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EBSCO Publishing : eBook Collection (EBSCOhost) – printed on 4/28/2022 8:49 AM via
AN: 1021761 ; R2 Library (Online service), American Nurses Association.; Nursing Informatics : Scope and Standards of
Practice
Account: s6527200

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

The Scope of NurSiNg iNformaTicS pracTice

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

The Scope of NurSiNg iNformaTicS pracTice

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
affect patient outcomes.

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The Scope of NurSiNg iNformaTicS pracTice

Nursing Informatics: Scope and Standards of Practice, 2nd Edition 9

■ Promotes data integrity and the access and exchange of health data for
all consumers of health information.

■ Supports national and international agendas on interoperability and
the efficient and effective transfer and delivery of data, information, and
knowledge.

■ Ensures that collaboration is an integral characteristic of practice.

■ Interleaves user experience and computer–human interaction concepts
throughout practice.

■ Incorporates key ethical concerns of NI such as advocacy, privacy, and
assurance of the confidentiality and security of data and information.

■ Considers the impact of technological changes on patient safety, health-
care delivery, quality reporting, and the nursing process.

■ Leads in the design and promotion of useful, innovative information
technologies that advance practice and achieve desired outcomes.

nursing, the nursing Process, and Vocabularies
“Nursing is the protection, promotion, and optimization of health and
abilities, prevention of illness and injury, alleviation of suffering through
the diagnosis and treatment of human response, and advocacy in the
care of individuals, families, communities, and populations” (ANA, 2010).
Further explication of nursing practice and its complexity is found in the
established standards of professional nursing practice that incorporate the
nursing process of assessment, diagnosis, outcomes identification, plan-
ning, implementation, and evaluation. Delineated competencies accompany
each standard.

The importance of languages, vocabularies, and terminologies cannot be
overstated when describing nursing practice. Nursing leaders have identified
many different vocabularies and ways of organizing data, information, and
knowledge pertinent to nursing through numerous established research initia-
tives that have spanned decades. In the early 1990s, ANA began to formally
recognize these languages, vocabularies, and terminologies (listed in Table 2)
as valuable representations of nursing practice and to promote the integration
of standardized terminologies into information technology solutions. To date,
none has emerged as the leading standardized resource able to represent all
nursing practice concepts.

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

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table 2. AnA recognized terminologies and Data element sets

AnA-recognized informatics

systems

setting Where

Developed

Content

Data Element Sets

nMDs
Nursing Minimum Data Set

All nursing Clinical data elements

nMMDs
Nursing Management Minimum
Data Set

All settings Nursing administrative
data elements

Nursing-Developed Terminologies

CCC system
Clinical Care Classification
System

All nursing care + other
health professionals

Diagnoses, interven-
tions, and outcomes

iCnP®
International Classification for
Nursing Practice

All nursing Diagnoses, interven-
tions, and outcomes

nAnDA
NANDA International

All nursing Diagnoses

niC
Nursing Interventions
Classification

All nursing Interventions

noC
Nursing Outcomes Classification

All nursing Outcomes

omaha system Home care, public
health, and community

Diagnoses, interven-
tions, and outcomes

PnDs
Perioperative Nursing Data Set

Perioperative care
settings

Diagnoses, interven-
tions, and outcomes

Multidisciplinary Terminologies

AbC
ABC Codes

Nursing and other
health professionals

Interventions

LoinC®
Logical Observation Identifiers,
Names, and Codes

Nursing and other
health professionals

Outcomes and
assessments

snoMeD Ct
Systematic Nomenclature of
Medicine Clinical Terms

Nursing and other
health professionals

Diagnoses, interven-
tions, and outcomes

Adapted from ANA, 2012.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 11

Standardized terminologies have become a significant vehicle for facilitat-
ing interoperability between different concepts, nomenclatures, and infor-
mation systems. Continued evolution, mapping, and integration of concepts,
as well as research efforts, characterize today’s terminology environment in
light of passage of the Health Information Technology for Economic and
Clinical Health (HITECH) Act of 2009. HITECH’s accompanying funding
resources continue to stimulate more rapid movement toward electronic
data capture and health information exchanges (HIEs) (HealthIT.gov, 2009).
Two examples follow.

The International Classification for Nursing Practice (ICNP®), devel-
oped and maintained by the International Council of Nurses (ICN),
provides a global cross-map of nursing terminologies to unite nurs-
ing practice through comparison, new research generation, and to
inform and influence health policy. ICNP® has been harmonized
with SNOMED CT® and offers more than 18 different translations
(ICN, 2013).

The Systematized Nomenclature of Medicine, or SNOMED CT® (http://
www.ihtsdo.org/snomed-ct/), is a comprehensive universal health-
care reference terminology and messaging structure. SNOMED CT®
enables multiple nursing terminology systems to be mapped to one
another through harmonized concepts. Released in 2011, the Nursing
Problem List Subset of SNOMED CT® is the primary coding terminol-
ogy for nursing problems used in clinical documentation and based
on nursing concepts found within the National Library of Medicine’s
Unified Medical Language System (UMLS) Metathesaurus. The
UMLS Metathesaurus includes more than 100 source vocabularies
and is responsible for managing the nursing terminologies mapped
to SNOMED CT®. Other mapping initiatives are underway.

The U.S. federal government formalized its interest in standardized
terms to describe healthcare practice when the Office of the National
Coordinator for Health Information Technology (ONC) established the
HIT Standards Committee with its role to recommend the clinical vocabu-
laries to be used in the electronic specification process (Table 3). Clinical
vocabularies define the concepts used to measure clinical processes and
patient outcomes. Harmonization between the different vocabularies is
necessary to ensure appropriate implementation of the electronic measures
across all electronic health record (EHR) systems. This table does not

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table 3. onC Hit standards Committee recommended Clinical
Vocabulary standards

Vocabulary setting Application Content

CVX Codes for Vaccines
Administered

Nursing and other Vaccines
(administered)

CPt
Current Procedural Terminology

Other Medical, surgical, and
diagnostic services
rendered for claims

CDC-PHin/VADs
CDC-Public Health Information
Network/Vocabulary Access and
Distribution System

Nursing and other Patient characteristic
(administrative gender,
date of birth)

HCPCs
Healthcare Common Procedure
Coding System

Other Medical, surgical, and
diagnostic services
rendered for claims

iCD-9 CM
International Statistical
Classification of Diseases and
Related Health Problems—Clinical
Modification (9th ed.)

Nursing and other Diagnoses and
assessments

iCD-9 PCs
International Statistical
Classification of Diseases and
Related Health Problems—
Procedural Coding System (9th ed.)

Nursing and other Diagnoses and
assessments

iCD-10 CM
International Statistical
Classification of Diseases and
Related Health Problems—Clinical
Modification (10th ed.)

Nursing and other Diagnoses and
assessments

iCD-10 PCs
International Statistical Classification
of Diseases and Related Health
Problems—Procedural Coding
System (10th ed.)

Nursing and other Diagnoses and
assessments

iCF
International Classification of
Functioning, Disability, and Health

Nursing and other Functional status

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 13

iso-639
International Organization for
Standardization Standard 639

Nursing and other Representation
of languages and
language groups

LoinC®
Logical Observation Identifiers,
Names, and Codes

Nursing and other Outcomes and
assessments

rxnorM Nursing and other Normalized clinical
drug names

snoMeD Ct®
Systematic Nomenclature of
Medicine Clinical Terms

Nursing and other Diagnoses, interven-
tions, and outcomes

uCuM
Unified Code for Units of Measure

Nursing and other Units of measure for
results

include recognition of the important codes reflected in the Fifth Edition
of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
released in 2013.

Such diversity and disparity confirm that informatics nurses must seek a
broader picture of the implications of their work and the uses of languages
and vocabularies for documentation by end users and in outcomes analysis.
For instance, nurses mapping a home care vocabulary to an intervention
vocabulary must see beyond the technical aspect of the work to understand
how a case manager for a multisystem health organization or a home care
agency may be basing knowledge of nursing acuity and case mix on the dif-
fering vocabularies. By envisioning the varied uses of the terminologies, the
IN and INS promote continuity in the patient care process by harmonizing
concepts across disparate organizations and EHR systems. Success in this
area mandates active informatics nurse participation in associated standards
initiatives, such as the work being done by Health Level Seven International
(HL7) and the International Health Terminology Standards Development
Organisation (IHTSDO).

Adapted from CMS Measures Management System Blueprint v. 11.0, July 2014

(http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/

MMS/MeasuresManagementSystemBlueprint.html).

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Concepts and tools from information science
and Computer science
Tools and methods from information and computer sciences are fundamental
to NI, including:

■ Information management—An elemental process by which one files,
stores, manipulates, and reports data for various uses.

■ Information communication—Enables systems to send data and to
present information in formats that improve understanding.

■ Information structures—Organize data, information, and knowledge for
processing by computers.

■ Information technology—Includes computer hardware, software,
communication, and network technologies, derived primarily from com-
puter science. Its use distinguishes informatics from more traditional
methods of information management.

user experience and related Concepts
Usability, human–computer interaction (HCI), ergonomics, and human factors
have long been overlapping concepts of fundamental interest to the informatics
nurse. Contemporary thinking has identified user experience as the overarch-
ing descriptive term.

Although the 2001 Institute of Medicine (IOM) report, Crossing the Quality
Chasm: A New Health System for the 21st Century, publicized the importance
of human factors in health care, the emphasis for attention and action related
to usability goes much further. Many researchers (including Ash, Berg, &
Coiera, 2004; Ash, Sittig, Dykstra, Campbell, & Guappone, 2009; Koppel et
al., 2005; Staggers, Jennings, & Lasome, 2010; and Guo, Irdbarren, Kapsandoy,
Perri, & Staggers, 2011) have reported usability issues. Stead and Lin (2009)
concluded from their evaluation of top U.S. electronic health records that the
major impediment to their effectiveness was usability.

ISO 9241-11 defines usability as the extent to which a product can be used
by specific users in a specific context to achieve specific goals with effective-
ness, efficiency, and satisfaction. Usability in healthcare is fundamentally
about patient safety and human performance with tools and systems. Several
resources provide more details about usability:

■ Health Information and Management Systems Society (HIMSS),
Promoting Usability in Health Organizations: Initial Steps and

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 15

Progress Toward a Healthcare Usability Maturity Model (2011),
available at http://www.himss.org/files/HIMSSorg/content/files/
HIMSS_Promoting_Usability_in_Health_Org.pdf

■ National Institute of Standards and Technology (NIST), “Usability” web
page, available at http://www.nist.gov/healthcare/usability/

■ U.S. Food and Drug Administration (FDA), “General Human Factors
Information and Resource” web page, available at http://www.fda.
gov/medicaldevices/deviceregulationandguidance/humanfactors/
ucm124829.htm

■ Tiger Initiative, Designing Usable Clinical Information Systems:
Recommendations from the TIGER Usability and Clinical Application
Design Collaborative Team, available at http://www.thetigerinitiative.
org/docs/TigerReport_Usability_000.pdf

■ Jakob Nielsen of the Nielsen Norman Group (2012), “Usability 101:
Introduction to Usability,” available at http://www.nngroup.com/articles/
usability-101-introduction-to-usability/

HCI examines how people, software applications, and computer technology
interact and influence each other. Elements of HCI are rooted in psychology,
cognitive science, sociology, computer science, and information science. HCI
addresses the design, development, procurement, implementation, and evalu-
ation of applications as well as other components associated with the system
life cycle. For example, an informatics nurse would assess a bar-code medica-
tion administration system before purchase to determine whether the design
and operation complement the way nurses cognitively process medication
administration and document that action.

The IOM’s 2012 report, Health IT and Patient Safety: Building Safer
Systems for Better Care, identifies the importance of HCI in the integration
of applications and technology with healthcare delivery. Such integration into
everyday life has contributed to the empowerment of patients, now often
designated as e-patients, and the promotion of interprofessional collabora-
tion through mobile technology (m-health). This requires the IN and INS to
address all environments and all levels of user ability to assure accommodation
of the various devices being developed.

The IN and INS will also have to consider a variety of sociotechnical issues
and their effect on HCI (Sittig & Singh, 2010). These include clinical experience
level (Cho, Staggers, & Park, 2010), user literacy and user physical limitations

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(Huang, Chen, & Chung, 2005), and aging (Sibley, 2008). In the future, the
convenience of technologies available in commercial products can be expected to
drive similar functionality in healthcare technology and will increase the scope of
HCI factors. Finally, the effect of natural language processing (Zhou, 2007) and
implantable monitoring devices (Topol, 2011) on HCI is yet to be determined.

The term ergonomics refers to attributes of physical equipment or to prin-
ciples of arrangement of equipment in the work environment. For instance,
an informatics nurse may have a role in ensuring that sound ergonomics prin-
ciples are used in clinical settings to guide the selection and arrangement of
various devices to support workflow for interprofessional providers, patients
and their families, and other end users.

In the past, HCI, usability, and ergonomics have typically been subsumed
under the rubric of human factors, or how humans interact with tools, includ-
ing technology. The Human Factors and Ergonomics Society (HFES) identi-
fies ergonomics (or human factors) as “the scientific discipline concerned with
the understanding of interactions among humans and other elements of a
system, and the profession that applies theory, principles, data and methods
to design in order to optimize human well-being and overall system perfor-
mance” (https://www.hfes.org/web/educationalresources/hfedefinitionsmain.
html#profsoc). The concepts of efficiency, effectiveness, and safety are integral
and apply to the client, consumer, and others.

The term user experience encompasses all aspects of users’ interactions.
The International Organization for Standardization (ISO) 9241-11 defines
the term as “a person’s perceptions and responses that result from the use
or anticipated use of a product, system or service.” (ISO, 2009) describes it
as a range of experiences, from walking into a healthcare facility to designs
that fit into complex ecosystems with many users interacting. Development
of high-quality user experiences requires the diverse expertise of many pro-
fessions, such as engineering, graphic and industrial design, interface design,
and psychology. Staggers (2014) identified the interrelationship of the user
experience as encompassing human factors, HCI, ergonomics, and usability,
as displayed in Figure 5.

Phenomenon of nursing
The metaparadigm of nursing comprises four key concepts: nurse, person,
health, and environment. The phenomenon of nursing, both art and science,
is supported by the tenets of nursing informatics. The nurse continuously
collects data about persons, their health, and the environmental factors that

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influence health maintenance and the healing process. Nurses, using their edu-
cation, intellect, and experiential knowledge, place these data into categories
to create information. Finally, using critical thinking and wisdom, the nurse
is able to formulate a plan and prioritize interventions or actions that effect
the most positive outcome possible for the situation.

Nurses make decisions from their unique perspectives based on their edu-
cation, experience, and specialty. Decision-making is the process of choosing
among alternatives. The decisions that nurses make can be characterized both
by the quality of decisions and by the impact of the actions resulting from
those decisions. As knowledge workers, nurses make numerous decisions that
affect the lives and well-being of individuals, families, groups, communities,
and populations. The process of decision-making in nursing is guided by the
concept of critical thinking. Critical thinking is the intellectually disciplined
process of actively and skillfully searching out the best evidence and using
that knowledge to conceptualize, apply, analyze, synthesize, and/or evaluate
data and information as a guide to belief and action (adapted from Scriven
& Paul, 1987).

Figure 5. Relationship of User Experience to Other Concepts
Reference: Staggers, 2014, p. 337.

User Experience

Human Factors

Ergonomics

Usability

Human–computer
Interaction

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The nursing process of assessment, diagnosis, outcomes identification, plan-
ning, implementation, and evaluation can be enhanced through the utilization
of technology. Technology, when properly developed and applied, has been
shown to enhance the healthcare team’s ability to collect, categorize, interpret,
manage, evaluate, and share relevant information. This also enhances the
team’s ability to manage client care in a more efficient and productive manner.
In most cases, the utilization of technology has decreased the nurse’s workload
associated with collecting and categorizing data, while enabling and enhancing
the sharing of relevant information with other members of the healthcare team.
When the complexity of information sharing is decreased, enhanced sharing of
relevant information within the healthcare team theoretically improves quality
and safety and results in improved patient outcomes. The informatics nurse
is ideally suited to evaluate how technology can assist the nurse and other
members of the care delivery team to manage data and share information to
achieve desired outcomes.

In addition to enhancing the nursing process, data collection, informa-
tion sharing, intervention implementation, and resultant patient outcomes
can be tracked via database queries and processed through research meth-
ods. Evidence-based practice models can be developed through this research.
Models of practice that generate positive patient outcomes can then be rep-
licated and supported by systems optimized to allow seamless data capture,
intuitive data display, and expert system processing.

Nursing is focused on optimizing the health status of individuals, families,
groups, communities, and populations. Each of these entities is affected by the
environment in which it resides. Technology, when properly designed and imple-
mented, enhances the ability to track and trend data to help determine what,
where, when, how, and why resources could be allocated to achieve the greatest
good. Informatics nurses are uniquely qualified to assist in the development and
optimization of systems that capture, categorize, share, and evaluate data and
information while keeping the nursing process as the foundation of practice.

Functional Areas of Nursing Informatics
Informatics nurses, informatics nurse specialists, and other stakeholders are
helping transform health care through the use of informatics processes, tools,
and structures. Across all healthcare environments, INs and INSs most com-
monly practice in interprofessional healthcare environments and interact with
information technology (IT) professionals during all phases of the system

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life cycle. INs and INSs use scientific and informatics principles and employ
creative strategies in informatics solutions. They bring the perspectives of
nursing, and very often the patients, to interprofessional work through a solid
understanding of operational processes and the value of consumer advocacy to
informatics functions. INs and INSs may need additional education or other
types of advanced preparation to manage the informatics projects at hand.

Because of the tendency to confuse roles with titles, this section describes
the following dynamic and evolving functional areas of nursing informatics:

■ Administration, leadership, and management

■ Systems analysis and design

■ Compliance and integrity management

■ Consultation

■ Coordination, facilitation, and integration

■ Development of systems, products, and resources

■ Educational and professional development

■ Genetics and genomics

■ Information management/operational architecture

■ Policy development and advocacy

■ Quality and performance improvement

■ Research and evaluation

■ Safety, security, and environmental health

The last discussion in this section describes additional integrated functions,
especially those crossing clinical practice and informatics. INs and INSs may
be in positions that focus primarily on one functional area; more frequently,
though, several functional areas are combined within a particular NI position.

Administration, Leadership, and Management
As is true of administration in general, leadership and management functions in
nursing informatics incorporate both higher-level and mid-level administrative
functions. Increasingly, INSs are attaining senior leadership positions. Positions
may be titled Chief Nursing Informatics Officer (CNIO), Chief Information

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Officer (CIO), director, or similar leadership titles (American Organization of
Nurse Executives [AONE], 2012; Hodges & Wierz, 2012). In this functional
capacity, nursing informatics leaders are expected to be visionary and establish
the direction of large-scale informatics solutions. The nursing informatics
leader often serves as a catalyst for developing strategic plans and creating
national or system policies and procedures, while serving as the champion for
integrated projects and systems.

In mid-level management, INSs may supervise resources and activities for
all phases of the system life cycle. These activities may include needs analysis,
requirements gathering, design, development, selection and purchase, testing,
implementation, and evaluation of systems to support all facets of nursing and
healthcare delivery. At all levels, leadership is characterized by the combination
of superb communication skills, collaboration, change management, risk assess-
ment, and coalition building with political finesse, business acumen, and strategic
application knowledge. INSs serving in this functional area may put most of their
energy into leadership and management. In other positions, administration may
be part of a position merged with other functional areas. Typical examples include:

■ INS at a large hospital system, supervising an implementation and
education team, representing nursing interests on various IT com-
mittees, performing project management for multiple documentation
projects, and having oversight of nursing standards and vocabularies
used in applications.

■ Project director for a clinical software company, managing implementa-
tion teams for various client projects (hospitals to ambulatory facilities)
and consulting with clients on all aspects of systems selection, custom-
ization, adoption, and use of software.

■ Grants administrator for an information science research agency, seek-
ing and writing grants that would fund NI-related projects, designing
budgets, and ensuring optimal allocation of resources.

A crucial responsibility for any nursing informatics leader is fostering inter-
professional collaboration in designing, developing, and deploying technology
in healthcare settings. Interprofessional collaborative practice has been defined
as occurring “when multiple health workers from different professional back-
grounds work together with patients, families, carers [sic], and communities to
deliver the highest quality of care” (World Health Organization [WHO], 2010,
p. 13). Although informatics nurses may lead teams and projects, the output
of these teams rarely has an impact only on nursing care. Most commonly

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these efforts reflect concerns and actions of interprofessional stakeholders.
The Interprofessional Education Collaborative Expert Panel (2011, p. 14)
described multiple core competencies for interprofessional teamwork that
included “21st-century technologies for communication and coordination (i.e.,
informatics),” emphasizing how vital it is for all informatics nurse leaders to
work collaboratively with all members of the healthcare team.

systems Analysis and Design
Data can be aggregated and analyzed in a number of ways to synthesize knowl-
edge, inform decision support and outcomes management, advance the science
of nursing informatics, and support reimbursement. The IN and INS may use
a number of tools and resources to accomplish these ends, such as data flow
diagrams, entity-relationship modeling, taxonomies, clinical vocabularies, and
quality indicators. Meta-analysis can identify large-scale trends across multiple
groups of data. Systems requirements analysis can track the flow of data in a
process or system to aid in customization for end-user needs.

A major responsibility of the IN or INS is to understand workflow processes,
particular informatics solutions, and how these affect each other. Workflow
analysis (identifying the individual tasks of a work process), coupled with an
understanding of the clinical process, is essential to enhance safety and reduce
inefficiencies in a healthcare environment. Processes must be designed for
successful interactions between users and computers. Competence in formal
systems analysis techniques permits comparison of systems’ capabilities and
limitations and is required to design (or redesign) applications for successful
computer–user interactions or user experiences.

INs and INSs may also engage in the process of knowledge discovery in
databases (KDD). Using sound methodologies and practical evidence-based
recommendations, the INS can discover information and knowledge related to
diverse areas of nursing practice. Knowledge discovery methods (data mining
and machine learning methods) in combination with statistical analysis and
data visualization techniques help identify and understand patterns in very
large data stores, such as enterprise data warehouses.

Analysis is also required for the use of clinical vocabularies, languages, and
taxonomies. Nursing languages must be periodically re-evaluated for their
applicability and currency. Analysis of a meta-database, such as the Unified
Medical Language System (UMLS), requires knowledge of nursing and medical
vocabularies in order to analyze groups of taxonomies and map them to simi-
lar terms. An example is the effort to map SNOMED CT to the International

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Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
to aid in meeting and attesting to meaningful use requirements. IN and INS
expertise should be included in these efforts to support the collection, report-
ing, and analysis of nursing-sensitive data.

Outcomes analysis may be related to any domain of nursing practice:
clinical, education, research, or administration. The complexity and levels of
outcomes must be determined for healthcare consumers, populations, and
institutions. Analysis can include the use of humancomputer interaction
principles and methods. In that domain, INs and INSs use HCI tools and
methods, such as heuristics and cognitive walk-through, to evaluate the match
of systems to users, tasks, and contexts.

Analysts use other tools to (1) maintain data integrity and reliability,
(2) facilitate data aggregation and analysis, (3) identify outcomes, (4) identify
organizational barriers, and (5) develop performance measures. These tech-
niques allow nurses to contribute to building a knowledge base consisting of
the data, information, theories, and models used by nurses and other stake-
holders in decision-making that supports quality health care. The following
are examples of analysis activities:

■ A nursing analyst in a hospice setting tracks health consumer data to
establish a weighted case mix to determine nursing personnel allocations.

■ A quality improvement (QI) specialist in a hospital system aggregates
multisite research data related to diagnosis and nursing procedures or
risk mapping.

■ A quality assurance (QA) analyst works with nurse managers to retool
current work processes after examining existing system data in custom-
ized QA reports.

■ An analyst applies knowledge discovery methods to warehoused
electronic data to build a predictive model of patient falls.

■ A behavior analyst identifies organizational barriers or breakdowns to
avoid system failures or risk.

Compliance and integrity Management
Following the report To Err Is Human: Building a Safer Health System (IOM, 1999),
the downfall of Enron, passage of the Sarbanes-Oxley Act of 2002 (SOX), and
pay-for-performance incentives adopted by the Centers for Medicare & Medicaid
Services (CMS), healthcare organizations must have robust reporting systems to

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monitor compliance and integrity of their information and reporting activities,
infrastructures, employees, and business partners. Along with developing orga-
nizational cultures that encourage ethical conduct and regulatory compliance,
mechanisms must be in place to prevent and detect criminal conduct.

Computerized information systems must support compliance with the
1996 Health Insurance Portability and Accountability Act (HIPAA) efforts
by limiting access to personally identifiable health information to only those
who require and are authorized access. Auditing systems that detect red flags,
reporting systems that will preserve confidentiality or anonymity, and enter-
prise risk management (ERM) allow reporting of risks by everyone in an
organization. ERM breaks down silos and provides timely reporting of risks
and opportunities at a high level for immediate attention through risk scoring
and mapping (Carroll & Nakamura, 2011).

The IN and INS must have and maintain the knowledge to effectively apply
current ethical standards and regulatory requirements to help healthcare
organizations to:

■ Revise operational procedures for staff.

■ Establish technical processes to maintain compliance.

■ Meet new regulatory mandates at local, state, national, and global levels.

These standards, directives, guidelines, or mandates may include those from
government agencies, such as the Centers for Medicare & Medicaid Services,
the Food and Drug Administration (FDA), the Centers for Disease Control
and Prevention (CDC), the National Institutes of Health (NIH), and accredita-
tion organizations, such as The Joint Commission (TJC), Healthcare Facilities
Accreditation Program (HFAP), Det Norske Veritas Healthcare, Inc. (DNV),
and the World Health Organization (WHO).

Ethical issues surround the use of new products, such as embedded tech-
nologies and radio-frequency identification (RFID), which can be used in car-
ing for persons with Alzheimer’s disease and other dementias. As the science
matures, some of these issues will be resolved and standards will be established.
Requirements will continue to evolve. The following are examples of compli-
ance and integrity management activities:

■ The security officer for a hospital ensures that HIPAA standards are
met by software vendors within the organization, periodically moni-
tors software audit logs for breaches, and ensures that passwords are
not shared and that backup and disaster procedures are in place and
operational.

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

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■ A compliance officer for a state health agency writes and enforces poli-
cies that conform to state and national laws respecting records retention.

■ A care coordinator administrator for a hospital system ensures the confi-
dentiality of data transmitted via telehealth and telemedicine devices.

■ An internal auditor reviews charges to documented care given for
appropriate reimbursement or abnormal billing practices.

Consultation
Informatics nurses and informatics nurse specialists apply informatics knowledge
and skills to serve as transformational leaders and resources for clients, both
formally and informally, in external and internal settings. Informatics nurse
consultants are expected to have solid expertise in clinical nursing and areas
such as process redesign, strategic IT planning, system implementation, writ-
ing for informatics and other publications, evaluating clinical software products,
working with clients to write requests for proposals, performing market research,
and assisting in the planning of conferences, academic courses, and professional
development programs. Expert INSs may serve as internal consultants, work for
a consulting firm, own an independent practice, and be recognized as experts by
writing about NI and speaking at NI-related events. Flexibility, good communica-
tion skills, solid nursing/healthcare delivery background, breadth and depth of
clinical and informatics knowledge, and excellent interpersonal skills are needed
to respond to rapidly changing projects and priorities. Project examples include:

■ Consulting with individuals and groups in defining healthcare informa-
tion problems and identifying methods for implementing, utilizing, and
modifying IT solutions and data structures to support healthcare access,
delivery, and evaluation.

■ Consulting as the project manager to identify strengths, weaknesses,
opportunities, and threats; to ensure that team members are performing
duties as assigned; and to complete the project on time and within budget.

■ Consulting with clients in writing requests for proposals to elicit vendor
bids for informatics solutions and in evaluating vendor responses.

Coordination, Facilitation, and integration
One of the most common NI roles is implementing informatics solutions.
Nurses are particularly well suited for IT implementation, as it essentially

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follows the nursing process of assessment, diagnosis, outcomes identification,
planning, implementation, and evaluation (ANA, 2010). The IN or INS may
serve as project coordinator, facilitating change management and integrating
the information and technology to transform processes. In this role, project
management knowledge and skills are essential to the success of the project.
Project coordination can range from small, department-centered efforts to
enterprise-wide initiatives. Examples include:

■ Coordinating installations, system upgrades, and optimization of exist-
ing features and functions.

■ Employing research methodologies to disseminate new knowledge and
integrate that knowledge into practice.

■ Developing and defining healthcare policy to advance public health.

■ Serving as a systems administrator of a learning management system
(LMS) for the delivery of e-learning courses or training programs for
healthcare professionals.

The IN and INS frequently serve as a hub for interprofessional communi-
cation and as a bridge and communication liaison between and among infor-
matics solution users, clinical and nonclinical end users, and IT experts and
staff. The IN and INS often serve as translators and integrators addressing
system requirements and impacts.

Informatics nurses frequently serve as the liaison between engineers and
end users. In this capacity, the informatics nurse ensures that necessary test-
ing or research is performed to determine the end user’s needs and that infor-
mation is conveyed appropriately. The informatics nurse will also play a key
role in the development and testing of new applications or enhancements to
existing applications. Once the engineer has created a product, the informat-
ics nurse evaluates the use and usability of the product from the viewpoint
of the end user. This liaison type of facilitation and coordination occurs in
multiple environments. Ensuring the integration of nursing vocabularies and
standardized nomenclatures in applications is another example. In this case
INs and INSs can also act as usability experts and recommend ideal formats
for the utilization of technology. Examples of coordination, facilitation, and
integration include:

■ The project coordinator for a statewide electronic health record imple-
mentation coordinates all aspects of the project and supervises an inter-
disciplinary team to prepare public health personnel to use the application.

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

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■ The project manager for a clinical software company (using tools
such as project management software and project plans) manages the
resources and activities for clients whose responsibilities cross inpatient
and ambulatory areas.

■ The clinical liaison for a telehealth software vendor communicates
with providers and consumers to ensure that all parties are agreeable
to development and implementation plans, and ensures that providers
using the system receive adequate technical education.

■ A usability expert on a software development team advises software
engineers on screen design from the standpoint of clinical documenta-
tion needs, performs or coordinates testing of iterative designs, and
validates clinical requirements with the users.

Development of systems, Products, and resources
A developer is responsible for translating user requirements into effective infor-
matics solutions. Informatics nurses are involved in a vast array of development
activities, from conceptualizing models for applications, to software and hard-
ware design, to the design of education manuals and media, to the design of
complex technology networks. As part of this function, INs and INSs participate
in the process of design, iterative development, testing, and dissemination of
quality informatics solutions for nurses, other healthcare professionals, and
consumers. An understanding of the information needs of nurses and the nurs-
ing profession, consumers and consumer care processes, best business practices,
client services, projected market directions, product design and development
methods, market research, contemporary programming, systems design, and
modeling language are essential for practicing in a development environment.

Adherence to national standards and regulatory requirements is also
essential to any development work. To ensure interoperability between sys-
tems, INs and INSs involved in system development must be knowledge-
able about international standards requirements. Existing standards include
Health Level Seven (HL7), International Organization for Standardization
(ISO), Current Procedural Terminology (CPT), International Statistical
Classification of Disease and Related Health Problems (ICD), and Digital
Imaging and Communications in Medicine (DICOM) group standards, as
well as Section 508 accessibility standards. An understanding of the current
work on standards is mandatory. The following are examples of development
responsibilities:

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■ A developer employed by a personal health record software vendor
creates user-friendly screens for consumers to enter information as well
as screens for nurses to display and interpret the data.

■ A database administrator with a large multisite teaching organization
manages an expanded nursing vocabulary set for inpatient, ambulatory,
and home health nursing documentation.

■ A nurse Web content developer for a consortium creates and validates
content for educational handouts, help and tool tips for user interfaces
that display national guidelines, and educational tools. This content
includes new and innovative tools for knowledge dissemination.

■ A programmer in a hospital IT department codes software for docu-
menting diabetic education.

education and Professional Development
Education is a critical component of many NI functions and may directly affect
the success or failure of any new or modified IT solution. Vendors of informa-
tion systems frequently use the term training when referring to client education.
In nursing, however, the broader label of education is used. Adherence to solid
educational principles is a necessary component of education and professional
development. Teaching nurses and nursing students, healthcare consumers
and families, and members of the interprofessional healthcare team about the
effective and ethical uses of information technology, as well as NI concepts and
theories, is essential for the optimal use of informatics solutions in nursing
practice. Ever-changing requirements in health information technology make
continuing education essential as well. INs and INSs in this capacity develop,
implement, and evaluate educational curricula and educational technologies
to meet learners’ needs.

In this role, educators and trainers assess and evaluate informatics skills
and competencies while providing feedback to the learner regarding the effec-
tiveness of the activity and the learner’s ability to demonstrate newly acquired
skills. Educators and trainers manage, evaluate, report, and utilize data and
information related to the specific learner and the educational delivery system.
These informatics nurse innovators define and develop educational technolo-
gies, integrate the solutions into the educational and practice environments,
and challenge organizations to consider and adopt innovative informatics
solutions. The introduction of mobile technologies provides an opportunity
for additional creative learning methodologies.

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The informatics nurse must evaluate the users’ level of information literacy
as well as their computer literacy. Computer literacy is a core competency
needed in health care and nursing practice, and should be taught in nursing
curricula at all levels. In addition, information literacy must be integrated into
practice and used to support knowledge management. These are the founda-
tions of informatics competencies.

Education and professional development must include INs, INSs, end users,
and consumers. The use of innovative technologies to support telehealth/telemon-
itoring and mobile health (mHealth) has encouraged the use of Internet-based
consumer-accessible applications, especially by older adults. New competencies
are needed to ensure that health information is displayed to consumers at an
appropriate level of understanding for all delivery devices, so that support staff
personnel are rarely needed. Cultural issues, language considerations, and literacy
levels must be assessed and accommodated prior to implementation.

