impede progress.
How nursing can stay relevant
Nurses entering the profession today will undoubtedly witness substantive disruption and change from digital technology by the time they are mid-career. 59 Without immediate action, the nursing profession stands to miss a remarkable opportunity to generate new roles, knowledge, and relationships within future health systems and societies saturated by digital technologies.
Nursing will continue to offer value and importance to healthcare systems in the coming decades. However, the profession must consider its role, knowledge, and relationships with technologies and patients to remain relevant in digitally enabled societies and healthcare systems and continue to provide compassionate care in a digital world. Without proactive strategic self-reflection, planning, and action, nursing will fail to control its trajectory across the chasm separating the past, present, and future of practice.
Key recommendations
- Nursing must accelerate the transformation to a digitally enabled profession by investing in informatics education, research, and practice
- Nurses should upskill in data science and other digital health topics to ensure emerging technologies such as AI are developed appropriately and safe for nursing practice and patient care
- Nursing must invest in and lead digital health developments and collaborate with others to develop and deliver digital tools that patients and the public need
- Nurses should champion informatics across all areas of professional practice, create leadership opportunities in digital health, and inform health policy in this area
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.
This article is part of a series commissioned by The BMJ for the World Innovation Summit for Health (WISH). The BMJ peer reviewed, edited, and made the decision to publish. The series, including open access fees, is funded by WISH.
Nursing Informatics as Caring: A Literature Review
Citation: Webb, N. (2021 Nursing Informatics as Caring: A Literature Review. Online Journal of Nursing Informatics (OJNI), 25 (1). https://www.himss.org/resources/online-journal-nursing-informatics
Despite some societal influencers sounding the alarm on the malevolence of big data, the evidence shows that nursing informatics is one of the best hopes for healthcare in terms of keeping patients safe and doing no harm. Locsin's theoretical framework (2017) demonstrates that technology can peacefully coexist with nursing and is perhaps necessary for the profession to move forward and be truly integrated. Nurse leaders who are trained and can demonstrate informatics competencies are in a position to track, trend, and prevent patient harm from occurring, which will not only benefit patient outcomes but also prevent reduced federal healthcare reimbursement penalties and reduce litigation exposure.
Introduction and Background
On a recent trip to Oregon, the author, who loves reading books almost as much as nursing practice, visited the world’s largest bookstore. Housing more than two million tomes within its many shelves, a plethora of precious pieces of prose on printed parchment were procured. One particular work entitled “Weapons of Math Destruction: How Big Data Increases Inequality and Threatens Democracy” (2016) by Dr. Cathy O’Neil, was an impulse buy on the way to the register which turned out to be quite a thought-provoking text that was consumed in just one sitting.
In her text, O’Neil (a statistician who completed graduate studies in mathematics at Harvard) examined some of the pitfalls of utilizing big data (in this text, the terms informatics, and big data may be used interchangeably). “Big data processes codify the past” and “do not invent the future” (p. 204). She argued that for data to shape the future, it must have moral imagination, which must be facilitated by humans. She also stated that we “have to explicitly embed better values into our algorithms, creating big data models that follow our ethical lead" (p.204) which might entail putting fairness ahead of profit. O'Neil acknowledged the power of algorithms and big data but chose instead to focus on those instances where big data was not used responsibly. Perhaps part of the reason that the examples she provided turned out the way they did was that there was no harmony between (caring) humans and the technology. In the nursing profession, there must be a connection between the human element of caring and technology, which is used to help deliver nursing care.
Failure to use informatics constitutes a deficiency in care
The United States federal government’s efforts to improve quality care outcomes through the Centers for Medicare & Medicaid Services’ (CMS) Meaningful Use and Value-Based Purchasing means that healthcare organizations that do not reduce patient harm and improve the health and outcomes of their patients put themselves at risk. McCarty (2016) reported that more than fifty-percent of eligible professionals faced penalties under Meaningful Use in 2015 totaling $200 million in federal government reimbursement reductions. Failure to adopt EHRs and informatics reporting can result in reduced reimbursements from CMS, which can hurt an organization's bottom line. Impacts on a healthcare organization's bottom line may impact its ability to care for patients in the local community. If penalties are steep enough, they could theoretically put a healthcare organization out of business. For these reasons, nurse leaders need to embrace nursing informatics.
Nursing informatics can be used not only to track and trend data associated with quality outcomes associated with CMS Meaningful Use Requirements, but technology has advanced to the point where patients most likely to be at risk for harm can be identified early on in their hospital admissions. Kipnis and colleagues (2016) examined the efficacy of using an EMR to develop an automated Early Warning System (EWS) to predict patient deterioration in patients outside of the ICU and found that it had better sensitivity at predicting deterioration than traditional EWS’s. Utilizing such systems would not only help identify patients at risk earlier, helping them avoid more acute illness or injury, but it would also help increase Meaningful Use reimbursement from CMS. It would be a different situation if nurse leaders had no control over the outcomes, but we do have the ability to influence outcomes significantly using nursing informatics. Positively influencing patient outcomes can be a form of caring.
Theoretical framework
Through Locsin (2017), we find an evidence-based theoretical model where technology can peacefully coexist and thrive with the caring aspects of nursing. Concepts such as technology, which may not historically be looked at as being of a caring nature, have a place in the realm of nursing. Locsin asserted there are a series of five assumptions that allow technology to coexist and thrive in nursing peacefully . These include that people fundamentally care by virtue of their humanness; that the ideal of wholeness is a perspective of the unit; that knowing people occurs through a multidimensional process; incorporation of both health and technology are components of caring, and that nursing is fundamentally a discipline and a professional practice . It is Locsin's fourth assumption, that incorporation of both health and technology are components of caring, that is central to the author’s assertion that informatics can be used for the greater good, particularly for patient care. Locsin’s assumptions are summarized in Figure 1, below.
Locsin’s Five Assumptions Structure of the Theory of Technological Competency as Caring in Nursing
Nursing icon Jean Watson famously said that “Caring is the essence of nursing ” (1999, p. 33). There is nothing more fundamental to nursing than the ability of nurses to care for the sick, the tired, and the forgotten. How, then, do nursing informaticists care for their patients? Can informatics be used to care for the sick? Informatics can allow nurse leaders to champion and support initiatives that reduce harm, keep patients safe, improve quality outcomes, and decrease the amount of time patients spend in a hospital.
