In recent years, hackers have targeted medical records, from hospitals and other healthcare institutions, across the country. These records

C o p y r i g h t 2 0 1 5 . A m e r i c a n N u r s e s A s s o c i a t i o n . A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r

U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

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Standards of Practice for Nursing Informatics Nursing

Standard 1. Assessment The informatics nurse collects comprehensive data, information, and emerging evidence pertinent to the situation.

Standard 2. Diagnosis, Problems, and Issues Identification The informatics nurse analyzes assessment data to identify diagnoses, problems, issues, and opportunities for improvement.

Standard 3. Outcomes Identification The informatics nurse identifies expected outcomes for a plan individualized to the healthcare consumer or to the situation.

Standard 4. Planning The informatics nurse develops a plan that prescribes strategies, alternatives, and recommendations to attain expected outcomes.

Standard 5. Implementation The informatics nurse implements the individualized plan.

Standard 5A. Coordination of Activities The informatics nurse coordinates planned activities.

Standard 5B. Health Teaching and Health Promotion The informatics nurse employs informatics solutions and strategies for education and teaching to promote health and a safe environment.

Standard 5C. Consultation The informatics nurse provides consultation to influence the identified plan, enhance the abilities of others, and effect change.

Standard 6. Evaluation The informatics nurse evaluates progress toward attainment of outcomes.

The Standards of Practice for Nursing

Informatics describe a competent level of nursing

care as demonstrated by the critical thinking

model known as the nursing process. The

nursing process includes the components of

assessment, diagnosis, outcomes identification,

planning, implementation, and evaluation.

Accordingly, the nursing process encompasses

significant actions taken by nursing informatics nurses and forms the

foundation of the nurse’s decision-making.

source: American Nurses Association (2015). Nursing Informatics: Scope and Standards of Practice, 2nd Edition. Silver Spring, MD: Nursesbooks.org.

ANA Standards of Nursing Informatics Practice

http://www.Nursingworld.org © 2015 ANA

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American Nurses Association Silver Spring, Maryland

2015

Nursing Informatics: Scope and Standards of Practice Second Edition

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The American Nurses Association (ANA) is a national professional association. This publication, Nursing Informatics: Scope and Standards of Practice, Second Edition, reflects the thinking of the practice specialty of nursing informatics on various issues and should be reviewed in conjunction with state board of nursing policies and practices. State law, rules, and regulations govern the practice of nursing, while Nursing Informatics: Scope and Standards of Practice, Second Edition, guides informatics nurses in the application of their professional skills and responsibilities.

The American Nurses Association is the only full-service professional organization representing the interests of the nation’s 3.1 million registered nurses through its constituent/state nurses associations and its organizational affiliates. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on healthcare issues affecting nurses and the public.

American Nurses Association 8515 Georgia Avenue, Suite 400 Silver Spring, MD 20910-3492 1-800-274-4ANA http://www.Nursingworld.org

Published by Nursesbooks.org The Publishing Program of ANA http://www.Nursesbooks.org/

Copyright © 2015 American Nurses Association. All rights reserved. Reproduction or transmission in any form is not permitted without written permission of the American Nurses Association (ANA). This publication may not be translated without written permission of ANA. For inquiries, or to report unauthorized use, email [email protected]

ISBN-13: 978-1-55810-580-5 SAN: 851-3481 11/2014

First printing: November 2014.

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iii

Contents

Contributors vii

The Scope of Nursing Informatics Practice 1 Introduction 1 Definition of Nursing Informatics 1 Metastructures, Concepts, and Tools of Nursing Informatics 2

Metastructures: Data, Information, Knowledge, and Wisdom 2 Integration of Nursing Informatics into Practice 6 Nursing Informatics Practice 7 Tenets of Nursing Informatics 8 Nursing, the Nursing Process, and Vocabularies 9 Concepts and Tools from Information Science and

Computer Science 14 User Experience and Related Concepts 14 Phenomenon of Nursing 16

Functional Areas of Nursing Informatics 18 Administration, Leadership, and Management 19 Systems Analysis and Design 21 Compliance and Integrity Management 22 Consultation 24 Coordination, Facilitation, and Integration 24 Development of Systems, Products, and Resources 26 Education and Professional Development 27 Genetics and Genomics 29 Information Management and Operational Architecture 30 Policy Development and Advocacy 31 Quality and Performance Improvement 32 Research and Evaluation 32

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iv Nursing Informatics: Scope and Standards of Practice, 2nd Edition

