HEALTH INFORMATION TECHNOLOGY (HIT), and, more specifically, nursing informatics, is the driving force for the transformation of health care in the United States. This is evident with the signing of The American Recovery and Reinvestment Act of 2009, which encourages providers to become “meaningful users” of an electronic health record (EHR), and, beginning in 2015, reimbursement for care delivery will be attached to EHR adoption and compliance.1 A main goal of this act is to “provide affordable health care” with the help of HIT. In another example, the 2010 Institute of Medicine report titled, “The Future of Nursing: Leading Change, Advancing Health,” identified technology as the means toward both increased patient safety and cost-efficient care, citing nurses as having a “fundamental role” in this technology transformation.2 These movements call for a heightened need for HITs to be studied along with the role nursing plays in the clinical use of such technologies.
Nurses' role in patient care has evolved and so has their role in the use of technology to improve health care delivery. Nursing informatics is the subdiscipline of health informatics that applies information technology to the skills and work of nurses in health care. It integrates the science of nursing, computer technology, and information science to enhance the quality of the nursing practice through improved communication, documentation, and efficiency. Nursing informatics research seeks to study this science and make findings available to nursing leadership in order to inform operations in health care organizations. However, nursing leadership is not always aware of nursing informatics research studies, as they may not be readily available. The purpose of this study was to present the findings of a nursing informatics literature review and highlight those publications seen as most influential to the specialty by a group of experts in the last year. In addition, we seek identify common topics and emerging themes in nursing informatics.
A structured systematic review of the literature was conducted on published nursing informatics studies between August 1, 2011, and August 1, 2012. Both automated and manual search methods were used to compile an annotated bibliographical database. For the automated search, MeSH key words were used in both title and abstract to search for the terms “nursing informatics” and “informatics.” The search was conducted in the following databases: CINAHL, PubMed, AcademicOne, and ScienceDirect, which yielded 253 articles, with 150 from PubMed and 62 from CINAHL (Table 1). Articles filtered for inclusion required the first author to be a nurse, scholarly research in nature, and from a published, peer-reviewed journal.
The manual search consisted of an e-mail inquiry to members of the American Medical Informatics Association, Nursing Informatics Working Group (AMIA-NIWG), for citations that met the aforementioned criteria and are considered most influential to their work, practice, and/or thinking. From this e-mail request, 15 articles were identified by the AMIA-NIWG members.
From this initial search, duplicate articles and those without a nurse as primary author were eliminated from the study. The remaining articles were manually reviewed by the project team members for the publication journal, research setting, topic, and methods. Team member agreement of 100% was used to further eliminate articles that did not meet criteria (Figure).
A total of 80 published studies were found between August 1, 2011, and August 1, 2012. The process of removing duplicate articles and excluding articles that did not meet criteria through review resulted in 69 articles from the automated literature review and 11 unique ones from the AMIA-NIWG member submissions. Nursing informatics research was published predominately in Computers, Informatics, Nursing: CIN (33 publications). Five articles were published in the International Journal of Medical Informatics, and 4 were published in Journal of Biomedical Informatics and Journal of the American Medical Informatics Association (JAMIA). Thirty-four journals published the remaining articles. These journals ranged from an informatics online journal, Online Journal of Nursing Informatics to Nursing Management, and journals focusing on specific patient populations and areas of nursing specialty. The number of articles per journal is summarized in Table 2.
Research was conducted in acute care areas or hospital settings (34 articles or 42.5%), community settings (12 articles or 15%), and online, education, and ambulatory care areas. The setting characteristics are summarized in Table 3.
Nursing informatics research focused on several topics ranging from the EHR (14 articles), monitoring (12 articles), and human-computer interaction (8 articles) to bar code medication administration (2 articles). Three areas of focus are related but separated by agreement: terms/standardization (9 articles), communication (3 articles), and transitions/handoffs (2 articles).
Of the 80 research articles, 25 (31.25%) were categorized as using qualitative methods, 43 (53.75%) used quantitative methods, and 12 (15%) used mixed-methods designs. Research designs and data collection methods ranged from systematic reviews of the literature, chart reviews, case studies, interviews, focus groups, observations, surveys, secondary analyses, and variations on quasi-experimental studies. Furthermore, researchers used techniques in mapping and cognitive work analysis. The element of time was a focus of nursing informatics research using longitudinal, retrospective, prospective, and interrupted time-series studies.