Nursing may not be the first profession one thinks of when speaking about technology. However, if nurse leaders are going to be successful in helping nursing become a truly integrated profession that is separate from medicine, they must learn how to navigate toward the intersection of caring and technology. This needs to change because if nursing leaders do not define the parameters of success and failure within their profession when it comes to quality outcomes, they will be defined by outside stakeholders (such as physicians, for example). Nurse leaders must be able to speak in terms that interdisciplinary teams like medicine, pharmacy, and finance can understand and respect. Nurses are already known for their exemplary ability to care and must also be renowned for their power to influence patient care outcomes through informatics. Big data and nursing informatics, therefore, is not the problem but instead a novel solution.
Literature Review
A literature review was conducted on over forty scholarly peer-reviewed journal articles, with thirteen eventually being selected. Search terms included “nursing informatics competencies”, informatics nurse leaders”, and “nurse informatics impact.” Inclusion criteria included articles published in the last five years and articles from scholarly peer-reviewed journals. Articles from international journals were considered. Exclusion criteria included articles older than five years and articles which did not have a defined methodology. Many of the articles which were initially reviewed were excluded as they didn’t include clear methodology or data analysis sections.
The word “informatics” was introduced around 1957 and believed to be Russian in origin, being influenced by the words information and automatic . (Sengstack, 2015). Automatic information, either pushed from a centralized source or available at the nurse leader's fingertips, can be used to make clinical nursing decisions and leadership practice decisions. Nurse leaders who can use empirical data through nursing informatics can make decisions that positively impact care delivery at the bedside. Better care delivery also means higher reimbursement from CMS and fewer penalties for providing substandard care.
Informatics competencies for nurse leaders at the graduate level
Kassam et al., (2017) wrote about the importance of nursing informatics and acknowledged that nurse leaders are often not equipped with the requisite competencies to put the discipline to good use. However, there is hope. Informatics competencies are often taught at the nursing graduate school (MSN, Ph.D., and DNP) level. As more and more nurse leaders become educated at the graduate level, they must understand nursing informatics competencies so that they can be valuable participants and contributors to the profession. Shea and colleagues (2019) advocated that nurses who learn how to use data will be able to transform health care delivery, believing that nurses must have the skills to manage data for decision-making. There remains a shortage of clinicians to support these changes, and graduate education does not necessarily instill relevant nursing informatics competencies in students. The importance of ensuring that nurse leaders embody informatics competencies cannot be understated.
Nursing informatics competencies are a necessity
In order for nurse leaders to positively impact healthcare, they must exhibit evidence-based behaviors, in the form of competencies. The Outcome-Based Education Model (OB-CE), described by Graebe (2019), provides a framework to assess nurse competence, where achieving learner outcomes is the focus and time is the variable. The OB-CE model focuses less on time, as many traditional educational curriculums do (such as credit hours or continuing education hours), but rather on the validation of learner knowledge and performance (Graebe, 2019). The OB-CE, developed by the American Nurses Credentialing Center (ANCC), points out that learning takes place when environmental factors such as culture, institutional structure, resources, and systems issues exist (Graebe, 2019). This can undoubtedly be true of nursing informatics, where long-existing cultures and practices are beginning to meld with new technological advances and discoveries. Competency frameworks have also been found to help set clear goals and targets and improve how practice is organized (Stanford, 2016).
Competencies: closing the gap
It is essential to assess the baseline competence of nurse leaders as it relates to nursing informatics. Pordeli (2018) conducted an evidence-based study at a 304-bed, non-profit magnet recognized hospital in Florida. There, twenty-one informatics nurses were provided a pre-assessment to examine competency gaps in nursing informatics competencies. The researcher’s primary objective was to construct a professional development program to meet the organization’s informatics competency needs. The post-assessments after the education was delivered determined an increase in computer skills competency by 25.41%, privacy/security competencies increased by 26.21%, and data mining competencies by 51.64%. It is imperative that to become and remain an integrated profession, leaders at the forefront of nursing must adopt and embrace informatics. Remus (2016) found that the inability of health systems to reap the total benefits of an EHR is related to deficiencies in informatics competencies among nurse leaders, including chief nurse executives (CNEs). Remus further argued that informatics-savvy CNEs can be transformational by helping nurses become knowledge workers that can more positively impact patient care outcomes.
Though there are some in academia and industry who focus on the potential downsides of big data, their voices will be eclipsed by the swarms of nurse leaders being trained in informatics competencies and applying them to improve care outcomes. Locsin’s theoretical framework provides an avenue where caring and technology in the form of informatics can peacefully coexist and even thrive in nursing. Nurse leaders who are competent in informatics competencies can contribute to the body of evidence-based practice and dramatically transform care delivery for the better.
Online Journal of Nursing Informatics
Powered by the HIMSS Foundation and the HIMSS Nursing Informatics Community, the Online Journal of Nursing Informatics is a free, international, peer reviewed publication that is published three times a year and supports all functional areas of nursing informatics.
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References & Bios
Graebe, J. (2019). Continuing Professional Development: Utilizing Competency-Based Education and the American Nurses Credentialing Center Outcome-Based Continuing Education Model. Journal of Continuing Education in Nursing, 50 (3), 100-102. https://doi.org/10.3928/00220124-20190218-02
Haslem, B., Hutton, I., & Smith, A. H. (2017). How Much Do Corporate Defendants Really Lose? A New Verdict on the Reputation Loss Induced by Corporate Litigation. Financial Management , 46 (2), 323–358. doi: 10.1111/fima.12171
Kassam, I. et al. (2019). Informatics Competencies for Nurse Leaders: A Scoping Review. Journal of Nursing Administration , 49 (6), 323-330. doi: http://dx.doi.org/10.1097/NNA.0000000000000760
Kipnis, P., Turk, B., Wulf, D., LaGuardia, J., Liu, V., Churpek, M., Romero-Brufau, S., Escobar, G. (2016). Development and validation of an electronic medical record-based alert score for detection of inpatient deterioration outside the ICU. Journal of Biomedical Informatics , 64 (2016), 10-19. https://doi.org/10.1016/j.jbi.2016.09.013
Locsin, R. (2017). The Co-Existence of Technology and Caring in the Theory of Technological Competency as Caring in Nursing. The Journal of Medical Investigation , 64 (1.2), 160-16. doi: 10.2152/jmi.64.160
McCarty, M. (2016). Organized Medicine Sounds Alarm as Meaningful Use Penalties Kick In. American Medical Technologists , 2 (2015), 10-11. https://doi.org/10.1002/opph.201590070
O’Neil, C. (2016). Weapons of Math Destruction . New York City, NY: Crown Publishing.