Safety, Security, and Environmental Health 34 Integrated Functional Area Example: Telehealth and Informatics 36

Evolution of Informatics Competencies 37 Informatics Competencies Requisite for All Registered Nurses 37 Research About Nursing Informatics Competencies 39 Professional Organization Discussions on Informatics

Competencies 40 Healthcare Leadership Alliance 40 American Organization of Nurse Executives 40 Quality and Safety Education for Nurses 40 National League for Nursing 41 TIGER Initiative Foundation 41

Informatics Competencies: Spanning Careers and Roles 41 Informatics Competencies for Informatics Nurses and Informatics

Nurse Specialists 43 Informatics Competencies for Nurse Educators 43 Office of the National Coordinator for Health Information

Technology 44 Synthesis of Evolution of NI Competencies 46

Preparation for Nursing Informatics Specialty Practice 47 Certification of Informatics Nurses 48 An Advancing Professional Nursing Specialty 48

Ethics in Nursing Informatics 49 The Future of Nursing Informatics 52

Trends in Practice Roles and Competencies for Nurses and Informatics 52

Trends in Technology 53 Nanotechnology 54 Tools for Managing Population Health Concerns 54 Devices and Hardware 55 Robotics 57 Focus of Emerging Technologies 57 Knowledge Representation 59 Educational Technologies 59 Tools for Patient Access to Health Information 60 Expanded Use of IT in Nursing 60 Implications for Nursing Informatics 62

Trends in Regulatory Changes and Quality Standards 62

Contents

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition v

Trends in Care Delivery Models and Innovation 63 Consumer Informatics 64 External Partnerships 65 Implications for Nursing Informatics 65

NI Future and Trends: Summary 66

Standards of Nursing Informatics Practice 67 Significance of the Standards 67 Standards of Practice for Nursing Informatics 68

Standard 1. Assessment 68 Standard 2. Diagnosis, Problems, and Issues Identification 70 Standard 3. Outcomes Identification 71 Standard 4. Planning 72 Standard 5. Implementation 73 Standard 5a. Coordination of Activities 75 Standard 5b. Health Teaching and Health Promotion 76 Standard 5c. Consultation 77 Standard 6. Evaluation 78

Standards of Professional Performance for Nursing Informatics 79 Standard 7. Ethics 79 Standard 8. Education 81 Standard 9. Evidence-Based Practice and Research 83 Standard 10. Quality of Practice 84 Standard 11. Communication 86 Standard 12. Leadership 87 Standard 13. Collaboration 89 Standard 14. Professional Practice Evaluation 91 Standard 15. Resource Utilization 92 Standard 16. Environmental Health 93

Glossary 95

References 97

Appendix A. An Emerging Model of Wisdom 107

Appendix B. Nursing Informatics: Scope and Standards of Practice (2008) 109

Contents

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Index 205

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vii

Contributors

Work Group Members William Donovan, MA, RN, Chairperson

Linda Dietrich, MSN, RN-BC, PMP, CPHQ

Sandra Blair Ekimoto, MBA, BS, RN

Paulette Fraser, MS, RN-BC

Sharon Giarrizzo-Wilson, MS, RN-BC, CNOR

Linda Harrington, PhD, DNP, RN-BC, CNS, CPHQ, CENP, CPHIMS, FHIMSS

Luann Whittenburg, PhD, RN-BC, FNP-BC, CPHQ, CPHIMS

Kathleen “Katie” Hoy Johnson, DNP, RN-BC, NCSN

Mary Lynn McHugh, PhD, RN

Leigh Ann Chandler Poole, PhD, RN, FNP-BC, CRNP, CTCP, CTC

Cheryl D. Parker, PhD, RN-BC, FHIMSS

Troy Seagondollar, MSN-I, RN-BC

Nadia Sultana, DNP, MBA, RN-BC

Advisory Group Members Theresa L. Calderone, EdD, Med, MSN, RN-BC

Lory J. Maddox, MSN, MBA, RN

Susan A. Matney, MSN, RN, FAAN

Darla Shehy, MSN, RN

Rhonda Struck, BSN, RN, MS

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viii Nursing Informatics: Scope and Standards of Practice, 2nd Edition

American Nurses Association Staff Carol Bickford, PhD, RN-BC, CPHIMS, FAAN

Maureen Cones, Esq.

Eric Wurzbacher, BA

Yvonne Humes, MSA

About the American Nurses Association The American Nurses Association (ANA) is the only full-service professional organization representing the interests of the nation’s 3.1 million registered nurses through its constituent/state nurses associations and its organizational affiliates. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, project- ing a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on healthcare issues affecting nurses and the public.

