The Role of Nursing Informatics on Promoting Quality of

Health Care and the Need for Appropriate Education

Asieh Darvish, Fatemeh Bahramnezhad, Sara Keyhanian, and Mojdeh Navidhamidi

Abstract
In today’s dynamic health systems, technology plays an important role in education and nursing
work. So it seems necessary to study the role of nurses and highlight the need for appropriate
information technology educational programs to integrate with the ever-increasing pace of
technology. A review accompanied by an extensive literature search in databases and a library
search focused on the keywords were used. The criteria used for selecting studies primarily
focused on nursing informatics and the importance of expertise in the effective use of
information technology in all aspects of the nursing profession. In a critical assessment of
emerging technologies, the key elements of nursing informatics implementation were considered
as healthcare promotion, advanced systems, internet and network. In view of the nature and the
development of the information age, it is required to receive necessary IT training for all
categories of nurses. Due to the fast development of technology, in order to effectively take
advantage of information technology in nursing outcome and quality of health care and to
empower nurses; educational arrangement is recommended to set short-term and long-term
specialized courses focusing on four target groups: studying, working, graduate, senior
undergraduate, and graduate doctoral. The result of this study is expected to assist educational
providers with program development.

1. Introduction

1.1 History and Definition

Nurses has been working in the field of informatics near four decades, the term “nursing
informatics” has been considered a specialization in nursing resources since 1984 (Guenther &
Peters, 2006). Many aspects such as data recovery, ethics, patient care, decision support systems,
human-computer interaction, information systems, imaging informatics, computer science,
information science, security, electronic patient records, intelligent systems, e-learning and
telenursing have been added to the field. Hana has defined Nursing Informatics as the application
of IT in the nursing duties including education, management & practice in 1985. Integration of
information science, computer science and nursing science to support nursing practice and
knowledge management was the definition offered in 1989 by Graves and Corcoran. The
American Nurses Association (ANA) published its aim and standards in 1994-1995 and
presented the Nursing Informatics as a specialty that integrates nursing science, computer and
information science to provide data communication management, knowledge and nursing work
in 2001. Now most of nursing professionals believe that it is defined as the integration of
information technology and all aspects of nursing such as clinical nursing, management, research
or education (Guenther & Peters, 2006).
1.2 Competencies
The competency of nursing informatics specialists was determined through studying three
categories including computer skills, informatics knowledge and informatics skills. It
investigates four levels of nursing practice: beginning nurse, experienced nurse, informatics
specialist, and informatics innovator.
The following competencies were rejected: diagnostic coding, desktop publishing, managing
central facilities to enable data sharing and writing an original computer program (Staggers et al.,
2002). Some components of accepted competencies are shown below in brief.

1.2.1 Computer Skills

Selected computer skill competencies contain computerized searches and retrieving patient
demographics data, the use of telecommunication devices, the documentation of patient care, the
use of information technologies for improving nursing care, and the use of networks and
computer technology safely.

1.2.2 Informatics Knowledge

Selected informatics knowledge competencies are the recognition of the use or importance of
nursing data for improving practice, and the recognition of the fact that the computer can only
facilitate nursing care and that there are human functions that cannot be performed by computers,
the formulation of ethical decisions in computing, the recognition of the value of clinicians’
involvement in the design, selection, implementation, and evaluation of systems in health care,
the description of the present manual systems, the definition of the impact of computerized
information management on the role of the nurse and the determination of the limitations and the
reliability of computerized patient monitoring systems.

1.2.3 Informatics Skills

Informatics skills competencies includes the interpretation of information flow within the
organization, the preparation of process information flow charts for all aspects of clinical
systems, the development of standards and database structures to facilitate clinical care,
education, administration or research. It also includes the development of innovative and analytic
techniques for scientific inquiry in nursing informatics and new data organizing methods and
research designs with the aim of examining the impacts of computer technology on nursing, and
the conducting of basic science research to support the theoretical development of informatics.
Information literacy skills, competencies, and knowledge are investigated among educators,
administrators and clinicians of nursing groups nationally.

1.3 The Importance of Nursing Informatics

The history, definition and competencies of nursing informatics indicate the importance of this
field. It shows nurses are integrated into the field of IT automatically. So they should be able to
deal with it successfully to improve quality of care outcome. In this regard it is required to study
the influence of nursing informatics on health care and make bold the appropriate information
technology educational needs for nurses.
2. Method
An extensive literature search was performed by using databases Pubmed, Google Scholar, Ovid,
Science Direct and SID. Search terms were “education, nursing”; “quality of health care”;
“nursing informatics” and technology. The study was carried out from January to April, 2014. A
library search was also performed. As many as 135 articles were retrieved. With a critical point
of view, 40 articles in English were selected that specifically focused on nursing informatics
education and its influence on nursing outcomes and the quality of health care (Staggers et al.,
2002).