Pordeli, L. (2018). Informatics competency-based assessment: Evaluations and determinations of nursing informatics competency gaps among practicing nurse informaticists. Online Journal of Nursing Informatics, 22 (3).
Remus, S. (2016). The Big Data Revolution: Opportunities for Chief Nurse Executives. Nursing Leadership, 28 (4), 18-28. http://dx.doi.org/10.12927/cjnl.2016.24557
Sengstack, Patricia (2015). Mastering Informatics: A Healthcare Handbook for Success . Sigma Theta Tau International.
Shea, K. et al. (2019). A model to evaluate data science in nursing doctoral curricula. Nursing Outlook , 67 (1), 39-48. doi: 10.1016/j.outlook.2018.10.007
Stanford, P. (2016). How can a competency framework for advanced practice support care? British Journal of Nursing , 25 (20), 1117-1122. doi.:10.12968/bjon.2016.25.20.1117
Watson, J. (1999). Nursing human science and human care; a theory of nursing . National League for Nursing.
Author Biography Nicholas “Nick” R. Webb, JD, MSN, CPHIMS, RN-BC (Informatics) is a student in the Executive Leadership Doctor of Nursing Practice (ELDNP) program at the University of San Francisco. Nick has been a house supervisor, assistant nurse manager, nurse manager, nursing director, chief nursing officer, regional director of acuity, and currently oversees the regional electronic health record for a large, non-profit integrated healthcare system. He lives in Northern California with his wife, Elvia, and children, Nico (15) and Emily (12).
- Open Access
- Published: 15 October 2021
The information system stress, informatics competence and well-being of newly graduated and experienced nurses: a cross-sectional study
- Anu-Marja Kaihlanen 1 ,
- Kia Gluschkoff 1 ,
- Elina Laukka 1 &
- Tarja Heponiemi 1
BMC Health Services Research volume 21 , Article number: 1096 ( 2021 ) Cite this article
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The use of information systems takes up a significant amount of nurses’ daily working time. Increased use of the systems requires nurses to have adequate competence in nursing informatics and is known to be a potential source of stress. However, little is known about the role of nursing informatics competence and stress related to information systems (SRIS) in the well-being of nurses. Moreover, the potential impact of nurses’ career stage on this matter is unknown. This study examined whether SRIS and nursing informatics competence are associated with stress and psychological distress in newly graduated nurses (NGNs) and experienced nurses.
A cross-sectional study was conducted in Finland between October and December 2018. The participants were NGNs ( n = 712) with less than two years of work experience and experienced nurses ( n = 1226) with more than two years of work experience. The associations of nursing informatics and SRIS with nurses’ stress and psychological distress were analyzed with linear regression analysis. Analyses were conducted separately for NGNs and experienced nurses. Models were adjusted for age, gender, and work environment.
SRIS was associated with stress / psychological distress for both NGNs (β = 0.26 p < 0.001 / β = 0.22 p < 0.001) and experienced nurses (β = 0.21 p < 0.001/ β = 0.12 p < 0.001). Higher nursing informatics competence was associated with lower stress (β = 0.20 p < 0.001) and psychological distress (β = 0.16 p < 0.001) in NGNs, but not among experienced nurses.
Conclusions
SRIS appears to be an equal source of stress and distress for nurses who are starting their careers and for more experienced nurses, who are also likely to be more experienced users of information systems. However, informatics competence played a more important role among NGNs and a lack of adequate competence seems to add to the strain that is already known to be high in the early stages of a career. It would be important for educational institutions to invest in nursing informatics so that new nurses entering the workforce have sufficient skills to work in increasingly digital health care.
Peer Review reports
In recent years, the use of information technology has become an integral part of health care. Nurses, among other health care professionals, are required to adopt digital services and information systems as part of patient care [ 1 , 2 ]. Information systems are expected to provide benefits from both economic and quality-of-care perspectives [ 3 ] but may also have unfavorable consequences for the end-users, such as increased stress and strain from learning and adapting information systems to the workflow [ 4 , 5 , 6 , 7 ].
Stress is considered to be a response to a stressful situation, and general measurement of stress symptoms has been widely used to measure well-being at work [ 8 ]. Well-being is also often viewed through psychological distress, which refers to a state of emotional suffering associated with demands and stressors that a person finds difficult to deal with in daily life (General Health Questionnaire, GHO, being one of the most widely used and established measurements) [ 9 , 10 ]. Stress related to information systems (SRIS) refers to the stress caused by poorly functioning or constantly changing information systems [ 11 ]. Nurses’ SRIS has so far been little studied [ 12 ] compared with, for example, physicians’. Among physicians, SRIS has steadily increased in recent years [ 11 ], and using information systems with multiple functions has been associated with stress, especially if the work involves high time pressure [ 13 , 14 , 15 ]. Similarly, with nurses, information systems, such as demanding and detailed documentation in health records, have been found to take more time out of daily work than before [ 16 , 17 ] and to be a considerable source of stress [ 18 ]. Studies have shown that nurses are burdened by the constant need to redefine their nursing expertise to provide care in digital environments [ 1 ]. Furthermore, the poor usability of the information systems has been associated with stress [ 19 ] and cognitive strain among nurses [ 20 , 21 ].
Particularly the first years of professional nursing practice are known to be stressful with a lot of learning and adaptation [ 22 , 23 ]. Therefore, the use of information systems may be particularly stressful for newly graduated nurses (NGNs). Challenges – such as managing heavy workloads, meeting working life expectations [ 24 , 25 , 26 ], and gaps in competence [ 25 , 27 , 28 ] – are found to be the main sources of stress for NGNs [ 22 , 29 ]. In contrast, a higher level of task mastery has been shown to predict lower levels of stress [ 30 ].