About Nursesbooks.org, The Publishing Program of ANA Nursesbooks.org publishes books on ANA core issues and programs, including ethics, leadership, quality, specialty practice, advanced practice, and the pro- fession’s enduring legacy. Best known for the foundational documents of the profession on nursing ethics, scope and standards of practice, and social policy, Nursesbooks.org is the publisher for the professional, career-oriented nurse, reaching and serving nurse educators, administrators, managers, and research- ers as well as staff nurses in the course of their professional development.

Contributors

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1

The Scope of Nursing Informatics Practice

Introduction The American Nurses Association (ANA) identified nursing informatics as a nursing specialty in 1992. The first scope of practice statement for this specialty, Scope of Practice for Nursing Informatics, was published in 1994, followed by the 1995 release of an accompanying resource, Standards of Practice for Nursing Informatics. Those early publications were replaced in 2001 by the Scope and Standards of Nursing Informatics Practice, which combined both the scope and standards of practice into one document and created an enhanced and more robust definition of nursing informatics to reflect the contemporary healthcare informatics environment. The 2008 Nursing Informatics: Scope and Standards of Practice followed with a slightly revised specialty definition of nursing informatics and inclusion of an expanded presentation of compe- tencies for the informatics nurse and informatics nurse specialist.

The publication of this second edition of Nursing Informatics: Scope and Standards of Practice is the culmination of an 18-month-long intensive pro- fessional review and revision initiative hosted by ANA. Dedicated workgroup members with more than 280 person-years of nursing and informatics exper- tise met at least twice a month via telephone conference calls from April 2013 until the final draft was completed in July 2014. Weekly meetings became the norm as the workgroup members evaluated every response received from the 30-day public comment period. The final draft completed a two-step ANA review process with examination by the ANA Committee on Nursing Practice Standards and final approval by the Board of Directors.

Definition of Nursing Informatics Nursing informatics (NI) is the specialty that integrates nursing science with multiple information and analytical sciences* to identify, define, manage, and

* A listing of sciences that integrate with nursing informatics includes, but is not limited to: computer science, cognitive science, the science of terminolo- gies and taxonomies (including naming and coding conventions), information management, library science, heuristics, archival science, and mathematics.

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2 Nursing Informatics: Scope and Standards of Practice, 2nd Edition

The Scope of NurSiNg iNformaTicS pracTice

communicate data, information, knowledge, and wisdom in nursing practice. NI supports nurses, consumers, patients, the interprofessional healthcare team, and other stakeholders in their decision-making in all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes, and information technology.

The nursing informatics specialty and its constituent members contribute to achieving the goal of improving the health of populations, communities, groups, families, and individuals. Supporting activities include, but are not limited to, the identification of issues and the design, development, and implementation of effective informatics solutions and technologies within the clinical, admin- istrative, educational, and research domains of practice.

Metastructures, Concepts, and Tools of Nursing Informatics

Metastructures: Data, information, Knowledge, and Wisdom In the mid-1980s, Blum (1986) introduced the concepts of data, information, and knowledge as a framework for understanding clinical information systems and their impact on health care. Blum classified clinical information systems accord- ing to the three types of objects that these systems processed: data, information, and knowledge. Blum noted that the classification was artificial, with no clear boundaries, although the categories did represent a scale of increasing complexity.

In 1989, Graves and Corcoran built on these ideas in their seminal study of nursing informatics using the concepts of data, information, and knowl- edge. They contributed two general principles to NI: a definition of nursing informatics that has been widely accepted in the field, and an information management model that identified data, information, and knowledge as key components of NI practice (Figure 1).

Drawing from Blum’s 1986 work, Graves and Corcoran defined the three concepts as follows:

■ Data are discrete entities that are described objectively without interpretation.

■ Information is data that have been interpreted, organized, or structured.

■ Knowledge is information that is synthesized so that relationships are identified and formalized.

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The Scope of NurSiNg iNformaTicS pracTice

Nursing Informatics: Scope and Standards of Practice, 2nd Edition 3

Data, information, and knowledge are of value to nurses in all areas of prac- tice. Data may be obtained from multiple sources; the data are processed into information and then into knowledge. For example, data derived from direct care of an individual can be compiled across disease states and then aggregated for decision-making by nurses, nurse administrators, or other health profes- sionals. Further aggregation can encompass geographical populations. Nurse educators can create case studies using these data, and nurse researchers can access the aggregated data for systematic study.

