HART, MICHAEL D. MS, BSN, RN-BC
According to the ANA Scope and Standards of Nursing Informatics Practice, "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 support is accomplished through the use of information structures, information processes, and information technology."1(p17) The nursing profession's incorporation of informatics knowledge, associated skills, and administrative support over the last 20 years has been progressing at a slower rate than the development of advancements. Technology advancements have increased at a dramatic rate, while attempts at incorporating a basic set of technology and information science competencies for nurses at various levels of education and practice have been dragging. In addition, the health profession as a whole has shown slow progress in using technology and information in the various forms. Much of what was standard and commonplace 10 years ago is no longer applicable in the current era of technology, information processing, and knowledge generation within healthcare.
Since the mid-1980s, several studies have focused on the use of information technology in nursing. Most of the studies that related to competencies were limited to students, faculty, or school curriculum, or were based in foreign countries whose school systems may not be comparable with those within the United States. In addition, the studies often used self-assessment tools, which required the individuals participating in the studies to know what they do not know.
This literature review focused on the US clinically based nursing population between 1999 and 2006. The area of concern was that informatics competency development focuses primarily on nursing educational institutions, whereas most of the nursing population is based in the clinical workforce. According to the 2004 National Sample Survey of Registered Nurses conducted by the Department of Health and Human Services,2 the average age of graduating RNs was 29.6 years for the years ranging from 1999 to 2004. The survey also found that graduates from initial education programs in more recent years are younger than graduates of previous surveys. The average age of RNs in 2004 was 46.8 years. Only 8.1% of all RNs are younger than 30 years. A large percentage of practicing nurses are not recent nursing graduates and are older than 30 years; 73.4% are older than 40 years. Although research has been geared toward developing core informatics curriculum for nursing schools, most of the nursing population is composed of individuals who have not been in a structured nursing program for several years and did not grow up in an era when technology utilization was commonplace in educational institutions or private homes.
In April 2004, the White House issued an executive order calling for the nationwide adoption of interoperable electronic medical records within a decade and establishing the position of National Coordinator for Health Information Technology. Fewer than 90 days later, newly appointed National Coordinator David Brailer, MD, PhD, released a strategic plan to make the idea a reality-a significant milestone in what is now being called the decade of healthcare information technology.3 Incorporating this move toward the integration of health information technology at a national level in healthcare with the aging nursing population and a dwindling nursing student population requires the development of basic computer and information science competencies within the workplace. Moreover, with 56% of hospitals reporting that they are using agency or traveling nurses to fill vacancies,3 it is obvious that hospitals which are moving to an electronic system must have an effective means to ensure that current, new, and transient nurses are competent in the use of information technology at several levels. In addition, it is important to ensure that nurses can demonstrate basic competencies in nursing, computer literacy, and information literacy and are able to integrate these competencies in their primary assignments/settings. The nursing profession must prepare its core members to effectively use nursing informatics skills that involve computers, information, and informatics literacy in multiple settings. Although some nurses may be proficient in a specific setting with specific applications, the real strength comes from development of skills that are capable of providing nursing informatics support in a variety of settings.
Under the ANA definition for nursing informatics, information technology provides an essential component in the support of informatics processes and goals. Over the last 20 years, the predominant area of research regarding nurses' utilization of information technology in the clinical setting has been about measuring nurses' attitudes toward information technology. Attitude has long been recognized as a determining factor in whether users intend to use or adopt an information system or a software package.4 However, with the most recent push toward a paperless system and the national efforts toward full-scale electronic healthcare systems, more and more nurses have no choice as to whether they choose to use systems. Attitudes are still important in determining how employees may use a system and use resources,4 but as more studies show that nurses have positive attitudes toward electronic medical systems, the areas that are becoming more important are those of computer knowledge and skills.4 A positive attitude does not help staff who do not have proper knowledge and skills. Not until 2002 was a research-based list of informatics competencies for nurses provided by Staggers et al,5 entitled "Informatics Competencies for Nurses at Four Levels of Practice." The study by Staggers et al was the first study to span four levels of nursing practice in the competencies of computer skills, informatics knowledge, and informatics skills. The study identified that although a current research-based list of informatics competencies exists, the core competencies by level of practice and job type remain to be defined, and valid and reliable tools used to evaluate informatics competency levels have yet to be created.5
A review of the literature relevant to informatics competency and education in the US clinical setting discovered that not only were computer and informatics nursing competencies not effectively defined until 2002 but also clinical assessment regarding informatics components has been predominantly limited over the last 7 years to attitudes and use of online resources. The only identified published study, by Pravikoff et al,6 evaluated the clinical nursing workforce in the United States for informatics-related skills, specifically information literacy and computer skills. The study by Pravikoff et al, although useful and insightful, still falls short of the overall goal, which is to establish a standardized list of nursing job-specific competencies with associated evaluation tools. Only then can healthcare organizations properly identify nursing informatics competency needs and bring their population up to speed for evidence-based practice and overall informatics skills that will allow them to be diversified enough to contribute across multiple settings.
