Standardized structures and terminologies available through electronic health records data sets are enabling the capture of patient outcome data... In today’s information-intensive healthcare industry, information and communication technology (ICT) and informatics are integral for any system to meet the needs of patients and providers and improve the quality and safety of the clinical environment (Canadian Nurses Association, 2006a; Canadian Nurses Association, 2006b; Poe, Abbott, & Pronovost, 2011). ICT and informatics applications, such as electronic health records, order-entry, electronic medication administration, and computerized documentation systems, facilitate timely access to accurate and reliable patient information. These types of evidence-informed resources are essential for clinical decision making at the point of care (Canadian Nurses Association, 2001; Canadian Nurses Association, 2006b). Standardized structures and terminologies available through electronic health records data sets are enabling the capture of patient outcome data such as length of stay and adverse events, both important quality indicators for evaluating the impact of care (Kleib, Sales, Doran, Mallette, & White, 2011).

Evidence-based outcomes shape policy and practice directions to support nursing practice and knowledge development. As the largest group of healthcare providers, nurses contribute to the health and well-being of people, communities, and populations. Nurse interactions with ICT can facilitate many opportunities for improvement in nursing practice, and can also impact the quality and safety of patient care (Canadian Nurses Association, 2006b; College and Association of Registered Nurses of Alberta [CARNA], 2009). For example, identifying patient outcomes relevant to nursing practice and measuring the effectiveness of nursing interventions in relation to improvements in these outcomes provides decision makers with an evidence-informed evaluation of the value of nurse contributions to healthcare. Evidence-based outcomes shape policy and practice directions to support nursing practice and knowledge development (Doran, 2011). Nurses, therefore, should “advocate for and lead efforts toward the collection, storage, retrieval and use of nursing data to generate information on nursing outcomes,” – a goal which can be realized by embracing and utilizing ICT effectively, as opposed to considering it as an add-on to current workload (Canadian Nurses Association, 2006b, p1). 

... the benefits of ICTs as tools to improve quality, safety, and effectiveness of clinical care must balance with its potential for patient harm, either directly or by inaccurate measurement of targeted outcomes. While ICTs promise a number of benefits to healthcare providers and users, they are not without risk (Coiera, Aarts, & Kulikowski, 2012; Poe et al., 2011). Usability issues related to human-computer interactions could pose significant risks to patient safety such as “juxtaposition errors,” which occur when the desired result is in close proximate to another option on the screen and the wrong option is selected (Ash, Berg, & Coiera, 2003). When clinical decision supports within ICT are made available to clinicians, the types and level of alerts may lead clinicians to override alerts that may be critical to providing safe patient care (Nanji et al., 2013). Another recognized area of potential error that impacts almost all patients is medication management using ICT applications. One issue pertains to inaccuracy of electronically transmitted medication history information used for medication reconciliation. Data may be missing special characters such as decimals; a drug dosage of 2.5mg might read 25mg. Healthcare providers that do not double-check the automated reports or assume that the system is accurate could potentially make serious drug errors (Institute for Safe Medication Practice, 2014). Thus the benefits of ICTs as tools to improve quality, safety, and effectiveness of clinical care must balance with its potential for patient harm, either directly or by inaccurate measurement of targeted outcomes. This paradox requires diligence to mitigate harm via user education and informatics competency development (Canadian Nurses Association, 2006b; Coiera et al., 2012; Darvish, Bahramnezhad, Keyhanian, & Navidhamidi, 2014).

Developing informatics competencies enables clinicians to comprehensively understand the value of ICT and its potential impact on patient safety and other important patient and organizational outcomes... The Institute of Medicine (2001) has identified five core competencies required by all healthcare professionals. Utilizing informatics is among them and is often viewed as essential to accomplish the remaining four competencies (providing patient-centered care, applying quality improvement, working in interdisciplinary teams, and employing evidence-based practice) (Dreher & Fitzgerald Miller, 2006; Remus & Kennedy, 2012). Developing informatics competencies enables clinicians to comprehensively understand the value of ICT and its potential impact on patient safety and other important patient and organizational outcomes, as opposed to simply mastering procedural skills to operate technology (Nagle, 2013).