3. Results
The study mentions the followings as the key elements of nursing informatics implementation:

3.1 Health Care Promotion

The advantages of applying information technology in all aspects of nursing, including clinical
areas, management, education and research and its influence on health care have been reviewed.
Today, the subjects of clinical nursing information systems, decision support systems and
medical diagnostic systems are associated with collecting patient information. Regarding the
technology-rich environment, health care and hospital information systems developers, the
quality of care is improving. For increasing patient safety and its leading to an evidence-based
nursing, nursing informatics has been enhanced for students and graduates by Columbia school
of nursing. The study has proved that informatics competence is a prerequisite to improving
patient care (Bakken et al., 2003). Technology and using multimedia integrated into nursing
curriculum can promote the use of informatics tools as an integral practice component and
increase patient safety (Norton et al., 2006). Managers can improve efficiency and performance
through information systems and new technologies. In addition, several studies have confirmed
the impact of careful shift planning and efficient management on nurse’s work and the quality of
health care. Information is the source of all management activities. Nursing care is an industry
service and its product is patient care. Information technology can promote the nursing
management outcome. Internet-based nurse scheduling systems are mostly designed according to
the self-scheduling model and need refining by the manager who overviews proper distribution,
it causes uniform resource allocation in scheduling and increases patient direct care time (Pierce
et al., 2003). Implementing information systems can provide better access to evidence; it can
affect the patient care quality and support evidence-based nursing. Software tools to facilitate
research are available in all medical fields (Kardan & Darvish, 2008). Nursing information
system had an influence on clinical patterns and decreased the time nurses spent on indirect care
(Darvish & Salsali, 2010). This is critical to the health care professionals to assess, apply, report
and manage data by the help of new tools of the information age (Hall, 1995).

3.2 Advanced Systems

Although using decision support systems can lead to a safer care, it may impair critical thinking.
The need for excessive working time could cause some delay in the nursing job and reduce the
quality of health care (Norton, 2006). Researchers recommended considering the following:
 -Involving nurse managers in the system selection and designing process
  -Designing a simple and efficient process
 -Recording a system-compatible guideline
 -Improving the system speed
 -Selecting hardware which can encourage nurses to use them
 -Upgrading the system through innovation in information technology
 Decision support systems have been defined to assist physicians to solve problems that
require specific decisions since 30 years ago. It is replacing the role of human knowledge
by formulating the knowledge in the system (Ting et al., 2008). Expert systems are the
most common types of clinical decision support systems and have applications in show
notes, diagnostic support, critical treatment plans, decision support, prescriptions,
recovery and the identification and the interpretation of pictures, however, as stand-alone
tools, are not able to replace human expertise. These systems should be integrated with
knowledge management. Several studies have shown that the integration of implicit and
explicit knowledge and management of different types of knowledge will help to
determine the best treatment plan. Logical design is required for the success of these
systems and seems to hardly have been considered. The application of guides and easy
access to up-to-date clinical evidence and the cutting of duplicate tests could reduce
medical mistakes and improve quality of care, but there are some limitations (Montani &
Bellazzi, 2002). To increase the usefulness and acceptability of such systems, the ease of
use, support and maintenance combined with the ability of systems hardware, software
applications, integration with hospital information systems and patient records should be
considered (Holbrook et al., 2003). Including smart and intelligent tools in diagnosis and
treatment methods can reduce medical errors and harm as well as financial loss for
humans. Artificial intelligence and expert systems are used to help the diagnosis.