Competence in nursing informatics, which refers to the processing of information and integrating information and communication technologies to promote the health of patients or clients [ 31 , 32 ], has become a prerequisite for nurses’ performance in digitalizing health care [ 33 , 34 , 35 ]. NGNs entering working life are expected to be sufficiently competent in informatics and ready to use the information systems effectively [ 36 ]. However, it has been questioned how well current nursing curricula meet this competence need [ 37 , 38 ]. Deficiencies have repeatedly been reported in students’ theoretical studies and in opportunities to practice using the systems and nursing informatics before starting working life [ 36 , 39 , 40 , 41 ]. Best practices for teaching and ensuring sufficient informatics competence for nurses are also not clearly identified [ 39 ]. Moreover, nurses in different stages of their careers have expressed concerns about the lack of formal training and unrealistic competence expectations regarding information technology [ 1 , 18 ].
Although the stress of NGNs, and nurses in general, is a widely studied topic [ 25 , 42 , 43 ], little is known about the potential impact of SRIS or nursing informatics competence on nurses’ overall well-being. Moreover, the potential impact of a nurse’s career stage on this matter is unknown. This study examined whether SRIS and nursing informatics competence are associated with stress and psychological distress in NGNs and experienced nurses.
A cross-sectional survey study was conducted in Finland between November and December 2018.
Participants and data collection
The study included two groups of participants. The first group consisted of NGNs ( n = 6979) who had up to two years of work experience at the time of the data collection. This group included all nurses who graduated in Finland between 2016 and 2018. The second group consisted of registered nurses with more than two years of work experience ( n = 10,000). These nurses were randomly picked from the Finnish Central Register of Valvira (the National Supervisory Authority for Welfare and Health). To obtain approximately equal numbers of respondents for both groups, the sample size of experienced nurses was defined to correspond to the number NGNs (taking into account possible non-response). Of these two groups, we were able to obtain email addresses for 3942 NGNs and 7000 experienced nurses from the register of the Finnish Association of Health and Social Care Professionals. Those whose email address was not obtained were excluded from the study (3037 NGNs and 3000 experienced nurses).
Nurses were invited to participate in the study and were sent a link to the electronic questionnaire via email. The invitation letter contained information on the purpose of the study, the voluntary nature of completing/sending the questionnaire, and the fact that the information will be processed both without identification of the participant and only by the members of the research team. A total of 712 NGNs (response rate: 18 %) and 1226 experienced nurses (response rate: 15 %) responded to the survey after three email reminders were sent.
Stress was measured with a validated single-item measure of stress symptoms [ 8 ]: ‘ Stress means feeling tense, restless, nervous or anxious or being unable to sleep at night because one’s mind is troubled all the time. Do you feel stressed these days? ’ The item was answered on a five-point scale (ranging from 1 = ‘not at all’ to 5 = ‘very much’).
Psychological distress
Psychological distress was measured using four items (Cronbach’s alpha: α = 0.86) from the General Health Questionnaire (GHQ) [ 9 , 44 ] that represent the anxiety/depression factor and is suggested to be the most preferable factor model for GHQ-12 [ 10 ]. Previously this measure has been associated with, for example, team climate and patient-related stress [ 45 , 46 ]. Items, such as ‘ have you recently felt constantly under strain?’ were assessed on a four-point scale (ranging from 1 = ‘not at all’ to 4 = ‘a lot more than usually’).
SRIS was measured by two items (α = 0.62) that assessed how often a person has been distracted, worried, or stressed during the last six months about (1) constantly changing information systems and (2) difficult, poorly functioning IT equipment/software [ 11 ] on a five-point scale (ranging from 1 = ‘very rarely or never’ to 5 = ‘very often or constantly’). The measure has been used in studies that have included physicians and has been associated with, for example, psychological distress (Heponiemi et al., 2018; Heponiemi et al., 2019).
Nursing informatics competence
Nursing informatics competence included four competence areas: (1) terminology-based documentation, (2) patient-related digital work, (3) general IT competency, and (4) electronic documentation according to structured national headings (Kinnunen et al., 2019). The participants were asked to evaluate how well they have mastered the following competencies on a five-point scale (ranging from 1 = ‘very poorly’ to 5 = ‘very well’): documentation by using structured national headings (competency 1); supporting the patient to use electronic services (competency 2); basic IT skills (e.g. data security information retrieval, word processing) (competency 3); and electronic documentation of the patient care according to the nursing process (competency 4) (α = 0.73).
Demographic information included age, gender, and the work environment ( emergency care, psychiatric and substance abuse services, specialized health care, elderly care, an outpatients department , or some other environment ).
The measures used in the study are presented in full in the supplementary material ( Supplement 1 ).
Data analysis
Multiple linear regression was used to examine the associations of SRIS and nursing informatics competence with stress and psychological distress. Analyses were conducted separately for both dependent variables (stress and psychological distress). First, as a preliminary analysis, we tested whether the possible associations of SRIS and informatics competence with stress and distress are different between NGNs and experienced nurses. This was done by combining the data from both nurse groups and included the interaction terms ‘SRIS*nurse group’ and ‘informatics competence*nurse group’ in the models predicting stress and distress. There was a significant interaction effect between nursing informatics competence and the nurse group for stress ( p = 0.04) and psychological distress ( p = 0.04). Therefore, the analyses were conducted separately for NGNs and experienced nurses. All models were adjusted for age, gender, and work environment. The analyses were conducted using R, version 1.2.1335.
The majority of the nurses were female. NGNs were on average 31 years old and experienced nurses 45 years old. In both groups, specialized health care and elderly care were the most common work environments. Nursing informatics competence was higher ( p < 0.001) and SRIS was lower ( p < 0.001) among NGNs compared with experienced nurses. The groups did not vary in the level of stress or psychological distress (see Table 1 )
The association of SRIS with stress and distress
SRIS was significantly associated with stress and distress in both NGNs and experienced nurses (see Table 2 ). The higher the nurses’ SRIS, the higher their stress and distress (see Fig. 1 ).