Informatics nurses need to ensure that the content of web-based knowl-
edge portals of both private and government health organizations are reliable,
accurate, and trustworthy. Education and professional development involve
not only education of INs and INSs, but also development of appropriate user
interfaces for the consumer and other healthcare team members. Examples of
education and professional development functions include:

■ An academic role teaching the basic NI principles to all levels of nursing
students or preparing graduate nursing students enrolled in a nursing
informatics degree program to implement, support, and evaluate
clinical applications.

■ A development role creating simulation technology scenarios and
curricula to support traditional learning and clinical placements.

■ A clinical preceptor role orienting newly hired nurses and students to
the use of telehealth, telehealth technology, and mHealth technologies,
integrating these technologies into clinical practice, and then providing
consumer education.

■ A vendor educator role involving international travel to educate nurses
on the operations, capabilities, troubleshooting, limitations, and benefits
of a product.

■ A staff development liaison role for a large hospital educating nurses
and other end users about how to integrate clinical applications into
their work processes.

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■ A consultant role assisting a clinician practice with the implementation,
use, and ongoing support of electronic health records and other related
technologies.

■ Working as a help desk team member assisting users with support
during clinical application upgrades/releases, answering clinical user
questions, or trouble-shooting user problems.

■ A patient education coordinator role facilitating electronic consumer
health resources.

■ Web developer responsibilities for development, maintenance, and
presentation of disease content for a hospital web portal.

■ Oversight of social media resources, products, and policies to enhance
this evolving and important communication technology, enabling open
and enhanced communication among healthcare consumers, providers,
vendors, and other stakeholders.

Genetics and Genomics
Advances in mapping the human genome and understanding the character-
istics and influence of individual DNA have had a dramatic impact on what
is known about patients. These data, especially when integrated into EHRs
or personal health records (PHRs), are leading to innovations in patient care
and customized medications and therapies targeted to the individual’s unique
responses. Care and medication can be more precisely individualized to patients
based on their unique DNA profiles. Data about their past response to medica-
tions and other interventions can be documented. This is dramatically chang-
ing how patients are being managed for specific diseases and conditions and
is extending into the prevention of some diseases.

Computerized clinical decision support can help manage the inherent
complexity of customized patient care. Predictive disease models based on
patients’ DNA profiles are emerging as clinicians better understand DNA
mapping. These advances have significant implications for a new model of
care and for the IN’s and INS’s participation in the development of genomic
IT solutions. More than ever, patients will need to be partners in this develop-
ment. Genomics is leading to many specialized advances in care delivery and
must be linked to exact, individualized data within a personal health record.
Subsequently, advanced disease management with the ultimate goal of disease
prevention will be possible. This change has many implications for ethics as

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well as informatics. In fact, genomics competencies and curricular guidelines
are available online (ANA & ISONG, 2011; http://www.genome.gov/Pages/
Health/HealthCareProvidersInfo/Grad_Gen_Comp.pdf ).

With the increased amount of research regarding the impact of genomic
variation on health and its increasing relevance to clinical practice, infor-
matics nurses need to build their genetics/genomics knowledge base so that
they may support this expanding practice area. This involves developing an
understanding of genomic bioinformatics, the types of genomic information
available, and how such information can be stored and abstracted within the
EHR for genomic clinical decision support.

The Genomic Nursing State of the Science Advisory Panel (Calzone et al.,
2013) calls for informatics nurses to contribute to the infrastructure for infor-
matics support systems that use genomic information. The genomic nursing
science blueprint has specifically targeted innovation supported through nurs-
ing research and technology development as a priority, including:

1. “Data storage and use to facilitate research process and outcomes;

2. Facilitate cross-generational sharing of genomic data (e.g., family
history, laboratory analyses);

3. Managing, analyzing, and interpreting genomic information (e.g.,
sequencing data);

4. Point-of-care decision support for client and healthcare provider;

5. Common terminology and taxonomy, and

6. Common formats for data storage/exchange and queries” (Calzone,
2013, p. 100).

Supporting clinical documentation and information system technologies
are changing to meet the demands created by the evolution of personalized
care and individualized therapies related to an individual’s genomic character-
istics. Informatics nurses have unique opportunities to engage in requirements
definition, design, implementation, and evaluation activities, as well as policy
development and ethics discussions.

information Management and operational Architecture
Information management (IM) acquires, organizes, controls, disseminates,
and uses (reuses) information from any source regardless of origin (internal
or external to the organization). Such management efforts address the quality,

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ownership, use, and security of information in the context of organizational
performance to support and achieve the effective operation of an organization
(adapted from Feather & Sturges, 2002).

An organization must manage electronic and physical information through
the information life cycle, regardless of origin source or format (data, paper
documents, electronic documents, wave forms, audio, social media, video, etc.),
for delivery through multiple channels (cable, Internet, and broadcast inter-
faces). Information management includes the capture, management, preserva-
tion, storage, and delivery of the right information to the right people at the
right time. The informatics nurse’s role in information management consists
largely of the organization and control of planning, structure, processing, evalu-
ation, and reporting of information activities to meet objectives and enable
the delivery of information.

Operational architecture (OpArc) can be used throughout the system life
cycle to address the complexity of information exchange through the use of

“views” to describe and interrelate the data elements, tasks, activities, and infor-
mation flows required to accomplish clinical operations. Operational architec-
ture provides a repeatable, standardized, structured, and integrated approach
linking operational concepts to the providing healthcare systems, as well as
technical standards for the objective analysis of information requirements.

Policy Development and Advocacy
Informatics nurses play a key role in formulation of health policy, in particu-
lar bringing expertise in data and information content, data structures, and
IT solutions, care coordination, and advocacy. Policy development may be at
any level: international, national, regional, state, and local. Informatics nurses
are experts in defining the data needed and the structure, management, and
availability of those data for decision-making. This allows them to advocate
for consumers, providers, and the enterprise, and to articulate relevant issues
from a nursing perspective or healthcare consumer viewpoint. Policy-related
activities may include developing, writing, implementing, and evaluating
guidance. Regardless of the level or activity, informatics nurses are partners
in setting health policy, particularly in relation to information management
and communication, infrastructure development, and economics.

The advocacy function of the IN or INS also encompasses consumer
health. Informatics nurses may be part of initiatives such as promoting the
adoption of technology for rural programs to increase access to health ser-
vices, or endorsing government and private initiatives to engage consumers

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in creating a personal health record. Advocacy may include educating legis-
lators about such topics as increasing telecommunication access, expanding
reimbursement for technology-enabled consumer services, or educating the
public on ways to access health-related materials via the Internet. Examples
of the policy development and advocacy function of the IN or INS include
the following:

■ The president of a health information management organization
represents nursing on a national information standards task force.

■ An informatics nurse lobbyist participates in advocacy efforts on behalf
of consumers for increased government funding of demonstration or
pilot informatics projects.

■ A president of a nursing informatics organization writes letters to
elected officials to obtain their support for reimbursement of services by
remote, technology-enabled providers.

Quality and Performance improvement
At present, emphasis is increasingly focused on ensuring seamless integration
of quality and performance improvement to enhance patient outcomes. All
aspects of healthcare services delivery require access to significant data, infor-
mation, and knowledge resources. Comparative effectiveness, meaningful use,
core quality measures, development of e-clinical measures, and the application
of protocols and critical paths will require further development and refine-
ment. The informatics nurse is uniquely positioned to help identify available
measurable content and generate queries and reports that trend and track
events and actions and respond to specific inquiries, questions, and concerns.
This functional role is closely aligned with development, research, evaluation,
safety, and security activities described in other sections.

research and evaluation
Informatics nurses and informatics nurse specialists may conduct research
into the design, development, implementation, and evaluation of informat-
ics solutions, models, and theories. INS researchers use systematic methods
of inquiry (including traditional and newer techniques) to identify, retrieve,
represent, and evaluate data, information, and knowledge within informatics
solutions and data repositories. Research and evaluation functions include,
but are not limited to:

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■ Research in concept or symbolic representation of nursing phenomena.

■ Evaluation of clinical decision-making in nursing.

■ Applied informatics research.

■ Assessment of the use of health information tools and resources by
consumers and interprofessional team members.

■ Evaluation of effective methods for information systems implementa-
tion, acceptance, and utilization.

■ User experience research about the design of systems and their
impact on interprofessional providers, consumers, nurses, and their
interactions.

■ Evaluation research about the effects of systems on the processes and
outcomes of care and customer satisfaction.

■ Usability testing of nursing and consumer applications.

■ Evaluating how consumers use computerized healthcare products.

■ Research concerning clinical vocabularies.

■ Consumer communication and usage of technology-based support groups.

Research in nursing informatics may span a range of activities, including
exploratory research (such as data mining), experimental research, process
improvement, and informal evaluation. An INS working in research and
evaluation might conduct research projects to develop and refine standard-
ized nursing vocabularies, or to link nursing interventions to outcomes in large
data sets. This work may include the evaluation of organizational attributes
for successful adoption of documentation systems or the impact and efficacy
of hardware and software solutions.

Nursing informatics research may also incorporate a consumer orientation,
through the study of effective nurse-consumer interactions and communica-
tions in web-based interactions with older consumers, or the impact of new
applications on nurses’ workflow. Patient reactions to instant messaging from
providers may be studied. The following are examples of the research func-
tion of the INS:

■ The chief of nursing research for a large software company oversees
projects to evaluate the impact of enterprise electronic health records on
patient care outcomes.

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■ A nursing informatics analyst in a hospital IT department aggregates
data about the incidence of pressure ulcers, creates trend reports and
predictive models for nurse managers, and analyzes outcomes against
quality indicators.

■ A nurse researcher conducts a usability study comparing consumer
entry of information at a clinic-based kiosk to in-person interviews.

safety, security, and environmental Health
The areas of safety and security, as well as environmental health, are rapidly
becoming more important concerns for informatics nurses. Informatics nurses
have multiple opportunities to assist in assuring the safety and security of
health-related IT (HIT) products that support clinicians, as well as patients,
families, and other caregivers. Though intended to reduce safety issues, HIT
can actually create errors. In 2007, sufficient evidence in the literature gave
rise to the term “e-iatrogenesis,” denoting harm resulting in part from HIT
(Weiner, Kfuri, Chan, & Fowles, 2007). The authors stated that e-iatrogenesis
is the most significant unintended consequence of HIT.

The implementation of electronic health records without regard to workflow
analysis and redesign, human–computer interaction, prevention of errors in
medication administration, and prevention of possible missed diagnoses have
increased the concern for patient safety. By 2011, the Institute of Medicine’s
Committee on Patient Safety and Health Information Technology had released
Health IT and Patient Safety: Building Safer Systems for Better Care, a 211-page
report describing in detail the issues surrounding HIT safety and security.
The report included recommendations for software vendors and HIT users on
building, integrating, and maintaining safer and more secure systems. It also
addressed opportunities for research and policy development. Poor usability
is the most significant safety issue currently confronting clinicians. A simple
example is the “adjacency error” whereby users mistakenly select an item next
to the one intended in a drop-down menu (IOM, 2012).

The increasing deployment and use of HIT to engage patients in their
own health care will require a unique strategy to support safety and security.
As device and system interoperability expands and “bring your own device”
(BYOD) strategies are increasingly deployed to satisfy clinical users and con-
sumers, the associated security and privacy risks, including the susceptibility
to malware and hacking, will likewise increase. Additional safety topics that
merit attention of informatics nurses include: implementation decisions about

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prompts and alerts, role-based security for access, authentication, student-
instructor signature/authentication, patient access to clinical notes and portals,
and impact and opportunities associated with health information exchanges.
See the ONC Health IT Patient Safety Action and Surveillance Plan (available
at http://www.healthit.gov/sites/default/files/safety_plan_master.pdf ).

With regard to environmental health and informatics, there are two tradi-
tional notions of “environment” in nursing practice: internal and external. In
an internal environment, typically some control exists by which the work area
can be modified to create safe and comfortable conditions where the nurse
cares for, or interacts with, clients. This could be a hospital, clinic, school, or a
client’s home. An external environment is characterized as offering no, or lim-
ited, control in manipulating the climate or environmental hazards. Examples
include industrial zones where an occupational health nurse may practice, a
neighborhood or public area where a community health nurse may practice,
or a disaster zone where a mobile intensive care nurse may be stationed. In
both internal and external environments, hazards and/or materials exist that
could cause physical or mental injury, such as that resulting from equipment
that is not ergonomically designed or correctly grounded. Similarly, hostility
and incivility in the work environment must be identified and addressed.

A number of initiatives at the federal (Recordkeeping—The OSHA 300
Log, 2013), state (Agency for Toxic Substances & Disease Registry, 2010),
and community (Community Health Nurses’ Initiatives Group, 2013) levels
actively support the nurse as an integral steward in monitoring and improv-
ing environmental safety for healthcare workers and their clients (individuals,
families, communities, and populations). In addition, a number of programs
are designed to educate nurses in environmental health principles and
even achieve certification as a Registered Environmental Health Specialist
(Registered Environmental Health Specialist Program, 2013).

Although environmental health is not typically considered part of the infor-
matics nurse’s scope of practice, informatics nurses can develop and coordinate
education, communication, and reference materials, as well as design system
tools that are easily accessible and pertinent to the needs of their colleagues.
Some examples of resources are online learning modules, hyperlinks embed-
ded into a clinical documentation tool directing the user to ergonomics infor-
mation and safety data sheets, and expert system alerts within the clinical
documentation system warning the caregiver when the assessment and other
criteria show a threat to health and safety of the patient or the nurse, such as
radioactive exposure, past violent behavior, or infections.

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Creation of a healthy, supportive work environment includes such activities
as noise reduction from the hum of electronic equipment and fans and audible
alerts and alarms; removal of trip and personal hazards, such as exposed elec-
trical cords and cables, heavy movable but unstable work stations; and expo-
sure to electromagnetic frequencies and potential electric shock. Responsible
recycling or disposal of electronic equipment, printer cartridges, and paper
printouts reflect environmental stewardship. Similarly, effective planning, com-
munication, and collaboration strategies help mitigate untoward stress, such
as that associated with unexpected change, software and equipment failure,
and system and communications network downtime.

integrated Functional Area example:
telehealth and informatics
Informatics solutions provide foundational support for healthcare delivery. In
some cases, however, informatics solutions are more closely integrated with
the delivery of care. This is particularly true for health care provided via tele-
health services, where clinical care and informatics intersect in the provision
of healthcare management.

Telehealth services are growing rapidly, with an expanding integration of
health information technology into a variety of products. These products include
tools used to provide direct patient care, but are certainly not limited to health-
care provider services. A variety of health applications (apps), remote monitoring,
contact-free monitoring apps, wearable health technology devices, mHealth, and
other health and fitness devices are available to the consumer and are heavily
marketed by new and developing companies using health information technology.

Such new tools and ideas are intended to provide increased access to
needed health services, improve quality of care, and reduce the cost of associ-
ated healthcare services, all while focusing on the goal of improving patient
outcomes. The explosively expanding use of telehealth services and products
creates a need to develop and amend certain laws, rules, and regulations, espe-
cially related to licensure portability, to allow the full use of telehealth services
by all practitioners for all people. Standards of care and best-practice recom-
mendations for the use of telehealth services in a variety of specialties have
been developed and revised (American Telemedicine Association [ATA], 2013),
and should be incorporated in practices and in policies governing the use of
telehealth services. The interface between nursing informatics and telehealth
nursing is evolving with an increasing emphasis on the appropriate use and
management of information and technology. Nursing informatics is used

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 37

primarily to support clinical roles and is an essential component of the provi-
sion of telehealth services.

Nursing informatics supports multiple constituencies and stakeholders,
such as healthcare consumers, interprofessional healthcare team members, IT
professionals, and healthcare agencies and organizations. Informatics nurses
are particularly well suited to work in such interprofessional environments,
because of their preparation in the foundation of professional nursing focused
on holistic patient, family, community, and population care and significant
experience in planning, implementing, and coordinating activities involving
multiple constituencies. With the continued developments in information
science and nursing science, NI functions will continue to expand and evolve
into functional areas not yet envisioned or recognized.

evolution of informatics Competencies
Because of the increased visibility of information and technology in health-
care settings and complementary educational programs, many stakeholders
are faced with a need to define informatics competencies for every registered
nurse, advanced practice registered nurse, and those who specialize in nursing
informatics practice. Managers, human resource managers, and educational
planners are just three examples of stakeholders who have an interest in hav-
ing defined competencies for nursing informatics.

informatics Competencies requisite
for All registered nurses
The increasing complexity of healthcare services and practice, combined with
the evolving mandate for ubiquitous electronic health information systems, has
raised the bar for the nursing professional. Select informatics competencies are
now required in all prelicensure, undergraduate, graduate, and doctoral nursing
curricula. The National League for Nursing (NLN, 2008) advises nursing faculty
to participate in programs to advance informatics development and to incorporate
principles of informatics into each level of nursing curriculum. The American
Association of Colleges of Nurses (AACN) identifies information management
and the application of technology in patient care as an essential element of bac-
calaureate (AACN, 2008), master’s (AACN, 2011), and doctor of nursing practice
level (AACN, 2006) education. The Quality and Safety Education for Nurses
(QSEN Institute, 2012a, 2012b; AACN, 2013) initiative has identified the nursing
informatics competencies vital for the provision of safe, quality care to the public.

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

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According to the Technology Informatics Guiding Education Reform
(TIGER) initiative, all practicing nurses should be equipped with the skills
necessary to practice in the technology-driven world of health care (Hebda &
Calderone, 2010). A reference list of specific competencies needed by all prac-
ticing nurses was developed in 2009 by the Technology Informatics Guiding
Education Reform group (TIGER, 2009). The TIGER initiative is “focused on
using informatics tools, principles, theories and practices to enable nurses to
make healthcare safer, more effective, efficient, patient-centered, timely and
equitable” (TIGER, 2009, p. 2).

The TIGER Nursing Informatics Competencies Model is based on inter-
national standards such as the European Computer Driving License, the
American Library Association Information Literacy Competency Standards;
the Electronic Health Record Functional Model: Clinical Care Components,
and the International Computer Driving License: Health (TIGER, 2009, p. 6).
The TIGER model consists of three parts:

1. basic computer competencies

2. information literacy

3. information management (including use of an electronic health record)

Unlike some other lists of competencies, there are measurable competen-
cies, such as:

■ Know what computer memory is: RAM (random-access memory) and
ROM (read-only memory), and distinguish between them or

■ Use the components of a citation (e.g., currency, reputation of author or
source, format, or elements of a URL) to choose those most suitable for
the information need.

The complete Informatics Competencies for Every Practicing Nurse:
Recommendations from the TIGER Collaborative report can be down-
loaded from http://www.the tigerinitiative.org/docs/TigerRepor t_
InformaticsCompetencies_000.pdf. Additional learning resources include
the TIGER Virtual Learning Environment (available at http://www

.thetigerinitiative.org/virtuallearning.aspx) and the government-funded
Workforce Development Program (available at http://www.healthit.gov/policy

-researchers-implementers/workforce-development-program; see also HealthIT
Help Center Workforce Programs, n.d.).

Accredited graduate-level educational programs for the NI specialty
nursing practice were first offered in 1989. Now graduate, doctoral, and

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postdoctoral degrees are more widely available via online and in-person
learning programs. Lifelong learning can easily be accommodated by free
nondegree online courses that offer open, unlimited, global enrollment
massive open online courses (MOOCs) and other distance education and
online programs. The current trend of requiring a graduate-level informat-
ics degree is expected to continue and become the professional specialty
practice standard.

research About nursing informatics Competencies
In their seminal work on informatics competencies for nurses, Staggers, Gassert,
and Curran (2001, 2002) studied the relationships between nursing roles
and informatics competencies for nurses at four levels of practice: beginning,
experienced, INS, and informatics innovator. This framework aligned with
educational requirements for all nursing specialties at the beginning and
experienced levels, and then identified specific competencies for the specialty
roles of INS and the informatics innovator. The work of these authors not
only promoted the integration of informatics competencies into educational
curricula, but also influenced policy documents.

Since the 2008 publication of Nursing Informatics: Scope and Standards
of Practice, research has progressed from determination to validation and
implementation of nursing informatics competencies. Choi (2012) examined
the informatics competencies of students in three undergraduate tracks:
Traditional Pre-Licensure, Registered Nurse (RN) to Bachelor of Science in
Nursing (BSN), and Accelerated BSN. Hsu et al. (2012) looked at the infor-
matics competencies for mid-tier public health practitioners in the public
health sector. Remus and Kennedy (2012) focused on the need for nursing
informatics competencies in Canadian nurse leaders.

Other researchers continue to advance the work of Staggers, Gassert, and
Curran. McGonigle, Hunter, Hebda, and Hill developed “a reliable and valid
instrument for self-assessment of perceived level 3 informatics specialist and
level 4 informatics innovator competencies in selected informatics activities”
(2013, para. 4). Choi and Bakken (2013) reported on the validation of the self-
assessment scale among undergraduate and graduate nursing students. Chang,
Poynton, Gassert, and Staggers (2011) provided insight into the international
use of Staggers, Gassert, and Curran’s 2002 work. The ongoing work has been
foundational in the development of this version of the nursing informatics
scope and standards of practice.

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

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Professional organization Discussions
on informatics Competencies
Multiple organizations have provided input to the discussion on informatics
competencies. This section provides an overview of several of these discussions.

HeALtHCAre LeADersHiP ALLiAnCe

The Healthcare Leadership Alliance (HLA) announced the creation of the
HLA Competency Directory in the fall of 2005. This directory (HLA, 2005)
identifies 300 competencies across multiple healthcare management roles,
categorized into 5 domains:

■ Leadership

■ Communications and relationship management

■ Professionalism

■ Business knowledge and skills

■ Knowledge of the healthcare environment

According to the web site (HLA, 2013, para. 4), the “directory provides a
comprehensive listing of the competencies managers and leaders need to meet
the challenges of managing the nation’s healthcare organizations,” including
healthcare information management. These competencies may assist in the
development and evaluation of informatics role definitions, including man-
agement roles.

AMeriCAn orGAnizAtion oF nurse exeCutiVes

The American Organization of Nurse Executives, building on the mandate
for informatics competencies for nurse leaders (AONE, 2005), demonstrated
its support for informatics nurse leaders in the 2012 position paper “Nursing
Informatics Executive Leader,” which stated: “The NI Executive leader rep-
resents the bridge between clinical practice and informatics that transforms
patient care delivery for the entire organization” (AONE, 2012, pg. 1).

QuALity AnD sAFety eDuCAtion For nurses

The Quality and Safety Education for Nurses (QSEN) initiative project began in
2005 with the stated goal to “address the challenge of preparing future nurses
with the knowledge, skills, and attitudes (KSAs) necessary to continuously
improve the quality and safety of the healthcare systems in which they work”
(QSEN Institute, 2012a, para. 1). QSEN has added informatics competences

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for prelicensure nursing education, based on work by Cronenwett et al. (2007),
and for graduate nursing programs (QSEN Institute, 2012b).

nAtionAL LeAGue For nursinG

In 2008, the National League for Nursing (NLN) released its position state-
ment on preparing the next generation of nurses to be capable of functioning
in a “technology rich environment” (NLN, 2008). To assist in that effort, NLN
created tool kits for helping educators to assess their own competencies and
provide teaching/learning strategies to assist with implementing informatics
competencies into nursing education programs.

■ NLN Informatics Education Toolkit (http://www.nln.org/
facultyprograms/facultyresources/index.htm)

■ NLN Competencies for Nursing Education (http://www.nln.org/
facultyprograms/facultyresources/informatics.htm)

tiGer initiAtiVe FounDAtion

The work of the original TIGER Initiative has been formalized with the estab-
lishment of a foundation that advances the integration of health informatics
to transform practice, education, and consumer engagement, including the
virtual learning environment (VLE). Ongoing results of the TIGER work can
be found at http://www.thetigerinitiative.org/.

informatics Competencies: spanning Careers
and roles
Very few of today’s nurses have worked in only one role or even one specialty
of nursing throughout their careers, and this will likely hold true for coming
generations of nurses. The need for informatics competencies exists in all nurs-
ing roles and specialties. This section examines the informatics competencies
required for all practicing nurses, regardless of specialty.

The National Council of State Boards of Nursing (NCSBN) has devel-
oped and is studying a Transition to Practice (TTP) (Spector, 2013) nursing
preceptor model that includes “five transition modules” consisting of “com-
munication and teamwork, patient-centered care, evidence-based practice,
quality improvement and informatics” (2013, para. 5). This model incor-
porates many key aspects from the Institute of Medicine’s report on The
Future of Nursing: Leading Change, Advancing Health (2010) related to

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

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competencies for all nurses, and “is an inclusive model, which would take
place in all health care settings that hire newly graduated nurses and for
all educational levels of nurses, including practical nurse, associate degree,
diploma, baccalaureate and other entry-level graduates” (2013, para. 2).
Because informatics and technology are now integral tools used in all aspects
of nursing practice, from entry-level to advanced practice, it is strongly rec-
ommended that the state boards of nursing require that basic informatics
competencies be incorporated into all nursing program curricula, ranging
from licensed practical nurse (LPN) to doctoral levels.

As noted previously, the American Association of Colleges of Nursing
(2008) provided guidance on the educational requirements for the bac-
calaureate education for professional nursing practice. “Essential IV:
Information Management and Application of Patient Care Technology”
identified informatics competencies that all BSN graduates should pos-
sess (pp. 1819). For nurses prepared at the graduate level, the AACN
provided foundational informatics competencies in The Essentials of
Master’s Education in Nursing, “Essential V: Informatics and Healthcare
Technologies” (2011, p. 19).

Nurses who hold a master’s degree in something other than nursing can
gain a postmaster’s certificate in nursing informatics. Many of the numerous
programs available have similar competencies, but in general the curricula
focus on gaining specific knowledge and skills in nursing and healthcare
informatics, thereby supporting evidence-based practice and the improve-
ment of healthcare outcomes.

AACN’s Essentials of Doctoral Education for Advanced Nursing Practice
(2008) lists informatics-based competencies in “Essentials III: Clinical
Scholarship and Analytical Methods for Evidence-Based Practice.” Although
only the Doctor of Nursing Practice (DNP) is specifically addressed by the
AACN, this does not imply that informatics education is not important in
PhD programs. In many PhD programs, computer science and biomedical
informatics are required courses. However, because the DNP is considered a

“practice doctorate” and the PhD a “nursing research doctorate,” the emphasis
on informatics and clinical practice impact is reduced, though these areas are
not considered unimportant (AACN, 2011; see also Duke University, 2012).
Thus, it is strongly recommended that PhD curriculum writers incorporate
courses that examine the tenets of nursing informatics and focus on the
methods of data entry, data storage, data retrieval, and data analysis from
EHRs, report writing programs, and database management systems.

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informatics Competencies for informatics nurses
and informatics nurse specialists
In addition to the competencies that every registered nurse needs, additional
competencies for the IN and INS are found in the “Standards of Nursing
Informatics Practice” section of this professional resource. As part of its prepara-
tion for the new nursing informatics certification exam test form, the American
Nurses Credentialing Center (ANCC) completed its Role Delineation Study:
Nursing Informatics—National Survey Results (ANCC, 2013), which reported
the collected information on the work activities that informatics nurses perform
in practice. The final report listed 8 domains and 71 separate tasks, as well as call-
ing out the 20 task statements with the highest and lowest values of initial risk.

The McGonigle, Hunter, Hebda, and Hill (2013) online assessment of nurs-
ing informatics competencies can assist faculty and management to develop
curricula or continuing education that best meets the needs of their students
or employees. While there are obvious concrete informatics competencies that
every nurse must have, there are many other, more progressive, processes that
will likely never be part of an educational curriculum or added to a formal list
of competencies. An example is the ever-changing landscape of meaningful
use criteria. Another example is the numerous ways in which technologies
are enhancing practitioners’ ability to monitor patients and coordinate care
remotely via telehealth methodologies. All of these areas require informatics
nurses and informatics nurse specialists to be involved in defining benefit
versus impact, although it may be difficult to predict how the evolving tech-
nologies will be used in the future.

In addition to numerous researchers, academics, and employers, many
professional organizations are actively working toward validating, creating
resources, and providing education in nursing informatics. These include the:

■ American Nurses Association (ANA)

■ American Medical Informatics Association (AMIA)

■ American Nursing Informatics Association (ANIA)

■ Health Information and Management Systems Society (HIMSS)
Nursing Informatics Working Group

informatics Competencies for nurse educators
Today’s nursing educators are challenged to include information on informatics
in a basic nursing education curriculum that is already full. A second challenge

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

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is that many nurse educators themselves lack informatics competencies (AACN,
2013; Flood, Gasiewicz, & Delpier, 2010).

The Gordon and Betty Moore Foundation funded a pilot conference to
teach faculty how to teach informatics. The “QSEN Nursing Informatics
Deep Dive Workshop” was co-sponsored by the American Association
of Colleges of Nursing and the Schools of Nursing at the Universities of
Minnesota and Maryland. The presentations and resources are available to
anyone, without charge, on the AACN website (http://www.aacn.nche.edu/
qsen-informatics/2012-workshop).

Additional challenges include (1) continuing to enhance and disseminate
resources and teaching strategies for all faculties across the country; (2) the
lack of requirements for PhD programs in nursing to include informatics
(researchers are going to need advanced informatics skills); and (3) the need
for methods required for “big data” research to be integrated into curricula for
future faculty and nurse researchers (Bickford, 2013, personal communication).

office of the national Coordinator for Health
information technology
In recognition of the need for health information technology specialists to
assist providers in selecting, implementing, maintaining, and utilizing elec-
tronic medical record systems to “improve health care quality, safety, and cost-
effectiveness” (HealthIT Help Center Workforce Programs, n.d., para. 1), and
the need for those professionals to have specific competencies, the Office of the
National Coordinator for Health Information Technology (ONC) sponsored
four programs using American Recovery and Reinvestment Act funds. These
four programs were:

■ Curriculum Development Centers

■ Community College Consortia to Educate Health Information
Technology Professionals (Community College Consortia, n.d.)

■ Program of Assistance for University-Based Training

■ Competency Examination Program (HealthIT.gov, 2014)

The purpose of the Curriculum Development Centers Program was to fund
and make resources available for curriculum building in higher education
institutions. Under this program, the Oregon Health and Science Center was
appointed to be the National Training and Dissemination Center (NTDC). Its
task was to create a standard curriculum with competencies for all educators

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 45

to use and students to understand and achieve (Curriculum Development
Centers, n.d.).

Subsequently, the materials and curriculum created by the NTDC have
been used by a community college consortium. This consortium consists of 82
member colleges in 5 regions across the United States. The program is focused
on health care and IT professionals who want to become knowledgeable about
and obtain jobs in the health IT sector. The following are key components of
the curriculum:

■ Practice workflow and information management redesign specialists

■ Clinician/practitioner consultants

■ Implementation support specialists

■ Implementation managers

■ Technical/software support

■ Trainers

The materials were only available for download by consortia colleges through
the end of 2012. Even though initial funding for the program has expired, most
have commited to continuing their programs. As of February 2013, 17,523
health IT professionals had successfully completed the program, and 70% are
working in the health IT field (HealthIT, 2013).

In addition to the community college consortium curriculum, funding was
also allocated to develop university-based programs to increase the number
of focused health IT professional roles. The six roles targeted by these pro-
grams are:

1. Clinician/public health leader

2. Health information management and exchange specialist

3. Health information privacy and security specialist

4. Research and development scientist

5. Programmer and software engineer

6. Health IT sub-specialist (Morton, 2011)

Lastly, the ONC funded the development and administration of a nation-
wide program of competency examinations. The purpose was to create “a
mechanism to assess whether examinees have attained a certain set of health

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

The Scope of NurSiNg iNformaTicS pracTice

IT competencies” (HealthIT.gov, 2014, para. 1). The project funding ended in
April 2013, but the American Health Information Management Association
(AHIMA) continues to administer the Certified in Healthcare Privacy and
Security (CHPS®) and Certified Healthcare Technology Specialist (CHTS)
examinations. To date, 9,527 health IT professionals have taken this examina-
tion (HealthIT.gov, 2014; see also CHPS, 2014; CHTS, 2013). The resources
from these federally funded initiatives remain available in the public domain
and have garnered signficant national and international interest and use.

synthesis of evolution of ni Competencies
After the initial work of Staggers et al. (2002), numerous authors and agen-
cies published work on informatics competencies. The focus of the work on
informatics competencies over the past five years has changed from determin-
ing informatics competencies to validation and implementation. The TIGER
Initiative’s work has provided specific and measureable criteria.

Multiple professional organizations are supporting the call for nursing and
healthcare informatics competencies as a part of professional practice. Figure 6
depicts the need for informatics education in all levels of nursing, from both

Figure 6. Informatics Competencies for All Registered Nurses

Nursing Informatics.indd 46 11/6/14 4:06 PM

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The Scope of NurSiNg iNformaTicS pracTice

Nursing Informatics: Scope and Standards of Practice, 2nd Edition 47

the clinical and educational points of view, as well as for those nurses who
specialize in informatics. Informatics education must be foundational for all
entry-level nurses. Over time, as their education, knowledge, and skills increase,
nurses grow in their understanding of how to use technology to enable them
to provide better patient care. Finally, as newer and better ways of using tech-
nology (innovation) emerge, nurses who specialize in informatics nursing will
have a leading role.

In the future, the rapid pace of technological change and generation of infor-
mation and knowledge will present challenges for the maintenance of current
and accurate competencies for nursing informatics. Nurses must understand
the need for achieving basic competence in nursing informatics; professional
organizations must continue to embrace informatics as a foundation for pro-
fessional practice; and faculty must make NI an integral part of curricula at
all levels of nursing education, as well as stimulate continued research. It is
the responsibility of informatics nurses to be the resource for these initiatives.

Preparation for Nursing Informatics
Specialty Practice
The following exemplifies one pathway for the novice nurse to move from an
entry-level informatics nurse job to a position deemed to be a true informat-
ics nurse leader, regardless of formal title. At any time in their careers, nurses
interested in health information technology could complete one or all of the
ONC community college consortia programs and pass the associated certifica-
tion exam to become a health information technology specialist, thus becoming
better able to function in and attain positions in academic, clinical practice,
administrative, and technology areas.