In this article, we first briefly describe progress in NI and then share a project exemplar that describes our experience in the design, implementation, and evaluation of a NI educational event. We developed a one-day boot camp format that was used to provide foundational knowledge in NI targeted primarily at frontline nurses in Alberta, Canada. Our goal was to provide this foundational knowledge to support use of NI to the fullest extent possible, thus benefiting from its ability to enhance safety and quality at the patient care level and measure important outcomes organizational levels. We will also discuss the project outcomes, including lessons learned and future implications.

Progress in Nursing Informatics

General Overview

The profession of nursing was among the first health disciplines to embrace informatics through the recognition of nursing informatics (NI) as a specialty practice area (Bickford, 2015). NI is the "science and practice (that) integrates nursing, its information and knowledge, with management of information and communication technologies to promote the health of people, families, and communities worldwide" (International Medical Informatics Association, 2009, para. 2). In a little over two decades, NI has evolved into an expanding body of knowledge, affirming its relevance and applicability to all domains of nursing (e.g., education, research, practice, administration). The evolution of NI is evident in the establishment of university-level NI education programs, and informatics dedicated professional organizations, standards and scope of practice, and certification (Anderson & Sensmeier, 2014; Bickford, 2015; HIMSS Nursing Informatics Awareness Task Force, 2007; Newbold, 2003).

...organizations employing nursing informatics professionals in executive leadership roles for a long period of time reported better clinical system processes and better overall quality of care for patients. Opportunities for continuing education in NI (e.g., workshops, webinars, boot camps, NI institutes) are also available to meet professional development needs of nurses in a variety of practice settings. Defining NI competencies for nurses at generalist and advanced levels of practice (Staggers, Gassert, & Curran, 2002) and the development of initiatives such as the Quality and Safety Education for Nurses (QSEN) (Barton & Skiba, 2009) and the Technology Informatics Guiding Education Reform (TIGER) in the United States (Schlak & Troseth, 2013) has facilitated and promoted NI in practice and academia. The impact and value of nurses with advanced level of NI education is also becoming more evident. A recent survey demonstrated that organizations employing nursing informatics professionals in executive leadership roles for a long period of time reported better clinical system processes and better overall quality of care for patients. Results also showed that nursing informatics professionals have a direct impact on the quality of patient care, workflow, patient safety, and user acceptance of clinical systems (Healthcare Information and Management Systems Society, 2015).

Informatics in Canada

In Canada, early attempts to identify NI competencies for Canadian nurses were brought forward by Hebert (2000) who proposed that Canadian nurses should have both skills and knowledge in NI. Hebert suggested that nurses should be able to “use information and communication, interpret and organize data, and combine information to contribute to knowledge development in nursing” (2000, p.3). To promote readiness among nurses, the E-Nursing Strategy for Canada recommended that nurses should have opportunities to support competency development for ICT use; have access to ICT to support evidence-based care; and be actively involved in the selection, design, deployment, and evaluation of ICT (Canadian Nurses Association, 2006a).

In 2012, the Canadian Association of Schools of Nursing (CASN) identified a list of NI competencies that all registered nurses should possess upon entry-to-practice (CASN, 2012). The primary intent of defining these competencies was to provide direction for curriculum development. The Canadian competency framework provides an overarching competency and three entry-to-practice NI competencies under three domains: Information and Knowledge Management, Use of ICT, and Professional and Regulatory Accountability. Each domain has a set of indicators to help acquire needed learning to develop competencies. Foundational ICT skills include device use (e.g., personal computers) and application use (e.g., electronic communication). These are basic skills that students typically have or could easily develop upon entry to a university program (CASN, 2012).