The appropriate use of knowledge involves the integration of empirical, ethi- cal, personal, and aesthetic knowledge into actions. The individual must apply a high level of empirical knowledge in understanding the current situation, apply a professional value system in considering possible actions, be able to predict the potential outcome of these actions with a high level of accuracy, and then have the means to carry out the selected action in the given environment.

Wisdom is defined as the appropriate use of knowledge to manage and solve human problems. It consists of knowing when and how to apply knowledge to deal with complex problems or specific human needs (Nelson & Joos, 1989; Nelson, 2002; Nelson & Staggers, 2014). Whereas knowledge focuses on what is known, wisdom focuses on the appropriate application of that knowledge and an appreciation of the consequences of selected actions. For example, a knowledge base may include several options for managing an anxious family; wisdom involves nursing judgment about which of these options is most appro- priate for a specific family, and use of that option in the care of that family.

An example can help distinguish data, information, knowledge, and wis- dom. If a nurse receives the list of numbers, 28, 68, 94, 98, and 110, those raw numbers are certainly data, but they are meaningless. If, however, the numbers are ordered, structured, and identified as follows: T 98o, P 94, R 28, and BP 110/68, the nurse recognizes this series as measurements of vital signs and will regard those numbers as information. Nevertheless, the nurse

Figure 1. Conceptual Framework for the Study of Nursing Knowledge Source: Graves & Corcoran (1989). Reprinted with permission of the publisher.

Information KnowledgeData

Management processing

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4 Nursing Informatics: Scope and Standards of Practice, 2nd Edition

The Scope of NurSiNg iNformaTicS pracTice

must be able to place these measures in the context of a particular patient’s situ- ation in order to interpret the meaning of those values. If these vital signs were obtained from a newborn, they mean one thing; if they were obtained from an adult, they have a very different meaning. The nurse’s knowledge of normal vital sign values for different types of patients, and the condition of the patient from whom the numbers were obtained, provide a context within which the nurse can interpret the information. Then the nurse will know if the numbers represent a normal, expected result or an abnormal, even pathological result. The numbers must be placed in a particular context so that the nurse can take appropriate clinical action, thereby demonstrating “knowledge-in-use” or wisdom.

Figure 2 builds on the work of Graves and Corcoran by depicting the relationship of data, information, knowledge, and wisdom. As data are

Figure 2. The Relationship of Data, Information, Knowledge, and Wisdom

(Copyright 2002 Ramona Nelson, Ramona Nelson Consulting. All rights reserved. Reprinted

with permission.)

Data Naming, collecting,

and organizing

Information Organizing and

interpreting

Knowledge Interpreting,

integrating, and understanding

Wisdom Understanding, applying, and applying with compassion

Data Naming, collecting,

and organizing

Information Organizing and

interpreting

Knowledge Interpreting,

integrating, and understanding

Wisdom Understanding, applying, and applying with compassion

Constant flux

Increasing interactions and interrelationships

In cr

e a si

n g c

o m

p le

xi ty

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The Scope of NurSiNg iNformaTicS pracTice

Nursing Informatics: Scope and Standards of Practice, 2nd Edition 5

transformed into information and information into knowledge, each level increases in complexity and requires greater application of human intellect. The x-axis represents interactions within and the interrelationships between the concepts as one moves from data to wisdom; the y-axis represents the increas- ing complexity of the concepts.

Figure 3 reflects Nelson’s recent evolution of her 2002 model depicting the dynamic interactivity of the inter- and intra-environmental factors that influence the movement across and within the data-to-wisdom continuum.

In a newly published model, Nelson identifies how information, decision support, and expert systems represent and enable the evolution of data to information to knowledge to wisdom (Figure 4). For some additional details on an emerging wisdom model, see Appendix A.

Figure 3. Revised Data Information Knowledge Wisdom (DIKW) Model—2013 Version (© 2013 Ramona Nelson, Ramona Nelson Consulting. All rights reserved. Reprinted with

permission.)