The association of SRIS with stress and distress in NGNs and experienced nurses (no interaction by nurse group)
The association of nursing informatics competence with stress and psychological distress
Nursing informatics competence was associated with stress and distress in NGNs but not in experienced nurses (see Table 2 ). Lower levels of competence were associated with high levels of stress and distress in NGNs, while in experienced nurses, competence was not associated with stress or distress (see Fig. 2 .).
The association of nursing informatics competence with stress and distress in NGNs and experienced nurses (interaction by nurse group)
This study examined whether SRIS and nursing informatics competence are associated with stress and psychological distress in NGNs and experienced nurses. Our results showed that high SRIS was associated with high stress and distress in both groups. High nursing informatics competence, in turn, was associated with low levels of stress and distress in NGNs, but not among experienced nurses.
According to our results, SRIS appears to be a source of stress and psychological distress for nurses, regardless of the stage of their career. A previous study by Harris et al. (2018) has similarly found that stress due to electronic health record use may be associated with nurses’ burnout symptoms. Nurses are known to experience stress, especially in the implementation phase of new information systems [ 47 ], and this most likely occurs due to the high workload and lack of time that are typical barriers to the adoption and acceptance of the systems [ 48 ]. In our study, the SRIS levels were significantly higher for experienced nurses than for NGNs, but were still at a moderate level in both groups compared with, for example, the SRIS levels for Finnish physicians [ 14 , 15 ]. Moreover, long experience with the use of information systems has been associated with lower SRIS levels in physicians, not the other way around [ 14 ]. The difference in nurses’ SRIS values can be partly explained by the fact that a significant proportion of NGNs represent a generation that is familiar with using a wide range of technologies, both in their studies and in their leisure time [ 49 ]. On the other hand, the widespread use of technology (e.g. in social interaction and knowledge sharing) does not directly indicate the ability to use these skills in academic or professional activities exists [ 41 ]. Nevertheless, NGNs attitudes and perceived self-efficacy in information and communication technology, and their understanding of its benefits appear to be higher than that of nurses with more experience and age [ 50 , 51 ]. This may to some extent protect NGNs from SRIS in the workplace, but our results suggest that SRIS still affects their well-being.
Based on the results, a lack of sufficient nursing informatics competence may increase NGNs’ perceived stress and distress. NGNs evaluated themselves to be more competent in nursing informatics than experienced nurses, which is consistent with previous knowledge [ 34 ], although having more experience in the use of health information systems has previously been associated with higher informatics competence among nurses [ 33 ].
Integrating nursing informatics into nursing education has been a mission in many countries, but global and national differences in the use of technologies have made it difficult to determine best teaching practices and ensure the coherence of curricula [ 52 ]. This study confirms the need to invest in adequate informatics education as good competence may alleviate the stress and distress in the first years of a nurse’s work. Even though the level of informatics competence was not similarly associated with stress or distress among more experienced nurses, the provision of on-the-job training about informatics would also be extremely important. Previous studies have stated the need to develop, for example, nurses’ competence in using online services in patient care, supporting patients in utilizing these services [ 1 , 53 ], structured documentation, and basic IT skills [ 54 ]. It is worth investing in the development of these competencies as there is repeated evidence of a link between the training received and nurses’ informatics competence [ 33 , 55 ]. Moreover, the importance of nursing informatics for ensuring the quality of health care is well recognized internationally [ 56 , 57 ].
So far, research knowledge on the stress caused by poorly functioning and constantly changing information systems is scarce among nurses, making it difficult to compare its potential effects on different health and social care settings and professionals at different career stages or to make international comparisons. As the use of various information systems is likely to increase globally in the future, further research is needed in this regard.
Limitations
Certain limitations need to be considered when interpreting the results of this study. It should be taken into account that the study used the self-assessment of nursing informatics competencies and not, for example, objective tests that could have shown a different result for the nurses’ competence, and thus could have influenced the results. In addition, SRIS was measured with only two items with a Cronbach’s alpha value that was somewhat low, although still at an acceptable level [ 58 ]. The cross-sectional design must also be taken into account as it does not allow establishing a causal association of nursing informatics or SRIS with stress and distress. Although the analyses of the study controlled the age, gender, and work environment of the participants, we are also aware that there are potential confounding factors that may have influenced the associations. Finally, response rates in this study also remained relatively low, which may reduce the generalisability of results. Regarding the response rate, it is not possible to know the number of those who did not receive the email invitation, for example, due to an expired email account or spam filtering, which quite often happens with these email invitations. In addition to non-response, the exclusion of potential participants due to the lack of email addresses increases the possibility of selection bias.
According to this study, poorly functioning, constantly changing information systems can be a substantial source of stress and psychological distress for NGNs as well as more experienced nurses. It is the responsibility of system vendors to further develop information systems to better support the work of healthcare professionals and not to increase their workload and strain. Our findings also suggest that good nursing informatics competence may be especially important for nurses who are starting their career in terms of preventing early career stress and distress, although adequate nursing informatics competence is known to be of the utmost importance and a prerequisite for performing work at any stage in a nurse’s career. It would be very important to take into account the stressors of nurses and invest in their well-being as this might mitigate nurses’ profession changes in a situation where there is already a global shortage of nurses. The tasks in nursing that require information management skills will increase in the future, thus, providing adequate and appropriate support and training in the use of information systems would be very important in both educational institutions and health care organizations.
Availability of data and materials
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.
Abbreviations
Newly graduated nurse
Stress related to information systems
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This study was funded by the Strategic Research Council (SRC) of the Academy of Finland (project 327145).
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Substantial contribution to study conception and design: A-M.K, K.G, T.H. Data analysis: A-M.K, K.G. Drafting of the manuscript: A-M.K, K.G, E.L, T.H. All authors read and approved the final manuscript.