Because nursing informatics requires a significant understanding of numer-
ous clinical workflows, it is advisable for an aspiring informatics nurse to spend
at least five years at the bedside or in other clinical practice experiences in
numerous departments and roles. As aspiring informatics nurses continue to
educate themselves through formal programs or through informatics-focused
areas of practice, they will become more comfortable in taking on greater levels
of responsibility and accountability reflective of nursing informatics practice.
Becoming a subject matter expert for a specialty role, whether academic, clini-
cal, or administrative, will further enhance the nurse’s understanding of the
nuances involved in developing, maintaining, and optimizing technology that
impacts nursing in all realms.

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

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Since 2004, the Health Information and Management Systems Society
(HIMSS) has surveyed the nursing informatics community to gain an understand-
ing of the roles and responsibilities of the informatics nurse professional. The
most recent Nursing Informatics Workforce Survey (HIMSS, 2014), supported by
the HIMSS Nursing Informatics Community, representing 6,000 nurses, builds
on previous HIMSS research from 2004, 2007, and 2011. This survey captures
current professional status and practice trends while identifying changes that
have occurred over the past nine years in the nursing informatics workforce. The
1,047 respondents reported that 60% had completed graduate or higher degree
educational preparation, 58% worked at a hospital, and 13% worked at the cor-
porate offices of a healthcare system; the average salary was $100,717. (Further
details are available at http://www.himss.org/ni-workforce-survey.)

Certification of informatics nurses
Professional certification as an informatics nurse became a reality in late 1995
when the American Nurses Credentialing Center offered the generalist-level
nursing informatics certification exam as its first computer-based examination.
As of December 31, 2013, the ANCC reported that 1,326 nurses have active
credentials of board certification in nursing informatics. Applicants currently
must have at least a BSN or baccalaureate degree in another related area,
have completed the specified continuing education credits, and have worked
in informatics practice for the designated number of hours. (More details are
available at www.nursecredentialing.org.) Informatics nurses and informatics
nurse specialists may elect to pursue other pertinent certifications in areas
such as project management, security and privacy, health information systems
management, network management, and knowledge management. Employers
are beginning to move from a preference to a requirement for certification for
hiring, advancement, and promotion decisions.

An Advancing Professional nursing specialty
The blending of clinical background, on-the-job training, refined and focused
informatics competencies, informatics certification, and the increase in for-
malized informatics education are proof of an advancing professional nursing
specialty that is ideally suited to lead in an informatics-based U.S. healthcare
system. Employers are beginning to recognize the value and contribution of
informatics nurses and are even requiring completion of graduate or higher level
educational preparation for hiring. Similarly, the informatics nurse specialist

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title is becoming more familiar. As the importance of nursing informatics con-
tinues to be recognized, the future should see a rise in executive-level or C-Suite
nursing informatics positions, such as “Chief Nursing Informatics Officer,” in
clinical, business, vendor, and IT arenas. In addition, the need for nursing
informatics professionals in governmental roles will be recognized at the local,
state, regional, and national levels. Nurses with an interest in informatics have
many avenues through which to pursue their specialty practice over the years.

Ethics in Nursing Informatics
Code of Ethics for Nurses (ANA, 2001) provides a framework for ethical prac-
tice in nursing informatics. While working in the informatics role, professional
nurses may not provide direct patient care, but do provide support for patient
care through work on the healthcare delivery system infrastructure through
which care is delivered. All provisions of this Code apply to nursing informatics—
some more directly than others, as illustrated in the following examples.

Provision 1: The nurse, in all professional relationships, practices with com-
passion and respect for the inherent dignity, worth and uniqueness of every
individual, unrestricted by considerations of social or economic status, personal
attributes, or the nature of health problems.

The informatics nurse and informatics nurse specialist function as integral
parts of the healthcare team. The nature of this work involves interaction and
collaboration with many different people with various areas of expertise, values,
priorities, and views. The informatics nurse values each of these people as indi-
viduals, with worth and dignity, regardless of status or power in the organiza-
tion, and in spite of some persons’ lack of informatics or nursing knowledge.
The team collaboration that is essential to successful information systems in
health care is created, enhanced, and preserved through the informatics nurse’s
compassion and respect for each person on the team.

Provision 2: The nurse’s primary commitment is to the patient, whether an
individual, family, group or community.

The informatics nurse always works to achieve results that will directly or
indirectly benefit patient care, safety, and well-being. This involves careful
consideration of the probable outcomes of decisions about data collection

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and protection of the privacy, security, and confidentiality of patient infor-
mation. The informatics nurse avoids participating in the development or
implementation of systems that may be desired by an interested party, but that
would have the effect of causing harm to the patient. For example, counter-
ing such adverse effects may require the development of an effective system
alert that directs a clinician to offer less costly and comparable alternatives
for medications or treatments.

Provision 3: The nurse promotes, advocates for and strives to protect the health,
safety and rights of the patient.

As the patient advocate, the informatics nurse collaborates in the development,
implementation, support, and maintenance of systems with data collection,
storage, retrieval, processing, and analytic features that support: (a) patient
safety, autonomy, and rights; (b) quality improvement efforts; (c) provision of
safe care; (d) appropriate information communication; (e) restriction of access
to patient data by those not authorized to have it; and (f ) use of data and
information to benefit healthcare outcomes and healthcare services delivery.
The informatics nurse is involved in addressing usability factors that support
the rights of the patient.

Provision 4: The nurse is responsible and accountable for individual nursing
practice and determines the appropriate delegation of tasks consistent with
the nurse’s obligation to provide optimum patient care.

The informatics nurse uses best practices in informatics to collaborate in the
development, implementation, support, and maintenance of systems that sup-
port nursing practice. The informatics nurse supports direct care providers in
their efforts to learn about, understand, and use information technology in a
way that supports patient care and promotes the patient’s welfare.

Provision 5: The nurse owes the same duties to self as to others, including the
responsibility to preserve integrity and safety, to maintain competence, and
to continue personal and professional growth.

The informatics nurse is responsible for maintaining currency in informatics
theory and practice through lifelong learning. This can be challenging in a field
with rapidly changing technologies and capabilities and a fiscally constrained

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environment that requires self-funding of relevant continuing education
programs and activities. For a more detailed discussion of lifelong learning
and maintenance of competence, see Professional Performance Standard 8,
Education.

Provision 6: The nurse participates in establishing, maintaining, and improv-
ing healthcare environments and conditions of employment conducive to the
provision of quality healthcare and consistent with the values of the profession
through individual and collective action.

The informatics nurse collaborates in the development, implementation, sup-
port, and maintenance of information systems that support and improve the
delivery of care, appropriate communication of health-related information,
data storage, protection of confidential information, and management of the
enterprise. Such behavior provides a model for successful interprofessional
teams.

Provision 7: The nurse participates in the advancement of the profession
through contributions to practice, education, administration, and knowledge
development.

Informatics nurses seek to advance the quality of nursing informatics practice.
As a specialty, nursing informatics offers both master’s and doctoral degrees
in which students can gain the advanced nursing education necessary to add
to the body of informatics knowledge, and the credentials to teach informatics
to the next generations of nurses. Informatics nurse specialists are prepared to
improve administration, education, and research in nursing informatics, and
to enhance dissemination of that knowledge.

Provision 8: The nurse collaborates with other health professionals and the
public in promoting community, national, and international efforts to meet
health needs.

The informatics nurse collaborates in efforts to develop systems that allow
system interoperability and data and information transfer and aggregation.
These efforts allow health data to be used to improve knowledge about indi-
vidual, community, national, and international health and health practices
and outcomes.

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Provision 9: The profession of nursing, as represented by associations and
their members, is responsible for articulating nursing values, for maintaining
the integrity of the profession and its practice, and for shaping social policy.

The informatics nurse participates in the informatics work of professional
nursing associations, in national and international health informatics organi-
zations, and in vendor organizations, to articulate nursing values, to ensure
that patient-centricity is always maintained, and to shape social and health
policy for the benefit of all persons.

the Future of nursing informatics
Five trends will continue to influence the future of nursing informatics:
(1) changing practice roles in nursing, (2) increasing informatics competence
requirements for all nurses, (3) rapidly evolving technology, (4) regulatory
changes and quality standards that include healthcare consumers as partners
in healthcare models, and (5) care delivery models and innovation.

trends in Practice roles and Competencies for nurses
and informatics
The principles of evidence-based practice and application of technologies are
now being integrated into the workplace in all settings. This results in the need
for every nurse to have some level of informatics competence, with the number
and complexity of informatics competencies evolving to meet their changing
practice roles. As discussed earlier, some of the basic informatics competencies
once ascribed to informatics specialists have become mandatory for nurses in
clinical, education, and administration practices. Similarly, the level of compe-
tencies required for INs and INSs has increased to meet the skill-set require-
ments necessary to participate on the development and implementation teams.

In the past several years, nursing specialties have incorporated informatics
into their practice. For example, nurses who rely on information and tech-
nology for telehealth, quality improvement, or product development might
be considered informatics nurses. Other nurses who design, implement, and
evaluate informatics solutions as active members of the interprofessional teams
are acting in very common nursing informatics roles. The scope of nursing
informatics practice will continue to expand as further technologic innova-
tions are developed for healthcare delivery solutions. Nursing informatics has
become a world community.

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The role boundaries between other health informatics roles and NI
are less conspicuous than in the past. One of the centerpieces of nursing
informatics practice is its interprofessional nature, with informatics nurse
specialists often leading projects to craft usable informatics solutions for
use by many stakeholders. Although INSs focus on technology and nurs-
ing practice, they work in teams with informatics specialists from other
healthcare professions such as medicine, pharmacy, and respiratory therapy.
These interprofessional teams are using a shared set of functions, skills, and
their knowledge of their respective professions to craft solutions that meet
the needs of all. This trend will likely continue as professional informatics
organizations define a shared set of core knowledge and skills required by
all informatics specialties.

Probably the clearest trend is ongoing change in the functional areas for
informatics nurses and informatics nurse specialists, moving from a generic
set of skills toward a shared set of competencies based on functional areas
required to enact a particular position (e.g., clinical analyst, informatics
executive, futurist, knowledge discovery and data mining [KDD] researcher,
database developer).

trends in technology
Information technology has become commonplace in everyone’s personal
lives, as well as in delivery of healthcare services. For the first time in history,
a generation exists that has never known a world without the Internet, cell
phones, online social networks, blogs, and other electronic media. People who
were raised using this technology (digital natives) are now entering the health-
care field as knowledge workers, as well as consumers of healthcare services.
Implications for nursing informatics include:

■ New models of work and education for technologically sophisticated
users who are less resistant to technology and in fact demand it.

■ Adapting to users with less skill in face-to-face communications.

■ Consumers with even greater expectations of accelerated information
and technology implementation.

Several advances in technology will likely have an impact on nursing
informatics in the future. A number of these are outlined in the following
subsections.

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nAnoteCHnoLoGy

Nanotechnology is microscopic technology on the order of one-billionth of a
meter. The application of this technology for healthcare delivery uses (nano-
medicine) will have an impact on the diagnosis and treatment of many diseases
and conditions (Jain, 2008; Maojo et al., 2011). For example, these minute
biomedical devices (smaller than molecules) are being developed to provide
a way to deliver therapies (medication and radiation) that will target cancer
cells or that can perform surgery (nanorobots) on specific cells. The imple-
mentation of this technology for patient care applications requires education
in its safe use as well as ethical practices (McGonigle & Mastrian, 2015, p. 485;
see also http://www.nano.gov/ and http://www.ihe.ca/publications/library/
2012-publications/exploratory-brief-on-nanomedicine-or-the-appliation-of

-nanotechnology-in-human-health-care/).

tooLs For MAnAGinG PoPuLAtion HeALtH ConCerns

As healthcare delivery moves into the global community setting, there will be
a growing need for informatics support for disease state management and
population health activities (e.g., public health, school health, and occupa-
tional health). Informatics provides tools that allow data collection, analysis,
and reporting of population health specialty data by the use of standardized
variables in interoperable electronic documentation systems (see http://www.
ncqa.org/HEDISQualityMeasurement.aspx and http://www.dartmouthatlas.
org/). Population health specialty data then become a useful tool to support
research, inform policy, and identify best practices to enhance treatment of
national population health concerns.

Syndromic surveillance of communicable disease using school absenteeism
records (Baer, Rodriguez, & Duchin, 2011), and management of immuniza-
tion data (Hinman & Ross, 2010), each provide insight into the potential of
population-level data. School health and public health nurses are leading move-
ments to standardize variables and data collection processes that will enhance
this ability. This potential for research and analysis is exemplified in the data
collected by school nurses on more than 95% of the school-aged population.
Other examples of this potential will be driven by business globalization and
the threat of bioterrorism. The desire for improved disease management across
traditional boundaries will lead to a demand for new population health tools
and solutions.

The need for population management tools and early disease detection has
led to partnerships with population health professionals and the emergence

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of public health informatics (Public Health Informatics Institute [PHII],
2009). MappyHealth and other geographic information system (GIS) applica-
tions are being implemented as strategies to support syndromic surveillance,
emergency preparedness, and disaster recovery efforts. Health information
exchanges and disease and immunization registries help identify and address
public health concerns.

DeViCes AnD HArDWAre

The miniaturization of devices has changed where and how IT solutions can
be deployed. No perfect hardware solution exists. However, technological inno-
vations are making headway in meeting changing healthcare delivery models,
particularly the caregiver needs for the older adult population. An increasing
focus on ergonomics, human–computer interaction, and user experience is
leading to new solutions to support diverse workflow requirements.

New integrated technologies, such as smartphones, tablets, and multifunc-
tional devices, have increased common access to health information. These
solutions are becoming ubiquitous in daily life. They have changed clinicians’
and patients’ expectations and their interactions with technology. In particular,
providers are being challenged to know as much about new disease treatments
and research findings as patients.

Some of the pending technologies that will affect INs, INSs, clinicians,
patients, and healthcare consumers include:
New methods for medication administration

■ Sensing a patient’s internal drug levels with miniature medical diagnos-
tic tools circulating in the patient’s bloodstream.

■ Chemotherapy delivered directly to a tumor site, reducing systemic side
effects.

New monitoring devices and miniaturization for the home that move content
to hardware and devices

■ A talking pill bottle that lets patients push a button to hear prescription
information.

■ Bathroom counters that announce whether it is safe to mix two
medications.

■ A shower with built-in scales to calculate body mass index (Hong Kong
Polytechnic University).

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■ Measuring devices in the bathroom to track urination frequency and
output and upload these data to a system or care manager.

■ Noninvasive blood glucose monitors to eliminate fingersticks; sensors to
compute blood sugar levels using a multi-wavelength reflective disper-
sion photometer (Hong Kong Polytechnic University).

Body area network (wearable computing)

■ Wearable computing, or body-borne computing, will continue to evolve
in the next several years and have an impact similar to that of mobile
computing on our daily lives. Innovations in development involve
eyeglasses or clothing that interact with the user based on the context of
the situation. With heads-up displays, sensors embedded in fabrics, unob-
trusive input devices, personal wireless local area networks, and a host of
other context-sensing and communication tools, wearable computers can
act as intelligent assistants or data collection and analysis devices.

Many of these devices are available now. Smart fabrics with embedded sen-
sors have been on the commercial market since 2000 and are being used in
shirts, gloves, and other clothing. These wearable computer and remote moni-
toring systems are intertwined with the user’s activity so that the technology
becomes transparent. Sensors and devices can gather data during the patient’s
daily routine, providing healthcare providers or researchers with periodic or
continuous data on the subject’s health at work, school, exercise, and sleep,
rather than the current snapshot captured during a typical hospital or clinic
visit. A few applications for wearable computing include:

■ Monitoring rescue workers’ vital signs, heat stress, and dehydration

■ Activity level of poststroke patients

■ Assessment of stress in individuals

■ Arrhythmia detection and control of selected cardiac conditions

■ Daily activity monitors

■ Proximity badges and RFID (radio-frequency identification) to track
providers for workflow or allow logon to systems.

■ Glasses with a heads-up display that can superimpose images (e.g.,
chest x-ray) in a display over a patient, without losing focus on the
patient (MIT Media Lab, 2012).

■ Bar-code scanners that fit on a finger, or wrist-activated input devices.

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Developments for input methods also apply to the healthcare market. For
example, an “interface-free,” touch-driven computer screen, manipulated
intuitively with the fingertips, responds to varying levels of pressure. Another
example is virtual keyboards using Bluetooth technology, in which a keyboard
can be displayed and used on any surface (ThinkGeek, 2014).

robotiCs

The use of robotics in patient care has also revolutionized health care. Robots
continue to be used to deliver supplies to patient care areas, enable remote
surgeries and virtual-reality surgical procedure training, and are being used
as translators for patients. Hand-assist devices help patients regain strength
after a stroke, and robotic technology is being used for immediate patient
assessments (Leventhal, 2010).

Robots are providing a remote presence by allowing clinicians to virtually
examine patients by manipulating remote cameras. Robotics are also being
used in direct patient care: for instance, to help lift morbidly obese patients,
to assist patients who have had traumatic injuries, and in other innovative
applications (Robotics Technology-Healthcare Robotics, n.d.). A notable use
is the research underway for using robotics to assist paralyzed patients to walk
(Houlihan, n.d.).

FoCus oF eMerGinG teCHnoLoGies

Clinicians are using new and evolving technologies to deliver care that results
in decreased barriers, increased access, improved outcomes, and increased
patient engagement in their own health. Telehealth tools and emerging tech-
nologies are positioned to change the face and practice of health care. Nurses
using informatics, telehealth tools, and new, transformative technologies will
be well positioned to interact with and care for their patients virtually. There
will be a decreasing number of brick-and-mortar practices and an increasing
number of clinicians and specialists available—for a fraction of traditional
costs—at the click of a button.

Gaming technology has entered the healthcare arena as well. Health and
fitness apps and devices are being marketed to consumers as products that can
be used to monitor actions and activities that affect health status. The use of
creative health-related technology with social media integration may increase
patient engagement and improve wellness.

Virtual worlds are being created (e.g., Second Life©) that allow consumers to
interact with providers to seek care at a distance. The Department of Defense

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is using avatars to help veterans with posttraumatic stress disorder (PTSD)
(Hemmerly-Brown, 2011). Practices are being developed completely online in
the virtual world that allow patients to create an avatar and seek health care
while concealing their physical identity. Nursing informatics involvement is
needed to bridge solutions that support virtual health worlds as well as comple-
ment face-to-face care with virtual care.

Healthcare education and research can be conducted within a virtual world
(Wisconsin Institute for Discovery, n.d.). Software programs have been devel-
oped to assist nursing and medical students to learn physical assessment via
simulated practice with a digital patient, document in an electronic medical
records system, and explore medical concepts in three dimensions in a virtual
world (Shadow Health, 2014).

Remote monitoring, mHealth devices and hardware, other devices creating
“smart” homes, and other digital solutions will continue to be developed and
improved. Healthcare professionals who use these emerging technologies will
need to be equipped with knowledge of rules, regulations, and responsibilities
surrounding the use of these technologies. Patients and clinicians alike will
need education on how to use, share, and benefit from the “big data” that are
produced and gathered by these devices.

Health-related education will move online with more frequency as providers
learn to interact with their patients virtually. Holograms are being utilized to
provide health education and serve as virtual coaches (Bassendowski, 2013).
Software has been developed that allows providers to choose a diagnosis and
allows the computer to provide structured educational programs for the patient.
Technology is also moving more toward a semantic web, in which technologi-
cal programs will actually interact with patients, learn their needs, and adjust
education based upon the patients’ responses.

New technology is being used to provide telecommunication connectivity
where broadband is not available. This allows specialists and other healthcare
providers to interact with those in need in rural communities, decreases barri-
ers related to transportation, and facilitates implementation of best practices
for vulnerable populations where access to health care was previously limited
or unavailable.

Goals related to care will remain the same in regard to decreasing hospital
admissions, improving outcomes, and keeping patients healthy at home and
in their local community. However, the methods for accomplishing these goals
may change as an understanding of the use and benefits of telehealth and
emerging technologies becomes more widespread.

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KnoWLeDGe rePresentAtion

Electronic data are now available for and about patients over their lifetime.
Clinicians need tools to help locate and synthesize these data remotely and
securely. Innovative technology is being used to allow the wireless display (via
smartphones, tablets, laptops, etc.) of data to clinicians to optimize patient care
and enhance patient and clinician efficiencies, while avoiding medical errors.
NI practice now requires that more nurses be educated about knowledge rep-
resentation, semantic representation, and other knowledge areas, including use
of standardized language that supports nursing practice and decision-making.
This also has implications for knowledge discovery in databases, data quality,
and a continued emphasis on data standards and data quality.

Nurses constantly make complex and diverse decisions in their daily practice.
Decision-making must consider relevant evidence-based and patient-specific
information. As nurse decision-making becomes more complex, the need for
computerized clinical decision support will increase. In the absence of explicit
evidence-based guidelines for nursing decisions, novel technologies will be neces-
sary to synthesize evidence from the literature or induce models from clinical data.

Knowledge discovery in databases could play an important role in the
induction of clinical knowledge models. Informatics nurses must partner in
the planning of and forward thinking about maintenance and evaluation of
legacy data, mandates for interoperability, and data conversion and retention,
as well as accessibility for future use.

eDuCAtionAL teCHnoLoGies

Evolving teaching technologies are changing the education techniques used
in the classroom, the lab, and the clinical setting. For example, patient care
simulation activities allow students to run programmed care scenarios in a
safe environment and provide innovative options for teaching and fostering
critical thinking skills (Sternberger, 2012). Group learning tools, such as elec-
tronic reminders and group scoring used in interactive teaching, can change
how students engage with class content, as well as how they learn to function
as members of a team (Michaelsen, n.d.).

Distance education technologies, and web-based and cloud-based col-
laboration (such as web-based course management systems and the related
student support services), are challenging basic education concepts such as
what academic resources must be included in a library collection or how a
university defines a credit hour of education. This automation is forcing insti-
tutions to review, and in many cases to revise, their educational policies and

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procedures. These technologies require a paradigm shift in knowledge delivery,
which affects students, instructors, and course content, and create significant
opportunities for innovative informatics nurses.

The traditional tuition models are no longer a barrier to the globalization
of education. New educational models are being created, such as global uni-
versities that reach students beyond their walls by offering courses on loca-
tion or by creating virtual educational experiences (e.g., partnering with other
institutions to deliver classes to students across a region). Universities are
also partnering with business entities and vendors to create other innovative
models of education (Emory University, 2011).

Curriculum design will change. The traditional classroom is also changing
to the concept of the flipped classroom model, which permits interactive col-
laboration in the classroom (Brame, 2013). Information is now generated and
made available so quickly that baseline knowledge for students will evolve away
from specific content to methods of finding accurate, current information and
knowledge. Future students may not be evaluated on specific knowledge for
one area or course, but instead be evaluated on their growth over time. The
INS will be at the center of this union of informatics and new educational
models because of the INS role’s focus on managing information.

tooLs For PAtient ACCess to HeALtH inForMAtion

Much emphasis is being placed on assisting healthcare consumers to become
partners with their providers, thereby increasing consumers’ accountability
for their own care. The healthcare consumers may be known as e-patients
(e-Patients.net, 2013). This type of healthcare model will require clinical nurses
and informatics nurses to devise personalized solutions and the best methods
of care and patient education, as well as solutions to monitor and maintain
patients’ health. Patient engagement is expected to include easy access to per-
sonal health information via the view, download, and transmit (VDT) capabili-
ties being mandated by the ONC for meaningful use compliance. Surrounding
issues that must be addressed include: healthcare consumer-centered care/
patient-centered care, patient accountability for care activities and data integ-
rity, interoperable data transfer, education about data protection and security,
and medical identity theft and encryption tools that monitor and protect.

exPAnDeD use oF it in nursinG

Technologic innovation has had an enormous impact on the scope of nurs-
ing practice in traditional work settings, in the home, and globally. Two

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implications are outlined here. One is a concern about students relying on
available, structured information, computerized alerts, and reminders in
EHRs and decision-support systems (DSSs). Some educators and adminis-
trators are concerned that students will rely only on this structured informa-
tion rather than applying their critical thinking skills, and that those skills
may thus diminish. INSs and educators are developing and testing new
academic and practice models that address this issue. One solution involves
the development of case studies that can be used in simulated settings and
include the integrated use of EHRs with DSSs. System designers may need
to modify systems to promote a different cognitive engagement by practi-
tioners. Educators may teach a new level of human information processing
to enhance thoughtful decision-making. The traditional model involves stu-
dents memorizing structures for a physical examination and similar static
information stored in an EHR. In the new model, information technology
serves as an aid to, not a replacement for, human thinking and judgment,
to promote collaborative patient management.

Reliability is the other implication of the increasing pervasiveness of IT.
As applications are increasingly integrated into health care, the impact of
downtime or system unavailability becomes more severe and quick recovery
methods become imperative. Especially with order management in place, insti-
tutions must ensure continuous business operations with uninterrupted access
to applications and data. Strategies and technologies to support continuous
uptime are available, and the INS is typically involved in defining, designing,
and installing them. Requirements for current and future systems will focus
more on proactive risk mitigation rather than reactive recovery efforts; these
may include:

■ 24/7 operation and performance with redundancies throughout the
system, failovers, and tested high reliability.

■ Tools to assist in monitoring and managing the IT environment,
monitor system use, and identify technology issues before system failure
occurs.

■ Scalable IT solutions as more clinical applications come online.

■ Solutions that IT departments can manage without in-depth technology
expertise.

■ Implementation of health information exchanges (HIEs) to facilitate
the sharing of patient information.

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iMPLiCAtions For nursinG inForMAtiCs

Informatics nurses will need a systematic method for becoming aware of
emerging technologies and tools and then evaluating their usability for and
projected impact(s) on health care and informatics. INs and INSs can be
essential leaders and partners for the safe and intelligent incorporation of new
technology and techniques into health informatics solutions and health care in
general. Because the content or information on devices is still the most critical
component, informatics nurses can serve as content designers. Areas such as
genomics have significant ethical ramifications, and informatics nurses must
ensure that attention is given to these issues. All of these areas have implica-
tions for curricular design and educational programming as well.

The expansion of technology amplifies the need for continuous availability
of systems. Nevertheless, the “digital divide” remains, as significant numbers
of people have little access to or experience with information technology.
Informatics nurses can also take the lead in eliminating the digital divide
between those with access to information and those without. In all situations,
informatics nurses can advocate and apply methods so that users can learn
and use new technologies effectively and safely.

trends in regulatory Changes
and Quality standards
Technologies cannot remain the primary focus when addressing the future of
nursing informatics and health care. The design and evolution of healthcare
systems, organizations, and enterprises, as well as the regulatory environment
and actual models of care delivery, must be integral and primary considerations.

The 2009 American Recovery and Reinvestment Act (ARRA) and Health
Information Technology for Economic and Clinical Health (HITECH) Act have
driven information technology and EHR installations in the United States to
a new national level, emphasizing the use of technology for patient safety and
error reduction in healthcare delivery. Organizations such as the Agency for
Healthcare Research and Quality (AHRQ) and the Institute for Healthcare
Improvement (IHI), as well as nonhealth organizations like Leapfrog, pro-
vide incentives for health institutions to implement informatics solutions.
The continuing requirement to meet meaningful use standards is supporting
the increasing pace of adoption. Mandates now direct organizations to use
value-based rather than return-on-investment models to justify health IT, and
the pay-for-performance models are accelerating EHR installations. Online

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 63

quality data and reported metrics are more visible to both consumers and hos-
pital and organizational boards. Organizations will continue to increase the
transparency of data and, more importantly, improve the care being delivered.

Regulatory requirements and standards will continue to shape the future.
INSs are involved in defining these and future standards, and in designing,
building, implementing, using, and certifying products that comply. A number
of projects have been implemented; among them are the following:

■ HL7 continues to define interoperability standards for systems.

■ The IEEE P2407 working group has developed standards for personal-
ized health informatics.

■ The Healthcare Information Technology Standards Panel (HITSP) is
harmonizing industry-wide health IT standards.

■ The Nationwide Health Information Network (NwHIN) initiative is
creating prototype architectures for widespread health information
exchange.

■ The Food and Drug Administration (FDA) initiatives related to (a) bar-
code label requirements for human drug products and biological products,
(b) guidelines for the safe and effective use of radio frequency devices, and
(c) nanotechnology development and potential expansion of products
covered (e.g., advanced decision support tools and similar informatics
applications).

■ Office of the National Coordinator for Health Information Technology’s
Connecting Health and Care for the Nation concept paper (HealthIT.
gov, n.d.).

trends in Care Delivery Models and innovation
Using technologies in new ways and inventing new technologies to enable
better care delivery models to achieve quality outcomes and safety are part
of the evolution to accountable care organizations (ACOs), a population
focus rather than individual focus, and pay-for-performance rather than fee-
for-service reimbursement. Care is no longer a local phenomenon. Patients
in rural ICUs can be monitored remotely by intensivists and ICU nurses.
Less experienced critical care nurses can be remotely mentored by expe-
rienced nurses. Pharmacists can provide remote pharmacologic assistance

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

The Scope of NurSiNg iNformaTicS pracTice

to rural areas. Radiologists can read images in real time from anywhere
in the world. Physicians are assisted by robots as they examine patients in
distant locations.

Care is no longer limited to traditional healthcare settings, even when it is
delivered locally. Clinicians are now available in retail stores, work settings, and
other nontraditional places. These new settings require new design, deploy-
ment, and support models that will challenge the informatics nurse specialist.
Involvement in the development of a robust health information infrastructure
includes, but is not limited to:

■ Continued innovation in systems and expansion into less traditional
settings, such as long-term care and rural communities.

■ ACOs, medical home, home health expansion, and patient-aligned
care teams (interprofessional team completing care coordination/
management).

■ Growth of personal health records. PHRs are more numerous and
the use of the patient portal (PP) is being implemented along with
electronic medical record (EMR) activations. Informatics nurses will
increasingly advocate for and assist patients with developing these
individually maintained records. These can include the patient’s own
electronic vaccination history, past medical history, medications, aller-
gies, condition, status, and visit history in an easily accessible online
format. Patients’ online communication with healthcare providers
through PPs will continue to increase as well.

■ Clinical data repositories and regional health information organizations/
exchanges. These structures will support accurate, timely, and secure
transfer of patient data across care settings (ultimately across hospitals,
clinics, pharmacies, laboratories, clinician office, long-term care facilities,
and others).

Consumer informatics
Healthcare consumers have become stronger partners with providers, embrac-
ing increased accountability for their own care and taking greater interest
in data accuracy and access to their own electronic health information. As
consumers become more technically adept, they will consider their electronic
healthcare data as necessary and accessible as their online banking informa-
tion or stock transactions. Likewise, consumers will begin monitoring and

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 65

managing the health of younger and older family members for whom they
are responsible.

In response to the increasing technology capabilities of healthcare consum-
ers, the Centers for Medicare & Medicaid Services created Physician Compare
(https://data.medicare.gov/data/physician-compare) and Hospital Compare
(http://www.medicare.gov/hospitalcompare/) to help healthcare consumers
select appropriate care delivery resources.

external Partnerships
Nontraditional organizations are now entering the healthcare arena, and their
contributions and innovations should be welcomed. For example, companies
with an online application for individual, secure financial records may expand
their apps to include personal health records. Partnerships with the video-
gaming industry yield ideas for optimal user interfaces and contribute to the
development of healthcare and clinician educational media, products, and
systems. Nurses need to be participants in this space, ideally as information
and facility architects.

implications for nursing informatics
New care delivery models will require development of informatics solutions
for care in multiple, remote locations. Informatics nurses will have a key role
in informatics solutions that emphasize quality care metrics developed as
e-measures. New models to shorten the time from design to installation in the
system life cycle are being used. An 18- to 24-month build-and-implementation
cycle is not tenable in an era of rapidly changing technology, care delivery, and
expanding information access.

With the increasing number of information technology installations and
the need to respond to burgeoning regulatory requirements, informatics
nurses are on center stage for all phases of the system life cycle. They are
developing and implementing new informatics solutions, ensuring data
quality for implemented solutions, and evaluating the impact of solutions.
The new model of consumer informatics requires technical solutions and
patient education jointly from clinical nurses and INSs. INSs will need
to devise the best methods of care and also design solutions that enable
patients to monitor and maintain their own health. INSs will play a key
role in designing new tools for data capture and analyses to comply with
regulatory guidelines.

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

The Scope of NurSiNg iNformaTicS pracTice

ni Future and trends: summary
The practice of nursing, expanding competencies, technologic innovations,
and new trends in healthcare delivery models and regulation will continue
to influence the future of nursing informatics. Important concepts will be
essential to these trends:

■ Preparing for technology innovations, evidence-based practice compe-
tencies, and data quality evaluation.

■ Introducing and delivering new educational models to teach both new
and existing nursing professionals.

■ Designing, developing, implementing, and evaluating solutions for
innovative information technologies across all areas of nursing and
health settings.

■ Incorporating telehealth and newer technologies and methods to facili-
tate access and care provision, research, and administrative processes.

■ Designing and facilitating changes in care models in response to
evidence-based practice outcomes as they evolve away from episodic
care toward more predictive and preventive models with collaborative
interprofessional care teams.

■ Focusing on usability, designing and evaluating how information is
presented to promote ease of use and adoption (human-computer
interaction).

■ Participating in global public and private initiatives to evaluate disease
patterns and trends.

In the future, care models and data will continue to be shared even more
widely. New technologies will create wider access to information and the need
for a new generation of data and information management skills, analytic tools,
educational models, and cognitive skills. Traditional boundaries of institutions,
care delivery, and education will continue to shift and evolve. New positions
and functional areas are emerging. Increased collaboration among nursing
informatics colleagues and a shared scope and standards of practice will con-
tinue to be a characteristic of the future.