ARTICLES RECOMMENDED BY INFORMATICS EXPERTS
As described, we elicited articles from nursing informatics experts, AMIA-NIWG members. The articles are presented later with both a brief overview of the article and, in part, rationale for recommendation from our members. This systematic review examined both the content and the structure of each peer-reviewed publication. Patient safety and impact on health care cost were themes of a variety of articles selected for inclusion for this literature review as evidenced by those articles recommended by nursing informatics experts. Refer to Table 4 for a list of each member recommended article.
A series of articles describe the efforts by a large Midwestern interdisciplinary research team working to design technologies to support “Aging in Place.” The goal of the 4-year project was to reduce avoidable hospitalizations, facilitate improved transitions of care, reduce costs, and ultimately reduce outcomes. Alexander and colleagues3 published research performed in an early independent living facility where sensors monitored elderly activity. This study resulted in 26 recommendations for sensor data-interface improvement. Rantz et al,4 in the same environment, using mix-methods and retrospective and prospective elements of time, found that participants reported increased confidence and relevance of the sensor data. Using a retrospective review of data, Alexander and colleagues5 described the evolution of early illness warning system in an elderly independent living facility. Sensor data are suggestive that this technology assisted in decisions for care as changes in health were detected and, in some cases, days before visiting the physician or hospital.
Fossum et al6 used quasi-experimental study design to evaluate the effects on the risks for and prevalence of pressure ulcers. As a result of this intervention, the number of malnourished residents decreased with the intervention. Rantz et al4 explored the use of bedside electronic medical record to improve care in long-term care environment. Using qualitative research methods, researchers determined that vendors should match their product with the needs of the long-term care environment, communication did improve between certified nursing assistants and nurses, and clinical information was easier to access and was more comprehensive. A consequence was identified that the electronic record did require more time to document care.
The article by Caligtan and colleagues7 was recommended as it describes further refinement and testing of Dyks's earlier approach for communicating fall prevention strategies and is a comprehensive study. Research performed in the hospital environment and with mixed-methods research design, this study sought to identify essential data elements used to define requirements for a bedside communication tool. Results were suggestive that patients sought information about their schedule and general hospital routines. Nurses were focused on nursing interventions while being cognizant of patient safety.
Research by Carrington and Effken8 captures how nurses view the EHR with and without nursing languages embedded, which should stimulate further research in the area. This research was also performed in the hospital environment, using qualitative research methods where nurses' use of the EHR with and without nursing languages was compared. Generally, nurses perceived the EHR to enhance irretrievability of patient information; however, the EHR was perceived as not efficient and with barriers since documentation lacked relevance for continuing patient care.
The work by Dowding and colleagues9 is one of the first analyses to link EHRs to nurse-sensitive outcomes. Conducted in 29 California hospitals, using interrupted time-series study, researchers found statistically significant associations between EHR implementation and an increase in documentation of hospital-acquired pressure ulcer risk but not for fall risk. The implementation was also associated with a 13% decrease in hospital-acquired pressure ulcer rates but not a decrease in falls.
Effken and colleagues10 used organization risk analyzer (ORA) to explore the relationship of nursing unit communication to patient safety and quality outcomes. This is likely the first time that overall nursing unit communication patterns have been linked to patient safety and quality outcomes specific to falls and medication errors. It is also a good example of applying a network analysis to nursing. This research used ORA to identify patient care unit communication patterns and identified more connections within shift than across shifts and greater on day shift for patient falls. Generally, ORA was an effective method for exploring communication patterns on nursing units.
Another study by Effken and colleagues11 demonstrated the usefulness of cognitive work analysis, designed for complex systems such as nuclear power plants, in nursing. This method of analysis was used to explore the work of nurse managers and how understanding their workflow can better inform the design of decision support tools that they can use to improve care outcomes. Research was performed in the hospital environment and used all domains of cognitive work analysis to better understand the environmental constraints that impact nurse managers and their need for decision support tools. This study revealed the competing priorities experienced by nurse managers and the external constraints they negotiate in decision making without support tools. Researchers concluded dashboards were helpful but lacked the “what if” decision assistance.