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Kaihlanen, AM., Gluschkoff, K., Laukka, E. et al. The information system stress, informatics competence and well-being of newly graduated and experienced nurses: a cross-sectional study. BMC Health Serv Res 21 , 1096 (2021). https://doi.org/10.1186/s12913-021-07132-6
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Published on 9.1.2020 in Vol 3 , No 1 (2020) :Jan-Dec
Education Into Policy: Embedding Health Informatics to Prepare Future Nurses—New Zealand Case Study
Authors of this article:
Original Paper
- Michelle Honey 1 , PhD ;
- Emma Collins 2 , MN ;
- Sally Britnell 3 , MHSc
1 School of Nursing, University of Auckland, Auckland, New Zealand
2 School of Nursing, Otago Polytechnic, Dunedin, New Zealand
3 Nursing Department, Auckland University of Technology, Auckland, New Zealand
Corresponding Author:
Michelle Honey, PhD
School of Nursing
University of Auckland
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Phone: 64 09 3737599 ext 87308
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Background: Preparing emerging health professionals for practicing in an ever-changing health care environment along with continually evolving technology is an international concern. This is particularly pertinent for nursing because nurses make up the largest part of the health workforce.
Objective: This study aimed to explore how health informatics can be included in undergraduate health professional education.
Methods: A case study approach was used to consider health informatics within undergraduate nursing education in New Zealand. This has led to the development of nursing informatics guidelines for nurses entering practice.
Results: The process used to develop nursing informatics guidelines for entry to practice in New Zealand is described. The final guidelines are based on the literature and are refined using an advisory group and an iterative process.
Conclusions: Although this study describes the development of nursing informatics guidelines for nurses entering practice, the challenge is to move these guidelines from educational rhetoric to policy. It is only by ensuring that health informatics is embedded in the undergraduate education of all health professionals can we be assured that future health professionals are prepared to work effectively, efficiently, and safely with information and communication technologies as part of their practice.
Introduction
Focus of study.
Health professionals work with people of all ages and stages of life; across primary, secondary, and tertiary care; and in a variety of settings, from hospitals to the community [ 1 ]. Modern health care often includes the use of technology, which is frequently mirrored in health strategy [ 2 ]. For example, the New Zealand Health Strategy calls for health care professionals to work “smarter” using technology to enhance the health and well-being of New Zealanders [ 3 ]. There is a general consensus that people will continue to be at the center of any successful digital health initiative [ 4 , 5 ]. This is particularly pertinent for nursing because nurses make up the largest component of the health workforce [ 6 ]. Focusing and investing in nursing is thought to improve health and gender equality and support the economic growth of a country [ 7 ]. Williamson and Muckle [ 8 ] considered technology an integral part of current nursing practice and therefore suggested the use of technology being integrated into the nursing curriculum for students. Although a systematic review suggests that learning mediated by technology may not be better than traditional approaches to teaching and learning, exposure to technology may help develop information and communication technologies (ICT) skills that can be transferred to the clinical setting [ 9 ].
The focus of this case study was nurses working in New Zealand. New Zealand is a small country situated deep in the South Pacific with a population of less than 5 million [ 10 ]. There are 52,700 practicing nurses or 1106.9 practicing nurses per 100,000 New Zealanders [ 1 ]. Nurses are recognized as the largest regulated health workforce in New Zealand, and because of having a generalist scope, diversity, flexibility, and demographic spread, they are the health professionals who are best able to provide a rapid response to emerging health needs [ 11 ]. Although historically New Zealand was an early leader in considering how to prepare nurses to work with technology, nursing informatics has not been consistently addressed in nursing curricula across the country’s 17 schools of nursing, meaning that New Zealand nurses may not be well prepared in this area [ 12 - 15 ]. Therefore, a project was established to address this gap.
There are many terms concerning the use of ICT in health care, but in this instance, the term health informatics, or when specifically for nursing—nursing informatics, has been selected. Health informatics is defined as the discipline focused on the acquisition, storage, and use of information in a specific setting or domain, in this case health care [ 16 ]. Within nursing, the term nursing informatics is preferred, and this is defined as a “science and practice [which] integrates nursing, its information and knowledge, and their management, with ICT to promote the health of people, families and communities worldwide” [ 17 ]. Or more simply, we are talking about the use of computers and ICT to support health care.
Including health informatics within health professional educational preparation was noted in the literature from the early 1970s; however, there seems to have been a surge of articles from 1999 [ 18 ]. In 2010, the International Medical Informatics Association (IMIA) revised the earlier (2000) international recommendations for health informatics or medical informatics education with the hope that these would help to establish courses and perhaps lead to sharing of courseware [ 18 ]. The revised 2010 recommendations were designed to meet the educational needs of health professionals from medicine, nursing, health care management, dentistry, pharmacy, public health, health record administration, and informatics/computer science and for dedicated programs in biomedical and health informatics [ 18 ]. This indicates a broad health professional reach. Despite the direction provided in the IMIA recommendations, there is still evidence that embedding informatics within a health professional education program is not commonplace [ 19 ].
A survey of medical schools in the United Kingdom identified that 17% of the 76% of medical schools that responded had little or no health informatics included in their curricula, and this is despite the General Medical Council’s curriculum requirements [ 20 ]. Similarly, in pharmacy schools in the United States, it was noted that little “progress had been made in pharmacy school curricula in response to the increasing importance of informatics to the profession” [ 21 ]. A global approach was suggested to provide flexible, Web-based, and standards-based medical informatics education, but this does not seem to have been well accepted [ 22 ]. A common issue has been the lack of suitably prepared faculty to teach health informatics [ 18 , 20 - 22 ].
For more than 30 years, nursing has had an interest in nursing informatics competencies [ 23 ]. However, early publications often described the use of computers by nurses and focused on computer skills and what should be included in nursing education [ 24 ]. An international initiative, driven from the United States, the Technology Informatics Guiding Education Reform (TIGER) developed competencies to guide the nursing profession, but these are not widely used [ 25 ]. Many countries have considered nursing informatics competencies for their nurses [ 26 - 29 ], recognizing that their context and needs may be particular to their country. More recently, the IMIA Nursing Informatics Special Interest Group focused on nursing informatics competencies at a postconference meeting of world leaders [ 30 ]. The aim of this meeting was to “publish a set of informatics competency recommendations for nurses educated in the next decade that cover the informatics skills required for improved, innovative and even transformative health and health care delivery” [ 23 ]. A comprehensive scope was set by including information management and the use ICT for aspects such as electronic health records, medical devices, telemedicine, patient portals, electronic health, and mobile apps, with the hope that the competencies would also help prepare nurses for future developments.