Of the initial 340 citations identified, 17 were deemed eligible for this evaluation. Eligibility was based on literature published in the last 7 years that focused on nursing informatics competency and education in the US clinical setting and the associated factors that affect the development of informatics skills and literacy in the clinical setting.
Systematic electronic database searches of PubMed (MEDLINE 1999-2006), CINAHL, and HealthSTAR were conducted to identify articles, clinical trials, observational studies, and all other articles available without limitation on article type. The searches focused on nursing informatics competency and education within the workplace over the last 7 years in the United States. The searches used direct database queries, related articles searches, and use of specific article references. Keywords used were nursing, informatics, competency, education, information technology, information systems, electronic, literacy, curriculum, computer, and evidence based.
Data Extraction and Synthesis
A single reviewer using a nonstandardized abstraction form abstracted data for final review and cross-comparison. Data were categorized according to two sources of information, which were supporting literature and research study results. Data were summarized and compared according to both categories and cross-compared for final results. The data analysis was a modified meta-analysis with qualitative methods used to identify themes within and among the articles.
Search criteria among all databases resulted in 340 citations. Of the initial 340 citations, citations were eliminated based on several criteria. First, citations must have been published between 1999 and 2006. It was deemed important to limit the literature to a relatively short time period because periods beyond a reasonable range would begin to exclude advancements in technology and changes in education, which may have made older information somewhat obsolete. Second, citations must have been published in English. Third, citations must have centered on US institutions. Fourth, citations had to have a primary focus on nursing informatics. Finally, these informatics-based citations had to focus on clinical settings. Many actual studies met four of the five criteria, but for the purposes of this review, it was necessary for actual study citations to meet all five criteria. Nonstudy citations were deemed appropriate if they met the first three criteria explicitly (between 1999 and 2006, English, US institutions) and were directly or indirectly related to clinical informatics competency or the associated skill sets necessary to support informatics according to the ANA definition.
Specific note should be made that the following three studies were not reviewed directly but were referenced in the Pravikoff et al study,6(pp50-51) which was of direct importance to the subject matter.
1. Pierce S. Readiness for Evidence-Based Practice: Information Literacy Needs of Nursing Faculty and Students in a Southern U.S. State [unpublished dissertation]. Natchitoches, LA: Northwestern State University of Louisiana; 2000.
* Excluded from this review because its focus was on faculty and students rather than clinical nurses.
2. Tanner A. Readiness for Evidence-Based Practice: Information Literacy Needs of Nurses in a Southern U.S. State [unpublished dissertation]. Natchitoches, LA: Northwestern State University of Louisiana; 2000.
* Excluded from this review because it is an unpublished dissertation, which the reviewer did not have access to, and details of the study were cited in the Pravikoff et al study, which was included in this review.
3. Russell A, Alpay L. Practice nurses' training in information technology: report on an empirical investigation. Health Inform J. 2000;6(3):142-146.
* Excluded from this review because it was not available locally and possibly was not based in the United States (their 2002 study was in the United Kingdom).
Review of the abstracts and many of the actual documents narrowed the selections to a total of 17 citations. Of these 17 citations, six were actual study citations and 11 were nonstudy citations related to the overall subject matter.
Study Citations Selected
Six study citations were selected. One study referred to the identification of a list of competencies for nursing practice at four levels that would be a requirement before clinical nurses could be assessed for competency. Two studies selected for inclusion studied nursing attitudes related to information technology, which have been determined to define how information technology will be received and used in clinical settings. Two studies selected were based on the use of online resources involving clinical staff and approaches the study of one component of informatics competency. Finally, one study addressed the assessment of skills of nurses in the United States regarding information literacy. A descriptive summary of findings of each study is provided in Table 1.