The work done by Koch et al12 was put forward for its success in identifying the informal challenges nurse participants faced; information was fragmented and with many gaps. Information was either difficult to access or difficult to read at a distance. The authors argued for more integrated displays to prevent errors and enhance practice. This work was performed in the hospital environment, using systematic observation. Authors recommended integrated consolidated information displays to improve nurses' situational awareness.
Matney and colleagues13 utilized quantitative research methods to create an interoperable set of diagnosis for use in Patient Problem List in the EHR to support interoperability. A total of 1320 concepts were returned by search in UMLS Metathesaurus query or nurse diagnosis, and duplicates were removed. Concepts were mapped to SNOMED CT, with a final data set of 369. The publication of the Nursing Problem List subset of SNOMED is significant for nursing and is representative of the work leading toward standardization.
The work by Moss and Saba14 is a noteworthy demonstration of using the Clinical Care Classification System for costing acute care nursing. It is unlikely that nursing care will be reimbursed directly; but it is a great approach for costing out nursing care in general and may be a model for others to follow. Using quantitative research methods, researchers combined an established methodology for coding nursing interventions and action types using Clinical Care Classification System with reliable formula-costing nurse services. The cleaned data set included 37 unique interventions and represented 5 interventions. Findings included the following: the cost for care coordination was calculated at $2.43, compared with nursing reassess monitoring at $4.22, and medication treatment calculated at $6.33.
Schnall and colleagues15 focused their work on the ambulatory care environment and used quantitative research methods to develop a prototype of Continuity of Care Record with context links for information to support care for patients with HIV. Participants acknowledged that the system worked well with ease of use, convenience, and understandability; however, labels for resources did not work well, such as transportation. This article expands the use of infobuttons to provide context-specific links to HIV management information resources. It is a natural extension to providing information to caregivers at the point of care.
With a relevant review of the various usability methodologies currently reported in the literature, Yen and Bakken16 successfully classified methods by their targets: system development life cycle. This work can assist researchers in more appropriate selection and application of usability methods, as well as readers of the research in assessing the strength of the methodology and its application. This literature review successfully classified studies according to the system development life cycle, and researchers stated that most studies focused on phases 4 and 5, noting that vendors or preimplementation had completed 3 prior stages.
As mentioned, this study explored the findings of a nursing informatics literature review and highlighted those articles seen as most influential in the last year. In addition, we identified common topics and emerging themes in nursing informatics. The emerging themes were medication administration, interdisciplinary communication, technology interventions, the use of decision support tools and nursing terminology, patient engagement, and nursing workflow efficiencies. We believe that nursing informaticists are performing noteworthy research and hypothesize that the lessons learned can be applied to nursing operations in order to ultimately enhance patient care.
The current review of literature was for a limited period of time, and we believe that by extending this effort over time, more lessons can be learned and bigger themes will arise. This review of the nursing informatics literature is planned to be an annual project, allowing for further exploration of trends in nursing informatics research. We recognize that by limiting the literature search to “nursing informatics” and “informatics” as umbrella terms, there is a strong likelihood that additional nursing informatics research articles were not included. The authors of this article are not suggesting that this work was omitted or not considered as relevant work building the science. To address this known limitation, there was a reliance on the AMIA-NIWG members to submit citations that might have been missed during the automated search. This manual method of literature review will also be repeated as a feature in the year in review of nursing informatics research. Further studies on the perceptions and impact of informatics research on nursing leadership may yield important results.
Overall, there is a large body of nursing informatics publications that cover important topics and themes to be considered by nursing leadership in the operations of health care organizations. The design, implementation, and evaluation of nursing technologies show promise in nursing efficiencies that may ultimately impact patient safety and health care cost. This literature review serves to highlight such work and its implications on the field of nursing and technology and patient care.
1. H.R. 1—111th
Congress: American Recovery and Reinvestment Act. 2009. GovTrack.us (database of federal legislation). http://www.govtrack.us/congress/bills/111/hr1
. Accessed December 9, 2012.
2. Institute of Medicine. The future of nursing: Leading change, advancing health. http://books.nap.edu/openbook.php?record_id=12956&page=R1
. Published 2010. Accessed December 9, 2012.
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