Despite the use of ICT in health care practice becoming increasingly commonplace in developed countries, nursing education has lagged in providing the preparation needed for new nurses to be aware and have the opportunity to develop the knowledge, skills, and attitudes they will need in practice. As Murphy and Goosen state, “After almost 25 years it is still problematic how few schools of nursing offer education on how the values of patient focused care can be mixed with careful application of health informatics tools and good professional information management” [ 23 ].
New Zealand as a Context
New Zealand provides a context for this project, and this section includes some of the New Zealand health informatics history that helped to shape the current informatics landscape. Despite early recognition of the need for nursing informatics competencies and guidelines to inform practice and undergraduate nurse education in New Zealand, the embedding of nursing informatics within the nursing curricula did not occur [ 13 , 31 ].
In 1989, a nurse educator, Jan Hausman, was seconded by the Ministry of Education to develop New Zealand guidelines for teaching nursing informatics [ 14 ]. However, this early initiative saw little change in the nursing curricula. Nevertheless, a growing interest in nursing informatics started around this time, and by 1991, a national nursing informatics group (Nursing Informatics New Zealand [NINZ]) was formed [ 31 ]. In the mid-1990s, this group developed and published Standards for Nursing Informatics with the notion that these guidelines would guide nursing practice [ 13 ]. Unfortunately, these guidelines were not widely adopted.
In 2000, NINZ joined the New Zealand Health Informatics Foundation to form Health Informatics New Zealand (HiNZ), a not-for-profit organization that supports the field of health informatics, with a focus on events and professional development in New Zealand. HiNZ members include health professionals (including nurses), health sector managers, ICT experts, industry managers, academics, students, and government personnel [ 32 ].
In 2006, a report identified that more people, particularly those already in the health workforce, needed to be trained in health informatics [ 33 ]. Subsequently in 2012, based on this work and that of IMIA [ 18 ], a cross-institutional group of New Zealand informatics educators collaborated to develop “Core Competencies for Health Informatics” under the umbrella of HiNZ [ 34 , 35 ]. These competencies were designed for the existing workforce and were directed to health professionals, managers, and technical experts in health care. An outcome was government recognition and funding of primer workshops based around introductory health informatics concepts that were delivered around the country to local health care organizations. It was hoped that in providing the primer workshops, more health care workers would be informed and engaged in health informatics, and this would, in the longer term, address the shortage of health professional champions and interdisciplinary team members trained in health informatics [ 34 , 35 ].
However, these efforts and the core competencies, although they included health professionals, were focused toward those already in practice and not those in training. A project to address this gap, specifically for nurses, commenced in 2016.
To identify the nursing competencies needed for New Zealand nurses, a project was initiated in 2016 by a team of 3 nurse educators from 3 different schools of nursing. The objective of this project was to use a case study approach to develop nursing informatics guidelines specific for the New Zealand context that were based on principles encompassing key knowledge, skills, and behaviors for student nurses to attain over the time of their undergraduate education to be ready to begin practice as a registered nurse (RN). A case study approach was selected as it allowed for descriptive and exploratory analysis [ 36 ]. In addition, any nursing informatics guidelines needed to align with the New Zealand Nursing Council competencies for RNs [ 37 ]. Over the next 2 years, evidence-based Guidelines for Nursing Informatics Competencies for Undergraduate Nurses in New Zealand were developed, and this work is now published and ready for dissemination [ 38 ]. Preceding this, in 2015, a study mapping the TIGER competencies [ 25 ] against the current legislation and practice in New Zealand was conducted, but the feeling was that the US-centric competencies did not suit the New Zealand health care and educational context [ 15 , 39 ]. This work was presented at the national nursing informatics conference in New Zealand, which identified other interested nurses and resulted in a collaboration to consider what nursing informatics competencies were needed for New Zealand nurses. The first stage of the collaboration was between nurse lecturers from 3 different schools of nursing and consisted of mapping their respective school’s existing undergraduate nursing curricula against the Australian nursing informatics standards [ 26 ]. This work identified gaps in the existing undergraduate curricula for each school [ 12 , 40 ]. To address this gap and identify the nursing competencies needed for New Zealand nurses, a review of literature and then iterative consultation with an advisory group and key stakeholders was undertaken. The project team met regularly (usually virtually) and collaboratively created the foundation for the guidelines for nursing informatics competencies for undergraduate nurses in New Zealand, which were shaped by feedback received from the advisory group and key stakeholders until the final product was developed: Guidelines: Informatics for nurses entering practic e [ 38 ].
The Guidelines: Informatics for nurses entering practice (hereafter called The Guidelines) identify 5 health informatics principles for nurses at the end of their undergraduate nursing education program as they enter practice as level 1 or novice RNs [ 38 ] ( Textbox 1 ).
The Guidelines identify the key knowledge, skills, and behaviors toward nursing informatics for nurses as they enter practice as an RN, and as such, they have been developed and articulated to inform undergraduate nursing education. The principles are explicitly aligned to the Nursing Council of New Zealand (NCNZ) Competencies for RNs [ 37 ] ( Figure 1 ).
Background literature that informed The Guidelines included reports from international nursing informatics initiatives including from Australia (the Australian National Informatics Standards for Nurses and Midwives) [ 26 ], from the initiative driven from the United States (TIGER) [ 25 ], from the Royal College of Nursing in England (Every nurse an e-nurse: Digital capabilities for 21st century nursing) [ 29 ], and from Canada (Nursing informatics entry to practice competencies for RNs) [ 27 ].
This project was informed by an advisory group of 12 nurse leaders from practice, education, policy, the nursing regulatory body, and industry. Drafts of The Guidelines were distributed, and feedback was sought using an iterative process. In addition, 4 nursing organizations were asked to be kept informed: The Office of the Chief Nurse in the Ministry of Health at the government level; the regulatory body, NCNZ; and The Council of Deans and Nurse Educators in the Tertiary Sector, from the education sector.
In addition, the formatting was considered, and alongside each principle, examples were provided. The inclusion of examples from everyday practice in the New Zealand health system adds a local context ( Figure 1 ). Finally, a glossary was added so that terms are defined, providing a common understanding.