Data Naming, collecting,

and organizing

Information Organizing, interpreting

Knowledge Interpreting, integrating,

understanding

Wisdom Understanding,

applying, integrating service with compassion

Constant flux

Increasing interactions and interrelationships

In cr

e a si

n g c

o m

p le

xi ty

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6 Nursing Informatics: Scope and Standards of Practice, 2nd Edition

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Benner (1984) defined the experiential stages of the nursing professional in Novice to Expert: Excellence and Power in Clinical Nursing Practice. Englebardt and Nelson (2002) also integrated wisdom into their model. Benner, Hooper- Kyriakidis, and Stannard (2011) have contributed Thinking-in-Action as an approach to administration of care. The addition of wisdom raises new and important research questions, challenging the profession to develop tools and processes for classifying, measuring, and encoding wisdom as it relates to nursing and informatics education. Research in these directions will help clarify the relationship between wisdom and the intuitive thinking of expert nurses. Such research will also be invaluable in building information systems to better support healthcare practitioners in decision-making.

integration of nursing informatics into Practice Data, information, knowledge, and wisdom are central to effective healthcare delivery. Nurses are skilled in managing and communicating information and

Figure 4. Moving from Data to Expert Systems Version (© 2013 Ramona Nelson, Ramona Nelson Consulting. All rights reserved. Reprinted with

permission.)

Data Naming, collecting,

organizing

Information Organizing, interpreting

Information system

Decision support system

Knowledge Interpreting, integrating,

understanding

Wisdom Understanding,

applying, integrating service with compassion

Increasing interactions and interrelationships

In cr

e a si

n g c

o m

p le

xi ty

Expert system

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The Scope of NurSiNg iNformaTicS pracTice

Nursing Informatics: Scope and Standards of Practice, 2nd Edition 7

are always concerned with content quality. Nursing informatics is also con- cerned with the creation, structure, storage, delivery, exchange, interoperability, and reuse of nursing and clinical information along the continuum of care. As electronic health information systems are integrated into every nursing role and setting, the use of technology at the point of care delivery; the external use of clinical information for quality, legal, and regulatory activities; and the use of analytics of data and metadata contribute to the creation of new nursing knowledge. Such an evolution in the healthcare environment and ubiquitous use of data, information, and knowledge resources contribute to the blurring of the boundaries between the roles of nurses, informatics nurses, and infor- matics nurse specialists.

The informatics nurse (IN) is a registered nurse with an interest or experi- ence in an informatics field, most often identified as nursing informatics. The informatics nurse specialist (INS) is a registered nurse with formal graduate- level education in informatics or an informatics-related field. The informatics nurse specialist is often responsible for implementing or coordinating projects involving multiple professions and specialties. Both INs and INSs employ their unique informatics knowledge, experience, and skills to support and enable other registered nurses to best use data, information, knowledge, and technology in their practice domain. They interact with healthcare consum- ers and other diverse stakeholders across all care settings and throughout the entire system life cycle.

nursing informatics Practice As previously presented, nursing informatics (NI) is the specialty that inte- grates nursing science with multiple information and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice. NI supports nurses, consumers, patients, the interprofessional healthcare team, and other stakeholders in their decision- making in all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes, and information technology.

Note that information technology does not define NI. The synthesis of data and information into knowledge and wisdom is a core principle of NI, while information technology supports a system lifecycle process. Both the IN and the INS strive to master information management and information technology in the design, structure, retrieval, presentation, storage, exchange, and use of data, information, and knowledge. The IN and INS consider the

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8 Nursing Informatics: Scope and Standards of Practice, 2nd Edition

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impact of information and applied computer science on healthcare deliv- ery and the nursing process. Table 1 illustrates the connection between the different foci of nursing and NI. These occur along a continuum without distinct boundaries.

table 1. nursing and nursing informatics Foci

nursing Focus nursing informatics Focus

Nurses, patients, health, environment Information user, information recipients, exchange of data, information, knowl- edge, and wisdom

Content of information, support for evidence-based practice

Design, structure, interpretation, and representation of data, information, knowledge, and wisdom

Using information applications and technology

Design, develop, implement, and evaluate applications and technologies, ensur- ing their safety, quality, effectiveness, efficiency, and usability

tenets of nursing informatics The following tenets of nursing informatics form a framework that character- izes the thinking and actions of informatics nurses in all aspects of practice and in every setting. Nursing informatics

■ Has a unique body of knowledge, preparation, and experience that aligns with the nursing profession. NI incorporates informatics concepts in specific application to the role of nursing and nurses in the health- care continuum.

■ Involves the synthesis of data and information into knowledge and wisdom.

■ Supports the decision-making of healthcare consumers, nurses, and other professionals in all roles and settings to achieve healthcare consumer safety and advocacy.

■ Supports data analytics, including quality-of-care measures, to improve population health outcomes and global health. The IN and INS under- stand that the real-time application of accurate information by nurses and other clinicians is a mechanism to change healthcare delivery and

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