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67

Standards of Nursing
Informatics Practice

Significance of the Standards
The Standards of Professional Nursing Practice, on which the Standards of
Nursing Informatics Practice are based, are authoritative statements of the
duties that all registered nurses, regardless of role, population, or specialty,
are expected to perform competently. The standards published herein may
be utilized as evidence of the standard of care, with the understanding that
application of the standards is context dependent. The standards are subject
to change with the dynamics of the nursing profession, as new patterns of
professional practice are developed and accepted by the nursing profession
and the public. In addition, specific conditions and clinical circumstances may
affect the application of the standards at a given time (e.g., during a natural
disaster). The standards are subject to formal, periodic review and revision.

The competencies that accompany each standard may be evidence of
compliance with the corresponding standard. The list of competencies is not
exhaustive. Whether a particular standard or competency applies depends on
the circumstances.

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

Standards of Practice for
Nursing Informatics

Standard 1. Assessment

The informatics nurse collects comprehensive data, information,

and emerging evidence pertinent to the situation.

CoMPetenCies

The informatics nurse:

■ Uses evidence-based assessment techniques, instruments, tools, and
effective communication strategies in collecting pertinent data to define
the issue or problem.

■ Uses workflow analyses to examine current practice, workflow, and the
potential impact of an informatics solution on that workflow.

■ Conducts a needs analysis to refine the issue or problem when necessary.

■ Involves the healthcare consumer, family, interprofessional team, and
key stakeholders, as appropriate, in relevant data collection.

■ Prioritizes data collection activities.

■ Uses analytical models, algorithms, and tools that facilitate assessment.
One example of an assessment algorithm is PIECES:

■ Performance—throughput or response time;

■ Information—outputs, inputs, and/or stored data;

■ Economics—costs versus profits;

■ Control—too little security or control or too much control or
security;

■ Efficiency—people, machines, or computers waste time, and;

■ Service—inaccurate, inconsistent, unreliable, hard to learn, difficult
to use, inflexible, incompatible, not coordinated with other systems
(Wetherbe, 1994).

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stAnDArDs oF nursinG inForMAtiCs PrACtiCe

■ Synthesizes available data, information, evidence, and knowledge
relevant to the situation to identify patterns and variances.

■ Applies ethical, legal, and privacy regulations and policies for the collec-
tion, maintenance, use, and dissemination of data and information.

■ Documents relevant data in a retrievable format.

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

Standard 2. Diagnosis, Problems, and Issues
Identification

The informatics nurse analyzes assessment data to identify

diagnoses, problems, issues, and opportunities for improvement.

CoMPetenCies

The informatics nurse:

■ Derives diagnoses, problems, needs, issues, and opportunities for
improvement based on assessment data.

■ Validates the diagnoses, problems, needs, issues, and opportunities for
improvement with the healthcare consumer, family, interprofessional
team, and key stakeholders when possible and appropriate.

■ Identifies actual or potential risks to the healthcare consumer’s health
and safety, or barriers to health, which may include, but are not limited
to, interpersonal, systematic, or environmental circumstances.

■ Uses standardized clinical terminologies, taxonomies, and decision
support tools, when available, to identify problems, needs, issues, and
opportunities for improvement.

■ Documents problems, needs, issues, and opportunities for improvement
in a manner that facilitates the discovery of expected outcomes and
development of a plan.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 71

Standard 3. Outcomes Identification

The informatics nurse identifies expected outcomes for a plan

individualized to the healthcare consumer or the situation.

CoMPetenCies

The informatics nurse:

■ Involves the healthcare consumer, family, healthcare providers, and
key stakeholders in formulating expected outcomes when possible and
appropriate.

■ Defines expected outcomes in terms of the healthcare consumer, health-
care worker, and other stakeholders; their values; ethical considerations;
and environmental, organizational, or situational considerations.

■ Formulates expected outcomes after considering associated risks,
benefits, costs, available expertise, evidence-based knowledge, and
environmental factors.

■ Develops expected outcomes that provide direction for project team
members, the healthcare team, and key stakeholders.

■ Includes a time estimate for the attainment of expected outcomes.

■ Modifies expected outcomes based on changes in the status or evalua-
tion of the situation.

■ Documents expected outcomes as measurable goals.

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Identifies expected outcomes that incorporate scientific evidence and
are achievable through implementation of evidence-based practices.

■ Identifies expected outcomes that maximize quality, efficiency, and
effectiveness balanced with economy.

■ Differentiates outcomes requiring care process interventions from those
requiring system-level interventions.

■ Supports the use and integration of clinical guidelines into practice,
information management system solutions, and knowledge bases.

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

Standard 4. Planning

The informatics nurse develops a plan that prescribes strategies,

alternatives, and recommendations to attain expected outcomes.

CoMPetenCies

The informatics nurse:

■ Develops a customized plan considering clinical and business character-
istics of the environment and situation.

■ Develops the plan in collaboration with the healthcare consumer, family,
healthcare team, key stakeholders, and others, as appropriate.

■ Establishes the plan priorities with key stakeholders and others as
appropriate.

■ Incorporates strategies in the plan to address each of the identified
diagnoses, problems, needs, and issues.

■ Incorporates planned strategies addressing health and wholeness across
the life span.

■ Incorporates an implementation pathway or timeline within the plan.

■ Considers the clinical, financial, social, and economic impact of the plan
on the stakeholders.

■ Integrates current scientific evidence, trends, and research into the
planning process.

■ Utilizes the plan to provide direction for the healthcare team and other
stakeholders.

■ Integrates current statutes, rules and regulations, and standards within
the planning process and plan.

■ Modifies the plan according to the ongoing assessment of the healthcare
consumer’s response and other outcome indicators.

■ Integrates informatics principles in the design of interprofessional
processes to address identified situations or issues.

■ Documents the plan in a manner that uses standardized terminologies
and taxonomies.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 73

Standard 5. Implementation

The informatics nurse implements the identified plan.

CoMPetenCies

The informatics nurse:

■ Partners with the healthcare consumer, healthcare team, and others, as
appropriate, to implement the plan on time, within budget, and within
plan requirements.

■ Utilizes health information technology to measure, record, and retrieve
healthcare consumer data, implement and support the nursing process,
and improve overall healthcare outcomes.

■ Uses specific evidence-based actions and processes to resolve diagnoses,
problems, or issues to achieve the defined outcomes.

■ Advocates for health care that is sensitive to the needs of healthcare
consumers, with emphasis on the needs of diverse populations and use
of self-care theory.

■ Applies available healthcare technologies to maximize access and
optimize outcomes for healthcare consumers.

■ Uses community and organizational resources systematically to imple-
ment the plan.

■ Collaborates with the healthcare team and other stakeholders from
diverse backgrounds to implement and integrate the plan.

■ Accommodates different styles of communication used by healthcare
consumers, families, healthcare providers, and others.

■ Implements the plan using principles and concepts of enterprise
management, project management, and systems change theory.

■ Promotes the healthcare consumer’s capacity for the optimal level of
participation and problem-solving.

■ Fosters an organizational culture that supports implementation of the
plan.

■ Incorporates new information and strategies to initiate change if desired
outcomes are not achieved.

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

■ Documents implementation and any modifications, including changes
or omissions, of the identified plan.

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Facilitates utilization of systems, organizations, and community
resources to implement the plan.

■ Supports collaboration with nursing and other colleagues to implement
the plan.

■ Uses advanced communication skills to promote relationships between
healthcare teams and healthcare consumers by providing open discus-
sion of shared experiences using information technologies.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 75

Standard 5a. Coordination of Activities

The informatics nurse coordinates planned activities.

CoMPetenCies

The informatics nurse:

■ Organizes the components of the plan.

■ Coordinates the implementation of the plan, including activities and
resources necessary to achieve desired outcomes.

■ Synthesizes data and information to prescribe necessary system and
environmental support measures.

■ Documents the coordination of delivery activities to have a successful
implementation.

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Provides leadership in the coordination of information technology and
healthcare activities for integrated delivery of efficient and cost-effective
healthcare services.

■ Coordinates system and community resources that enhance delivery of
health care across continuums.

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

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.

CoMPetenCies

The informatics nurse:

■ Integrates informatics solutions, resources, ergonomics, and disability
adaptations into clinical practice workflow and patient care routines.

■ Applies technology to support the dissemination of evidence-based
information to promote healthy lifestyle choices, risk reduction behav-
iors, disability and developmental adaptations, and preventive self-care.

■ Introduces technology to facilitate healthcare consumer, staff, commu-
nity, and population learning.

■ Seeks opportunities for feedback and evaluation of the effectiveness of
the strategies used.

■ Evaluates health information resources for accuracy, readability, and
comprehensibility to help healthcare consumers, families, clinicians,
staff, and others needing access to quality health information. An
example is obtaining shared data through credible organizations
(e.g., the Net Foundation [http://www.hon.ch/], HealthIT.gov
Policy Researchers & Implementers [http://www.healthit.gov/policy

-researchers-implementers], and Centers for Medicare & Medicaid
E.H.R. Incentive Programs [http://www.cms.gov/Regulations-and

-Guidance/Legislation/EHRIncentivePrograms/index.html]).

■ Assists consumer alliances and advocacy groups in the proper utilization
of technology to perform health promotion activities.

■ Creates informatics solutions for feedback and evaluation of the
effectiveness of the educational content and teaching strategies used
for continuing education and professional development programs.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 77

Standard 5c. Consultation

The informatics nurse provides consultation to influence the

identified plan, enhance the abilities of others, and effect change.

CoMPetenCies

The informatics nurse:

■ Synthesizes data, information, knowledge, theoretical frameworks, and
evidence when providing consultation.

■ Facilitates the effectiveness of a consultation by involving healthcare
consumers, healthcare team members, and stakeholders in decision-
making processes.

■ Communicates consultation recommendations that influence the identi-
fied plan, facilitate understanding by involved stakeholders, enhance the
work of others, and effect change.

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Develops recommendations and strategies to address and resolve
complex informatics issues and problems.

■ Uses risk management techniques to mitigate risks and take advantage
of opportunities.

■ Establishes formal and informal consultative relationships that provide
professional informatics development and mentorship opportunities.

■ Promotes collaborative relationships for consultation with thought lead-
ers to expand the influence of health information solutions in enhancing
population health at local, regional, national, and international levels.

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

Standard 6. Evaluation

The informatics nurse evaluates progress toward attainment of

outcomes.

CoMPetenCies

The informatics nurse:

■ Conducts a systematic, ongoing, and criterion-based evaluation of the
outcomes in relation to the structures and processes prescribed by the
project plan and indicated timeline.

■ Collaborates with the healthcare consumer, healthcare team members,
and other key stakeholders involved in the plan or situation in the
evaluation process.

■ Evaluates, in partnership with the key stakeholders, the effectiveness
of the planned strategies in relation to attainment of the expected
outcomes.

■ Evaluates the link between outcomes and evidence-based methods,
tools, and guidelines.

■ Evaluates the effectiveness of planned strategies in relation to attain-
ment of the expected outcomes.

■ Documents the results of the evaluation.

■ Disseminates the results to key stakeholders and others involved, in
accordance with organizational requirements and federal and state
regulations.

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Synthesizes the results of the evaluation analyses to determine the
impact of the plan on healthcare consumers, families, communities,
resources, networks, and healthcare organizations.

■ Uses the results of the evaluation analyses to make or recommend
process or structural changes, including policy, procedure, or protocol
development, as appropriate.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 79

Standards of Professional
Performance for Nursing Informatics

Standard 7. Ethics

The informatics nurse practices ethically.

CoMPetenCies

The informatics nurse:

■ Uses Code of Ethics for Nurses with Interpretive Statements (ANA,
2001) to guide practice.

■ Recognizes the centrality of the healthcare consumer and family as core
members of any healthcare team.

■ Uses nursing and informatics principles, standards, and methodologies
in a manner that preserves and protects healthcare consumer autonomy,
dignity, and rights.

■ Employs informatics principles, standards, and methodologies to
establish and maintain healthcare consumer confidentiality within legal
and regulatory parameters.

■ Evaluates factors related to privacy, security, and confidentiality in the
use and handling of data, information, and knowledge.

■ Contributes to resolving ethical issues involving healthcare consumers,
colleagues, community groups, systems, and other stakeholders.

■ Takes appropriate action regarding instances of illegal, unethical, or
inappropriate behavior that could endanger or jeopardize the best
interests of the healthcare consumer, others, or the organization.

■ Reports illegal, incompetent, or impaired practices.

■ Speaks up when appropriate to question healthcare practice when
necessary for safety and quality improvement.

■ Advocates for systems conducive to staff workflow.

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

■ Advocates for healthcare consumer access to electronic healthcare
records and mobile health technologies, and for the reduction of associ-
ated disparities.

■ Seeks available resources as needed when formulating ethical decisions.

■ Demonstrates a commitment to practicing self-care, managing stress,
and connecting with self and others.

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Participates in interprofessional teams that address ethical risks, ben-
efits, and outcomes.

■ Informs administrators or others of the risks, benefits, and outcomes of
programs and decisions that affect healthcare delivery.

■ Promotes active engagement of stakeholders in the oversight and
management of the exchange of data, information, and knowledge.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 81

Standard 8. Education

The informatics nurse attains knowledge and competence that

reflect current nursing and informatics practice.

CoMPetenCies

The informatics nurse:

■ Participates in ongoing education to advance his or her knowledge base
and professional practice.

■ Demonstrates a commitment to lifelong learning through self-reflection
and inquiry to address learning and personal growth needs.

■ Seeks experiences that reflect current practice to maintain knowledge,
skills, abilities, and judgment in informatics practice and role performance.

■ Acquires knowledge and skills appropriate to the role, population, specialty
area, setting, or situation.

■ Seeks formal and independent learning experiences to develop and
maintain professional skills and knowledge.

■ Identifies individual learning needs based on nursing knowledge, nursing
roles, and the changing needs of target populations.

■ Participates in knowledge acquisition to support the evolution and
continuous improvement of enterprise management in support of plan
implementation.

■ Participates in formal and informal consultations to address issues in
nursing practice to improve education and knowledge bases, as well as to
contribute evidence for best practice.

■ Continues to examine and review clinical care issues and new practice
modalities for implications related to informatics solutions and practice.

■ Shares educational findings, experiences, and ideas with peers.

■ Develops skills to contribute to a work environment conducive to the
education of healthcare professionals.

■ Promotes educational opportunities and programs related to informatics.

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

■ Contributes to educational opportunities and programs related to
informatics.

■ Maintains professional records that provide evidence of competence and
lifelong learning.

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Uses current research findings and other evidence to expand knowledge,
skills, abilities, and judgment; to enhance role performance; and to
increase knowledge of professional issues.

■ Creates educational opportunities and programs related to informatics.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 83

Standard 9. Evidence-Based Practice and Research

The informatics nurse integrates evidence and research findings

into practice.

CoMPetenCies

The informatics nurse:

■ Uses data to communicate evidence to promote effective care processes
and decisions.

■ Utilizes current evidence-based nursing knowledge, including research
findings, to guide practice.

■ Incorporates current evidence when initiating changes in nursing
practice.

■ Participates in the formulation of evidence-based practice as appropri-
ate to her or his education level, background, and position.

■ Shares personal or third-party research findings with colleagues and peers.

■ Uses the skills and tools available to the informatics nurse for research
studies.

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Supports nursing knowledge by conducting or synthesizing research
and other evidence to promote the discovery, examination, and evalu-
ation of current practice, knowledge, theories, criteria, and creative
approaches to improve healthcare outcomes.

■ Promotes a climate of research and clinical inquiry.

■ Promotes the efficient, effective, and secure use of electronic health
record data.

■ Identifies and promotes documentation standards that facilitate the
development of clinical databases that will allow research (e.g., standard
data sets and formatting of reports).

■ Formally disseminates research findings through activities such as
presentations, publications, consultation, and journal clubs.

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

Standard 10. Quality of Practice

The informatics nurse contributes to quality and effectiveness of

nursing and informatics practice.

CoMPetenCies

The informatics nurse:

■ Demonstrates quality by documenting the application of the nursing pro-
cess in a responsible, accountable, and ethical manner, and by facilitating a
unified or defined level of documentation by nurses in clinical practice.

■ Uses the results of quality improvement activities to initiate changes in
nursing and informatics practice and in the healthcare delivery system.

■ Contributes to the development and continuous improvement of organi-
zational systems that support the planning process.

■ Uses creativity and innovation to enhance nursing and informatics practice
to improve care delivery and client satisfaction, and reduce healthcare costs.

■ Uses nursing informatics principles to utilize electronic health record
data to analyze outcomes of nursing practice.

■ Incorporates new knowledge to initiate changes in nursing and informat-
ics practice if desired outcomes are not achieved.

■ Uses informatics principles to participate in quality improvement.
Activities may include:

■ Identifying aspects of practice important for quality monitoring.

■ Using appropriate indicators to monitor quality and effectiveness of
nursing and informatics practice.

■ Collecting data to monitor quality and effectiveness of nursing and
informatics practice.

■ Analyzing quality data to identify opportunities to improve nursing
and informatics practice.

■ Formulating recommendations to improve nursing and informatics
practice or outcomes.

■ Implementing activities to enhance the quality of nursing and
informatics practice.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 85

■ Developing, implementing, and/or evaluating policies, procedures,
and guidelines to improve the quality of practice.

■ Participating on and/or leading interprofessional teams to evaluate
clinical care or health services.

■ Participating in and/or leading efforts to minimize costs and
unnecessary duplication.

■ Integrating human–computer interaction (HCI) principles to
improve nursing workflow, delivery of care, and client access to
health information.

■ Analyzing factors to improve quality, user and client safety, and
effectiveness.

■ Analyzing organizational systems for barriers to quality healthcare
consumer outcomes.

■ Implementing processes to remove or weaken barriers within
organizational systems.

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Provides leadership in the design and implementation of quality
improvements.

■ Designs innovations in data collection and management to effect
change in practice and improve health outcomes.

■ Evaluates the practice environment and quality of nursing care rendered
in relation to existing evidence.

■ Identifies opportunities for the generation and use of research and
evidence.

■ Obtains and maintains professional informatics certification.

■ Uses the results of quality improvement studies to initiate changes in
nursing practice and the healthcare delivery system.

■ Promotes the ability of nursing personnel to use electronic documenta-
tion systems to effectively describe the nursing process.

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

Standard 11. Communication

The informatics nurse communicates effectively in a variety of

formats in all areas of practice.

CoMPetenCies

The informatics nurse:

■ Assesses communication preferences of healthcare consumers, families,
and colleagues.

■ Supports communication preferences of healthcare consumers, families,
and colleagues.

■ Assesses her or his own communication skills in encounters with
healthcare consumers, families, and colleagues to identify gaps, areas for
improvement, and opportunities for education.

■ Seeks continuous improvement of communication skills and
technologies.

■ Seeks continuous improvement of conflict resolution skills.

■ Conveys information to healthcare consumers, families, the interprofes-
sional team, and others using communication formats that promote
accuracy and accessibility.

■ Communicates strategies to improve and enhance the value of
documentation.

■ Problem-solves to report, address, and resolve hazards and errors in
care or the practice environment.

■ Identifies strategies and technologies to enhance communication among
healthcare clinicians and consumers to minimize risks, especially those
associated with transitions in care.

■ Contributes the informatics professional perspective in discussions with
the interprofessional team.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 87

Standard 12. Leadership

The informatics nurse demonstrates leadership in the

professional practice setting and the profession.

CoMPetenCies

The informatics nurse:

■ Promotes the organization’s vision, the associated goals, and the
strategic plan.

■ Demonstrates a commitment to continuous education and lifelong
learning for self and others, especially related to informatics content.

■ Mentors colleagues for the advancement of nursing informatics practice,
the profession, and quality health care.

■ Treats colleagues with respect, trust, and dignity.*

■ Demonstrates advanced communication and conflict resolution skills.

■ Participates in professional and informatics organizations.

■ Seeks ways to advance nursing autonomy and accountability.*

■ Influences the development and implementation of healthcare policy
involving healthcare consumers and the profession.

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Influences decision-making bodies to improve the professional practice
environment and healthcare consumer outcomes.

■ Provides direction to enhance the effectiveness of the interprofessional
team.

■ Promotes and develops nursing informatics by interpreting its role for
healthcare consumers, families, and others.

* Board of Higher Education & Massachusetts Organization of Nurse Executives
[BHE/MONE], 2006.

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

■ Models expert nursing informatics practice to interprofessional team
members and healthcare consumers.

■ Mentors colleagues in the acquisition of clinical knowledge, skills, abili-
ties, and judgment.

■ Promotes the use of data, information, knowledge, and wisdom to improve
healthcare delivery and support effective nursing practice.

■ Identifies opportunities to share innovative practice.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 89

Standard 13. Collaboration

The informatics nurse collaborates with the healthcare

consumer, family, and others in the conduct of nursing and

informatics practice.

CoMPetenCies

The informatics nurse:

■ Partners with others to effect change and produce positive outcomes
through the sharing of data, information, and knowledge of the health-
care consumer and/or situation.

■ Communicates with the healthcare consumer, family, and others regard-
ing provision of care and the role of technology in that care.

■ Implements strategies to increase healthcare consumer use of personal
health records (PHRs) and similar health information technology (IT)
tools to engage more fully in their health and health care.

■ Implements strategies to increase healthcare consumers’ participation
and ownership in their care process and to take greater ownership of
their own outcomes and safety in all healthcare venues.

■ Participates in building consensus or resolving conflict in the context of
patient care and the application of technology to support that care.

■ Applies group process and negotiation techniques with healthcare
consumers and colleagues.

■ Adheres to standards and applicable codes of conduct that govern
behavior among peers and colleagues to create a work environment that
promotes cooperation, respect, and trust.

■ Promotes the development and use of electronic health records that are
focused on patient-centered outcomes and decision-making.

■ Engages in teamwork and team-building processes.

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

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Partners with others, within and outside of health care, to enhance
healthcare consumer outcomes through interprofessional activities, such
as education, consultation, management, technological development,
or research opportunities to create technologies that support consumer
engagement.

■ Invites the contribution of the healthcare consumer, family, and team
members in order to achieve optimal outcomes.

■ Leads in establishing, improving, and sustaining collaborative relation-
ships to design and implement technologies to achieve safe, quality
health care.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 91

Standard 14. Professional Practice Evaluation

The informatics nurse evaluates his or her own nursing practice

in relation to professional practice standards and guidelines,

relevant statutes, rules, and regulations.

CoMPetenCies

The informatics nurse:

■ Supports delivery of appropriate care and services in a culturally, ethnically,
and developmentally sensitive manner.

■ Engages in self-evaluation of practice on a regular basis, identifying
areas of strength as well as areas in which professional growth would be
beneficial.

■ Obtains informal feedback regarding her or his own practice from health-
care consumers, peers, professional colleagues, and others.

■ Participates in peer review as appropriate.

■ Takes action to achieve goals identified during the evaluation process.

■ Provides the evidence for practice decisions and actions as part of the
informal and formal evaluation processes.

■ Interacts with peers and colleagues to enhance his or her own profes-
sional nursing practice or role performance.

■ Provides peers with formal or informal constructive feedback regarding
their practice or role performance.

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Engages in a formal process seeking feedback regarding her or his own
practice from healthcare consumers, peers, professional colleagues, and
others.

■ Provides mentorship to informatics nurses and those studying to
become informatics nurses.

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

Standard 15. Resource Utilization

The informatics nurse employs appropriate resources to plan

and implement informatics and associated services that are safe,

effective, and fiscally responsible.

CoMPetenCies

The informatics nurse:

■ Monitors the healthcare information needs of individual consumers and
communities, as well as the available operational and technical enterprise
resources to achieve desired outcomes.

■ Identifies opportunities, potential for harm/risk, complexity of the task,
and desired outcomes when considering resource allocation.

■ Identifies best practices and evidence for safety and care outcomes when
evaluating the allocation of resources.

■ Supports the integration of clinical, human, financial, and technical
resources to enhance and facilitate the healthcare decision-making process.

■ Advocates for resources, including technology, that enhance nursing
practice.

■ Modifies practice as technologies and resources emerge and evolve.

■ Assists the healthcare consumer and family in researching and securing
appropriate and affordable information and technology resources to
address care needs across the healthcare continuum.

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Uses organizational and community resources and information tech-
nologies to empower the interprofessional team and enhance planning
initiatives.

■ Formulates solutions that address the requirements of informatics
projects, such as project plan, software specification documents, and
request for proposal (RFP).

■ Designs evaluation strategies that measure fiscal outcomes, user satis-
faction, and project effectiveness.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 93

Standard 16. Environmental Health

The informatics nurse supports practice in a safe and healthy

environment.

CoMPetenCies

The informatics nurse:

■ Attains knowledge of environmental health concepts, such as imple-
mentation of environmental health strategies.

■ Promotes a practice environment that reduces ergonomic and environ-
mental health risks for workers and healthcare consumers.

■ Assesses the practice environment for factors that threaten health, such
as sound, odor, noise, electromagnetic forces, and light.

■ Advocates for the judicious and appropriate use of ergonomic and
environmentally safe products in health care.

■ Communicates environmental health risks and exposure reduc-
tion strategies to healthcare consumers, families, colleagues, and
communities.

■ Employs scientific evidence to determine if a product or treatment is an
environmental or ergonomic risk.

■ Participates in strategies to promote healthy communities.

■ Assists in the development of health and safety alerts within the clinical
documentation and technology solutions.

■ Advocates for convenient electronic resources that allow quick and easy
access to information.

ADDitionAL CoMPetenCies For tHe

inForMAtiCs nurse sPeCiAList

The informatics nurse specialist:

■ Creates partnerships that promote sustainable environmental health
policies and conditions.

■ Analyzes the impact of social, political, and economic influences on the
environment and human health exposures.

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

■ Critically evaluates the manner in which environmental health issues
are presented by the popular media.

■ Advocates for implementation of environmental principles in nursing
practice.

■ Supports nurses in advocating for and implementing environmental
principles in nursing practice.

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95

Glossary
Data. Discrete entities that are described objectively without interpretation.

Human–computer interaction (HCi). The study of how people design, imple-
ment, and evaluate interactive computer systems in the context of users’
tasks and work (Nelson & Staggers, 2014, pp. 511–512).

informatics nurse (in). A registered nurse with an interest or experience in an
informatics field, most often identified as nursing informatics.

informatics nurse specialist (ins). A registered nurse with formal, graduate-
level education in informatics or a related field.

information. Data that are interpreted, organized, or structured.

Knowledge. Information that is synthesized so that relationships are identi-
fied and formalized.

Meaningful use. Delineated sets of specific objectives associated with purchase
and use of health information technology solutions and quality reporting
that must be met to qualify for federal incentive payments.

Metadata. Data about data. Metadata describes how, when, and by whom a
particular set of data was collected, and how the data are formatted (http://
www.webopedia.com/TERM/M/metadata.html).

operational architecture. A data management process that enables a respon-
sive end-to-end healthcare information environment in which: (1) informa-
tion exchange processes are transparent and actionable; (2) the means to
produce, exchange, and use information are protected; and (3) resources
are allocated based on operational requirements and implemented through
the use of precedence, priority, and resource allocation techniques.

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

Glossary

system life cycle. Conceptual model or framework used to formally describe
each stage of a living or nonliving system, such as an information system.

usability. Extent to which a product can be used by specific users in a spe-
cific context to achieve specific goals with effectiveness, efficiency, and
satisfaction.

Wisdom. The appropriate use of knowledge to manage and solve human
problems.

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97

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107

Appendix A.

An emerging Model of Wisdom
Susan Matney describes the development of wisdom through the use of
knowledge in her model, Wisdom-in-Action for Clinical Nursing©. This model
denotes that knowledge encompasses:

■ The center core of clinical judgment;

■ Values, relativism, and tolerance;

■ Life span contextualism;

■ Rich procedural knowledge; and

■ Rich factual knowledge.

Antecedents to this knowledge are the person-related factors and the envi-
ronmental factors of setting and systems. When nurses are put into a stressful
situation that has a degree of uncertainty, their specialized knowledge mastery
produces insight and intuition into the decision-making needed for action.
This learning, reflection, and discovery of meaning for the situation become
integrated into their inherent knowledge base or “wisdom” for future actions.

Figure 1. Matney Model of Wisdom-in-Action for Clinical Nursing©

(Work in progress; Permission to use granted by Susan Matney)

Wisdom-in-Action

Decision

Application

Increasing
complexity

Knowledge

Antecedents

System-related
factors

Life span contextualism

Rich procedural
knowledge

Rich factual knowledge

Person-related
factors

(Nurse/Patient/
Family) Experience-speci�c factorsMentors/role models

Life experiences
Clinical experiences
Clinical training

Context-related factors
Age
Education
Social interaction
Culture/religion
Cognition
Openness to learning

Setting-related
factors

Setting type
Setting culture
Nurse familiarity with setting
Nurse expertise with setting specialty

Data Information

Logic
or rules Integration into

Produces
insight and

intuition

Stressful
situation or

management of
uncertainty

Specialized
knowledge

mastery

Discovery of
meaning

Re�ection

Learning

Clinical judgment

Values, relativism, and
tolerance

Structured
in context

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109

Appendix B.

Nursing Informatics: Scope and
Standards of Practice (2008)

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

The content in this appendix is not current and is of historical significance only.

APPenDix b. nursinG inForMAtiCs: sCoPe & stAnDArDs oF PrACtiCe (2008)

iii

ACKNOWLEDGMENTS

Work Group Members (2007)

Nancy Staggers, PhD, RN, FAAN, Chairperson
Michele Calogero, MSN, RN
Margaret F. Budnik, DM, RN
Diane Castelli, RN
Melissa Christensen
Mary F. Clarke, PhD, RN, BC
Tina Dieckhaus, BSN, RN-BC, Leader, Integration and Tenets
Paulette Fraser, MS, RN-BC, Co-leader Metastructures
Josette Jones, PhD, RN-BC, Co-leader Competencies
Sally Kellum, MSN, RN-C
Rosemary Kennedy, MBA, RN, Co-leader NI Standards
Kathleen Krichbaum, RN, PhD
Sheryl LaCoursiere, PhD, RN-BC, Leader, Functional Areas
Angela Lewis, BSN, RN-BC
Teresa McCasky, MBA, BSN, RN-BC
Ramona Nelson, PhD, RN, FAAN, Co-leader, Metastructures
Agnes Padernal, PhD, RN
Amy Peck, RN
Mollie R. Poynton PhD, APRN
Loretta Schlachta-Fairchild, PhD, RN, CHE
Norma Street, MSN, RN
Sharon Sweeney Fee, PhD, RN, Leader, Ethics section
Dawn Weathersby, MS, RN, Co-leader NI Standards
Jill Winters, PhD, RN
Seth Wolpin PhD MPH RN, Co-leader Competencies
Lisa Wynn, MA, RN-BC

ANA Staff

Carol J. Bickford, PhD, RN-BC—Content editor
Yvonne D. Humes, MSA—Project coordinator
Therese Myers, JD—Legal counsel

iii

Informatics Nursing_FM_Pgs_i-viii.PMD 1/10/2008, 8:59 AM3

v

CONTENTS

Acknowledgments iii

The Scope of Nursing Informatics Practice 1
Introduction 1
Metastructures, Concepts, and Tools of Nursing Informatics 3

Metastructures: Data, Information, Knowledge, and Wisdom 3
Sciences Underpinning Nursing Informatics 7
Language as a Tool for Nursing Informatics 7
Concepts and Tools from Information Science 9
and Computer Science
Human–Computer Interaction and Related Concepts 10
Phenomena of Nursing 11
References: Introduction, Metastructures, Concepts, 13
and Tools

Functional Areas for Nursing Informatics 16
Administration, Leadership, and Management 18
Analysis 19
Compliance and Integrity Management 21
Consultation 22
Coordination, Facilitation, and Integration 23
Development 24
Education and Professional Development 25
Policy Development and Advocacy 27
Research and Evaluation 28
Integrated Functional Areas: Telehealth and 29
Telenursing as Exemplar
NI Functional Areas: Conclusions 30
References: Functional Areas 31

Informatics Competencies 33
The Intersection of Informatics Competencies 34
and NI Functional Areas
A New Competencies Matrix 36
Competencies and Metastructures 37
Work in Progress 40
NI Competencies: Conclusion 40
References: NI Competencies 40

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 111

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

iii

ACKNOWLEDGMENTS

Work Group Members (2007)

Nancy Staggers, PhD, RN, FAAN, Chairperson
Michele Calogero, MSN, RN
Margaret F. Budnik, DM, RN
Diane Castelli, RN
Melissa Christensen
Mary F. Clarke, PhD, RN, BC
Tina Dieckhaus, BSN, RN-BC, Leader, Integration and Tenets
Paulette Fraser, MS, RN-BC, Co-leader Metastructures
Josette Jones, PhD, RN-BC, Co-leader Competencies
Sally Kellum, MSN, RN-C
Rosemary Kennedy, MBA, RN, Co-leader NI Standards
Kathleen Krichbaum, RN, PhD
Sheryl LaCoursiere, PhD, RN-BC, Leader, Functional Areas
Angela Lewis, BSN, RN-BC
Teresa McCasky, MBA, BSN, RN-BC
Ramona Nelson, PhD, RN, FAAN, Co-leader, Metastructures
Agnes Padernal, PhD, RN
Amy Peck, RN
Mollie R. Poynton PhD, APRN
Loretta Schlachta-Fairchild, PhD, RN, CHE
Norma Street, MSN, RN
Sharon Sweeney Fee, PhD, RN, Leader, Ethics section
Dawn Weathersby, MS, RN, Co-leader NI Standards
Jill Winters, PhD, RN
Seth Wolpin PhD MPH RN, Co-leader Competencies
Lisa Wynn, MA, RN-BC

ANA Staff

Carol J. Bickford, PhD, RN-BC—Content editor
Yvonne D. Humes, MSA—Project coordinator
Therese Myers, JD—Legal counsel

iii

Informatics Nursing_FM_Pgs_i-viii.PMD 1/10/2008, 8:59 AM3

v

CONTENTS

Acknowledgments iii

The Scope of Nursing Informatics Practice 1
Introduction 1
Metastructures, Concepts, and Tools of Nursing Informatics 3

Metastructures: Data, Information, Knowledge, and Wisdom 3
Sciences Underpinning Nursing Informatics 7
Language as a Tool for Nursing Informatics 7
Concepts and Tools from Information Science 9
and Computer Science
Human–Computer Interaction and Related Concepts 10
Phenomena of Nursing 11
References: Introduction, Metastructures, Concepts, 13
and Tools

Functional Areas for Nursing Informatics 16
Administration, Leadership, and Management 18
Analysis 19
Compliance and Integrity Management 21
Consultation 22
Coordination, Facilitation, and Integration 23
Development 24
Education and Professional Development 25
Policy Development and Advocacy 27
Research and Evaluation 28
Integrated Functional Areas: Telehealth and 29
Telenursing as Exemplar
NI Functional Areas: Conclusions 30
References: Functional Areas 31

Informatics Competencies 33
The Intersection of Informatics Competencies 34
and NI Functional Areas
A New Competencies Matrix 36
Competencies and Metastructures 37
Work in Progress 40
NI Competencies: Conclusion 40
References: NI Competencies 40

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

vi

The Integration of Nursing Informatics 43
The Boundaries of Nursing Informatics 45
Tenets of Nursing Informatics 46
Ethics in Nursing Informatics 47
The Future of Nursing Informatics 49

Trends in Positions and Competencies for Nurses 50
and Informatics
Trends in Technology 51
Trends in Healthcare Delivery and Regulation 58
NI Future and Trends: Conclusions 61
References (Future and Trends) 62

Standards of Nursing Informatics Practice 65

Standards of Practice 67
Standard 1. Assessment 67
Standard 2. Problem and Issues Identification 68
Standard 3. Outcomes Identification 69
Standard 4. Planning 70
Standard 5. Implementation 71

Standard 5a. Coordination of Activities 72
Standard 5b. Health Teaching and Health Promotion, 73

and Education
Standard 5c. Consultation 75

Standard 6. Evaluation 76

Standards of Professional Performance 77
Standard 7. Education 77
Standard 8. Professional Practice Evaluation 78
Standard 9. Quality of Practice 79
Standard 10. Collegiality 81
Standard 11. Collaboration 82
Standard 12. Ethics 83
Standard 13. Research 85
Standard 14. Resource Utilization 86
Standard 15. Advocacy 87
Standard 16. Leadership 89

Glossary 91

Informatics Nursing_FM_Pgs_i-viii.PMD 1/10/2008, 8:59 AM6

vii

Appendix A. Scope and Standards of Nursing Informatics 93
Practice (2001)

Appendix B. Standards of Practice for Nursing Informatics 154
(1995)

Appendix C. Scope of Practice for Nursing Informatics (1994) 175

Index 191

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 113

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

vi

The Integration of Nursing Informatics 43
The Boundaries of Nursing Informatics 45
Tenets of Nursing Informatics 46
Ethics in Nursing Informatics 47
The Future of Nursing Informatics 49

Trends in Positions and Competencies for Nurses 50
and Informatics
Trends in Technology 51
Trends in Healthcare Delivery and Regulation 58
NI Future and Trends: Conclusions 61
References (Future and Trends) 62

Standards of Nursing Informatics Practice 65

Standards of Practice 67
Standard 1. Assessment 67
Standard 2. Problem and Issues Identification 68
Standard 3. Outcomes Identification 69
Standard 4. Planning 70
Standard 5. Implementation 71

Standard 5a. Coordination of Activities 72
Standard 5b. Health Teaching and Health Promotion, 73

and Education
Standard 5c. Consultation 75

Standard 6. Evaluation 76

Standards of Professional Performance 77
Standard 7. Education 77
Standard 8. Professional Practice Evaluation 78
Standard 9. Quality of Practice 79
Standard 10. Collegiality 81
Standard 11. Collaboration 82
Standard 12. Ethics 83
Standard 13. Research 85
Standard 14. Resource Utilization 86
Standard 15. Advocacy 87
Standard 16. Leadership 89

Glossary 91

Informatics Nursing_FM_Pgs_i-viii.PMD 1/10/2008, 8:59 AM6

vii

Appendix A. Scope and Standards of Nursing Informatics 93
Practice (2001)

Appendix B. Standards of Practice for Nursing Informatics 154
(1995)

Appendix C. Scope of Practice for Nursing Informatics (1994) 175

Index 191

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

1

THE SCOPE OF NURSING INFORMATICS PRACTICE

Introduction

Nursing informatics (NI) is a specialty that integrates nursing science,
computer science, and information science to manage and communi-
cate data, information, knowledge, and wisdom in nursing practice. NI
supports consumers, patients, nurses, and other providers in their deci-
sion-making in all roles and settings. This support is accomplished
through the use of information structures, information processes, and
information technology.