The Canadian model is unique in providing a concise list that addresses key knowledge, skills and attitudes related to using technology in the context of patient care and in highlighting and mapping regulatory and accountability responsibilities to nurses’ scope of practice and code of ethics. In addition, CASN, in collaboration with Canada Health Infoway, also published the CASN/Infoway Nursing Informatics Teaching Toolkit: Supporting the Integration of Nursing Informatics Competencies into Nursing Curricula resource for nurse educators (CASN, 2013) to facilitate integrating informatics in undergraduate nursing education. More recently, CASN and Infoway launched the Digital Health Nursing Faculty Peer Leader Network, a project currently underway to support nursing faculty in integrating consumer health informatics and digital health in nursing curricula. Similar initiatives are much needed to support nurses in practice settings as they are at the forefront of using patient care technology.

While most nurses do recognize the benefits and potential of ICT and health informatics applications to improve the quality of health information and healthcare delivery, many continue to find it difficult to identify the relevance of NI and its application in their individual practice settings (Canadian Nurses Association, 2001; Canadian Nurses Association & Canada Health Infoway, 2014; Nagle, 2013). Practicing nurses belong to different generational groups that have had varying exposure to informatics education and sometimes limited opportunities to utilize ICT in their personal and professional lives (Bell, 2013). In one study of factors associated with computer literacy among nurses, the authors found that computer experience of nurses and personal innovation in information technology were associated with computer literacy and computer anxiety (Hsu, Hsiao, Huang, & Lin, 2006). In another study, basic computer skills and formal informatics education were identified as factors associated with nurses’ informatics competency development (Hwang & Park, 2011). Among nurse managers, Yang et al. (2014) found that level of education, nursing administration experience, and informatics training/education were significant factors affecting competency levels.

Nurses were likely to be more satisfied when they felt they were involved... In a national survey (n=992) of Canadian nurses’ use of digital health technologies in practice, results showed that less than three in four nurses used a combination of paper and electronic records; however variations existed per clinical practice setting (Canadian Nurses Association & Canada Health Infoway, 2014). The main uses of electronic systems included entering and retrieving clinical patient notes; ordering of lab tests; and listing of medications. Nurses reported varying degrees of satisfaction with electronic systems in relation to a number of factors. Nurses were likely to be more satisfied when they felt they were involved; had received adequate training to use the system and the flexibility to use it in a variety of ways; and if the system improved productivity and quality of patient care. One in three nurses believed that they had received adequate training, and a few agreed that they were consulted regarding system implementation (Canadian Nurses Association & Canada Health Infoway, 2014).

As healthcare continues to further use ICTs, assisting nurses develop desired levels of informatics competencies and identifying mechanisms to engage them in the planning, implementation, and evaluation of health technologies is paramount for successful transitions to digital applications. However, preparing a work force with the necessary knowledge, skills, and attitudes in informatics to be able to work in technologically-enabled work environments is not an easy undertaking. Rather, it is a complex process that requires collaboration among multiple stakeholders, including service providers, academia, professional and regulatory bodies, and nurses themselves (Canadian Nurses Association, 2006b; Charlebois & Allen, 2013; CARNA, 2009; Fetter, 2009; Nagle & Clarke, 2004). In the next section, we describe a project recently designed and implemented to support the development of informatics competencies for nurses in Alberta, Canada.

Project Exemplar: The Inaugural Alberta Nursing Informatics Boot Camp

The province of Alberta has over 35,000 registered nurses that are highly regarded for their competent professional practice. Over 26,000 of these are employed by Alberta Health Services (AHS), representing over half of the clinical work force in AHS (Alberta Health Services, 2015). Recently, AHS invested in a number of ICT systems, such as NetCare—an electronic health record, and e-CLINICIAN—an electronic medical record, to enhance the provision of a patient-centric care. One positive outcome of this transition will be to collect appropriate electronic data to track outcomes for planning at the individual patient and organizational levels.

To achieve the benefits of informatics systems, it is critical that the largest provider group both supports the application of such systems and demonstrates competency in their use. As the largest group of healthcare professionals in Alberta affected by these transformations, identifying mechanisms to support nurses’ informatics educational needs became a priority. To achieve the benefits of informatics systems, it is critical that the largest provider group both supports the application of such systems and demonstrates competency in their use. In this section, we share our experience in the planning, implementation, and evaluation of a nursing informatics educational day, the inaugural, Alberta Nursing Informatics Boot Camp: Advancing Nursing Practice through Informatics, hosted and coordinated by MacEwan University, Centre for Professional Nursing Education (CPNE) and supported by Alberta Health Services. In concluding, we offer some recommendations for practice leaders, policy makers, educators, and researchers regarding supporting informatics competency development in nursing.

