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.
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.
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.
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.
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.
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.
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).
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.
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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).