The goal of NI is to improve the health of populations, communities,
families, and individuals by optimizing information management and
communication. These activities include the design and use of informatics
solutions and technology to support all areas of nursing, including, but
not limited to, the direct provision of care, establishing effective admin-
istrative systems, designing useful decision support systems, managing
and delivering educational experiences, enhancing lifelong learning, and
supporting nursing research (Staggers & Thompson, 2002).

The NI definition remains essentially that found in Scope and Standards
of Nursing Informatics (2001), but now includes the additional concept of
wisdom. The term individuals refers to patients, healthcare consumers, and
any other recipients of nursing care or informatics solutions. The term
patient refers to consumers in both a wellness and illness model. The dis-
cussion of the definition and goal of nursing informatics evolved from
work by Staggers and Thompson (2002).

Nursing informatics is one example of a discipline-specific informatics
practice within the broader category of health informatics. NI has be-
come well established within nursing since its recognition as a specialty
for registered nurses by the American Nurses Association (ANA) in 1992.
It focuses on the representation of nursing data, information, knowledge
(Graves & Corcoran, 1989) and wisdom (Nelson & Loos, 1989; Nelson,
2002) as well as the management and communication of nursing infor-
mation within the broader context of health informatics. Nursing
informatics (per Brennan, 2002):

• provides a nursing perspective,

• illuminates nursing values and beliefs,

Nursing informatics is one example of a discipline-specifi c informat-
ics practice within the broader category of health informatics. NI has
become well established within nursing since its recognition as a spe-
cialty for registered nurses by the American Nurses Association (ANA)
in 1992. It focuses on the representation of nursing data, information,
knowledge (Graves & Corcoran, 1989) and wisdom (Nelson & Loos, 1989;
Englebardt & Nelson, 2002) as well as the management and commu-
nication of nursing information within the broader context of health
informatics. Nursing informatics (per Brennan, 2002):

• provides a nursing perspective,

• illuminates nursing values and beliefs,
2 Nursing Informatics: Scope and Standards of Practice

• denotes a practice base for nurses in nursing informatics,

• produces unique knowledge,

• distinguishes groups of practitioners,

• focuses on the phenomena of interest for nursing, and

• provides needed nursing language and word context to health
informatics.

The scope and standards of practice address both informatics nurse
specialists (INSs), those formally prepared at the graduate level in
informatics or a related field, and informatics nurses (INs), generalists
who have experience but are not educated at the graduate level. How-
ever, informatics practice is highly complex and in the near future all
nurses working in this specialty will have studied at the graduate level.

Nursing Informatics: Scope and Standards of Practice expands on earlier
work in NI, builds on historical knowledge (ANA, 1994, 1995, 2001), and
includes new, state-of-the-art material for the specialty. Because of rapid
changes in related sciences, NI roles, and advances in the science of
informatics, a new document was needed. New material in this revision
includes: a) the concept of wisdom in NI metastructures, b) redirecting the
discussion of roles from job titles to functions that may be integrated into
various NI roles and subspecializations, c) identifying commonalities be-
tween INSs and other informatics specialists, d) distinguishing between
INs and INSs, e) expanding the coverage of NI competencies to describe
typical NI competencies for typical NI functional areas, f ) expanding the
discussion of ethics, human-computer interaction, and the future of NI, g)
integrating new functions across clinical practice and NI, and h) chang-
ing the section titled “Boundaries of Nursing Informatics” to a discussion
of the cross-disciplinary nature of NI that acknowledges the blurred
boundaries of other informatics and nursing specialties.

This revised scope and standards document serves in several functions:

• An outline of the attributes and definition of the specialty.

• A reference and guide for educators and NI practitioners.

• A reference for employers and regulatory agencies to assist with
developing position descriptions, determining required informatics
competencies, and initiating NI positions in health organizations.

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Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

1

THE SCOPE OF NURSING INFORMATICS PRACTICE

Introduction

Nursing informatics (NI) is a specialty that integrates nursing science,
computer science, and information science to manage and communi-
cate data, information, knowledge, and wisdom in nursing practice. NI
supports consumers, patients, nurses, and other providers in their deci-
sion-making in all roles and settings. This support is accomplished
through the use of information structures, information processes, and
information technology.

The goal of NI is to improve the health of populations, communities,
families, and individuals by optimizing information management and
communication. These activities include the design and use of informatics
solutions and technology to support all areas of nursing, including, but
not limited to, the direct provision of care, establishing effective admin-
istrative systems, designing useful decision support systems, managing
and delivering educational experiences, enhancing lifelong learning, and
supporting nursing research (Staggers & Thompson, 2002).

The NI definition remains essentially that found in Scope and Standards
of Nursing Informatics (2001), but now includes the additional concept of
wisdom. The term individuals refers to patients, healthcare consumers, and
any other recipients of nursing care or informatics solutions. The term
patient refers to consumers in both a wellness and illness model. The dis-
cussion of the definition and goal of nursing informatics evolved from
work by Staggers and Thompson (2002).

Nursing informatics is one example of a discipline-specific informatics
practice within the broader category of health informatics. NI has be-
come well established within nursing since its recognition as a specialty
for registered nurses by the American Nurses Association (ANA) in 1992.
It focuses on the representation of nursing data, information, knowledge
(Graves & Corcoran, 1989) and wisdom (Nelson & Loos, 1989; Nelson,
2002) as well as the management and communication of nursing infor-
mation within the broader context of health informatics. Nursing
informatics (per Brennan, 2002):

• provides a nursing perspective,

• illuminates nursing values and beliefs,

Nursing informatics is one example of a discipline-specifi c informat-
ics practice within the broader category of health informatics. NI has
become well established within nursing since its recognition as a spe-
cialty for registered nurses by the American Nurses Association (ANA)
in 1992. It focuses on the representation of nursing data, information,
knowledge (Graves & Corcoran, 1989) and wisdom (Nelson & Loos, 1989;
Englebardt & Nelson, 2002) as well as the management and commu-
nication of nursing information within the broader context of health
informatics. Nursing informatics (per Brennan, 2002):

• provides a nursing perspective,

• illuminates nursing values and beliefs,
2 Nursing Informatics: Scope and Standards of Practice

• denotes a practice base for nurses in nursing informatics,

• produces unique knowledge,

• distinguishes groups of practitioners,

• focuses on the phenomena of interest for nursing, and

• provides needed nursing language and word context to health
informatics.

The scope and standards of practice address both informatics nurse
specialists (INSs), those formally prepared at the graduate level in
informatics or a related field, and informatics nurses (INs), generalists
who have experience but are not educated at the graduate level. How-
ever, informatics practice is highly complex and in the near future all
nurses working in this specialty will have studied at the graduate level.

Nursing Informatics: Scope and Standards of Practice expands on earlier
work in NI, builds on historical knowledge (ANA, 1994, 1995, 2001), and
includes new, state-of-the-art material for the specialty. Because of rapid
changes in related sciences, NI roles, and advances in the science of
informatics, a new document was needed. New material in this revision
includes: a) the concept of wisdom in NI metastructures, b) redirecting the
discussion of roles from job titles to functions that may be integrated into
various NI roles and subspecializations, c) identifying commonalities be-
tween INSs and other informatics specialists, d) distinguishing between
INs and INSs, e) expanding the coverage of NI competencies to describe
typical NI competencies for typical NI functional areas, f ) expanding the
discussion of ethics, human-computer interaction, and the future of NI, g)
integrating new functions across clinical practice and NI, and h) chang-
ing the section titled “Boundaries of Nursing Informatics” to a discussion
of the cross-disciplinary nature of NI that acknowledges the blurred
boundaries of other informatics and nursing specialties.

This revised scope and standards document serves in several functions:

• An outline of the attributes and definition of the specialty.

• A reference and guide for educators and NI practitioners.

• A reference for employers and regulatory agencies to assist with
developing position descriptions, determining required informatics
competencies, and initiating NI positions in health organizations.

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 3

• A source document for legal opinions, funding agencies, and others
seeking to improve health through nursing informatics.

Metastructures, Concepts, and Tools of Nursing Informatics

To understand NI, first its metastructures, sciences, concepts, and tools
should be explained. Metastructures are overarching concepts used in
theory and science. Also of interest are the sciences underpinning NI,
concepts and tools from information science and computer science,
human–computer interaction and ergonomics concepts, and the phe-
nomena of nursing.

Metastructures: Data, Information, Knowledge, and Wisdom

In the mid-1980s Blum (1986) introduced the concepts of data, informa-
tion, and knowledge as a framework for understanding clinical informa-
tion systems and their impact on health care. He classified the then
current clinical information systems according to the three types of
objects that these systems processed: data, information, and knowledge.
He noted that the classification was artificial, with no clear boundaries,
although it did represent a scale of increasing complexity. In 1989,
Graves and Corcoran built on these ideas in their seminal study of nurs-
ing informatics using the concepts of data, information, and knowledge.
They contributed two general principles to NI. The first was a definition
of nursing informatics that has been widely accepted in the field. The
second contribution of their 1989 contribution was an information
model that identified data, information, and knowledge as key compo-
nents of NI practice (Figure 1).

Drawing from Blum (1986), Graves and Corcoran defined the three
concepts as follows:

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

• Information is data that are interpreted, organized, or structured.

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

Data, which are processed into information and then knowledge, may
be obtained from individuals, families, communities, and populations.

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4 Nursing Informatics: Scope and Standards of Practice

Data, information, and knowledge are of value to nurses in all areas of
practice. For example, data derived from direct care of an individual can
then be compiled across persons and aggregated for decision-making
by nurses, nurse administrators, or other health professionals. Further
aggregation can encompass communities and populations. Nurse-edu-
cators can create case studies using these data, and nurse-researchers
can access aggregated data for systematic study

The vital signs for an individual at a single moment—heart rate, res-
piration, temperature, and blood pressure—are an example of data. A
chronological set of vital signs, placed into a context and used for lon-
gitudinal comparisons, is considered information. That is, a dropping
blood pressure, increasing heart rate, respiratory rate, and fever in an
elderly, catheterized person are recognized as abnormal. The recogni-
tion that the person may be septic and therefore may need certain nurs-
ing interventions reflects information synthesis (knowledge) based on
nursing knowledge and experience.

Figure 2 builds on the work of Graves and Corcoran by depicting the
relationship of data, information, knowledge, and a fourth level, wisdom.
As data are transformed into information and information into knowl-
edge, each level increases in complexity and requires greater application
of human intellect. The X-axis represents interactions within and between
the concepts as one moves from data to wisdom; the Y-axis represents the
increasing complexity of the concepts and interrelationships.

Source: Graves and Corcoran (1989) Reprinted with permission of the publisher.

Management

Processing

Data Information Knowledge

Figure 1. Conceptual Framework for the Study of Nursing Knowledge.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 117

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 3

• A source document for legal opinions, funding agencies, and others
seeking to improve health through nursing informatics.

Metastructures, Concepts, and Tools of Nursing Informatics

To understand NI, first its metastructures, sciences, concepts, and tools
should be explained. Metastructures are overarching concepts used in
theory and science. Also of interest are the sciences underpinning NI,
concepts and tools from information science and computer science,
human–computer interaction and ergonomics concepts, and the phe-
nomena of nursing.

Metastructures: Data, Information, Knowledge, and Wisdom

In the mid-1980s Blum (1986) introduced the concepts of data, informa-
tion, and knowledge as a framework for understanding clinical informa-
tion systems and their impact on health care. He classified the then
current clinical information systems according to the three types of
objects that these systems processed: data, information, and knowledge.
He noted that the classification was artificial, with no clear boundaries,
although it did represent a scale of increasing complexity. In 1989,
Graves and Corcoran built on these ideas in their seminal study of nurs-
ing informatics using the concepts of data, information, and knowledge.
They contributed two general principles to NI. The first was a definition
of nursing informatics that has been widely accepted in the field. The
second contribution of their 1989 contribution was an information
model that identified data, information, and knowledge as key compo-
nents of NI practice (Figure 1).

Drawing from Blum (1986), Graves and Corcoran defined the three
concepts as follows:

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

• Information is data that are interpreted, organized, or structured.

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

Data, which are processed into information and then knowledge, may
be obtained from individuals, families, communities, and populations.

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM3

4 Nursing Informatics: Scope and Standards of Practice

Data, information, and knowledge are of value to nurses in all areas of
practice. For example, data derived from direct care of an individual can
then be compiled across persons and aggregated for decision-making
by nurses, nurse administrators, or other health professionals. Further
aggregation can encompass communities and populations. Nurse-edu-
cators can create case studies using these data, and nurse-researchers
can access aggregated data for systematic study

The vital signs for an individual at a single moment—heart rate, res-
piration, temperature, and blood pressure—are an example of data. A
chronological set of vital signs, placed into a context and used for lon-
gitudinal comparisons, is considered information. That is, a dropping
blood pressure, increasing heart rate, respiratory rate, and fever in an
elderly, catheterized person are recognized as abnormal. The recogni-
tion that the person may be septic and therefore may need certain nurs-
ing interventions reflects information synthesis (knowledge) based on
nursing knowledge and experience.

Figure 2 builds on the work of Graves and Corcoran by depicting the
relationship of data, information, knowledge, and a fourth level, wisdom.
As data are transformed into information and information into knowl-
edge, each level increases in complexity and requires greater application
of human intellect. The X-axis represents interactions within and between
the concepts as one moves from data to wisdom; the Y-axis represents the
increasing complexity of the concepts and interrelationships.

Source: Graves and Corcoran (1989) Reprinted with permission of the publisher.

Management

Processing

Data Information Knowledge

Figure 1. Conceptual Framework for the Study of Nursing Knowledge.

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 5

Wisdom is defined as the appropriate use of knowledge to manage
and solve human problems. It is knowing when and how to apply knowl-
edge to deal with complex problems or specific human needs (Nelson,
1989; Nelson, 2002). While knowledge focuses on what is known, wis-
dom focuses on the appropriate application of that knowledge. For ex-
ample, a knowledge base may include several options for managing an
anxious family, while wisdom would help decide which option is most
appropriate for a specific family. The scope of NI is commensurate with
the scope of nursing practice and nursing science, with a concentration
on data, information, and knowledge. It is not limited by current tech-
nologies. If NI were limited to what a computer can process, the disci-
pline of informatics could not fully appreciate the relationships between
nursing science and practice and information science and technology.
Nursing informatics must take into consideration how nurses influence
technology and how technology influences nursing. Understanding this

Reprinted with modification from Englebardt & Nelson, 2002, Figure 1-4, page 13 with
permission from Elsevier.

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

Increasing

complexity

Data

Naming,

collecting, and

organizing

Information

Organizing and

interpreting

Knowledge

Interpreting,

integrating,

and understanding

Wisdom

Understanding,

applying, and

applying with

compassion

Constant Flux

Wisdom is defi ned as the appropriate use of knowledge to manage and
solve human problems. It is knowing when and how to apply knowl- edge
to deal with complex problems or specifi c human needs (Nelson, 1989;
Englebardt & Nelson, 2002). While knowledge focuses on what is known,
wis- dom focuses on the appropriate application of that knowledge. For
ex- ample, a knowledge base may include several options for managing
an anxious family, while wisdom would help decide which option is most
appropriate for a specifi c family. The scope of NI is commensurate with
the scope of nursing practice and nursing science, with a concentration
on data, information, and knowledge. It is not limited by current tech-
nologies. If NI were limited to what a computer can process, the disci-
pline of informatics could not fully appreciate the relationships between
nursing science and practice and information science and technology.
Nursing informatics must take into consideration how nurses infl uence
technology and how technology infl uences nursing. Understanding this

6 Nursing Informatics: Scope and Standards of Practice

interaction makes it possible to understand how nurses create knowl-
edge and how they use that knowledge in their practice.

The appropriate use of knowledge involves the integration of empiri-
cal, ethical, personal, and aesthetic knowledge into actions. The indi-
vidual 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 ac-
tions with a high level of accuracy, and then have the will power to carry
out the selected action in the given environment. An example of applied
wisdom integrating these attributes in NI is the appropriate use of in-
formation management and technological tools to support effective
nursing practice.

The addition of wisdom raises new and important research questions.
It challenges the discipline to develop tools and processes for classify-
ing, measuring, and encoding wisdom as it relates to nursing, NI, and
informatics education. Research in these directions will help clarify the
relationship between wisdom and the intuitive thinking of expert
nurses. Such research will be invaluable in building information systems
to support expert healthcare practitioners as well as support the less
experienced in decision-making.

Two related forces are behind the expansion of the NI model to in-
clude wisdom. First, the initial work was limited to the types of objects
processed by automated systems in the mid-1980s. However, NI is now
concerned with the use of information technology to improve the ac-
cess and quality of health care that is delivered to individuals, families,
and communities. The addition of the concept of wisdom expands the
model beyond technology and the processing of objects to include the
interaction of the human with the technology and the resultant out-
comes.

Second, nurses have been recognized as primary users and proces-
sors of information for over 40 years (Jydstrup & Gross, 1966; Zielstroff,
1981). Other authors have focused on the amount of time nurses actu-
ally spend administering direct care to patients or the time involved in
documentation (Norrie, 1999; Jinks, 2000; Harrison, 2002). In fact,
Jydstrup and Gross estimated in the 1960s that nurses in acute care
spent 30% to 40% of their time in information processing activities.
Hendrickson (1990) determined that nurses spent only 31% of their time

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 119

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 5

Wisdom is defined as the appropriate use of knowledge to manage
and solve human problems. It is knowing when and how to apply knowl-
edge to deal with complex problems or specific human needs (Nelson,
1989; Nelson, 2002). While knowledge focuses on what is known, wis-
dom focuses on the appropriate application of that knowledge. For ex-
ample, a knowledge base may include several options for managing an
anxious family, while wisdom would help decide which option is most
appropriate for a specific family. The scope of NI is commensurate with
the scope of nursing practice and nursing science, with a concentration
on data, information, and knowledge. It is not limited by current tech-
nologies. If NI were limited to what a computer can process, the disci-
pline of informatics could not fully appreciate the relationships between
nursing science and practice and information science and technology.
Nursing informatics must take into consideration how nurses influence
technology and how technology influences nursing. Understanding this

Reprinted with modification from Englebardt & Nelson, 2002, Figure 1-4, page 13 with
permission from Elsevier.

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

Increasing

complexity

Data

Naming,

collecting, and

organizing

Information

Organizing and

interpreting

Knowledge

Interpreting,

integrating,

and understanding

Wisdom

Understanding,

applying, and

applying with

compassion

Constant Flux

Wisdom is defi ned as the appropriate use of knowledge to manage and
solve human problems. It is knowing when and how to apply knowl- edge
to deal with complex problems or specifi c human needs (Nelson, 1989;
Englebardt & Nelson, 2002). While knowledge focuses on what is known,
wis- dom focuses on the appropriate application of that knowledge. For
ex- ample, a knowledge base may include several options for managing
an anxious family, while wisdom would help decide which option is most
appropriate for a specifi c family. The scope of NI is commensurate with
the scope of nursing practice and nursing science, with a concentration
on data, information, and knowledge. It is not limited by current tech-
nologies. If NI were limited to what a computer can process, the disci-
pline of informatics could not fully appreciate the relationships between
nursing science and practice and information science and technology.
Nursing informatics must take into consideration how nurses infl uence
technology and how technology infl uences nursing. Understanding this

6 Nursing Informatics: Scope and Standards of Practice

interaction makes it possible to understand how nurses create knowl-
edge and how they use that knowledge in their practice.

The appropriate use of knowledge involves the integration of empiri-
cal, ethical, personal, and aesthetic knowledge into actions. The indi-
vidual 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 ac-
tions with a high level of accuracy, and then have the will power to carry
out the selected action in the given environment. An example of applied
wisdom integrating these attributes in NI is the appropriate use of in-
formation management and technological tools to support effective
nursing practice.

The addition of wisdom raises new and important research questions.
It challenges the discipline to develop tools and processes for classify-
ing, measuring, and encoding wisdom as it relates to nursing, NI, and
informatics education. Research in these directions will help clarify the
relationship between wisdom and the intuitive thinking of expert
nurses. Such research will be invaluable in building information systems
to support expert healthcare practitioners as well as support the less
experienced in decision-making.

Two related forces are behind the expansion of the NI model to in-
clude wisdom. First, the initial work was limited to the types of objects
processed by automated systems in the mid-1980s. However, NI is now
concerned with the use of information technology to improve the ac-
cess and quality of health care that is delivered to individuals, families,
and communities. The addition of the concept of wisdom expands the
model beyond technology and the processing of objects to include the
interaction of the human with the technology and the resultant out-
comes.

Second, nurses have been recognized as primary users and proces-
sors of information for over 40 years (Jydstrup & Gross, 1966; Zielstroff,
1981). Other authors have focused on the amount of time nurses actu-
ally spend administering direct care to patients or the time involved in
documentation (Norrie, 1999; Jinks, 2000; Harrison, 2002). In fact,
Jydstrup and Gross estimated in the 1960s that nurses in acute care
spent 30% to 40% of their time in information processing activities.
Hendrickson (1990) determined that nurses spent only 31% of their time

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM6

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

8 Nursing Informatics: Scope and Standards of Practice

Setting Where Developed Content

Data Element Sets

NMDS
Nursing Minimum Data Set All Nursing Clinical Data Elements

NMMDS
Nursing Management Minimum Data Set All Settings Nursing Administrative Data Elements

Nursing-Developed Terminologies*

CCC
Clinical Care Classification All Nursing Care Diagnoses, Interventions, and Outcomes

ICNP®
International Classification of Nursing Practice All Nursing Diagnoses, Interventions, and Outcomes

NANDA
NANDA International All Nursing Diagnoses

NIC
Nursing Interventions Classification All Nursing Interventions

NOC
Nursing Outcomes Classification All Nursing Outcomes

Omaha System
Omaha System Home Care, Diagnoses, Interventions, and Outcomes

Public Health,
and Community

PCDS
Patient Care Data Set* (retired) Acute Care Diagnoses, Interventions, and Outcomes

10. PNDS
Perioperative Nursing Data Set Perioperative Diagnoses, Interventions and Outcomes

Multidisciplinary Terminologies

ABC
ABC Codes Nursing and Other Interventions

LOINC®
Logical Observation Identifiers, Names, and Codes Nursing and Other Outcomes and Assessments

SNOMED CT
Systematic Nomenclature of Medicine Clinical Terms Nursing and Other Diagnoses, Interventions, and Outcomes

Source: ANA 2006a. (* Except for the retired PCDS, all nursing-developed terminologies are still
currently in use.)

Table 1. ANA Recognized Terminologies and Data Element Sets

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Nursing Informatics: Scope of Practice 7

with patients. Other aspects of the nursing role included information
management with ancillary services.

Sciences Underpinning Nursing Informatics

The work of Graves and Corcoran (1989) was a significant contribution to
the NI definition of that was widely accepted in the field in the 1990s—
that nursing informatics combines nursing science, information science,
and computer science to manage and process nursing data, information,
and knowledge to facilitate the delivery of health care. The central notion
was that the application of these three core sciences was what made NI
unique and differentiated it from other informatics specialties.

Other sciences may be required to solve informatics issues. Turley
expanded the model of NI to include cognitive science (1996). Certainly
the cognitive aspect of humans is a critical piece for INSs and INs to
understand. However, other sciences may be equally critical. If the INS
is implementing a system in an institution, for instance, an understand-
ing of organizational theory may be germane (Staggers & Thompson,
2002). As science in general evolves, other sciences may emerge that
need to be included in NI models.

Although the core sciences are foundational to the work in NI, the
practice of the specialty can be considered an applied science rather
than a basic science. The combination creates a unique blend that de-
fines the NI specialty. Further, informatics realizes its full potential in
health care when it is grounded in an established discipline; in this case,
nursing. Computer and information science will have less impact ap-
plied in isolation and outside of a disciplinary framework.

Language as a Tool for Nursing Informatics

Many of the tools used by the informatics nurse and informatics nurse
specialist are based on metastructures and concepts that incorporate
knowledge from nursing and other health and information sciences. Nurs-
ing knowledge is refined by extracting, synthesizing, and analyzing data
that defines nursing phenomena. The many different languages and ways
of organizing data, information, and knowledge are built on nursing tax-
onomies and nomenclatures created over decades. ANA (2006a) has for-
malized these languages and vocabularies (listed in Table 1) after review
by the Committee on Nursing Practice Information Infrastructure (CNPII).

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 121

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

8 Nursing Informatics: Scope and Standards of Practice

Setting Where Developed Content

Data Element Sets

NMDS
Nursing Minimum Data Set All Nursing Clinical Data Elements

NMMDS
Nursing Management Minimum Data Set All Settings Nursing Administrative Data Elements

Nursing-Developed Terminologies*

CCC
Clinical Care Classification All Nursing Care Diagnoses, Interventions, and Outcomes

ICNP®
International Classification of Nursing Practice All Nursing Diagnoses, Interventions, and Outcomes

NANDA
NANDA International All Nursing Diagnoses

NIC
Nursing Interventions Classification All Nursing Interventions

NOC
Nursing Outcomes Classification All Nursing Outcomes

Omaha System
Omaha System Home Care, Diagnoses, Interventions, and Outcomes

Public Health,
and Community

PCDS
Patient Care Data Set* (retired) Acute Care Diagnoses, Interventions, and Outcomes

10. PNDS
Perioperative Nursing Data Set Perioperative Diagnoses, Interventions and Outcomes

Multidisciplinary Terminologies

ABC
ABC Codes Nursing and Other Interventions

LOINC®
Logical Observation Identifiers, Names, and Codes Nursing and Other Outcomes and Assessments

SNOMED CT
Systematic Nomenclature of Medicine Clinical Terms Nursing and Other Diagnoses, Interventions, and Outcomes

Source: ANA 2006a. (* Except for the retired PCDS, all nursing-developed terminologies are still
currently in use.)

Table 1. ANA Recognized Terminologies and Data Element Sets

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM8

Nursing Informatics: Scope of Practice 7

with patients. Other aspects of the nursing role included information
management with ancillary services.

Sciences Underpinning Nursing Informatics

The work of Graves and Corcoran (1989) was a significant contribution to
the NI definition of that was widely accepted in the field in the 1990s—
that nursing informatics combines nursing science, information science,
and computer science to manage and process nursing data, information,
and knowledge to facilitate the delivery of health care. The central notion
was that the application of these three core sciences was what made NI
unique and differentiated it from other informatics specialties.

Other sciences may be required to solve informatics issues. Turley
expanded the model of NI to include cognitive science (1996). Certainly
the cognitive aspect of humans is a critical piece for INSs and INs to
understand. However, other sciences may be equally critical. If the INS
is implementing a system in an institution, for instance, an understand-
ing of organizational theory may be germane (Staggers & Thompson,
2002). As science in general evolves, other sciences may emerge that
need to be included in NI models.

Although the core sciences are foundational to the work in NI, the
practice of the specialty can be considered an applied science rather
than a basic science. The combination creates a unique blend that de-
fines the NI specialty. Further, informatics realizes its full potential in
health care when it is grounded in an established discipline; in this case,
nursing. Computer and information science will have less impact ap-
plied in isolation and outside of a disciplinary framework.

Language as a Tool for Nursing Informatics

Many of the tools used by the informatics nurse and informatics nurse
specialist are based on metastructures and concepts that incorporate
knowledge from nursing and other health and information sciences. Nurs-
ing knowledge is refined by extracting, synthesizing, and analyzing data
that defines nursing phenomena. The many different languages and ways
of organizing data, information, and knowledge are built on nursing tax-
onomies and nomenclatures created over decades. ANA (2006a) has for-
malized these languages and vocabularies (listed in Table 1) after review
by the Committee on Nursing Practice Information Infrastructure (CNPII).

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 9

To promote the integration of standardized terminologies into informa-
tion technology solutions, ANA’s Nursing Information and Data Set Evalu-
ation Center (NIDSEC) develops and disseminates standards pertaining to
information systems that support the documentation of nursing practice,
and evaluates voluntarily submitted information systems against these
standards.

At a higher level of structure, several resources facilitate inter-
operability between different systems of concepts and nomenclature.
For instance, the Systematized Nomenclature of Medicine, or SNOMED
CT (IHTSDO, 2007), is considered a universal healthcare reference termi-
nology and messaging structure. SNOMED CT enables one nursing ter-
minology system to be mapped to another, e.g., Omaha System with
North American Nursing Diagnosis Association (NANDA), Nursing Inter-
ventions Classification (NIC), and Nursing Outcomes Classification (NOC).
On a larger scale, the Unified Medical Language System (UMLS) of the
National Library of Medicine (NLM, 2006) incorporates the work of over
one hundred vocabularies, including SNOMED CT. The informatics nurse
and informatics nurse specialist must be aware of these tools, and may
be called upon to understand the concepts of one or more languages,
the relationships between concepts, and integration into existing
vocabularies for a given organization.

The importance of languages and vocabularies cannot be overstated.
Informatics nurses must seek a broader picture of the implications of
their work, and the uses and outcomes of languages and vocabularies
for end users. For instance, nurses mapping a home care vocabulary to
an intervention vocabulary must see beyond the technical aspect of the
work. They must understand that a case manager for a multi-system
health organization or a home care agency may be basing knowledge
of nursing acuity and case mix on the differing vocabularies that they
have integrated. The INS must attempt to envision the varied uses of the
data, information, and knowledge that have been created.

Concepts and Tools from Information Science and Computer Science

Tools and methods from computer and information sciences are funda-
mental to NI, including:

• Information technology

• Information structures

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10 Nursing Informatics: Scope and Standards of Practice

• Information management

• Information communication

Information technology includes computer hardware, software, com-
munication, and network technologies, derived primarily from computer
science. The other three elements are derived primarily from informa-
tion science. Information structures organize data, information, and
knowledge for processing by computers. Information management is an
elemental process by which one files, stores, and manipulates data for
various uses. Information communication enables systems to send data
and to present information in a format that improves understanding.
The use of information technology distinguishes informatics from more
traditional methods of information management.