3.3 Internet and Network

The first internet-based Nursing Informatics courses were offered by Duck University in 1997.
Represented advantages were clearly defined and measurable learning outcomes and real-world
problems were introduced as the main component of instructional strategies. There were some
disadvantages like hardware and software problems, deficiency in prerequisite skills,
troubleshooting difficulties, and low internet access speed and poor time management to master
the material (Goodwin, 1997). The evaluation of an innovative consumer health informatics
intervention proved that the patient and nurses are satisfied with the use of electronic and
communication devices and home care (Kossman et al., 2006). Nurses can have networks such
as AJN and AMN now. In the world wide web, it is possible to have a common network for
nursing organizations and develop a forum to discuss nursing issues and design online meetings
(Rizzolo & DuBois, 1995). The other aspects of nursing practice potential in the new decade are
offering services from distance through telemedicine or telenursing. In this regard, easy remote
diagnostic software and hardware are designed to facilitate E-health services. Tele-nurses can
provide various services such as education, patient monitoring and counselling through Internet
facilities. Telenurses are satisfied with their role. They care remotely using special skills and
knowledge. It can cover nurse shortages and the global demand for nurses (Darvish & Salsali,
2010). In a telenursing Survey most of nurses believed that it is better to design educational
programs for nurses to be able to work as telenurse (Grady, 2007). Using online library resources
and outreach programs would be beneficial and produce positive outcomes for nurses (Wozar &
Worona, 2003). Information and communication technology progress provided the possibility of
improving health through e-education irrespective of time and place. Patient education systems
on the internet can increase patient satisfaction and influence their self-care behaviour. E-health
educational programs make people aware of disease management and increase coordination with
the health care professional team. It influences the life style and the prevention of diseases such
as cancer, HIV and chronic diseases. On the other hand, it empowers medical groups by
enhancing and upgrading their knowledge. The web-based computer simulation educational
program in crisis decreased medical errors in emergency departments. Information technology
application refers to providing simultaneous access to education in specified locations which
require huge spending. It decreases cost loss (Kardan & Darvish, 2007). Online access to journal
articles prevents repeated research programs and makes assessment easy. Online databases
provided up-to-date article access and informed nurses about new technologies, easy software
and the results of investigations (Darvish, 2010).

3.4 Related Organizations Activity

National advisory council on nurse education and practice addresses nursing practice challenges;
and mentions electronic health records, patient monitoring systems, bar code medication
administration, computerised provider order entry, data capture tools, care planning tools and
telehealth; and the need to consider nursing shortage, reducing medical errors, improve tracking
of patient data, improve efficiency of data collection, improve access to care, support national
surrveilance capabillities. These are also mentioned as ways to address nursing education
challenges: E-learning to deliver education, simulation to deliver education, inclusion of Health
Care IT in curricula, and faculty development for health care. It centeralizes these as solutions
which can improve capacity of nursing schools, reduce faculty shortage, and increase health IT
skills of graduating students. There are many group projects and organizations which support
nurses’ involvment for optimal use of IT in their job. Some are introduced in the following:
 -The National Coordinator for Health Information Technology (ONC)
 -The American Health Information Community (AHIC)
 -The Nationwide Health Information Network (NHIN)
 -The Faculty Development: Integrated Technology into Nursing Education and Practice
Initiative (ITNEP)
 -National Advisory Council on Nurse Education and Practice (NACNEP)
 -National League of Nursing (NLN)
 -National Institute of Health (NIH)
 -National Institute of Nursing Research (NINR)
 -North American Nursing Diagnosis International (NANDA)
 -Technology Informatics Guiding Education Reform Initiative (TIGER)
It is reported that without proper training for nurses, efforts to integrate healthcare IT with
nursing practice will be hampered. It gives evidence that nurses are not getting adequate training
for IT usage (NACNEP annual report, 2009).

3.5 Need for Educational Programs

Due to the fast growth and development of technology, in order to effectively take advantage of
information technology in nursing outcome and quality of health care, educational arrangement
is recommended to strengthen nurses at different levels for implementing information technology
tools in all aspects of their profession.