Identifying Key NI Educational Needs and Target Audience

NI is an emerging specialty area with applications in all practice settings; its use continues to present challenges for nurses, professional regulatory bodies, nursing education institutions, and healthcare organizations. Although CASN defined entry-to-practice NI competencies for Registered Nurses in 2012, to date there is limited evidence to inform the status of NI competencies and educational needs among nurses in Canada, and specifically Alberta (Canadian Nurses Association & Canada Health Infoway, 2014; Nagle & Clarke, 2004). There are no national mandates to enforce adoption of NI competencies in nursing education and practice. A professional role responsibility of nurses is to identify gaps in NI competencies and seek appropriate professional development opportunities (CARNA, 2009).

The Nursing Informatics Association of Alberta (NIAA) is a specialty practice group founded in 2013 to engage Alberta nurses in learning about the role of informatics in nursing practice and create educational opportunities to support NI competency development (Canadian Nurses Association, 2006b; Kleib, Shaben, Zimka, & Kwan, 2013). NIAA provides a forum for professional dialogue about important issues in NI and opportunities for networking and continuing education through scheduled bi-monthly, one-hour educational sessions on various NI topics. Although valuable, these educational opportunities are limited to members of NIAA. The MacEwan University CPNE has identified informatics education as a priority area. The goal was thus to provide comprehensive, clinically relevant, easily-accessible educational opportunities for NI to meet the educational needs of frontline nurses in Alberta, our target audience, who may not be aware of NIAA or the CASN NI competencies.

Defining Desired Outcomes, Content, and Educational Activities

A one-day continuing education event offered focused learning about concepts of health and nursing informatics and their potential to improve healthcare delivery and patient outcomes across the continuum of care. The purpose of this boot camp was to engage Alberta nurses in thinking about the role of health information technology. A one-day continuing education event offered focused learning about concepts of health and nursing informatics and their potential to improve healthcare delivery and patient outcomes across the continuum of care. Because this was the first educational event in Alberta of this kind, our goal was to focus on foundational knowledge to meet the needs of most frontline nurses, regardless of their previous knowledge in informatics. Providing introductory information allowed nurses to explore and review their competency levels and identify future directions.

The boot camp format offered short, intensive educational sessions. The program consisted of a keynote address and four sessions. Session topics included:

• an overview of informatics in healthcare, including a discussion of its relevance to nurses’ work and CASN competencies and resources for developing these competencies;
• computer and information literacy applications in healthcare;
• common information systems used in healthcare, with an emphasis on computerized documentation tools and their benefits in capturing nurses’ contributions to patient care; and
• a knowledge application session.

Educational activities were targeted to adult learners using various learning styles (e.g., structured presentation sessions with opportunities for questions/answer, interactive case study discussions, hands-on demonstration sessions). There were opportunities for event sponsorship at four levels and the incentive of free attendance for individuals manning stations.

Registration and Event Marketing

Four months prior to the event date, we announced the boot camp program via a poster advertisement. Two months prior, the Web Services team at MacEwan University (part of the Information Technology Department) set up the boot camp webpage on the university website. The webpage included: a program description; sessions; speaker biographies; registration procedures; venue layout and maps; accommodations; sponsorship opportunities; and contact information for program organizers and coordinators. Other marketing strategies included word of mouth; directly emailing the poster to nurses in our networks and educational institutions; advertising on CARNA’s event webpage and on social media platforms. Registration fees (early bird and late) were posted on the boot camp webpage with options for online, in person, phone, and fax registration. We tracked registration rates weekly and sent reminder invites accordingly.