Human–Computer Interaction and Related Concepts

Human–computer interaction (HCI), usability, and ergonomics are con-
cepts of fundamental interest to the INS. Essentially, HCI deals with
people, software applications, computer technology, and the ways they
influence each other (Dix, Finlay, Abowd, & Beale, 2004). Elements of HCI
are rooted in psychology, social psychology, and cognitive science. How-
ever, the design, development, implementation, and evaluation of ap-
plications derive from applied work in computer science, a specific
discipline (in this case nursing), and information science. For example,
an INS would assess a medication ordering application before purchase
to determine whether the design complements the way nurses
cognitively process orders.

A related concept is usability, which deals with human performance
during computer interactions for specific tasks in a specific context.
Usability means the efficiency and effectiveness of an application. An
INS might study the ease of learning an application, the ease of using
it, the speed of task completion, or errors that occur during use when
determining which system or application would best fit a nursing unit.

In the United States, the term ergonomics typically is used to describe
the design and implementation of equipment, tools, and machines re-
lated to human safety, comfort, and convenience. Commonly, the term
ergonomics refers to attributes of physical equipment or to principles
of arrangement of equipment in the work environment. For instance, an
INS may have a role in ensuring that sound ergonomics principles are

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 123

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 9

To promote the integration of standardized terminologies into informa-
tion technology solutions, ANA’s Nursing Information and Data Set Evalu-
ation Center (NIDSEC) develops and disseminates standards pertaining to
information systems that support the documentation of nursing practice,
and evaluates voluntarily submitted information systems against these
standards.

At a higher level of structure, several resources facilitate inter-
operability between different systems of concepts and nomenclature.
For instance, the Systematized Nomenclature of Medicine, or SNOMED
CT (IHTSDO, 2007), is considered a universal healthcare reference termi-
nology and messaging structure. SNOMED CT enables one nursing ter-
minology system to be mapped to another, e.g., Omaha System with
North American Nursing Diagnosis Association (NANDA), Nursing Inter-
ventions Classification (NIC), and Nursing Outcomes Classification (NOC).
On a larger scale, the Unified Medical Language System (UMLS) of the
National Library of Medicine (NLM, 2006) incorporates the work of over
one hundred vocabularies, including SNOMED CT. The informatics nurse
and informatics nurse specialist must be aware of these tools, and may
be called upon to understand the concepts of one or more languages,
the relationships between concepts, and integration into existing
vocabularies for a given organization.

The importance of languages and vocabularies cannot be overstated.
Informatics nurses must seek a broader picture of the implications of
their work, and the uses and outcomes of languages and vocabularies
for end users. For instance, nurses mapping a home care vocabulary to
an intervention vocabulary must see beyond the technical aspect of the
work. They must understand that a case manager for a multi-system
health organization or a home care agency may be basing knowledge
of nursing acuity and case mix on the differing vocabularies that they
have integrated. The INS must attempt to envision the varied uses of the
data, information, and knowledge that have been created.

Concepts and Tools from Information Science and Computer Science

Tools and methods from computer and information sciences are funda-
mental to NI, including:

• Information technology

• Information structures

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM9

10 Nursing Informatics: Scope and Standards of Practice

• Information management

• Information communication

Information technology includes computer hardware, software, com-
munication, and network technologies, derived primarily from computer
science. The other three elements are derived primarily from informa-
tion science. Information structures organize data, information, and
knowledge for processing by computers. Information management is an
elemental process by which one files, stores, and manipulates data for
various uses. Information communication enables systems to send data
and to present information in a format that improves understanding.
The use of information technology distinguishes informatics from more
traditional methods of information management.

Human–Computer Interaction and Related Concepts

Human–computer interaction (HCI), usability, and ergonomics are con-
cepts of fundamental interest to the INS. Essentially, HCI deals with
people, software applications, computer technology, and the ways they
influence each other (Dix, Finlay, Abowd, & Beale, 2004). Elements of HCI
are rooted in psychology, social psychology, and cognitive science. How-
ever, the design, development, implementation, and evaluation of ap-
plications derive from applied work in computer science, a specific
discipline (in this case nursing), and information science. For example,
an INS would assess a medication ordering application before purchase
to determine whether the design complements the way nurses
cognitively process orders.

A related concept is usability, which deals with human performance
during computer interactions for specific tasks in a specific context.
Usability means the efficiency and effectiveness of an application. An
INS might study the ease of learning an application, the ease of using
it, the speed of task completion, or errors that occur during use when
determining which system or application would best fit a nursing unit.

In the United States, the term ergonomics typically is used to describe
the design and implementation of equipment, tools, and machines re-
lated to human safety, comfort, and convenience. Commonly, the term
ergonomics refers to attributes of physical equipment or to principles
of arrangement of equipment in the work environment. For instance, an
INS may have a role in ensuring that sound ergonomics principles are

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM10

Nursing Informatics.indd 123 11/6/14 4:06 PM

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 11

used in an intensive care unit to select and arrange various devices to
support workflow for cross-disciplinary providers as well as patients’
families.

HCI, usability, and ergonomics are typically subsumed under the ru-
bric of human factors, or how humans and technology relate to each
other. The overall goal is to design software, devices, and equipment to
promote optimal task completion. Optimal task completion includes the
concepts of efficiency and effectiveness; it also considers the safety of
the user. The INS and IN must understand all these concepts to success-
fully develop, select, implement, and evaluate information structures
and informatics solutions.

The importance of human factors in healthcare was elevated with the
Institute of Medicine’s 2001 report. Before this, HCI and usability assess-
ments and methods were being incorporated into health at a glacial
speed. In the past five years the number of HCI and usability publica-
tions in healthcare has increased substantially. Vendors have installed
usability laboratories and incorporated usability testing of their prod-
ucts into their systems life cycles. The FDA has mandated usability test-
ing as part of their approval process for new devices (FDA, 2007a). Thus,
HCI and usability are critical concepts for INs and INSs to understand.
Numerous usability methods and tools are available, e.g., heuristics
(rules of thumb), naturalistic observation, and think-aloud protocols.

Phenomena of Nursing

The metaparadigm of nursing comprises four key concepts: nurse, per-
son, health, and environment. Nurses make decisions about interven-
tions from their unique perspectives. Nursing actions are based upon
the inter-relationships between the concepts and are related to the val-
ues nurses hold relative to them. Decision-making is the process of
choosing among alternatives. The decisions that nurses make can be
characterized by both the quality of decisions and the impact of the
actions resulting from those decisions. As knowledge workers, nurses
make numerous decisions that affect the life and well-being of individu-
als, families, and communities. The process of decision-making in nurs-
ing is guided by the concept of critical thinking. “Critical thinking is the
intellectually disciplined process of actively and skillfully using knowl-
edge to conceptualize, apply, analyze, synthesize, and/or evaluate data
and information as a guide to belief and action.” (Scriven & Paul, 2003)

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12 Nursing Informatics: Scope and Standards of Practice

Clinical wisdom is the ability of the nurse to add experience and in-
tuition to a situation involving the care of a person (Benner, Hooper-
Kyriakidis, & Stannard, 1999). Wisdom in informatics is the ability of the
informatics nurse specialist to evaluate the documentation drawn from
a health information system (HIS) and the ability to adapt or change the
system settings or parameters to improve the workflow of the clinical
nurse.

Nurses’ decision-making can be described as an array of choices that
include specific behaviors, as well as cognitive processing of one or
more issues. For example, nurses use data transformed into information
to determine interventions for persons, families, and communities.
Nurses make decisions about potential problems presented by an indi-
vidual and about recommendations to address those problems. They
also make decisions in collaboration with other healthcare profession-
als such as physicians, pharmacists, or social workers. Decisions also may
occur outside the practice environment, as in executive offices, class-
rooms, and research laboratories.

An information system collects and processes data and information.
Decision support systems are computer applications designed to facili-
tate human decision-making. Decision support systems are typically
rule-based: they use a knowledge base and a set of rules to analyze data
and information and provide recommendations. Other decision support
systems are based on knowledge models induced directly from data,
regression, or classification models that predict characteristics or out-
comes.

An expert system is a decision support system that implements the
knowledge of human experts. Recommendations take the form of alerts,
such as calling user attention to abnormal lab results or potential ad-
verse drug events, or suggestions, e.g., appropriate medications, thera-
pies, or other actions (Haug, Gardner, & Evans, 1999). Whereas control
systems implement decisions without involvement of a user, decision
support systems merely provide recommendations and rely on the wis-
dom of the user to apply them. As Blum (1986) demonstrated, the con-
cepts of data, information, knowledge, and wisdom exemplify different
levels of automated systems. The relationships between these concepts
and information, decision support, and expert systems are represented
in Figure 3.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 125

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 11

used in an intensive care unit to select and arrange various devices to
support workflow for cross-disciplinary providers as well as patients’
families.

HCI, usability, and ergonomics are typically subsumed under the ru-
bric of human factors, or how humans and technology relate to each
other. The overall goal is to design software, devices, and equipment to
promote optimal task completion. Optimal task completion includes the
concepts of efficiency and effectiveness; it also considers the safety of
the user. The INS and IN must understand all these concepts to success-
fully develop, select, implement, and evaluate information structures
and informatics solutions.

The importance of human factors in healthcare was elevated with the
Institute of Medicine’s 2001 report. Before this, HCI and usability assess-
ments and methods were being incorporated into health at a glacial
speed. In the past five years the number of HCI and usability publica-
tions in healthcare has increased substantially. Vendors have installed
usability laboratories and incorporated usability testing of their prod-
ucts into their systems life cycles. The FDA has mandated usability test-
ing as part of their approval process for new devices (FDA, 2007a). Thus,
HCI and usability are critical concepts for INs and INSs to understand.
Numerous usability methods and tools are available, e.g., heuristics
(rules of thumb), naturalistic observation, and think-aloud protocols.

Phenomena of Nursing

The metaparadigm of nursing comprises four key concepts: nurse, per-
son, health, and environment. Nurses make decisions about interven-
tions from their unique perspectives. Nursing actions are based upon
the inter-relationships between the concepts and are related to the val-
ues nurses hold relative to them. Decision-making is the process of
choosing among alternatives. The decisions that nurses make can be
characterized by both the quality of decisions and the impact of the
actions resulting from those decisions. As knowledge workers, nurses
make numerous decisions that affect the life and well-being of individu-
als, families, and communities. The process of decision-making in nurs-
ing is guided by the concept of critical thinking. “Critical thinking is the
intellectually disciplined process of actively and skillfully using knowl-
edge to conceptualize, apply, analyze, synthesize, and/or evaluate data
and information as a guide to belief and action.” (Scriven & Paul, 2003)

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM11

12 Nursing Informatics: Scope and Standards of Practice

Clinical wisdom is the ability of the nurse to add experience and in-
tuition to a situation involving the care of a person (Benner, Hooper-
Kyriakidis, & Stannard, 1999). Wisdom in informatics is the ability of the
informatics nurse specialist to evaluate the documentation drawn from
a health information system (HIS) and the ability to adapt or change the
system settings or parameters to improve the workflow of the clinical
nurse.

Nurses’ decision-making can be described as an array of choices that
include specific behaviors, as well as cognitive processing of one or
more issues. For example, nurses use data transformed into information
to determine interventions for persons, families, and communities.
Nurses make decisions about potential problems presented by an indi-
vidual and about recommendations to address those problems. They
also make decisions in collaboration with other healthcare profession-
als such as physicians, pharmacists, or social workers. Decisions also may
occur outside the practice environment, as in executive offices, class-
rooms, and research laboratories.

An information system collects and processes data and information.
Decision support systems are computer applications designed to facili-
tate human decision-making. Decision support systems are typically
rule-based: they use a knowledge base and a set of rules to analyze data
and information and provide recommendations. Other decision support
systems are based on knowledge models induced directly from data,
regression, or classification models that predict characteristics or out-
comes.

An expert system is a decision support system that implements the
knowledge of human experts. Recommendations take the form of alerts,
such as calling user attention to abnormal lab results or potential ad-
verse drug events, or suggestions, e.g., appropriate medications, thera-
pies, or other actions (Haug, Gardner, & Evans, 1999). Whereas control
systems implement decisions without involvement of a user, decision
support systems merely provide recommendations and rely on the wis-
dom of the user to apply them. As Blum (1986) demonstrated, the con-
cepts of data, information, knowledge, and wisdom exemplify different
levels of automated systems. The relationships between these concepts
and information, decision support, and expert systems are represented
in Figure 3.

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 13

In summary, the INS must navigate the complex relationships be-
tween the following elements and understand how they facilitate de-
cision-making:

• Data, information, knowledge, and wisdom

• Nursing science, information science, computer science, cognitive
science and other sciences of interest

• Nurse, person, health, and environment

• Information structures, information technology, management and
communication of information

References: Introduction, Metastructures, Concepts, and Tools

American Nurses Association (ANA). (2006a). ANA Recognized Terminolo-
gies and Data Element Sets. Retrieved October 10, 2007 from http://
nursingworld.org/npii/terminologies.htm

Reprinted from Englebardt & Nelson, 2002, Figure 1-5, page 14 with permission from Elsevier.

Figure 3. Levels and Types of Automated Systems

Wisdom

Knowledge

Information

Data

Decision
Support
System

Information
System

Expert
System

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM13

14 Nursing Informatics: Scope and Standards of Practice

Benner, P.E., Hooper-Kyriakidis, P.L., & Stannard, D. (1999). Clinical wisdom
and interventions in critical care: A thinking-in-action approach. Philadel-
phia: W.B. Saunders.

Bellinger, G., Castro, D., & Mills, A. (2004). Data, information, knowledge,
and wisdom. Retrieved October 10, 2007 from http://www.systems-
thinking.org/dikw/dikw.htm

Blum, B. (1986). Clinical information systems. New York: Springer-Verlag.

Clark, D. (2004) The continuum of understanding. From The way of
systems. Retrieved October 10, 2007 from http://www.nwlink.com/
~donclark/performance/understanding.html.

Dix, A., Finlay, J., Abowd, G., & Beale, R. (2004). Human-computer inter-
action. Harlow, England: Pearson, Prentice Hall.

Englebardt, S. & Nelson, R. (2002) Health care informatics: An interdiscipli-
nary approach. St. Louis: Mosby-Year Book, Inc.

Graves, J., & Corcoran, S. (1989). The study of nursing informatics. Image,
21(4), 227–230.

Harrison, L. (2002). Nursing activity in general intensive care. Journal of
Clinical Nursing, 11(2), 158–67.

Haug, P., Gardner, R., & Evans, S. (1999). Hospital-based decision support.
In E.S. Berner (Ed.), Clinical Decision Support Systems: Theory and Prac-
tice, pp. 77–104. New York: Springer-Verlag.

Hendrickson, G. (1990). How do nurses use their time? Journal of Nurs-
ing Administration, 20(3), 31–38.

Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health
system for the 21st century. Washington, DC: National Academies Press.

International Health Terminology Standards Development Organization
(IHTSDO). (2007). SNOMED-CT. Retrieved October 10, 2007 from http:/
/www.ihtsdo.org/.

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM14

Nursing Informatics.indd 126 11/6/14 4:06 PM

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 127

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 13

In summary, the INS must navigate the complex relationships be-
tween the following elements and understand how they facilitate de-
cision-making:

• Data, information, knowledge, and wisdom

• Nursing science, information science, computer science, cognitive
science and other sciences of interest

• Nurse, person, health, and environment

• Information structures, information technology, management and
communication of information

References: Introduction, Metastructures, Concepts, and Tools

American Nurses Association (ANA). (2006a). ANA Recognized Terminolo-
gies and Data Element Sets. Retrieved October 10, 2007 from http://
nursingworld.org/npii/terminologies.htm

Reprinted from Englebardt & Nelson, 2002, Figure 1-5, page 14 with permission from Elsevier.

Figure 3. Levels and Types of Automated Systems

Wisdom

Knowledge

Information

Data

Decision
Support
System

Information
System

Expert
System

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM13

14 Nursing Informatics: Scope and Standards of Practice

Benner, P.E., Hooper-Kyriakidis, P.L., & Stannard, D. (1999). Clinical wisdom
and interventions in critical care: A thinking-in-action approach. Philadel-
phia: W.B. Saunders.

Bellinger, G., Castro, D., & Mills, A. (2004). Data, information, knowledge,
and wisdom. Retrieved October 10, 2007 from http://www.systems-
thinking.org/dikw/dikw.htm

Blum, B. (1986). Clinical information systems. New York: Springer-Verlag.

Clark, D. (2004) The continuum of understanding. From The way of
systems. Retrieved October 10, 2007 from http://www.nwlink.com/
~donclark/performance/understanding.html.

Dix, A., Finlay, J., Abowd, G., & Beale, R. (2004). Human-computer inter-
action. Harlow, England: Pearson, Prentice Hall.

Englebardt, S. & Nelson, R. (2002) Health care informatics: An interdiscipli-
nary approach. St. Louis: Mosby-Year Book, Inc.

Graves, J., & Corcoran, S. (1989). The study of nursing informatics. Image,
21(4), 227–230.

Harrison, L. (2002). Nursing activity in general intensive care. Journal of
Clinical Nursing, 11(2), 158–67.

Haug, P., Gardner, R., & Evans, S. (1999). Hospital-based decision support.
In E.S. Berner (Ed.), Clinical Decision Support Systems: Theory and Prac-
tice, pp. 77–104. New York: Springer-Verlag.

Hendrickson, G. (1990). How do nurses use their time? Journal of Nurs-
ing Administration, 20(3), 31–38.

Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health
system for the 21st century. Washington, DC: National Academies Press.

International Health Terminology Standards Development Organization
(IHTSDO). (2007). SNOMED-CT. Retrieved October 10, 2007 from http:/
/www.ihtsdo.org/.

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM14

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 15

Jinks, A.M. (2000) What do nurses do? An observational survey of the
activities of nurses on acute surgical and rehabilitative wards. Journal
of Nursing Management 8(5), 273–279.

Jydstrup, R.A., & J.J.Gross. (1966) Cost of information handling in hospitals.
Health Services Research 1(3): 235–271.

Nelson, R. (2002). A placeholder for a missing ref item for a citation in this
section. Nursing Miscellany: A Catch-all Journal of the Fourth Kind, 42(4),
656–666.

Nelson, R., & Joos, I. (1989). On language in nursing: From data to wisdom.
PLN Vision. p. 6.

Norrie, P. (1997). Nurses’ time management in intensive care. Nursing
Critical Care, 2(3), 121–125.

Norrie, P. (1999) The parameters that cardiothoracic intensive care nurses
use to assess the progress or deterioration of their patients. Nursing
Critical Care, 4(3), 133–137.

Scriven, M., & Paul, R. (2003). Defining critical thinking. Santa Rosa, CA.:
Foundation for Critical Thinking. Retrieved December 13, 2007 from
http://www.criticalthinking.org

Staggers, N., & Thompson, C.B. (2002). The evolution of definitions for
nursing informatics: A critical analysis and revised definition. Journal
of the American Medical Informatics Association, 33(1), 75–81.

Turley, J.P. (1996). Toward a model for nursing informatics. Image: Journal
of Nursing Scholarship, 28(4), 309–313.

Zielstroff, Z. Z. (1981). Yet another placeholder for a missing ref item for
a citation in this section. Nursing Miscellany: A Catch-all Journal of the
Fourth Kind, 42(4), 666–669.

Nelson, R., & Joos, I. (1989). On language in nursing: From data to wisdom.
PLN Vision. p. 6.

Norrie, P. (1997). Nurses’ time management in intensive care. Nursing Criti-
cal Care, 2(3), 121–125.

Norrie, P. (1999) The parameters that cardiothoracic intensive care nurses
use to assess the progress or deterioration of their patients. Nursing
Critical Care, 4(3), 133–137.

Scriven, M., & Paul, R. (2003). Defi ning critical thinking. Santa Rosa, CA.:
Foundation for Critical Thinking. Retrieved December 13, 2007 from
http://www.criticalthinking.org

Staggers, N., & Thompson, C.B. (2002). The evolution of defi nitions for nurs-
ing informatics: A critical analysis and revised defi nition. Journal of the
American Medical Informatics Association, 33(1), 75–81.

Turley, J.P. (1996). Toward a model for nursing informatics. Image: Journal of
Nursing Scholarship, 28(4), 309–313.

Zielstorff, R.D. (1981). How computer systems infl uence nursing activities
in hospitals. In The Proceedings of the First National Conference: Comput-
er Technology and Nursing, pp. 1–6. Bethesda, MD: National Institutes of
Health.

16 Nursing Informatics: Scope and Standards of Practice

Functional Areas for Nursing Informatics

Two recent studies illuminate the current work of INs. Newbold (per-
sonal communication, January 17, 2006) created a database of job titles
for nurses working in informatics beginning in the early 1980s. As of
early 2006, the database included titles for 6338 members of nursing
and informatics organizations, conference attendees and participants on
NI electronic discussion lists. However, the top 50 job titles did not con-
sistently map to their responsibilities and activities. INs with different
titles may actually be performing the same functions, and INs with the
same titles may perform very different functions.

A 2007 Health Information Management and Systems Society (HIMSS)
survey of 776 informatics nurses categorized NI work into job respon-
sibilities as opposed to job titles (HIMSS, 2007). The top job responsibil-
ity of respondents was systems implementation (45%), down from 67%
in 2004. The second and third top job responsibilities reported by HIMSS
respondents were system development (41%) and liaison (35%).

Not only are there assorted titles and activities within nursing
informatics, the environments in which INSs and INs practice are many
and evolving. Initially, NI focused nearly exclusively on the hospital set-
ting. Now INs work in such diverse settings as home health and hos-
pice agencies, nursing homes, public and community health agencies,
physician offices, and ambulatory care centers. They are employed by
medical device vendors, large and small software companies, web con-
tent providers, disease management companies, and government
agencies, in numerous settings (Sensmeier, West, & Horowicz, 2004).
Across environments , INSs and INs commonly practice in interdisci-
plinary healthcare environments and are often expected to interact
with information technology (IT ) professionals during all phases of the
systems life cycle. And more commonly than in the past, INs may be
the IT professionals themselves.

Nursing informatics supports multiple constituencies and stakehold-
ers such as cross-disciplinary team members, healthcare consumers,
information technology professionals, and healthcare agencies and or-
ganizations. INSs are particularly well suited to work in multidisciplinary
and interdisciplinary environments. After all, nurses have planned, imple-
mented, and coordinated activities involving multiple constituencies in
a consumer-centered fashion from their earliest days.

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM16

Nursing Informatics.indd 128 11/6/14 4:06 PM

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 129

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 15

Jinks, A.M. (2000) What do nurses do? An observational survey of the
activities of nurses on acute surgical and rehabilitative wards. Journal
of Nursing Management 8(5), 273–279.

Jydstrup, R.A., & J.J.Gross. (1966) Cost of information handling in hospitals.
Health Services Research 1(3): 235–271.

Nelson, R. (2002). A placeholder for a missing ref item for a citation in this
section. Nursing Miscellany: A Catch-all Journal of the Fourth Kind, 42(4),
656–666.

Nelson, R., & Joos, I. (1989). On language in nursing: From data to wisdom.
PLN Vision. p. 6.

Norrie, P. (1997). Nurses’ time management in intensive care. Nursing
Critical Care, 2(3), 121–125.

Norrie, P. (1999) The parameters that cardiothoracic intensive care nurses
use to assess the progress or deterioration of their patients. Nursing
Critical Care, 4(3), 133–137.

Scriven, M., & Paul, R. (2003). Defining critical thinking. Santa Rosa, CA.:
Foundation for Critical Thinking. Retrieved December 13, 2007 from
http://www.criticalthinking.org

Staggers, N., & Thompson, C.B. (2002). The evolution of definitions for
nursing informatics: A critical analysis and revised definition. Journal
of the American Medical Informatics Association, 33(1), 75–81.

Turley, J.P. (1996). Toward a model for nursing informatics. Image: Journal
of Nursing Scholarship, 28(4), 309–313.

Zielstroff, Z. Z. (1981). Yet another placeholder for a missing ref item for
a citation in this section. Nursing Miscellany: A Catch-all Journal of the
Fourth Kind, 42(4), 666–669.

Nelson, R., & Joos, I. (1989). On language in nursing: From data to wisdom.
PLN Vision. p. 6.

Norrie, P. (1997). Nurses’ time management in intensive care. Nursing Criti-
cal Care, 2(3), 121–125.

Norrie, P. (1999) The parameters that cardiothoracic intensive care nurses
use to assess the progress or deterioration of their patients. Nursing
Critical Care, 4(3), 133–137.

Scriven, M., & Paul, R. (2003). Defi ning critical thinking. Santa Rosa, CA.:
Foundation for Critical Thinking. Retrieved December 13, 2007 from
http://www.criticalthinking.org

Staggers, N., & Thompson, C.B. (2002). The evolution of defi nitions for nurs-
ing informatics: A critical analysis and revised defi nition. Journal of the
American Medical Informatics Association, 33(1), 75–81.

Turley, J.P. (1996). Toward a model for nursing informatics. Image: Journal of
Nursing Scholarship, 28(4), 309–313.

Zielstorff, R.D. (1981). How computer systems infl uence nursing activities
in hospitals. In The Proceedings of the First National Conference: Comput-
er Technology and Nursing, pp. 1–6. Bethesda, MD: National Institutes of
Health.

16 Nursing Informatics: Scope and Standards of Practice

Functional Areas for Nursing Informatics

Two recent studies illuminate the current work of INs. Newbold (per-
sonal communication, January 17, 2006) created a database of job titles
for nurses working in informatics beginning in the early 1980s. As of
early 2006, the database included titles for 6338 members of nursing
and informatics organizations, conference attendees and participants on
NI electronic discussion lists. However, the top 50 job titles did not con-
sistently map to their responsibilities and activities. INs with different
titles may actually be performing the same functions, and INs with the
same titles may perform very different functions.

A 2007 Health Information Management and Systems Society (HIMSS)
survey of 776 informatics nurses categorized NI work into job respon-
sibilities as opposed to job titles (HIMSS, 2007). The top job responsibil-
ity of respondents was systems implementation (45%), down from 67%
in 2004. The second and third top job responsibilities reported by HIMSS
respondents were system development (41%) and liaison (35%).

Not only are there assorted titles and activities within nursing
informatics, the environments in which INSs and INs practice are many
and evolving. Initially, NI focused nearly exclusively on the hospital set-
ting. Now INs work in such diverse settings as home health and hos-
pice agencies, nursing homes, public and community health agencies,
physician offices, and ambulatory care centers. They are employed by
medical device vendors, large and small software companies, web con-
tent providers, disease management companies, and government
agencies, in numerous settings (Sensmeier, West, & Horowicz, 2004).
Across environments , INSs and INs commonly practice in interdisci-
plinary healthcare environments and are often expected to interact
with information technology (IT ) professionals during all phases of the
systems life cycle. And more commonly than in the past, INs may be
the IT professionals themselves.

Nursing informatics supports multiple constituencies and stakehold-
ers such as cross-disciplinary team members, healthcare consumers,
information technology professionals, and healthcare agencies and or-
ganizations. INSs are particularly well suited to work in multidisciplinary
and interdisciplinary environments. After all, nurses have planned, imple-
mented, and coordinated activities involving multiple constituencies in
a consumer-centered fashion from their earliest days.

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM16

Nursing Informatics.indd 129 11/6/14 4:06 PM

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 17

INSs use scientific and informatics principles. More importantly, they
employ creative strategies in meaningful informatics solutions. INSs also
bring unique perspectives of cross-disciplinary work, solid understand-
ing of operational processes, and the value of consumer advocacy to
informatics functions. INs and INSs may find that they need varying
kinds of advanced preparation to match the informatics project at hand.
For instance, an INS coordinating the implementation of a learning
management system may benefit from advanced preparation in adult
education.

Many registered nurses have worked on informatics initiatives for
many years and have built their knowledge base and expertise from on-
the-job experience. The evolving mandate for electronic information
systems and the increasing complexity of healthcare services and prac-
tice have raised the bar for the nursing professional. Select informatics
competencies will soon be required in all undergraduate and graduate
nursing curricula. Accredited graduate level educational programs for
this specialty nursing practice were first offered in 1989 and are now
more widely available, especially through distance education and online
programs. Rather than offer discipline-specific informatics programs,
some universities have elected to embrace an interdisciplinary approach
and offer graduate studies in health informatics or bioinformatics. A
graduate level informatics degree is becoming the standard.

Professional certification as an informatics nurse became a reality in
late 1995 when the American Nurses Credentialing Center (ANCC) of-
fered the nursing informatics certification exam as its first computer-
based examination. Informatics nurses and informatics nurse specialists
may elect to pursue other pertinent certifications in areas such as
project management, security and privacy, network management, and
knowledge management. Employers are beginning to use certification
as a preferred characteristic during the hiring process.

Because of the tendency to confuse roles with titles and the vast num-
ber of position titles and lack of standardization among them, this
section describes the functional areas for INSs and INs. The following
present overall functional areas of nursing informatics:

• Administration, leadership, and management

• Analysis

• Compliance and integrity management

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM17

18 Nursing Informatics: Scope and Standards of Practice

• Consultation

• Coordination, facilitation, and integration

• Development

• Educational and professional development

• Policy development and advocacy

• Research and evaluation

The last discussion in this section describes integrated functions, es-
pecially those crossing clinical practice and informatics. INSs may be in
positions that focus primarily in one functional area, or, more frequently,
several functional areas are combined within a particular NI position.

Administration, Leadership, and Management

As is true of administration in general, leadership and management
functions in nursing informatics consist of both higher-level and mid-
level administrative functions (ANA, 2004b). Increasingly, INSs are attain-
ing senior leadership positions. Positions may be titled President,
Director, Chief Information Officer (CIO), or similar leadership titles
(AMIA, 2006a; Staggers & Lasome, 2005; Greene, 2004). In this functional
capacity, nursing informatics leaders are expected to be visionary and
establish the direction of large-scale informatics solutions. The nursing
informatics leader often serves as a catalyst for developing strategic
plans, creating national or system policies and procedures, and serving
as champion for complex projects and disparate system users.

In mid-level management, INSs may supervise resources and activi-
ties for all phases of the systems life cycle. These activities may include
needs analysis, requirements gathering, design, development, selection
and purchase, testing, implementation, and evaluation of systems to
support all facets of nursing and healthcare delivery. In all levels, leader-
ship combines the skills of superb communication, change manage-
ment, risk assessment, and coalition building with political finesse,
business acumen, and strategic application knowledge.

INSs serving in this functional area may put most of their energy into
leadership and management. In other positions, administration may be
part of a position merged with other functional areas. Examples might
include:

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM18

Nursing Informatics.indd 130 11/6/14 4:06 PM

EBSCOhost – printed on 4/28/2022 8:49 AM via . All use subject to https://www.ebsco.com/terms-of-use

Nursing Informatics: Scope and Standards of Practice, 2nd Edition 131

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 17

INSs use scientific and informatics principles. More importantly, they
employ creative strategies in meaningful informatics solutions. INSs also
bring unique perspectives of cross-disciplinary work, solid understand-
ing of operational processes, and the value of consumer advocacy to
informatics functions. INs and INSs may find that they need varying
kinds of advanced preparation to match the informatics project at hand.
For instance, an INS coordinating the implementation of a learning
management system may benefit from advanced preparation in adult
education.

Many registered nurses have worked on informatics initiatives for
many years and have built their knowledge base and expertise from on-
the-job experience. The evolving mandate for electronic information
systems and the increasing complexity of healthcare services and prac-
tice have raised the bar for the nursing professional. Select informatics
competencies will soon be required in all undergraduate and graduate
nursing curricula. Accredited graduate level educational programs for
this specialty nursing practice were first offered in 1989 and are now
more widely available, especially through distance education and online
programs. Rather than offer discipline-specific informatics programs,
some universities have elected to embrace an interdisciplinary approach
and offer graduate studies in health informatics or bioinformatics. A
graduate level informatics degree is becoming the standard.

Professional certification as an informatics nurse became a reality in
late 1995 when the American Nurses Credentialing Center (ANCC) of-
fered the nursing informatics certification exam as its first computer-
based examination. Informatics nurses and informatics nurse specialists
may elect to pursue other pertinent certifications in areas such as
project management, security and privacy, network management, and
knowledge management. Employers are beginning to use certification
as a preferred characteristic during the hiring process.

Because of the tendency to confuse roles with titles and the vast num-
ber of position titles and lack of standardization among them, this
section describes the functional areas for INSs and INs. The following
present overall functional areas of nursing informatics:

• Administration, leadership, and management

• Analysis

• Compliance and integrity management

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM17

18 Nursing Informatics: Scope and Standards of Practice

• Consultation

• Coordination, facilitation, and integration

• Development

• Educational and professional development

• Policy development and advocacy

• Research and evaluation

The last discussion in this section describes integrated functions, es-
pecially those crossing clinical practice and informatics. INSs may be in
positions that focus primarily in one functional area, or, more frequently,
several functional areas are combined within a particular NI position.

Administration, Leadership, and Management

As is true of administration in general, leadership and management
functions in nursing informatics consist of both higher-level and mid-
level administrative functions (ANA, 2004b). Increasingly, INSs are attain-
ing senior leadership positions. Positions may be titled President,
Director, Chief Information Officer (CIO), or similar leadership titles
(AMIA, 2006a; Staggers & Lasome, 2005; Greene, 2004). In this functional
capacity, nursing informatics leaders are expected to be visionary and
establish the direction of large-scale informatics solutions. The nursing
informatics leader often serves as a catalyst for developing strategic
plans, creating national or system policies and procedures, and serving
as champion for complex projects and disparate system users.

In mid-level management, INSs may supervise resources and activi-
ties for all phases of the systems life cycle. These activities may include
needs analysis, requirements gathering, design, development, selection
and purchase, testing, implementation, and evaluation of systems to
support all facets of nursing and healthcare delivery. In all levels, leader-
ship combines the skills of superb communication, change manage-
ment, risk assessment, and coalition building with political finesse,
business acumen, and strategic application knowledge.