The 4 principles.
Principle 1: Professional practice
Nurses are accountable and responsible for their use of information and communication technologies (ICT)
Principle 2: Information management
Use of information to inform and manage patient care
Principle 3: ICT to enhance the health of New Zealanders
Nurses effectively use ICT to assist with the delivery of quality nursing care to improve patient outcomes
Principle 4: General computer and ICT skills
The nurse is adaptable in different health care environments through transferrable ICT skills
Principal Findings
This project aims to inform, influence, and potentially change professional nursing practice and policy through providing clear guidelines for nursing informatics competencies. The Guidelines align with the NCNZ competencies for RNs [ 37 ], which all schools of nursing in New Zealand work with the development of their curricula. Furthermore, this project supports the national health strategy as nurses provide health care service to support people in New Zealand to “Live well, Stay well, Get well,” which is a key component of the 2016 New Zealand Health Strategy [ 3 ].
By considering the past and previous attempts to introduce nursing informatics competencies in New Zealand, there is an opportunity to learn and to improve on earlier endeavors. A common problem faced by earlier efforts includes moving from the creation of guidelines to a position where competencies are recognized and inform policy to where they are embedded in education. This project supports actively building connections between the tertiary education providers within the schools of nursing, thereby crossing perceived divisions between universities, polytechnics, and institutes of technology. By demonstrating engagement within the nursing communities, specifically nurse lecturers and the key nursing regulatory and policy stakeholders, The Guidelines may be acceptable to all and are more likely to be accepted and influence policy.
In terms of policy impact, this project has the potential to influence the NCNZ to explicitly address the inclusion of nursing informatics within undergraduate nursing curricula. The implementation of these guidelines nationally would impact all 17 schools of nursing in New Zealand by ensuring that present and future RNs are consistently prepared for working in a technological age. This will likely have flow-on effects for patient care, potentially improving safety and efficiency within the health care system and improving quality of care for recipients, while acknowledging the role of nurses in health maintenance and health promotion as well as providing health care for those who are sick or dying. Technology is used in all aspects of health care, and ensuring that our workforce is adequately prepared for its use in health care has the potential to assist all recipients of care, including Māori—the indigenous people of New Zealand—and those from neighboring Pacific Islands, who are overrepresented in New Zealand’s worst health statistics [ 3 ].
The impact of policy in terms of education will affect nursing students, who remain predominantly women (9% of the current nursing workforce is male) [ 1 ]. Understanding the use of technology in health care will better prepare them to be competent and effective future nurses. The Guidelines form a bridge between the theory of nursing informatics, education of nurses, and clinical practice.
The challenge is to now disseminate this work to the New Zealand nursing education community so that The Guidelines can be incorporated into nursing curricula. The first step is to share The Guidelines across all schools of nursing in New Zealand so that nurse educators can consider how The Guidelines can be implemented into their undergraduate programs of nursing, which will facilitate effective knowledge transfer and uptake of The Guidelines into practice. Furthermore, there is a need to identify and then address the concerns, barriers, and facilitators to using The Guidelines in nursing education. In addition, from a New Zealand perspective, where the indigenous people are Māori, there is a need to understand any issues specifically from the perspectives of Māori as concerns related to data guardianship and nurses acting as kaitiaki/guardians of the data may apply [ 41 ].
Conclusions
Despite local and international efforts to include health informatics as part of the curricula for preparing health professionals for practice in the 21st century, there remains inconsistency in achieving this. This case study illustrates the development of heath informatics competencies and guidelines for one profession, in one country. The challenge is moving from educational rhetoric to practice and policy to ensure that health informatics is embedded into the educational preparation for all health professionals. The importance of learning from past initiatives is highlighted. The process used to develop the “Guidelines: Informatics for nurses entering practice” for use in New Zealand is expected to guide undergraduate nursing education and as such form a bridge between theory, education, and practice.
Conflicts of Interest
None declared.
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Abbreviations
Edited by E Borycki; submitted 09.09.19; peer-reviewed by D Marshall, P Procter, T Hebda, P Sousa; comments to author 08.10.19; revised version received 17.11.19; accepted 25.11.19; published 09.01.20
©Michelle Honey, Emma Collins, Sally Britnell. Originally published in JMIR Nursing Informatics (https://nursing.jmir.org), 09.01.2020.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
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Nursing informatics: consumer-centred digital health.
1. Introduction
2. communication, 3. conclusions, author contributions, institutional review board statement, informed consent statement, acknowledgments, conflicts of interest.
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Skiba, D.; Honey, M. Nursing Informatics: Consumer-Centred Digital Health. Informatics 2021 , 8 , 67. https://doi.org/10.3390/informatics8040067
Skiba D, Honey M. Nursing Informatics: Consumer-Centred Digital Health. Informatics . 2021; 8(4):67. https://doi.org/10.3390/informatics8040067
Skiba, Diane, and Michelle Honey. 2021. "Nursing Informatics: Consumer-Centred Digital Health" Informatics 8, no. 4: 67. https://doi.org/10.3390/informatics8040067
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An appraisal of Nursing Informatics Research and the Influence of the Unified Theory of Acceptance and Use of Technology
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The study recognized the importance of healthcare informatics in today’s dynamic health systems, and narrows down to how nursing informatics, a component of healthcare informatics, can provide efficient and effective healthcare delivery. Hence, underpinned by the unified theory of acceptance and use of technology (UTAUT), the study aimed at situating research activities on nursing informatics within existing studies that have applied the theory to investigate healthcare informatics in general. The study adopted a systematic review of literature to explored online databases: Google Scholar and Ebscohost from 2014 to 2019. The search returned a total of 205 articles for the specified period. However, only 8 eligible studies were found to be related specifically to nursing informatics. The study also revealed that performance expectancy and effort expectancy (respectively), both being constructs of the UTAUT, are the dominating factors influencing the acceptance/adoption/use of nursing informatics among the papers under review. The study recommends that researchers should further explore the use of nursing informatics technologies in healthcare. In addition; nursing informatics system designers should factor in the effectiveness and ease of use of the technologies for easy usage. On the other hand, the stakeholders in medical field are called upon to provide the enabling infrastructure to enhance the use of nursing informatics technologies.
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