Planning Budget Requirements

The MacEwan University CPNE has a history of coordinating, planning, and hosting continuing education events designed to meet the current practice needs of nurses in Alberta. Nurses who have previously attended events have requested: a central location; offered within regular working hours to allow them to organize travel; and cost low enough for self-pay but high enough to qualify for employer reimbursement. Taking those factors into consideration, and reviewing historical data from previous one-day long educational events held by the CPNE, we estimated an attendance of 75 nurses. To keep the event accessible to all nurses, our overarching budget goal was to keep registration fees to a minimum, with cost recovery only. Utilizing the expertise of local speakers helped to limit costs to operational items (e.g., food, materials, general overhead). This local perspective also allowed nurses to recognize resources within their own health region and academic centers.

Boot Camp Implementation and Analysis

Boot camp took place on May 1, 2015. The central location of MacEwan University in Edmonton facilitated accessibility. Distinguished informatics experts from AHS and academic institutions in Alberta presented on the first three sessions according to their areas of expertise. Speakers provided a session overview along with more specific learning outcomes (available to attendees on the boot camp webpage and in the conference delegate package). The fourth session reinforced learning and application of knowledge via interactive case studies and hands-on demonstration. Case study topics included: personal health records, smart pump technology, telehealth, and computerized documentation in electronic health records.

Two organizations participated in the event: (1) Wolters Kluwer Health provided a demo of electronic health records and nursing documentation, and (2) CARNA in collaboration with NIAA provided posters and flyers to increase awareness about professional associations supportive of NI in Alberta. In addition, AHS provided stations showcasing examples of CIS currently used in practice settings. These opportunities promoted networking and increased learning through better understanding of existing informatics initiatives in various clinical sites. At the end of the boot camp, attendees completed a learning-needs survey for future events and a boot camp topic-based evaluation survey about the CASN NI competency expectations. We used descriptive statistics and thematic analysis of open-ended questions to summarize responses to surveys.

Project Outcomes: Lessons Learned and Future Implications

Lessons Learned

Even with sequential advertisement about the event, registration remained low, but we had made a commitment to offer the boot camp and felt there was value in proceeding. Low registration numbers impacted the budget initially proposed to cover the costs of 75 attendees, however financial support from event exhibitors helped to offset costs. Twenty-five individuals from varying practice settings registered for the event. However, with the addition of session speakers, event coordinators, and individuals manning posters and exhibition stations, we had a total of 50 individuals in attendance. Almost 50% of registrants had an informatics role designation, some in senior leadership roles. Registrants included frontline nurses, nurse managers, educators, and graduate students. Figure 1 shows the main reasons identified for attending the boot camp. Figure 2 shows the overall boot camp evaluation.

Figure 1.

Figure 2.

Responses to open-ended questions suggested that attendees highly valued the learning experiences offered and the opportunity to interact with speakers and event organizers. The keynote address, case study sessions, and opportunities for discussion throughout the day were valued for engagement in learning about current state in AHS and projects taking place in different clinical sites. A few noted the limited attendance of frontline staff. Attendees identified a number of topics for potential future continuing education events (Figure 3). Priorities identified were areas of ICT use, particularly clinical documentation and decision-support tools, and information and knowledge management. Interprofessional educational opportunities in informatics and inviting international speakers were also recommended for future events.

Figure 3.

Overall, the experience highlighted the complexity of meeting informatics educational needs for practicing nurses. A key concern was the low attendance rate, which may be attributed to several factors. First, many nurses work shifts with inflexible scheduling. Although our nurses have five yearly days to attend continuing education events to fulfill competency requirements, some may have used these prior to our event. Second, the event coincided with several CIS updates taking place in Alberta; this may have affected nurses working in informatics or IT roles. Third, because the concept of informatics is new to most frontline nurses in this area and many clinical environments do not have fully integrated CIS, it could be assumed that nurses did not perceive this educational day as an immediate priority. Lastly, fiscal constraints due to economic downturn in Alberta prevented healthcare organizations from sponsoring staff to attend.