INSs serving in this functional area may put most of their energy into
leadership and management. In other positions, administration may be
part of a position merged with other functional areas. Examples might
include:

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM18

Nursing Informatics.indd 131 11/6/14 4:06 PM

EBSCOhost – printed on 4/28/2022 8:49 AM via . All use subject to https://www.ebsco.com/terms-of-use

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 19

• INS at a large hospital system, supervising an implementation and
education team, representing nursing interests on various IT com-
mittees, performing project management for multiple documen-
tation projects, and having oversight of nursing standards and
vocabularies used in applications.

• Project director for a clinical software company, managing imple-
mentation teams for various client projects (hospitals to ambula-
tory facilities) and consulting with clients on all aspects of systems
selection, customization, adoption, and use of software.

• Grants administrator for an information science research agency
seeking and writing grants that would fund NI-related projects,
designing budgets, and ensuring optimal allocation of resources.

Analysis

Data can be aggregated and analyzed in an infinite number of ways to
synthesize knowledge, inform decision support and outcomes manage-
ment, and advance the science of nursing informatics. The INS may use
a number of tools to accomplish these ends. Taxonomies and clinical
vocabularies can be used to tag consumer data for higher-level analy-
sis. Meta-analysis can identify large-scale trends across multiple groups
of data. Systems and requirements analysis can track the flow of data
in a system, customized to end-user needs. Workflow analysis can de-
tail steps taken for a number of tasks.

A major responsibility of the INS is to understand work process flows,
the particular informatics solution, and how these affect each other. Pro-
cesses must be designed for successful interactions between users and
computers. Competency in formal systems analysis techniques and use
of statistical software may be required. These techniques compare the
capabilities and limitations of systems to be installed, and where
changes must be designed. Discrepancies between the current and ideal
systems must be identified and redundancies removed. The clinical
analysis process also may include tools and systematic methods, such
as process redesign, to enhance safety and reduce inefficiencies.

INSs may also engage in the process of knowledge discovery in data-
bases (KDD). Using sound methodologies and practical evidence-based
recommendations, the INS can discover information and knowledge
related to diverse areas of nursing practice. Knowledge discovery

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM19

20 Nursing Informatics: Scope and Standards of Practice

methods, including data mining and machine learning methods, can be
applied along with statistical analysis and data visualization techniques,
to identify and understand patterns in very large data stores, such as
enterprise data warehouses (Fayyad, 1996).

Analysis is also required with languages and taxonomies. Nursing
languages such as Nursing Interventions Classification (NIC), Nursing
Outcomes Classification (NOC), and medical vocabularies must be peri-
odically re-evaluated for their applicability and currency (CNCCE, 2004).
Analysis of a meta-database such as the Unified Medical Language
System or UMLS (NLM, 2006) requires knowledge of nursing as well as
medical vocabularies in order to analyze groups of taxonomies, a task
ideally suited to the expertise of an INS.

Analysis of outcomes may be related to any domain of nursing prac-
tice—clinical, education, research, or administration. The complexity and
levels of outcomes must be determined for healthcare consumers,
populations, and institutions. Analysis can include the use of Human-
Computer Interaction (HCI) principles and methods. In that domain, INSs
use HCI tools and methods such as heuristics and cognitive walk-
through to analyze the fit of users, tasks, and contexts. Other tools are
also available. Analysts use system tools to maintain data integrity and
reliability, facilitate data aggregation and analysis, identify outcomes,
and develop performance measurements. These techniques allow
nurses to contribute to building a knowledge base consisting of the
data, information, theories, and models used by nurses and other stake-
holders in decision-making and support of healthcare. Analysis activi-
ties may include:

• A nursing analyst in a hospice setting tracks health consumer data
to establish a weighted case mix to determine nursing personnel
allocations.

• A quality improvement (QI) specialist in a hospital system aggre-
gates multi-site research data related to diagnosis and nursing pro-
cedures.

• A quality assurance (QA) analyst works with nurse managers to re-
tool current work processes after examining existing system data
in customized QA reports.

• An analyst applies knowledge discovery methods to warehoused
electronic data to build a predictive model of patient falls.

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM20

Nursing Informatics.indd 132 11/6/14 4:06 PM

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 133

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 19

• INS at a large hospital system, supervising an implementation and
education team, representing nursing interests on various IT com-
mittees, performing project management for multiple documen-
tation projects, and having oversight of nursing standards and
vocabularies used in applications.

• Project director for a clinical software company, managing imple-
mentation teams for various client projects (hospitals to ambula-
tory facilities) and consulting with clients on all aspects of systems
selection, customization, adoption, and use of software.

• Grants administrator for an information science research agency
seeking and writing grants that would fund NI-related projects,
designing budgets, and ensuring optimal allocation of resources.

Analysis

Data can be aggregated and analyzed in an infinite number of ways to
synthesize knowledge, inform decision support and outcomes manage-
ment, and advance the science of nursing informatics. The INS may use
a number of tools to accomplish these ends. Taxonomies and clinical
vocabularies can be used to tag consumer data for higher-level analy-
sis. Meta-analysis can identify large-scale trends across multiple groups
of data. Systems and requirements analysis can track the flow of data
in a system, customized to end-user needs. Workflow analysis can de-
tail steps taken for a number of tasks.

A major responsibility of the INS is to understand work process flows,
the particular informatics solution, and how these affect each other. Pro-
cesses must be designed for successful interactions between users and
computers. Competency in formal systems analysis techniques and use
of statistical software may be required. These techniques compare the
capabilities and limitations of systems to be installed, and where
changes must be designed. Discrepancies between the current and ideal
systems must be identified and redundancies removed. The clinical
analysis process also may include tools and systematic methods, such
as process redesign, to enhance safety and reduce inefficiencies.

INSs may also engage in the process of knowledge discovery in data-
bases (KDD). Using sound methodologies and practical evidence-based
recommendations, the INS can discover information and knowledge
related to diverse areas of nursing practice. Knowledge discovery

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM19

20 Nursing Informatics: Scope and Standards of Practice

methods, including data mining and machine learning methods, can be
applied along with statistical analysis and data visualization techniques,
to identify and understand patterns in very large data stores, such as
enterprise data warehouses (Fayyad, 1996).

Analysis is also required with languages and taxonomies. Nursing
languages such as Nursing Interventions Classification (NIC), Nursing
Outcomes Classification (NOC), and medical vocabularies must be peri-
odically re-evaluated for their applicability and currency (CNCCE, 2004).
Analysis of a meta-database such as the Unified Medical Language
System or UMLS (NLM, 2006) requires knowledge of nursing as well as
medical vocabularies in order to analyze groups of taxonomies, a task
ideally suited to the expertise of an INS.

Analysis of outcomes may be related to any domain of nursing prac-
tice—clinical, education, research, or administration. The complexity and
levels of outcomes must be determined for healthcare consumers,
populations, and institutions. Analysis can include the use of Human-
Computer Interaction (HCI) principles and methods. In that domain, INSs
use HCI tools and methods such as heuristics and cognitive walk-
through to analyze the fit of users, tasks, and contexts. Other tools are
also available. Analysts use system tools to maintain data integrity and
reliability, facilitate data aggregation and analysis, identify outcomes,
and develop performance measurements. These techniques allow
nurses to contribute to building a knowledge base consisting of the
data, information, theories, and models used by nurses and other stake-
holders in decision-making and support of healthcare. Analysis activi-
ties may include:

• A nursing analyst in a hospice setting tracks health consumer data
to establish a weighted case mix to determine nursing personnel
allocations.

• A quality improvement (QI) specialist in a hospital system aggre-
gates multi-site research data related to diagnosis and nursing pro-
cedures.

• A quality assurance (QA) analyst works with nurse managers to re-
tool current work processes after examining existing system data
in customized QA reports.

• An analyst applies knowledge discovery methods to warehoused
electronic data to build a predictive model of patient falls.

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM20

Nursing Informatics.indd 133 11/6/14 4:06 PM

EBSCOhost – printed on 4/28/2022 8:49 AM via . All use subject to https://www.ebsco.com/terms-of-use

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 21

Compliance and Integrity Management

With the advent of national laws advocating for the protection of health
information, INSs are responsible for ensuring the ethical use of data, as
well as data integrity, security, and confidentiality of protected health
information. One function of the INS is knowledge and application of
ethical standards. The Health Insurance Portability and Accountability
Act (HIPAA) of 1996 has obliged healthcare organizations to revise op-
erational procedures for staff, as well as technical processes, to maintain
compliance. INSs must be fluent in these new requirements; they are
involved in creating, implementing, and assuring organizational change
to meet new legislative mandates. Compliance also includes adherence
to national and international standards. These standards may include
those from government agencies, such as the Food and Drug Adminis-
tration (FDA) and National Institutes of Health (NIH), as well as accredi-
tation organizations such as the Joint Commission.

Ethical issues related to consumer privacy abound. One arises from
knowledge discovery in databases (KDD), where prediction of outcomes
based on individual characteristics, behavior, or usage may be used to
stratify groups of people. Although used in a variety of industries, KDD
remains controversial in health care. Adequate HIPAA protections must
be in place, and relevant ethical issues must be considered in all phases
of data retrieval and analysis. For example, analysis of genomic data may
result in sensitive predictions of susceptibility to disease. Given the ex-
plosive growth of large data stores and enterprise data warehouses, KDD
is important for extraction of useful information and knowledge; never-
theless, protecting consumer privacy is vital. The INS can help ensure a
balance between access and privacy.

The emerging sciences of genomics and bioinformatics could be used
to predict risk for certain diseases, and thus insurability risk. Ethical is-
sues surround the use of new products, such as embedded technolo-
gies and radio-frequency identification (RFID) and their application in
caring for persons with Alzheimer’s disease and other dementias. As the
profession matures, some of these issues will be resolved and standards
will be established. Requirements will continue to evolve; see the sec-
tion, Future of NI, on page 61. Examples of compliance and integrity
management activities include:

• The security officer for a hospital ensures that HIPAA standards are
met by software vendors within the organization, periodically

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22 Nursing Informatics: Scope and Standards of Practice

monitors software audit logs for breaches, and ensures that pass-
words are not shared and backup and disaster procedures are in
place and operational.

• A compliance officer for a state health agency writes and enforces
policies that conform to state and national laws respecting records
retention.

• A care coordinator administrator for a hospital system ensures the
confidentiality of data transmitted via telehealth and telemedicine
devices

Consultation

Informatics nurses and informatics nurse specialists apply informatics
knowledge and skills to serve as a resource to clients, both formally and
informally, in external and internal settings. Consultants are experts in
the areas of process redesign, strategic IT planning, system implemen-
tation, writing informatics publications, evaluating clinical software
products, working with clients to write requests for proposals, perform-
ing market research, and assisting in the planning of conferences, aca-
demic courses, and professional development programs. These expert
INSs may work for a consulting firm, be employed as staff of the orga-
nization where they consult, own an independent practice, or be recog-
nized as an expert by writing about NI and speaking at NI-related events.
Flexibility, good communication skills, breadth and depth of clinical and
informatics knowledge, and excellent interpersonal skills are needed to
respond to rapidly changing projects and demands. Examples include:

• Consulting with individuals and groups in defining healthcare in-
formation problems and identifying methods for implementing,
utilizing, and modifying IT solutions and data structures to support
healthcare access, delivery, and evaluation.

• Consulting as the project manager, ensuring that team members
are performing duties as assigned and the project is completed
within budget.

• Consulting with clients in writing requests for proposals to elicit
vendor bids for informatics solutions and in evaluating vendor
responses.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 135

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 21

Compliance and Integrity Management

With the advent of national laws advocating for the protection of health
information, INSs are responsible for ensuring the ethical use of data, as
well as data integrity, security, and confidentiality of protected health
information. One function of the INS is knowledge and application of
ethical standards. The Health Insurance Portability and Accountability
Act (HIPAA) of 1996 has obliged healthcare organizations to revise op-
erational procedures for staff, as well as technical processes, to maintain
compliance. INSs must be fluent in these new requirements; they are
involved in creating, implementing, and assuring organizational change
to meet new legislative mandates. Compliance also includes adherence
to national and international standards. These standards may include
those from government agencies, such as the Food and Drug Adminis-
tration (FDA) and National Institutes of Health (NIH), as well as accredi-
tation organizations such as the Joint Commission.

Ethical issues related to consumer privacy abound. One arises from
knowledge discovery in databases (KDD), where prediction of outcomes
based on individual characteristics, behavior, or usage may be used to
stratify groups of people. Although used in a variety of industries, KDD
remains controversial in health care. Adequate HIPAA protections must
be in place, and relevant ethical issues must be considered in all phases
of data retrieval and analysis. For example, analysis of genomic data may
result in sensitive predictions of susceptibility to disease. Given the ex-
plosive growth of large data stores and enterprise data warehouses, KDD
is important for extraction of useful information and knowledge; never-
theless, protecting consumer privacy is vital. The INS can help ensure a
balance between access and privacy.

The emerging sciences of genomics and bioinformatics could be used
to predict risk for certain diseases, and thus insurability risk. Ethical is-
sues surround the use of new products, such as embedded technolo-
gies and radio-frequency identification (RFID) and their application in
caring for persons with Alzheimer’s disease and other dementias. As the
profession matures, some of these issues will be resolved and standards
will be established. Requirements will continue to evolve; see the sec-
tion, Future of NI, on page 61. Examples of compliance and integrity
management activities include:

• The security officer for a hospital ensures that HIPAA standards are
met by software vendors within the organization, periodically

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM21

22 Nursing Informatics: Scope and Standards of Practice

monitors software audit logs for breaches, and ensures that pass-
words are not shared and backup and disaster procedures are in
place and operational.

• A compliance officer for a state health agency writes and enforces
policies that conform to state and national laws respecting records
retention.

• A care coordinator administrator for a hospital system ensures the
confidentiality of data transmitted via telehealth and telemedicine
devices

Consultation

Informatics nurses and informatics nurse specialists apply informatics
knowledge and skills to serve as a resource to clients, both formally and
informally, in external and internal settings. Consultants are experts in
the areas of process redesign, strategic IT planning, system implemen-
tation, writing informatics publications, evaluating clinical software
products, working with clients to write requests for proposals, perform-
ing market research, and assisting in the planning of conferences, aca-
demic courses, and professional development programs. These expert
INSs may work for a consulting firm, be employed as staff of the orga-
nization where they consult, own an independent practice, or be recog-
nized as an expert by writing about NI and speaking at NI-related events.
Flexibility, good communication skills, breadth and depth of clinical and
informatics knowledge, and excellent interpersonal skills are needed to
respond to rapidly changing projects and demands. Examples include:

• Consulting with individuals and groups in defining healthcare in-
formation problems and identifying methods for implementing,
utilizing, and modifying IT solutions and data structures to support
healthcare access, delivery, and evaluation.

• Consulting as the project manager, ensuring that team members
are performing duties as assigned and the project is completed
within budget.

• Consulting with clients in writing requests for proposals to elicit
vendor bids for informatics solutions and in evaluating vendor
responses.

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 23

Coordination, Facilitation, and Integration

One of the most common NI roles is implementing informatics solu-
tions. Nurses are particularly well suited for IT implementation, as it es-
sentially follows the nursing process of assessment, planning,
implementation, and evaluation (ANA, 2004a). Also, the INS frequently
serves as a bridge between informatics solution users and IT experts.
The IN or INS serves as project coordinator, facilitating change man-
agement and integrating the information and technology to transform
processes. In this role, project management knowledge and skills are
essential to the successful outcome of the project. Project coordination
can range from small, department-centered applications to enterprise-
wide electronic health record (EHR) installations, from coordinating a
rehabilitation module in the rehabilitation unit to installing a com-
plete EHR in 42 hospitals.

Of particular note, effective communication is an inherent part of
many NI functions, but especially related to coordination, facilitation,
and integration. The IN and INS are at the hub of cross-disciplinary com-
munication among professional disciplines and IT, serving as translators
and integrators for system requirements and impacts.

In another instance, informatics nurses serve as the liaison between
software engineers and end users. In this capacity, the informatics nurse
ensures that the necessary testing or research is performed to deter-
mine the end user’s needs, and that this information is conveyed to the
software engineers in terms they can understand. Once the engineer has
created a product, the INS evaluates the utility of the product from the
viewpoint of the end user. This liaison type of facilitation and coordina-
tion occurs in multiple environments. Ensuring the integration of nurs-
ing vocabularies and standardized nomenclatures in applications is
another example. In this case INSs also act as usability experts and rec-
ommend ideal formats for the utilization of technology. Examples of
coordination, facilitation, and integration might include:

• The project coordinator for a statewide electronic medical record
implementation coordinates all aspects of the project and super-
vises a cross-disciplinary team to train public health personnel to
use the application.

• The project manager for a clinical software company manages the
resources and activities using tools such as project management

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM23

24 Nursing Informatics: Scope and Standards of Practice

software and project plans for clients whose responsibilities cross
inpatient and ambulatory areas

• The clinical liaison for a telehealth software vendor communicates
with providers and consumers to ensure that all parties are agree-
able to development and implementation plans, and ensures that
providers using the system receive adequate technical education.

• A usability expert on a software development team advises soft-
ware engineers on screen design from the standpoint of clinical
documentation needs, performs or coordinates testing of iterative
designs, and validates clinical requirements with the users.

Development

Development was listed as the second most common responsibility of
HIMSS NI respondents in 2007 (HIMSS, 2007). A developer is responsible
for translating user requirements into effective informatics solutions.
INSs are involved in a vast array of development activities, from concep-
tualizing models for applications, to software and hardware design, to
the design of education manuals, to the design of complex technology
networks. As part of this function, INSs and INs participate in the pro-
cess of design, iterative development, testing, and dissemination of qual-
ity informatics solutions for nurses, interdisciplinary providers, and
consumers. An understanding of the information needs of nurses and
the nursing profession, consumers and consumer care processes, as well
as knowledge of business, client services, projected market directions,
product design, product development methods, market research, con-
temporary programming, systems design, and modeling language are
essential for practicing in a development environment.

Adherence to national standards and regulatory requirements is also
essential to any development work. In order to ensure interoperability
between systems, INSs and INs involved in system development must
be knowledgeable about international standards requirements. Existing
standards include Health Level Seven (HL-7), International Organization
for Standardization (ISO), Current Procedural Terminology (CPT ), Inter-
national Classification of Disease (ICD), and Digital Image Communica-
tion (DICOM) group standards, as well as Section 508 accessibility
standards (Hammond, 1995; GSA, 2006). An understanding of the cur-
rent work on standards is mandatory. Development responsibilities
might include:

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 137

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 23

Coordination, Facilitation, and Integration

One of the most common NI roles is implementing informatics solu-
tions. Nurses are particularly well suited for IT implementation, as it es-
sentially follows the nursing process of assessment, planning,
implementation, and evaluation (ANA, 2004a). Also, the INS frequently
serves as a bridge between informatics solution users and IT experts.
The IN or INS serves as project coordinator, facilitating change man-
agement and integrating the information and technology to transform
processes. In this role, project management knowledge and skills are
essential to the successful outcome of the project. Project coordination
can range from small, department-centered applications to enterprise-
wide electronic health record (EHR) installations, from coordinating a
rehabilitation module in the rehabilitation unit to installing a com-
plete EHR in 42 hospitals.

Of particular note, effective communication is an inherent part of
many NI functions, but especially related to coordination, facilitation,
and integration. The IN and INS are at the hub of cross-disciplinary com-
munication among professional disciplines and IT, serving as translators
and integrators for system requirements and impacts.

In another instance, informatics nurses serve as the liaison between
software engineers and end users. In this capacity, the informatics nurse
ensures that the necessary testing or research is performed to deter-
mine the end user’s needs, and that this information is conveyed to the
software engineers in terms they can understand. Once the engineer has
created a product, the INS evaluates the utility of the product from the
viewpoint of the end user. This liaison type of facilitation and coordina-
tion occurs in multiple environments. Ensuring the integration of nurs-
ing vocabularies and standardized nomenclatures in applications is
another example. In this case INSs also act as usability experts and rec-
ommend ideal formats for the utilization of technology. Examples of
coordination, facilitation, and integration might include:

• The project coordinator for a statewide electronic medical record
implementation coordinates all aspects of the project and super-
vises a cross-disciplinary team to train public health personnel to
use the application.

• The project manager for a clinical software company manages the
resources and activities using tools such as project management

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM23

24 Nursing Informatics: Scope and Standards of Practice

software and project plans for clients whose responsibilities cross
inpatient and ambulatory areas

• The clinical liaison for a telehealth software vendor communicates
with providers and consumers to ensure that all parties are agree-
able to development and implementation plans, and ensures that
providers using the system receive adequate technical education.

• A usability expert on a software development team advises soft-
ware engineers on screen design from the standpoint of clinical
documentation needs, performs or coordinates testing of iterative
designs, and validates clinical requirements with the users.

Development

Development was listed as the second most common responsibility of
HIMSS NI respondents in 2007 (HIMSS, 2007). A developer is responsible
for translating user requirements into effective informatics solutions.
INSs are involved in a vast array of development activities, from concep-
tualizing models for applications, to software and hardware design, to
the design of education manuals, to the design of complex technology
networks. As part of this function, INSs and INs participate in the pro-
cess of design, iterative development, testing, and dissemination of qual-
ity informatics solutions for nurses, interdisciplinary providers, and
consumers. An understanding of the information needs of nurses and
the nursing profession, consumers and consumer care processes, as well
as knowledge of business, client services, projected market directions,
product design, product development methods, market research, con-
temporary programming, systems design, and modeling language are
essential for practicing in a development environment.

Adherence to national standards and regulatory requirements is also
essential to any development work. In order to ensure interoperability
between systems, INSs and INs involved in system development must
be knowledgeable about international standards requirements. Existing
standards include Health Level Seven (HL-7), International Organization
for Standardization (ISO), Current Procedural Terminology (CPT ), Inter-
national Classification of Disease (ICD), and Digital Image Communica-
tion (DICOM) group standards, as well as Section 508 accessibility
standards (Hammond, 1995; GSA, 2006). An understanding of the cur-
rent work on standards is mandatory. Development responsibilities
might include:

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 25

• A developer with a personal health record software vendor creates
user-friendly screens for consumers to enter information as well as
screens for nurses to display and interpret the data.

• A database administrator with a large multi-site teaching organi-
zation manages an expanded nursing vocabulary set for inpatient,
ambulatory, and home health nursing documentation.

• A nurse web content developer for a consortium creates and vali-
dates content for educational handouts, help and tool tips for user
interfaces that display national guidelines, and educational tools.
This would include new and innovative tools for knowledge
dissemination.

• A programmer in a hospital IT department codes software for docu-
menting diabetic education.

Education and Professional Development

Education is a critical component of many NI functions and may directly
affect the success or failure of any new or modified IT solution. Vendors
of information systems frequently use the term training when referring
to client education. In nursing, however, the broader label of education
is used. Adherence to solid educational principles is a component of
education and professional development (ANA, 2000). Teaching nurses
and nursing students, healthcare consumers, and other interdisciplinary
health team members about the effective and ethical uses of informa-
tion technology, as well as NI concepts and theories, is essential for the
optimal use of informatics solutions in nursing practice. Ever-changing
requirements in health information technology make continuing edu-
cation essential as well. INSs and INs in this capacity develop, implement,
and evaluate educational curricula and educational technologies that
meet the needs of students.

In this role, educators and trainers assess and evaluate informatics
skills and competencies while providing feedback to students regard-
ing the effectiveness of the learning activity and the students’ ability to
demonstrate newly acquired skills. Educators and trainers manage,
evaluate, report, and utilize data and information related to students and
the educational delivery system. These INSs are innovators in defining
and developing educational technologies, integrating the solutions into
the educational and practice environments, and challenging organiza-
tions to consider and adopt innovative informatics solutions.

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26 Nursing Informatics: Scope and Standards of Practice

The INS must consider information competency as well as literacy.
Computer literacy is a core competency needed in health care, and
should be taught in nursing curricula at all levels. In addition, informa-
tion literacy must be integrated into practice and used to support
knowledge management. These are the foundations of informatics
competencies.

Education and professional development includes not only INSs, INs,
and end users, but also consumers. With the advent of distance tech-
nologies such as telehealth and Internet-based consumer-accessible
applications, new competencies are needed to ensure that health infor-
mation is displayed to consumers at an appropriate level of under-
standing; support staff may not be available in person. Cultural issues,
language considerations, and literacy of consumers may not be appar-
ent, and materials may need to be more fully assessed for appropriate
presentation and understanding.

INSs may need to ensure presentation of content for web-based
knowledge portals of private and government health organizations that
may exist in multiple locations, or only virtually. Health information may
need to be distilled for consumer consumption. Thus education and
professional development involve not only educating INs and INSs, but
also developing appropriate interfaces for the consumer. Education and
professional development might include:

• A professor of nursing at a major university teaches graduate nurs-
ing students enrolled in a nursing informatics degree program or
teaches nursing students at all levels the basic NI principles and
foundations.

• A clinical preceptor for newly hired nurses and students provides
orientation about telehealth, engages them in using telehealth
technology, and role models the telehealth nurse responsibilities
of monitoring physiologic parameters and providing consumer
education.

• An educator for a vendor travels internationally to train nurses on
the product’s operations, capabilities, troubleshooting, limitations,
and benefits.

• A staff development liaison for a large hospital educates nurses and
other end users about how to integrate clinical applications into
their work processes.

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 139

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 25

• A developer with a personal health record software vendor creates
user-friendly screens for consumers to enter information as well as
screens for nurses to display and interpret the data.

• A database administrator with a large multi-site teaching organi-
zation manages an expanded nursing vocabulary set for inpatient,
ambulatory, and home health nursing documentation.

• A nurse web content developer for a consortium creates and vali-
dates content for educational handouts, help and tool tips for user
interfaces that display national guidelines, and educational tools.
This would include new and innovative tools for knowledge
dissemination.

• A programmer in a hospital IT department codes software for docu-
menting diabetic education.

Education and Professional Development

Education is a critical component of many NI functions and may directly
affect the success or failure of any new or modified IT solution. Vendors
of information systems frequently use the term training when referring
to client education. In nursing, however, the broader label of education
is used. Adherence to solid educational principles is a component of
education and professional development (ANA, 2000). Teaching nurses
and nursing students, healthcare consumers, and other interdisciplinary
health team members about the effective and ethical uses of informa-
tion technology, as well as NI concepts and theories, is essential for the
optimal use of informatics solutions in nursing practice. Ever-changing
requirements in health information technology make continuing edu-
cation essential as well. INSs and INs in this capacity develop, implement,
and evaluate educational curricula and educational technologies that
meet the needs of students.

In this role, educators and trainers assess and evaluate informatics
skills and competencies while providing feedback to students regard-
ing the effectiveness of the learning activity and the students’ ability to
demonstrate newly acquired skills. Educators and trainers manage,
evaluate, report, and utilize data and information related to students and
the educational delivery system. These INSs are innovators in defining
and developing educational technologies, integrating the solutions into
the educational and practice environments, and challenging organiza-
tions to consider and adopt innovative informatics solutions.

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM25

26 Nursing Informatics: Scope and Standards of Practice

The INS must consider information competency as well as literacy.
Computer literacy is a core competency needed in health care, and
should be taught in nursing curricula at all levels. In addition, informa-
tion literacy must be integrated into practice and used to support
knowledge management. These are the foundations of informatics
competencies.

Education and professional development includes not only INSs, INs,
and end users, but also consumers. With the advent of distance tech-
nologies such as telehealth and Internet-based consumer-accessible
applications, new competencies are needed to ensure that health infor-
mation is displayed to consumers at an appropriate level of under-
standing; support staff may not be available in person. Cultural issues,
language considerations, and literacy of consumers may not be appar-
ent, and materials may need to be more fully assessed for appropriate
presentation and understanding.

INSs may need to ensure presentation of content for web-based
knowledge portals of private and government health organizations that
may exist in multiple locations, or only virtually. Health information may
need to be distilled for consumer consumption. Thus education and
professional development involve not only educating INs and INSs, but
also developing appropriate interfaces for the consumer. Education and
professional development might include:

• A professor of nursing at a major university teaches graduate nurs-
ing students enrolled in a nursing informatics degree program or
teaches nursing students at all levels the basic NI principles and
foundations.

• A clinical preceptor for newly hired nurses and students provides
orientation about telehealth, engages them in using telehealth
technology, and role models the telehealth nurse responsibilities
of monitoring physiologic parameters and providing consumer
education.

• An educator for a vendor travels internationally to train nurses on
the product’s operations, capabilities, troubleshooting, limitations,
and benefits.

• A staff development liaison for a large hospital educates nurses and
other end users about how to integrate clinical applications into
their work processes.

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 27

• A help desk team member for a large oncology center works with
users as product upgrades are released, answers clinical user ques-
tions on the phone or in person, and trouble-shoots user problems.

• A patient education coordinator facilitates electronic consumer
health resources.

• A web developer is responsible for development, maintenance, and
presentation of disease content for a hospital web portal.

Policy Development and Advocacy

INSs play a key role in formulation of health policy, particularly bring-
ing expertise in data and information content, data structures, and IT
solutions with those attributes. Policy development may be at any
level—international, national, state, professional specialty, institution or
a work unit. INSs are experts in defining the data needed and the struc-
ture, management, and availability of those data for decision-making. As
such, they advocate for consumers, providers, and the enterprise, and
articulate relevant issues from a nursing perspective. Policy-related ac-
tivities may include developing, writing, implementing, and evaluating
guidance. Regardless of the level or activity, INSs are partners in setting
health policy, particularly related to information management and com-
munication, infrastructure development, and economics.

The advocacy function of the INS or IN also encompasses consumer
health. INs may be part of initiatives such as promoting the adoption of
technology for rural programs to increase access to health services.
Advocacy may include educating legislators about increasing telecom-
munication access, expanding reimbursement for technology-enabled
consumer services, or educating the public on ways to access health-
related materials via the Internet. Examples of policy development and
advocacy function of the INS or IN might include:

• The president of a health information management organization
represents nursing on a national information standards task force.

• A lobbyist participates in advocacy efforts on behalf of consumers
for increased government funding of demonstration or pilot
informatics projects.

• A president of a nursing informatics organization writes letters to
elected officials to obtain their support for reimbursement of ser-
vices by remote, technology-enabled providers.

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28 Nursing Informatics: Scope and Standards of Practice

Research and Evaluation

INSs conduct research into the design, development, and implementa-
tion of informatics solutions, and their impact on users, such as health-
care organizations, providers, consumers, and payers. INS researchers use
systematic methods of inquiry (including traditional and newer tech-
niques) to identify and evaluate data, information, knowledge, and
wisdom in informatics solutions and data repositories. Research and
evaluation functions include, but are not limited to:

• Research in concept or symbolic representation of nursing
phenomena

• Evaluation of clinical decision-making in nursing

• Applied research in development, implementation, usability, and
outcome implications of solutions

• Consumers’ and interdisciplinary providers’ use of health informa-
tion tools and resources

• Evaluation of effective methods for information systems implemen-
tation, acceptance, and utilization

• Human factors or ergonomics research into the design of systems
and their impact on interdisciplinary providers, consumers, nurses,
and their interactions

• Evaluation research on the effects of systems on the processes and
outcomes of consumer care

• Usability testing of nursing and consumer applications

• Evaluating how consumers utilize computerized healthcare products

• Research in clinical vocabularies

• Interaction of consumers, providers, and technology

• Consumer communication and usage of technology-based support
groups

Research in nursing informatics can span a range of activities, from
experimental research to process improvement and informal evaluation
to evidence-based practice. Much of the work is innovative and may be
initiated by INSs or conducted at the request of an organization or
agency. INSs working in research and evaluation might conduct research
projects to develop and refine standardized nursing vocabularies, or link

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 141

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 27

• A help desk team member for a large oncology center works with
users as product upgrades are released, answers clinical user ques-
tions on the phone or in person, and trouble-shoots user problems.

• A patient education coordinator facilitates electronic consumer
health resources.

• A web developer is responsible for development, maintenance, and
presentation of disease content for a hospital web portal.

Policy Development and Advocacy

INSs play a key role in formulation of health policy, particularly bring-
ing expertise in data and information content, data structures, and IT
solutions with those attributes. Policy development may be at any
level—international, national, state, professional specialty, institution or
a work unit. INSs are experts in defining the data needed and the struc-
ture, management, and availability of those data for decision-making. As
such, they advocate for consumers, providers, and the enterprise, and
articulate relevant issues from a nursing perspective. Policy-related ac-
tivities may include developing, writing, implementing, and evaluating
guidance. Regardless of the level or activity, INSs are partners in setting
health policy, particularly related to information management and com-
munication, infrastructure development, and economics.

The advocacy function of the INS or IN also encompasses consumer
health. INs may be part of initiatives such as promoting the adoption of
technology for rural programs to increase access to health services.
Advocacy may include educating legislators about increasing telecom-
munication access, expanding reimbursement for technology-enabled
consumer services, or educating the public on ways to access health-
related materials via the Internet. Examples of policy development and
advocacy function of the INS or IN might include:

• The president of a health information management organization
represents nursing on a national information standards task force.

• A lobbyist participates in advocacy efforts on behalf of consumers
for increased government funding of demonstration or pilot
informatics projects.

• A president of a nursing informatics organization writes letters to
elected officials to obtain their support for reimbursement of ser-
vices by remote, technology-enabled providers.