4. Conclusion
In today’s world the potential for information and communication technology application is
increasing so that it can enhance the quality of nursing domains outcome (McNelis et al., 2012).
Nurses have the most communication with patients, and interact with technology more
frequently. Using technology should create a positive attitude in nursing productivity. It is
essential for nurses to be involved in the initial design of systems to improve the quality of health
care and change their culture in this regard (Darvish & Salsali, 2010), (Jenkins et al., 2007).
Mediating technically and technologically on the borderline between medicine and nursing,
nurses have become known as the medical Goddesses in the form of Tele-nurses. Nurses have
got more authority in decision-making with the use of new technologies (Gassert, 1998). For
successful implementation of the electronic health reporting system, nurses must be
knowledgeable about information technology, computer skills and informatics knowledge and
skills. In telenursing, the importance of data quality criteria, transparency and integrity,
authenticity, confidentiality, the updating of information, accountability, productivity, standards
and accessibility of health web sites should be considered (Darvish, 2008). The NACNEP
recommended to prepare nurses to adopt intelligent and quality-based information technology
use in patient care by implementing five strategies: providing core informatics courses to nursing
schools, educating nurses specialized in informatics skills who are able to solve related issues,
offering more powerful nursing care through the implication of telecommunication projects,
preparing more nursing faculties in the informatics field to facilitate students skills enhancement
and enhancing collaboration to advance informatics. The benefits of extending nursing
informatics strategies directly and indirectly influence patient and people health positively
(Matarrese & Helwig, 2000). Courses affect nursing students’ perceptions about informatics
(Jetté et al., 2010); and they may learn at the BSc level about patient-centered evidence-based
care through the use of informatics tools, and get informed about benefits such as promotion of
safety, quality and effective clinical decisions (Norton et al., 2006; Ainsley & Brown, 2009). The
may even learn how remote care and personal phone can improve nursing care in different areas
such as psychiatric nursing (Tseng et al., 2012; Goossen, 2007; Wittmann-Price, 2012). At the
same time, nursing workers are busy in the wards giving care. If they are not alert to new
technologies, it will be difficult to accept the new nurses’ ideas who are educated recently with a
positive attitude to the advantages of information technology. This group of nurses can be
encouraged to be integrated into the potential of E-learning as well as continuing education
(Button, 2013), based on the summit of technology informatics guide education reform (Schlak
& Troseth, 2013). It seems necessary to prepare knowledgeable nurses to deal with selecting,
developing, implementing and evaluating IT to interpret data as usable knowledge and
information. In the nursing world, four domains should be empowered. Undergraduate and
diploma programs can be integrated with courses. Graduate programs can be designed. Formal
and informal continued educational programs for nurses on job and fellowships for PhD
graduated nurses can be useful. Trying to make different groups of nurses ready for the ever-
increasing speed of technology in the current century is possible, not only by parallel
opportunities of learning, but also with the help of evaluating tools such as Self-assessment of
nursing informatics competencies scale which can bring the same range of comprehention about
informatics implementation (Choi & Bakken, 2013). In conclusion, considering nursing
outcomes takes advantage of information technology; educational arrangement is recommended
to set short-term and long-term specialized courses focusing on the four target groups.
Informatics courses for nursing students continued educational programs for registered nurses in
work area, graduate programs at MSc and PhD levels for nurses and fellowship programs for
doctoral graduates are recommended to be considered (Figure 1).

Figure 1
The proposed educational model for empowering nurses on the subject of nursing informatics in four
groups
It is essential that nurse educators incorporate the entire concept of informatics into the education of
nurses.

Acknowledgements
It is hereby acknowledged colleagues and all those who assisted in conducting the study or
critiquing the manuscript. The main enthusiasm of this study came out from the international
symposium of telemedicine was held by Tehran University of Medical Sciences.
 REACTION PAPER

Health informatics is information engineering applied to the field of health care,

essentially the management and use of patient health care information. It is a multidisciplinary
field that uses health information technology to improve health care via any combination of
higher quality, higher efficiency, and new opportunities. The disciplines involved include
information science, computer science, social science, behavioral science, management science,
and others.
Health care has and is continuing to evolve as we enter a new technological era. With the
advancements made in science and technology, the medical scene has to keep up with the times,
providing not just adequate but the best quality of care utilizing the new tools available due to
discoveries and advancements. Nursing informatics, an expertise that is relatively new, takes
advantage of technology to enhance the effectiveness of providing care to patients. The
information age and its development along the years requires nurses to acquire even more
knowledge for this field, IT training is almost a necessity for all nurses.
Nurses communicate with patients the most, but not only that, nurses also have to interact
with technological tools the most. Nurses must be hands-on with new programs that aim to
enhance health care and education. For example, for successful implementation of the electronic
health reporting system, nurses must be knowledgeable about information technology, computer
skills and informatics knowledge and skills.
As taxing as it sounds, these tasks can be mastered by early exposure to activities of this
nature. The NACNEP recommended to prepare nurses to adopt intelligent and quality-based
information technology use in patient care by implementing five strategies: providing core
informatics courses to nursing schools, educating nurses specialized in informatics skills who are
able to solve related issues, offering more powerful nursing care through the implication of
telecommunication projects, preparing more nursing faculties in the informatics field to facilitate
students skills enhancement and enhancing collaboration to advance informatics.
The world continues to demand more from medical practitioners, especially nurses. As
new technology and health care programs roll in, nurses must be able to adapt to it, as to not
jeopardize the quality of care. It may seem like things are piling up, with more concepts to study
and skills to learn, but all is worth it when we nurses are able to provide patients with the care
they truly deserve. Mediating technically and technologically on the borderline between
medicine and nursing, nurses have become known as the medical Goddesses.