Guest Editorial
How will nurses make the transition to the information era?
Evelyn JS Hovenga
Faculty of Health Science, Central Queensland University, QLD
PP: 042 - 044
Article Text
Back in 1984 when I was asked to represent Australian nurses on an international working group under the auspices of the International Medical Informatics Association to promote nursing informatics, I couldn't think of how or why nurses would be using computers to support their practice. How times have changed. Yet many of you are no doubt still grappling with this question. At that time, I had learned how to use a mainframe computer and program in BASIC as part of my undergraduate studies. I had used a TRS80 personal computer to analyse my research data, was using computer generated information for policy analysis, and had given a talk to the Victorian Nursing Research Group about the use of computers in research. The term 'nursing informatics' was new to me then, as it may be to many of you today.
In 1996 we are well and truly in the information age. Information technology is all around us, health care facilities are no exception. It is no longer a question of computing information technologies are an integral part of most people's lives. The technologies can be used to document all care, to document observations made, for practice evaluation, to manage nursing resources, analyse data for research purposes, to retrieve information from the literature or from electronic health records or from the Internet including the World Wide Web, for patient and staff education using interactive multimedia, to consult experts from a distance, to support decision making or to 'manage or control' machines such as IV pumps - to list the most obvious. Information is now being digitised. This includes pictures such as wound photos, x-rays or scans, videos, physiological signals, numerals, symbols and text. That is, all types of information are being represented as a sequence of binary digits or 'bits' with only two possible values, 1 and O. These 'bits' are the DNA of information. Computing technology is merging with communication technologies enabling the 'bits' or coded information to be transmitted around the world. Thus we are moving from an atom-based world to a digital world. That is, we will see less use for media which has physical properties such as videos or printed paper and greater use for digitised information sources.
Soon there will be little distinction between television sets and computers other than the size of the screen. We are becoming more and more reliant upon telephone lines and communication networks. Good examples are the airline and banking industries which, through the use of technology, enable us to withdraw funds from our accounts anywhere in Australia and a number of overseas places as well, or to make a flight reservation anywhere in the world for any commercially scheduled flight. The health industry has a long way to go to get such a sophisticated network - but it is moving fast towards this end. How will these changes impact nursing practice? More importantly what are nurses doing to prepare for these changes and to influence these directions? Why should they concern themselves with these technological trends?
Nursing is about processing information. Nurses are engaged in collecting, managing, processing, transforming, and communicating information as part of their every day practice. The discipline of nursing informatics is concerned with the application of information science, computing and communications technologies to assist nurses with this information processing. Yet nursing informatics as a discipline is not formally recognised as such by any Australian university. There are no degree programs in nursing informatics. Some health care agencies do recognise it as is evident by the appointment of nurses to a nursing informatics position. So how have these nurses prepared themselves for these new roles?
In most instances, they have seen the possibilities of using these technologies to improve nursing practice, management, research, or education. They have acquired new skills by undertaking mainstream computing and information systems units of study as part of their post registration studies. They are strongly motivated, adept at self-directed learning and at learning on the job while working with qualified technical staff. They have been helped along the way by some Australian but mostly overseas produced publications; health or nursing special interest groups; the Health Informatics Society of Australia; and by attending local, national and overseas medical and nursing informatics conferences.
Few nurses are involved in the development of our National Health Data Dictionary, which at this stage defines very little clinical data but it will no doubt do so in the near future as it is updated annually. It should be noted that most State Governments are now actively looking to acquire clinical systems to enable the capture of data representing process and outcomes. How will clinical nursing data be represented electronically? This is a major issue given that Australian nurses do not use a common coded data set, such as the International Classification of Diseases, the North American Nursing Diagnosis Association terms, the Nursing Intervention Classification system and any of the many others in use elsewhere. Such standardised and coded nomenclatures are needed to digitise clinical data. The National Library of Medicine in Washington DC began this process by producing a Unified Medical Language System (UMLS) through the mapping and amalgamation of numerous available nomenclatures. This now includes four recognised nursing data sets. It is used for indexing the literature and electronic health records to facilitate data retrieval and aggregation. Australia has seen the development of the Community Nursing Minimum Data Set (now nearing completion) established by the International Nursing Council to develop an international clinical nursing language. There have been many other efforts towards this end internationally but to my knowledge no further work is being undertaken in Australia nor did we contribute beyond the CNMDS. Yet if we are not able to name what we do then we can't count it, teach it, research it, or cost it. In other words this deficiency is likely to lead to the nonofficial recognition of the value of nursing practice. Just like we are now able to define, describe and cost our hospital products in terms of AN-DRCs, we need to be able to consistently and on a national basis, describe and define nursing services in terms which are amenable to national statistical data collections. I am of the view that such information is richer than our current data collections in that it will tell everyone more about what is really happening in our health care system as nursing is central to it. This has been well demonstrated in Belgium where around 20 critical indicators of nursing dependency are collected from all hospitals four times a year. These parameters are part of their acute nursing minimum data set and used for a variety of planning and policy purposes. What is preventing us from collecting our patient dependency data nationally on such a basis?
Do we have and do we want to preserve a unique Australian way of defining nursing or are we content to import and use the results of nursing initiatives elsewhere? Do we have nurses in sufficient numbers with the ability to identify our current and future information system requirements, and to evaluate the local applicability of overseas developed clinical information systems? Nurses need to be educated about these new technologies, how they can be used to enhance nursing practice and what nurses need to do to prepare our nursing knowledge for digitisation and to be active participants in the development, selection and implementation of clinical information systems.
The European Community has recognised this educational need as it is funding a three-year project to develop a nursing informatics curriculum and multimedia courseware. Also, the Nursing Informatics special interest group of the International Medical Informatics Association has established a working group to examine the required nursing informatics competencies and to investigate opportunities for the electronic delivery of courseware by using experts situated in a variety of universities around the world.
There is an urgent need for formal nursing informatics education in Australia. However, until Australian nurses recognise this urgency and a university can demonstrate a demand, it is extremely difficult for any faculty to introduce a new degree program. The best we can do for the moment is to integrate informatics into nursing curricula, and to continue to rely on individuals who seek their own educational opportunities through mainstream computing and information systems educational programs, and their ability to make the quantum leap to apply these newly acquired skills to nursing. The irony is that nursing informatics is becoming subsumed by health informatics as the disciplines merge through the use of multidisciplinary teams and integrated health information systems. In the meantime if you want to know more about health informatics I suggest you acquire and read my new edited text on this topic. It consists of exclusive Australian contributions and provides an excellent overview of the discipline. It is published by Churchill Livingstone, Melbourne. I look forward to receiving a flood of enquiries about offering a formal nursing informatics degree program.
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