Nonstudy Citations Selected
Eleven citations were nonstudy citations. Two of the citations addressed information regarding nurse informatics competency. Two citations were about use of informatics in preparing for evidence-based practice. Three citations were about the issues that will affect the growth of informatics within nursing over the upcoming years. The remaining four citations were about the methods of educating staff on items related to information technology and about using information technology to provide education in general. These 11 articles helped to provide insights into issues related to informatics competency in clinical settings. A descriptive summary of the supporting literature is provided in Table 2 along with the associated grouping.
Of the 17 citations that were deemed applicable to the topic, two primary categories were created: study citations (35.3%, n = 6) and nonstudy citations (64.7%, n = 11). The study citations were then divided into three subcategories: competencies (33.33%, n = 2), attitudes (33.33%, n = 2), and use of online resources (33.33%, n = 2). The nonstudy citations were divided into four subcategories: competencies (18.2%, n = 2), informatics and evidence-based practice (18.2%, n = 2), issues affecting future informatics progress (27.2%, n = 3), and informatics education (36.4%, n = 4).
The competency study by Staggers et al5 showed that there is a research-based list of competencies but tools for measuring informatics competency and job-specific competencies still need to be identified. Both studies about nursing attitudes toward electronic systems indicated that overall nursing attitudes toward technology were positive and that proper support from administration at multiple levels was very important in overcoming barriers that were presented with the use of electronic health records (EHRs). The two study citations regarding use of information resources indicated that nursing employees have limited skills but benefit from training and, with training, are more likely to use available systems.
In 2005, Pravikoff et al published a national study to examine the perceptions of nurses related to their "access to tools with which to obtain evidence" and "whether they have the skills to do so."6(p40) The study by Pravikoff et al cited the results of previous studies by Tanner, Pierce, and Russell as summarized: Tanner's study of 223 nurses and Pierce's study of 339 nurses both demonstrated that only a small percentage were familiar with the process of evidence-based practice. Although about half had Internet access, only about 20% used it. Less than 20% said that they were able to successfully use the online bibliographic databases. They noted that other researchers had also commented that nurses do not have "adequate knowledge of information technology."6(p43)
The information presented by Pravikoff et al6 provides useful insights into the state of information literacy in US clinical nurses. Pravikoff made several important observations. Although evidence-based practice has been widely discussed in the literature over the last several years, less than half (46%) of respondents said they were familiar with the term. Although 83% of respondents considered themselves at least somewhat successful when searching the Internet or World Wide Web, only 19% and 36%, respectively, were as confident in their ability to search CINAHL or MEDLINE. Apparently, 76% of respondents never searched CINAHL and 58% never searched MEDLINE. Most respondents rarely or never sought a librarian's assistance (83%), did not use the hospital library if one existed (82%), and had never received instruction in the use of electronic resources (77%). When asked whether they had identified a researchable problem in their practice within the last year, most (59%) said that they had not, and a greater percentage (72%) said they had not evaluated research reports. A "lack of value for research in practice" was the most frequently selected barrier to the use of research in practice. All of the major barriers can be addressed through teachable skills.
The conclusion by the Pravikoff et al study states that RNs in the United States are not ready for evidence-based practice because of the gaps in their information literacy and computer skills, their limited access to high-quality information resources, and above all, their attitudes toward research. These attributes are reinforced by their perception of organizational priorities.6 In addition to the results by Pravikoff et al, with the remaining four studies reviewed, it became further evident that gaps in informatics adoption by staff are strongly affected by training, experience, and design and availability of supporting systems.
Regarding the nonstudy citations, the two competency citations indicated that additional research was needed to define competencies more precisely and to build informatics competency curriculum and assessment tools. This supports the recommendations made by Staggers.5 The two informatics and evidence-based practice articles describe several barriers and resistance to the use of evidence-based practice as related to informatics. These barriers centered on inadequate access to resources, insufficient time, and insufficient training. The three citations on challenges to future growth focused on increasing demands for increased technology while there are increasing shortages of nurses, increasing use of transient (agency) nurses, and decreasing nursing school enrollments. The remaining four citations all indicate that the answer to education for informatics-related information requires several approaches to facilitate the various barriers that exist at different levels within nursing. Informatics training should be provided through several approaches: educators, preceptors, tutorials, and various types of training material. These multiple approaches will help to account for the various issues that confront different staff in various situations.