Future Implications

It is important to articulate the relevance of informatics as it applies to nursing practice roles and provides data to evaluate patient outcomes. NI competency development among practicing nurses in Alberta, and everywhere, is paramount to ensure that they are able to appropriately support the benefits of ICT and mitigate potential harm to patients. We identified several implications for the future related to this area. Nurse leaders in practice settings, particularly those transitioning to digital health delivery platforms, need to promote nurse participation in informatics continuing education activities. It is important to articulate the relevance of informatics as it applies to nursing practice roles and provides data to evaluate patient outcomes (CNA, 2006b; CARNA, 2009). Professional and regulatory associations could identify informatics as a key learning area of annual continuing competency expectations of nurses, thus encouraging them to develop informatics competencies. Educational institutions can support informatics education and competency development through integrating CASN NI entry-to-practice competencies in undergraduate nursing education (CASN, 2012; CASN, 2013). Encouraging graduate and undergraduate student attendance at events increases awareness about the relevance of informatics to nursing practice. Furthermore, providing graduate level education in informatics could advance nursing practice roles and increase nurse participation in healthcare ICT decisions. Finally, nurses need to individually acknowledge the value of informatics competency to their practice and identify means to best meet their educational needs (Canadian Nurses Association, 2006b; CARNA, 2009).

... research examining the impact of informatics and health technology education on patient, organizational, and system outcomes is lacking. Research reporting on the status of informatics integration in nursing education is emerging (De Gagne, Bisanar, Makowski, & Neumann, 2012; Gracie, 2011; Hunter, McGonigle, & Hebda, 2013; Kleib, Zimka, & Olson, 2013). Yet, research assessing the impact of informatics educational interventions (Kleib et al., 2013a) and research examining the impact of informatics and health technology education on patient, organizational, and system outcomes is lacking. Furthermore, research is needed to inform the status of informatics competencies and nurses’ level of participation in continuing education to fulfill informatics related professional expectations within the Canadian context (Kleib, Sales, Lima, Andrea-Baylon, & Beaith, 2010).

For program planners considering offering similar events, ongoing environmental scans are helpful to assess informatics education needs and identify priorities to plan and offer continuing education opportunities. In addition to topics identified by attendees for future events, highlighting informatics roles (e.g., nurse informaticians) and tailoring informatics education to specific practice settings (e.g., critical care, mental health) could increase understanding of the relevance of informatics to nursing practice. It is challenging for most nurses to leave clinical units for a whole day to attend educational events; therefore, the use of online learning tools may provide a more flexible learning approach (Kleib & Olson, 2015). Lastly, collaboration of key stakeholders (e.g., service providers, professional and regulatory associations, academia) is key to ensure that informatics continuing education opportunities address current needs in clinical settings.

Conclusion

Providers must continue to work with ICTs to support evidence-based outcomes and data driven decisions at both the individual and organizational levels. Overall, the boot camp was a promising start that successfully raised some Alberta nurses’ awareness about the importance of informatics in nursing practice. Providers must continue to work with ICTs to support evidence-based outcomes and data driven decisions at both the individual and organizational levels. A continued focus on NI educational needs and development of relevant, engaging learning opportunities will support the early Institute of Medicine (2001) call for competency in utilizing informatics, and the ongoing proficiency in this critical area.

Authors

Manal Kleib, RN, MSN, MBA, PhD
Email: manal.kleib@ualberta.ca

Dr. Kleib is the founder of the Nursing Informatics Association of Alberta (NIAA) and a strong advocate for advancing nursing practice in Canada through informatics and digital health. She was consulted by MacEwan University to lead and run this boot camp initiative. Currently, she is leading a number of research projects focused on informatics competencies assessment and development in nursing.

Nicole Simpson, RN, BScN
Email: simpsonn9@macewan.ca

Ms. Simpson has a diverse background in clinical practice, research and education. In her current role with MacEwan University and in previous positions within the health region, she has worked to evaluate and support the educational needs of nurses in clinical practice. She has successfully facilitated national and local educational opportunities including certification, annual practice based symposiums, workshops and course development.

Beverly Rhodes, RN, MSN
Email: bev.rhodes@albertahealthservices.ca

Ms. Rhodes is the Program Director—Informatics Competency and Practice Standards at Alberta Health Services, Alberta, Canada and currently the President Elect for the Nursing Informatics Association of Alberta (NIAA).