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28 Nursing Informatics: Scope and Standards of Practice

Research and Evaluation

INSs conduct research into the design, development, and implementa-
tion of informatics solutions, and their impact on users, such as health-
care organizations, providers, consumers, and payers. INS researchers use
systematic methods of inquiry (including traditional and newer tech-
niques) to identify and evaluate data, information, knowledge, and
wisdom in informatics solutions and data repositories. Research and
evaluation functions include, but are not limited to:

• Research in concept or symbolic representation of nursing
phenomena

• Evaluation of clinical decision-making in nursing

• Applied research in development, implementation, usability, and
outcome implications of solutions

• Consumers’ and interdisciplinary providers’ use of health informa-
tion tools and resources

• Evaluation of effective methods for information systems implemen-
tation, acceptance, and utilization

• Human factors or ergonomics research into the design of systems
and their impact on interdisciplinary providers, consumers, nurses,
and their interactions

• Evaluation research on the effects of systems on the processes and
outcomes of consumer care

• Usability testing of nursing and consumer applications

• Evaluating how consumers utilize computerized healthcare products

• Research in clinical vocabularies

• Interaction of consumers, providers, and technology

• Consumer communication and usage of technology-based support
groups

Research in nursing informatics can span a range of activities, from
experimental research to process improvement and informal evaluation
to evidence-based practice. Much of the work is innovative and may be
initiated by INSs or conducted at the request of an organization or
agency. INSs working in research and evaluation might conduct research
projects to develop and refine standardized nursing vocabularies, or link

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 29

nursing interventions to outcomes in large data sets. This work is essen-
tial in defining, describing, and evaluating data, information, knowledge,
and wisdom. It may include the evaluation of organizational attributes
for successful adoption of documentation systems or the impact and
efficacy of hardware and software solutions.

Nursing informatics research may also incorporate a consumer orien-
tation. It may study effective nurse-consumer interactions in web-based
interactions with older consumers, or the impact of new applications on
nurses’ workflow. Patient reactions to instant messaging from providers
may be studied. Examples of the research function of the INS include:

• The chief for nursing research for a large software company over-
sees projects to evaluate the impact of enterprise electronic health
records on patient care outcomes.

• A nursing informatics analyst in a hospital IT department aggre-
gates data about the incidence of decubiti, creates trend reports
and predictive models for nurse managers, and analyzes outcomes
against quality indicators.

• A nurse researcher conducts a usability study comparing consumer
entry of information at a clinic-based kiosk to in-person interviews.

Integrated Functional Areas: Telehealth and Telenursing as Exemplar

Informatics solutions are foundational support for healthcare delivery.
In some cases, however, informatics solutions are more tightly integrated
with care delivery. Clinical care and informatics intersect in areas such
as telehealth and radiation oncology and serve as examples of inte-
grated functional areas. In the discussion below, telehealth serves as the
exemplar.

Telehealth, as defined by the U.S. Office for the Advancement of
Telehealth, is “the use of electronic information and telecommunications
technologies to support long-distance clinical healthcare, patient and
professional health-related education, public health and health admin-
istration” (HRSA, 2001). Telenursing is the use of distance or telecommu-
nications technologies by nurses to monitor consumer and public
health and administrative functions, as well as deliver healthcare edu-
cation (Milholland, 2000; NCSNB, 2003). With the widespread expansion
of telehealth technologies, standards have been developed that take
into account differing countries’ cultures and governance standards

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM29

30 Nursing Informatics: Scope and Standards of Practice

(Milholland-Hunter, 2001). Standards may pertain to the transmission of
data and information as well as protocols for providing care.

Nursing informatics primarily fulfills a clinical support role, as opposed
to a direct clinical practice role. Telehealth is primarily a clinical practice
role, with technical aspects required to deliver care. The 2004 Interna-
tional Telenursing Survey (Grady, Schlachta-Fairchild, & Elfrink, 2005)
surveyed international telenurses worldwide. Of the 719 participants,
only 18 had informatics in their job titles. Within this group, over half
were advanced practice clinicians. Ten of the clinicians had the term
informatics in their titles. Thus, the interface between nursing infor-
matics and telehealth nursing today primarily occurs at the technical or
support level. In the future, telehealth may evolve toward an emphasis
on information (versus technology), and informatics principles, methods,
and tools may expand in the future.

Standards for telehealth nursing clinical practice are outlined in ANA’s
Core Principles on Telehealth (1998) and Competencies for Telehealth Tech-
nologies in Nursing (1999). These describe the interface between tele-
health and informatics, referring to the technical aspects of telehealth
as clinical support and telehealth as clinical practice. Examples of the
telehealth role of the IN or INS might be:

• A telehealth network coordinator for a rural telehealth program en-
sures the appropriate deployment of technology, and customization
for distance-related needs.

• A program manager for telehealth in a home health agency orga-
nizes the integration of telehealth into the agency’s operations,
supports the alignment of telehealth technology with the overall
technology strategy of the agency, leads the adoption and imple-
mentation of the program, and evaluates and maintains telehealth
outcomes and accountability for those outcomes (Starren et al., 2005).

• A nurse researcher conducting a program evaluation compares the
impact of an online, telehealth cardiac education program to that
of an in-person support group on level of depression and adher-
ence to diet.

NI Functional Areas: Conclusions

With the continued miniaturization of technology, as well as develop-
ments in information science and nursing science, NI functions will

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 143

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 29

nursing interventions to outcomes in large data sets. This work is essen-
tial in defining, describing, and evaluating data, information, knowledge,
and wisdom. It may include the evaluation of organizational attributes
for successful adoption of documentation systems or the impact and
efficacy of hardware and software solutions.

Nursing informatics research may also incorporate a consumer orien-
tation. It may study effective nurse-consumer interactions in web-based
interactions with older consumers, or the impact of new applications on
nurses’ workflow. Patient reactions to instant messaging from providers
may be studied. Examples of the research function of the INS include:

• The chief for nursing research for a large software company over-
sees projects to evaluate the impact of enterprise electronic health
records on patient care outcomes.

• A nursing informatics analyst in a hospital IT department aggre-
gates data about the incidence of decubiti, creates trend reports
and predictive models for nurse managers, and analyzes outcomes
against quality indicators.

• A nurse researcher conducts a usability study comparing consumer
entry of information at a clinic-based kiosk to in-person interviews.

Integrated Functional Areas: Telehealth and Telenursing as Exemplar

Informatics solutions are foundational support for healthcare delivery.
In some cases, however, informatics solutions are more tightly integrated
with care delivery. Clinical care and informatics intersect in areas such
as telehealth and radiation oncology and serve as examples of inte-
grated functional areas. In the discussion below, telehealth serves as the
exemplar.

Telehealth, as defined by the U.S. Office for the Advancement of
Telehealth, is “the use of electronic information and telecommunications
technologies to support long-distance clinical healthcare, patient and
professional health-related education, public health and health admin-
istration” (HRSA, 2001). Telenursing is the use of distance or telecommu-
nications technologies by nurses to monitor consumer and public
health and administrative functions, as well as deliver healthcare edu-
cation (Milholland, 2000; NCSNB, 2003). With the widespread expansion
of telehealth technologies, standards have been developed that take
into account differing countries’ cultures and governance standards

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM29

30 Nursing Informatics: Scope and Standards of Practice

(Milholland-Hunter, 2001). Standards may pertain to the transmission of
data and information as well as protocols for providing care.

Nursing informatics primarily fulfills a clinical support role, as opposed
to a direct clinical practice role. Telehealth is primarily a clinical practice
role, with technical aspects required to deliver care. The 2004 Interna-
tional Telenursing Survey (Grady, Schlachta-Fairchild, & Elfrink, 2005)
surveyed international telenurses worldwide. Of the 719 participants,
only 18 had informatics in their job titles. Within this group, over half
were advanced practice clinicians. Ten of the clinicians had the term
informatics in their titles. Thus, the interface between nursing infor-
matics and telehealth nursing today primarily occurs at the technical or
support level. In the future, telehealth may evolve toward an emphasis
on information (versus technology), and informatics principles, methods,
and tools may expand in the future.

Standards for telehealth nursing clinical practice are outlined in ANA’s
Core Principles on Telehealth (1998) and Competencies for Telehealth Tech-
nologies in Nursing (1999). These describe the interface between tele-
health and informatics, referring to the technical aspects of telehealth
as clinical support and telehealth as clinical practice. Examples of the
telehealth role of the IN or INS might be:

• A telehealth network coordinator for a rural telehealth program en-
sures the appropriate deployment of technology, and customization
for distance-related needs.

• A program manager for telehealth in a home health agency orga-
nizes the integration of telehealth into the agency’s operations,
supports the alignment of telehealth technology with the overall
technology strategy of the agency, leads the adoption and imple-
mentation of the program, and evaluates and maintains telehealth
outcomes and accountability for those outcomes (Starren et al., 2005).

• A nurse researcher conducting a program evaluation compares the
impact of an online, telehealth cardiac education program to that
of an in-person support group on level of depression and adher-
ence to diet.

NI Functional Areas: Conclusions

With the continued miniaturization of technology, as well as develop-
ments in information science and nursing science, NI functions will

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 31

continue to expand, evolving into functions not yet envisioned. INSs and
INs will need to continually assess new knowledge management and
technology trends and incorporate them into their own practices. Inte-
grated functional areas will continue to expand. The functional areas
listed here will be combined with new areas to create innovative posi-
tions of the future.

References: Functional Areas

American Medical Informatics Association (AMIA). (2006a). Nursing
Informatics Working Group. Roles in nursing informatics. Retrieved
October 10, 2007 from http://www.amia.org/mbrcenter/wg/ni/roles/
inf_nrs.asp

American Nurses Association (ANA). (1998). Core principles on telehealth.
Washington, DC: American Nurses Publishing.

American Nurses Association (ANA). (1999). Competencies for telehealth
technologies in nursing. Washington, DC: American Nurses Publishing.

American Nurses Association (ANA). (2000). Scope and standards of prac-
tice for nursing professional development. Washington, DC: American
Nurses Publishing.

American Nurses Association (ANA). (2004a). Nursing scope and standards
of practice. Silver Spring, MD: Nursesbooks.org.

American Nurses Association (ANA). (2004b). Scope and standards for
nurse administrators (2nd ed.). Silver Spring, MD: Nursesbooks.org.

Bellinger, G., Castro, D., & Mills, A. (2004). Data, information, knowledge,
and wisdom. Retrieved October 10, 2007 from http://www.systems-
thinking.org/dikw/dikw.htm

Center for Nursing Classification and Clinical Effectiveness (CNCCE).
(2004). Overview of NIC/NOC. Retrieved October 10, 2007 from http://
w w w. n u r s i n g . u i o w a . e d u / e x c e l l e n c e / n u r s i n g _ k n o w l e d g e /
clinical_effectiveness/index.htm

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM31

32 Nursing Informatics: Scope and Standards of Practice

General Services Administration (GSA). (2006). Office of Government-
wide Policy, IT Accessibility & Workforce Division (ITAW). Section 508.
Retrieved October 10, 2007 from http://www.section508.gov.

Fayyad, U. (1996). Data mining and knowledge discovery: Making
sense out of data. IEEE Expert 11(5), 220–225. Retrieved December 13,
2007, from http://www.aaai.org/AITopics/assets/PDF/AIMag17-03-2-
article.pdf.

Grady, J., Schlachta-Fairchild, L. & Elfrink, V. (2005). Results of the 2004
International Telenursing Survey. Telemedicine and e-Health, 11(2), 197.

Greene, J. (2004). RN to CIO: High-tech nurses bridge hospitals’ cultural
divide. Hospitals and Health Networks 78(2):40–46.

Hammond, W.E. (1995). Glossary for healthcare standards. Retrieved
February 28, 2006 from http://dmi-www.mc.duke.edu/dukemi/
acronyms.htm.

Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Retrieved October 10, 2007 from http://aspe.hhs.gov/admnsimp/
pl104191.htm.

Health Resources and Services Administration (HRSA). (2001). Office for
the Advancement of Telehealth. Report to Congress on telemedicine.
Retrieved October 10, 2007 from http://www.hrsa.gov/telehealth/
pubs/report2001.htm.

Healthcare Information and Management Systems Society (HIMSS).
(2007). 2007 HIMSS nursing informatics sur vey. Retrieved October
10, 2007 from http://www.himss.org/content/files/surveyresults/
2007NursingInformatics.pdf.

Milholland, K. (2000). Telenursing, telehealth. Nursing and technology ad-
vance together. Geneva: International Council of Nurses.

Milholland-Hunter, K. (2001). International professional standards for
telenursing programmes. Geneva: International Council of Nurses.

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM32

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 145

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 31

continue to expand, evolving into functions not yet envisioned. INSs and
INs will need to continually assess new knowledge management and
technology trends and incorporate them into their own practices. Inte-
grated functional areas will continue to expand. The functional areas
listed here will be combined with new areas to create innovative posi-
tions of the future.

References: Functional Areas

American Medical Informatics Association (AMIA). (2006a). Nursing
Informatics Working Group. Roles in nursing informatics. Retrieved
October 10, 2007 from http://www.amia.org/mbrcenter/wg/ni/roles/
inf_nrs.asp

American Nurses Association (ANA). (1998). Core principles on telehealth.
Washington, DC: American Nurses Publishing.

American Nurses Association (ANA). (1999). Competencies for telehealth
technologies in nursing. Washington, DC: American Nurses Publishing.

American Nurses Association (ANA). (2000). Scope and standards of prac-
tice for nursing professional development. Washington, DC: American
Nurses Publishing.

American Nurses Association (ANA). (2004a). Nursing scope and standards
of practice. Silver Spring, MD: Nursesbooks.org.

American Nurses Association (ANA). (2004b). Scope and standards for
nurse administrators (2nd ed.). Silver Spring, MD: Nursesbooks.org.

Bellinger, G., Castro, D., & Mills, A. (2004). Data, information, knowledge,
and wisdom. Retrieved October 10, 2007 from http://www.systems-
thinking.org/dikw/dikw.htm

Center for Nursing Classification and Clinical Effectiveness (CNCCE).
(2004). Overview of NIC/NOC. Retrieved October 10, 2007 from http://
w w w. n u r s i n g . u i o w a . e d u / e x c e l l e n c e / n u r s i n g _ k n o w l e d g e /
clinical_effectiveness/index.htm

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM31

32 Nursing Informatics: Scope and Standards of Practice

General Services Administration (GSA). (2006). Office of Government-
wide Policy, IT Accessibility & Workforce Division (ITAW). Section 508.
Retrieved October 10, 2007 from http://www.section508.gov.

Fayyad, U. (1996). Data mining and knowledge discovery: Making
sense out of data. IEEE Expert 11(5), 220–225. Retrieved December 13,
2007, from http://www.aaai.org/AITopics/assets/PDF/AIMag17-03-2-
article.pdf.

Grady, J., Schlachta-Fairchild, L. & Elfrink, V. (2005). Results of the 2004
International Telenursing Survey. Telemedicine and e-Health, 11(2), 197.

Greene, J. (2004). RN to CIO: High-tech nurses bridge hospitals’ cultural
divide. Hospitals and Health Networks 78(2):40–46.

Hammond, W.E. (1995). Glossary for healthcare standards. Retrieved
February 28, 2006 from http://dmi-www.mc.duke.edu/dukemi/
acronyms.htm.

Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Retrieved October 10, 2007 from http://aspe.hhs.gov/admnsimp/
pl104191.htm.

Health Resources and Services Administration (HRSA). (2001). Office for
the Advancement of Telehealth. Report to Congress on telemedicine.
Retrieved October 10, 2007 from http://www.hrsa.gov/telehealth/
pubs/report2001.htm.

Healthcare Information and Management Systems Society (HIMSS).
(2007). 2007 HIMSS nursing informatics sur vey. Retrieved October
10, 2007 from http://www.himss.org/content/files/surveyresults/
2007NursingInformatics.pdf.

Milholland, K. (2000). Telenursing, telehealth. Nursing and technology ad-
vance together. Geneva: International Council of Nurses.

Milholland-Hunter, K. (2001). International professional standards for
telenursing programmes. Geneva: International Council of Nurses.

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 33

National Council of State Boards of Nursing (NCSBN). (2003). Position
paper on telenursing: A challenge to regulation. Retrieved October 10,
2007 from http://www.ncsbn.org/pdfs/TelenursingPaper.pdf

National Library of Medicine (NLM). (2006). Unified Medical Language
System. Retrieved October 10, 2007 from http://www.nlm.nih.gov/
research/umls.

Newbold, S. K. (2006). Nursing informatics database—Job titles as
of January 17, 2006. Electronic correspondence. Email to
[email protected]

Sensmeier, J., West, L., & Horowicz, J.K. (2004). Survey reveals, role,
compensation of nurse informaticists. Computers, Informatics, Nurs-
ing 22(3), 171, 178–181.

Staggers, N, & Lasome, C. F. (2005). RN, CIO: An executive informatics
career. Computer, Informatics, Nursing 23(4), 201–206.

Starren, J., Tsai, C., Bakken, S., Aidala, A., Morin, P., Hilliman, C., et al. (2005).
The role of nurses installing telehealth technology in the home. Com-
puters, Informatics, Nursing, 23(4), 181–189.

Willson, D., Bjornstad, G., Lussier, J., Matney, S., Miller, S., Nelson, N., et al.
(2000). Nursing informatics career opportunities. In B. Carty (ed.),
Nursing informatics: education for practice. New York: Springer.

Informatics Competencies

Because of the increased visibility of information and technology in
healthcare settings and complementary educational programs, many
stakeholders are faced with a need to define informatics competencies
for nurses. Human resource managers and educational planners are just
two examples of stakeholders who have an interest in competencies for
nursing informatics.

Since 2000, researchers and professional organizations have com-
pleted substantial work in defining nursing informatics competencies
(Androwich et al., 2003; Curran, 2003; Desjardins et al., 2003; HIMSS, 2005;

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM33

34 Nursing Informatics: Scope and Standards of Practice

Jiang, Chen, & Chen, 2004; Staggers, Gassert, & Curran, 2000, 2001, 2002).
Several lists of informatics competencies are available, especially those
geared toward nurses’ educational levels.

Stakeholders such as employers and educators are keenly interested
in identifying informatics competencies for various nursing roles. For the
discussion here, competencies for typical nursing informatics roles are
especially pertinent. To this end, a matrix has been developed, based
upon a thorough literature review and the work from a consensus panel.
This text and accompanying matrix ( Table 2) suggests competencies for
typical nursing informatics functional areas discussed in the previous
section.

The Intersection of Informatics Competencies and NI Functional Areas

Staggers, Gassert, and Curran (2000, 2001, 2002) studied the relation-
ships between nursing roles and informatics competencies for nurses
at four levels of practice: beginning, experienced, INS, and informatics
innovator. This framework aligns with educational requirements for all
nursing specialties at the beginning and experienced levels, and then
identifies specific competencies for the specialty roles of INS and the
informatics innovator. Their work not only promoted the integration of
informatics competencies into educational curricula, but also influenced
policy documents.

To date, the majority of authors have focused on the competencies
needed for nursing curricula. Curran (2003) identified informatics com-
petencies for nurse practitioners at Columbia University School of Nurs-
ing. Desjardins, Cook, Jenkins, and Bakken (2005) focused on beginning
nurse competencies, expanding them to include the knowledge and
skills for information literacy to support evidenced-based practice. Like
Staggers et al. (2002), this study also linked competencies to four levels
of nursing practice. Barton (2005) presented a similar view of informatics
competencies for the beginning nurse, identifying a need for competen-
cies in technology or computer literacy as well as information literacy
for undergraduate nursing programs.

McNeil, Elfrink, Pierce, Beyea, Bickford, and Averill (2005) examined
educational content for required informatics competencies. They asked
the deans and directors of 672 baccalaureate and above education pro-
grams to describe informatics content taught in their undergraduate
and graduate programs. Twenty-five unique content areas were identi-

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 147

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 33

National Council of State Boards of Nursing (NCSBN). (2003). Position
paper on telenursing: A challenge to regulation. Retrieved October 10,
2007 from http://www.ncsbn.org/pdfs/TelenursingPaper.pdf

National Library of Medicine (NLM). (2006). Unified Medical Language
System. Retrieved October 10, 2007 from http://www.nlm.nih.gov/
research/umls.

Newbold, S. K. (2006). Nursing informatics database—Job titles as
of January 17, 2006. Electronic correspondence. Email to
[email protected]

Sensmeier, J., West, L., & Horowicz, J.K. (2004). Survey reveals, role,
compensation of nurse informaticists. Computers, Informatics, Nurs-
ing 22(3), 171, 178–181.

Staggers, N, & Lasome, C. F. (2005). RN, CIO: An executive informatics
career. Computer, Informatics, Nursing 23(4), 201–206.

Starren, J., Tsai, C., Bakken, S., Aidala, A., Morin, P., Hilliman, C., et al. (2005).
The role of nurses installing telehealth technology in the home. Com-
puters, Informatics, Nursing, 23(4), 181–189.

Willson, D., Bjornstad, G., Lussier, J., Matney, S., Miller, S., Nelson, N., et al.
(2000). Nursing informatics career opportunities. In B. Carty (ed.),
Nursing informatics: education for practice. New York: Springer.

Informatics Competencies

Because of the increased visibility of information and technology in
healthcare settings and complementary educational programs, many
stakeholders are faced with a need to define informatics competencies
for nurses. Human resource managers and educational planners are just
two examples of stakeholders who have an interest in competencies for
nursing informatics.

Since 2000, researchers and professional organizations have com-
pleted substantial work in defining nursing informatics competencies
(Androwich et al., 2003; Curran, 2003; Desjardins et al., 2003; HIMSS, 2005;

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM33

34 Nursing Informatics: Scope and Standards of Practice

Jiang, Chen, & Chen, 2004; Staggers, Gassert, & Curran, 2000, 2001, 2002).
Several lists of informatics competencies are available, especially those
geared toward nurses’ educational levels.

Stakeholders such as employers and educators are keenly interested
in identifying informatics competencies for various nursing roles. For the
discussion here, competencies for typical nursing informatics roles are
especially pertinent. To this end, a matrix has been developed, based
upon a thorough literature review and the work from a consensus panel.
This text and accompanying matrix ( Table 2) suggests competencies for
typical nursing informatics functional areas discussed in the previous
section.

The Intersection of Informatics Competencies and NI Functional Areas

Staggers, Gassert, and Curran (2000, 2001, 2002) studied the relation-
ships between nursing roles and informatics competencies for nurses
at four levels of practice: beginning, experienced, INS, and informatics
innovator. This framework aligns with educational requirements for all
nursing specialties at the beginning and experienced levels, and then
identifies specific competencies for the specialty roles of INS and the
informatics innovator. Their work not only promoted the integration of
informatics competencies into educational curricula, but also influenced
policy documents.

To date, the majority of authors have focused on the competencies
needed for nursing curricula. Curran (2003) identified informatics com-
petencies for nurse practitioners at Columbia University School of Nurs-
ing. Desjardins, Cook, Jenkins, and Bakken (2005) focused on beginning
nurse competencies, expanding them to include the knowledge and
skills for information literacy to support evidenced-based practice. Like
Staggers et al. (2002), this study also linked competencies to four levels
of nursing practice. Barton (2005) presented a similar view of informatics
competencies for the beginning nurse, identifying a need for competen-
cies in technology or computer literacy as well as information literacy
for undergraduate nursing programs.

McNeil, Elfrink, Pierce, Beyea, Bickford, and Averill (2005) examined
educational content for required informatics competencies. They asked
the deans and directors of 672 baccalaureate and above education pro-
grams to describe informatics content taught in their undergraduate
and graduate programs. Twenty-five unique content areas were identi-

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 35

fied for undergraduate (i.e., beginning nurse) and graduate (i.e., experi-
enced nurse) levels of practice. Among the top-ranked competencies for
both programs were: a) accessing electronic resources, b) ethical use of
information systems, c) evidence-based practice skills, and d) skills for
computer-based patient records. The undergraduate program respon-
dents more often identified basic hardware and software skills, whereas
the graduate program respondents included competencies related to
innovation and change theory, national health database knowledge, and
general systems theory.

Jiang, Chen, and Chen (2004) surveyed Taiwanese nursing education
programs ranging from non-vocational and vocational nursing pro-
grams to collegiate programs for two-, four-, five-year, and graduate-level
programs. The authors identified seven domains of competencies and
linked them to differing levels of nursing education in Taiwan. In con-
trast to work in the United States, they identified domains mostly related
to computer versus information literacy, including hardware, software,
and network concepts; principles of computer application; skills in com-
puter usage; program design; limitations of the computer; personal and
social issues; and attitudes toward the computer.

New categories and concomitant competencies for education, as
well as practice, are also available. Androwich et al. (2003) described
NI competencies needed to improve patient safety and expand nurs-
ing practice. Garde, Harrison, and Hovenga (2005) reported specific
competencies for:

• Nursing informatics knowledge and skills (e.g., health information
systems, electronic patient records, telehealth).

• Information technology knowledge and skills (e.g., programming
principles, software development, methodologies and processes,
system analysis and design, database design and management).

• Knowledge and skills in organizational and human behavior (e.g.,
project management, inter-professional communication, risk man-
agement, policies and procedures).

• Clinical and health-related knowledge and skills (e.g., evidence
based practice, clinical guidelines, care pathways).

The Healthcare Leadership Alliance (HLA) announced the creation of
the HLA Competency Directory in the fall of 2005. This directory (HLA,

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM35

36 Nursing Informatics: Scope and Standards of Practice

2005) identifies 300 competencies across multiple healthcare manage-
ment roles, categorized into five domains:

• Leadership

• Communications and relationship management

• Professionalism

• Business knowledge and skills

• Knowledge of the healthcare environment

This directory may be especially pertinent for interdisciplinary settings.

A New Competencies Matrix

The competencies matrix in Table 2 (on page 38 and 39) is derived from
Staggers, Gassert, and Curran (2002) and other authors mentioned
earlier, and from the ANCC NI Certification exam (ANCC, 2007). These
competencies are categorized in three overall areas: Computer Literacy,
Information Literacy, and Professional Development/Leadership. Com-
puter literacy competencies relate to the psychomotor use of comput-
ers and other technological equipment (Barton, 2005). Information
literacy competencies deal with information retrieval knowledge and
skills: knowing when there is a need for information; identifying the in-
formation needed to address a given problem or issue; finding the
needed information and evaluating it; organizing the information; and
using the information effectively to address the problem or issue. (ALA,
2006). Professional development and leadership competencies refer to
the ethical, procedural, safety, and management issues for informatics
solutions in nursing practice, education, research, and administration.

The horizontal axis of the matrix is based on the four educational lev-
els as well as the NI functional areas defined earlier. It is important to
recognize that informatics competencies need to be integrated into all
educational levels. The panel identified competency foci for each func-
tional area indicated by an X. Competencies cross the different nursing
informatics functional areas. Although each sub-heading includes more
granular competencies beneath it, nurses would not necessarily be ex-
pected to achieve every competency within a sub-heading. The areas
identified by the X merely indicate an area of emphasis.

The absence of an X does not mean that the skill is completely irrel-
evant to that role; rather it means that the skill may not be emphasized

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Nursing Informatics: Scope and Standards of Practice, 2nd Edition 149

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 35

fied for undergraduate (i.e., beginning nurse) and graduate (i.e., experi-
enced nurse) levels of practice. Among the top-ranked competencies for
both programs were: a) accessing electronic resources, b) ethical use of
information systems, c) evidence-based practice skills, and d) skills for
computer-based patient records. The undergraduate program respon-
dents more often identified basic hardware and software skills, whereas
the graduate program respondents included competencies related to
innovation and change theory, national health database knowledge, and
general systems theory.

Jiang, Chen, and Chen (2004) surveyed Taiwanese nursing education
programs ranging from non-vocational and vocational nursing pro-
grams to collegiate programs for two-, four-, five-year, and graduate-level
programs. The authors identified seven domains of competencies and
linked them to differing levels of nursing education in Taiwan. In con-
trast to work in the United States, they identified domains mostly related
to computer versus information literacy, including hardware, software,
and network concepts; principles of computer application; skills in com-
puter usage; program design; limitations of the computer; personal and
social issues; and attitudes toward the computer.

New categories and concomitant competencies for education, as
well as practice, are also available. Androwich et al. (2003) described
NI competencies needed to improve patient safety and expand nurs-
ing practice. Garde, Harrison, and Hovenga (2005) reported specific
competencies for:

• Nursing informatics knowledge and skills (e.g., health information
systems, electronic patient records, telehealth).

• Information technology knowledge and skills (e.g., programming
principles, software development, methodologies and processes,
system analysis and design, database design and management).

• Knowledge and skills in organizational and human behavior (e.g.,
project management, inter-professional communication, risk man-
agement, policies and procedures).

• Clinical and health-related knowledge and skills (e.g., evidence
based practice, clinical guidelines, care pathways).

The Healthcare Leadership Alliance (HLA) announced the creation of
the HLA Competency Directory in the fall of 2005. This directory (HLA,

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM35

36 Nursing Informatics: Scope and Standards of Practice

2005) identifies 300 competencies across multiple healthcare manage-
ment roles, categorized into five domains:

• Leadership

• Communications and relationship management

• Professionalism

• Business knowledge and skills

• Knowledge of the healthcare environment

This directory may be especially pertinent for interdisciplinary settings.

A New Competencies Matrix

The competencies matrix in Table 2 (on page 38 and 39) is derived from
Staggers, Gassert, and Curran (2002) and other authors mentioned
earlier, and from the ANCC NI Certification exam (ANCC, 2007). These
competencies are categorized in three overall areas: Computer Literacy,
Information Literacy, and Professional Development/Leadership. Com-
puter literacy competencies relate to the psychomotor use of comput-
ers and other technological equipment (Barton, 2005). Information
literacy competencies deal with information retrieval knowledge and
skills: knowing when there is a need for information; identifying the in-
formation needed to address a given problem or issue; finding the
needed information and evaluating it; organizing the information; and
using the information effectively to address the problem or issue. (ALA,
2006). Professional development and leadership competencies refer to
the ethical, procedural, safety, and management issues for informatics
solutions in nursing practice, education, research, and administration.

The horizontal axis of the matrix is based on the four educational lev-
els as well as the NI functional areas defined earlier. It is important to
recognize that informatics competencies need to be integrated into all
educational levels. The panel identified competency foci for each func-
tional area indicated by an X. Competencies cross the different nursing
informatics functional areas. Although each sub-heading includes more
granular competencies beneath it, nurses would not necessarily be ex-
pected to achieve every competency within a sub-heading. The areas
identified by the X merely indicate an area of emphasis.

The absence of an X does not mean that the skill is completely irrel-
evant to that role; rather it means that the skill may not be emphasized

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM36

Nursing Informatics.indd 149 11/6/14 4:06 PM

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

Appendix B. nursing informAtics: scope & stAndArds of prActice (2008)

The content in this appendix is not current and is of historical significance only.

Nursing Informatics: Scope of Practice 37

in a particular functional area or NI role. Nor is someone in a given role
required to have every skill indicated. For example, a quality improve-
ment (QI) specialist is an NI role that would stress the Analysis functional
area. An Informatics Nurse Specialist working in a quality improvement
area would require competency in many of the indicated computer lit-
eracy skills including administration, communication, desktop, systems,
and quality improvement, but would not likely need the simulation skills
identified in the matrix. However, a quality assurance specialist, listed in
the same functional area, would need knowledge and skills about simu-
lations, especially if the NI in this role worked in an institution using
simulation for staff development or for a vendor using this product.

The Functional Area-Competency Framework provides an example of
the nursing informatics competencies for different functional areas
within NI roles. Telehealth, which may be seen as more of an integrative
area rather than a stand-alone functional role, is included to reflect in-
tersections with various competencies. The list is not exhaustive, but
presents beginning guidance to the essential NI competencies across
computer literacy, information literacy, and professional development
skills and knowledge. Currently the competencies are at different lev-
els. In the future they may be re-evaluated, expanded, or collapsed.

Competencies and Metastructures

The components of metastructures—data, information, knowledge, and
wisdom—can be compared to the elements in the competencies ma-
trix. Using a patient care example, the beginning nurse uses skills that
rely on the ability to obtain data. Computer skills, data entry, and the use
of the patient’s electronic medical record are the major focus of their
practice. The experienced nurse builds on this and applies basic com-
puter skills to information.

The INS has expertise in nursing, as well as higher levels of computer
literacy, information literacy, and professional development and leader-
ship. This increased level represents knowledge in nursing informatics. The
INS analyzes systems and processes in order to apply knowledge to
patient care, administration, research, or education. Last, the informatics
innovator has achieved a level of knowledge coupled with experience,
a combination that exemplifies wisdom. Wisdom in informatics may be
the creation of unique methods for system design or evaluation, or the
political finesse to justify purchase of a system.

Informatics Nursing_Pgs_1-204.PMD 1/10/2008, 8:59 AM37

38 Nursing Informatics: Scope and Standards of Practice

(continues)

ycaretiLretupmoC

noitartsinimdA—sllikSretupmoC × × × × × × × ×

noitacinummoC—sllikSretupmoC × × × × × × ×

sseccAataD—sllikSretupmoC × ×

noitatnemucoD—sllikSretupmoC × × × × ×

noitacudE—sllikSretupmoC × × × ×

gnirotinoM—sllikSretupmoC × × × × × × × ×

erawtfoSpotkseDcisaB—sllikSretupmoC × × × × × × × × × ×

smetsyS—sllikSretupmoC × × × × × × × × ×

tnemevorpmIytilauQ—sllikSretupmoC × × × × × × ×

hcraeseR—sllikSretupmoC × × × × × × ×

tnemeganaMtcejorP—sllikSretupmoC × × × × × ×

noitalumiS—sllikSretupmoC × × × × × × × × × ×

ycaretiLnoitamrofnI

noitaulavE—sllikSscitamrofnI × × × × × × × × × × × ×

eloR—sllikSscitamrofnI × × × × × × × × ×

ecnanetniaMmetsyS—sllikSscitamrofnI × × × × × × × × × ×

sisylanA—sllikSscitamrofnI × × × × × × × × × × ×

erutcurtSataD/ataD—sllikSscitamrofnI × × × × × × × × × × ×

tnempoleveD&ngiseD—sllikSscitamrofnI × × × × × × × × × × × ×

tnemeganaMlacsiF—sllikSscitamrofnI × × × × × × × × × × ×

noitatnemelpmI—sllikSscitamrofnI × × × × × × × × ×

tnemeganaM—sllikSscitamrofnI × × × × × × × × × ×

gnimmargorP—sllikSscitamrofnI × × × × ×

stnemeriuqeR—sllikSscitamrofnI × × × × × × × × × × ×

Table 2. Informatics Competencies by NI Functional Areas

Competency Categories Knowledge and Skills Be
gi

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e

Ex
pe