Evaluation of nursing informatics competency and the development of such competencies in the workplace have not been standardized at a job-specific level, although the content that should be covered has been identified. History of the progression toward an informatics-competent nursing population has been slow, and results have been minimal. Effects of the lack of progression toward informatics competency have greatly diminished the overall capacity of the nursing population to effectively develop and use ongoing efforts to implement evidence-based practice. Concerns regarding aging Baby Boomers, nursing workforce shortages, and federal movements to implement electronic health systems bring the need for job-specific standardized informatics competencies development to a state of urgency. Popular thought on the subject leans toward the idea that new graduates are already competent in the use of technology, and therefore, the problem with the current population will not exist in the years to come. However, several limiting factors slow the rate of graduates from nursing programs, and the concept does not take into account that the current population of nurses has not benefited from recent changes in university curricula. If the advancement of informatics in nursing is to progress at a sufficient pace for the benefit of the occupation and the patient communities, there must be the development of job-specific competencies for informatics along with the appropriate evaluation tools; only then can the appropriate training be provided to facilitate each employee obtaining the necessary skills in his/her given positions that at the same time will provide the diversity to allow him/her to use this knowledge in a variety of environments.
CONCLUSIONS AND RECOMMENDATIONS
Although informatics in nursing has been researched and written about for the last 20 years, it was not until 2002 that a thorough list of competencies was established for the US nursing population according to level of nursing practice. It has been repeatedly documented that even with the development of this comprehensive list of informatics competencies, a job-specific development was needed, and there was a desperate need for an established set of tools for the evaluation of these competencies. However, 4 years after the establishment of these baseline informatics competencies for nurses, there have been no published advancements toward the established job-specific competencies or evaluation tools. The study by Pravikoff et al gives further evidence regarding the state of informatics in the US nursing profession and the urgency of addressing these core requirements.
Although nursing attitudes are good, three primary issues cannot be overcome by positive attitudes: insufficient knowledge, insufficient skills, and insufficient support in terms of training, resources, and time. In addition, it is clear that the capacity for provision of knowledge and skills cannot be left solely to universities because most of the nursing population will not benefit from new advancements in university curriculums. Also, it is clear that the capacity for provision of knowledge, skills, and support cannot be delayed for years to come, as has been the case historically. According to future projections, the capacity for bringing the clinical nursing population's knowledge and skills up to speed will be progressively more difficult with increased need for healthcare from an aging population, increased staffing shortages, continued struggles with limited funds, and increased technology advancements that require additional training.
Finally, the current research indicates a large number of gaps in the nursing profession that render US nurses unprepared for evidence-based practice. Pravikoff et al6 identified that the issues are related to gaps in information literacy and computer skills and attitudes toward research. Some studies, two of which are included in this review, evaluated use of electronic clinical information resources by certain clinical populations, but these studies were small-scale and had several limitations, which made the results less informative. However, the results that were obtained from both studies indicated that clinical nurses need additional training before utilization of electronic information resources would be a viable tool in the clinical setting. It is evident from research and available literature that the core issues for why informatics knowledge and skills of the clinical population have not been thoroughly studied is due to several contributing factors. The primary contributing factors are (1) the absence of clearly defined informatics competencies for job-specific titles, (2) absence of standardized tools for evaluating each informatics competency component, (3) absence of standardized guidelines for development of tools to evaluate informatics competency in a clinical setting, and (4) practical limitations that make it difficult to effectively study the clinical population in this regard.
The issues remaining to be addressed should begin with the identification of job-specific competencies based on the research of Staggers et al.5 In addition, the development of evaluation tools should be published for each of the competencies that Staggers et al5 produced. These two advances will then enable the efficient and effective evaluation of the nursing population and thereby enable focused development efforts in advancing the overall nursing population's knowledge base in the proper direction needed to facilitate the growth of informatics, implementation of evidence-based practice, and effective efficient use of electronic-based healthcare systems.
The author thanks Dr Sue Boren and Dr Jonathan Halbesleben of the University of Missouri at Columbia, School of Medicine's Health Information Management program, for their thoughtful and insightful review of this article during its preparation.
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