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Scope and Standards of Practice
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Standards of Practice for
Nursing Informatics Nursing
Standard 1. Assessment
The informatics nurse collects comprehensive data,
information, and emerging evidence pertinent to the situation.
Standard 2. Diagnosis, Problems, and
Issues Identification
The informatics nurse analyzes assessment data to
identify diagnoses, problems, issues, and opportunities for
improvement.
Standard 3. Outcomes Identification
The informatics nurse identifies expected outcomes for a plan
individualized to the healthcare consumer or to the situation.
Standard 4. Planning
The informatics nurse develops a plan that prescribes strategies,
alternatives, and recommendations to attain expected outcomes.
Standard 5. Implementation
The informatics nurse implements the individualized plan.
5. 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,
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American Nurses Association
Silver Spring, Maryland
2015
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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
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viii
NursingInformatics:ScopeandStandardsofPractice,2ndEdition
American Nurses Association Staff
CarolBickford,PhD,RN-BC,CPHIMS,FAAN
MaureenCones,Esq.
EricWurzbacher,BA
YvonneHumes,MSA
About the American Nurses Association
TheAmericanNursesAssociation(ANA)istheonlyfull-
serviceprofessional
organization representing the interests of the nation’s 3.1
million registered
nursesthroughitsconstituent/statenursesassociationsanditsorgani
zational
affiliates.TheANAadvancesthenursingprofessionbyfosteringhigh
44. 1
The Scope of Nursing
Informatics Practice
Introduction
TheAmericanNursesAssociation(ANA)identifiednursinginformat
icsasa
nursingspecialtyin1992.Thefirstscopeofpracticestatementforthiss
pecialty,
Scope of Practice for Nursing Informatics, was published in
1994, followed
by the 1995 release of an accompanying resource, Standards of
Practice for
NursingInformatics.Thoseearlypublications werereplaced
in2001bythe
ScopeandStandardsofNursingInformaticsPractice,whichcombine
dboththe
scopeandstandardsofpracticeintoonedocumentandcreatedanenhan
ced
andmorerobustdefinitionofnursinginformaticstoreflectthecontem
porary
healthcare informatics environment. The 2008 Nursing
Informatics: Scope
andStandardsofPracticefollowedwithaslightlyrevisedspecialtydef
inition
ofnursinginformaticsandinclusionofanexpandedpresentationofco
mpe-
tenciesfortheinformaticsnurseandinformaticsnursespecialist.
ThepublicationofthissecondeditionofNursingInformatics:Scopea
nd
Standards of Practice istheculmination of an 18-month-
longintensivepro-
fessionalreviewandrevisioninitiativehostedbyANA.Dedicatedwo
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2 NursingInformatics:ScopeandStandardsofPractice,2ndEdition
The Scope of NurSiNg iNformaTicS pracTice
communicatedata,information,knowledge,andwisdominnursingpr
actice.
NIsupportsnurses,consumers,patients,theinterprofessionalhealth
careteam,
and other stakeholders in their decision-making in all roles and
settings to
achievedesiredoutcomes.This supportis accomplished
throughthe use of
informationstructures,informationprocesses,andinformationtech
nology.
Thenursinginformaticsspecialtyanditsconstituentmemberscontrib
uteto
achievingthegoalofimprovingthehealthofpopulations,com munitie
s,groups,
families,andindividuals.Supportingactivitiesinclude,butarenotli
mitedto,
theidentificationofissuesandthedesign,development,andimpleme
ntation
ofeffectiveinformaticssolutionsandtechnologieswithintheclinical
,admin-
istrative,educational,andresearchdomainsofpractice.
Metastructures, Concepts, and
Tools of Nursing Informatics
Metastructures: Data, information, Knowledge,
and Wisdom
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The Scope of NurSiNg iNformaTicS pracTice
NursingInformatics:ScopeandStandardsofPractice,2ndEdition 3
Data,information,andknowledgeareofvaluetonursesi nallareasofpr
ac-
tice.Datamaybeobtainedfrommultiplesources;thedataareprocesse
dinto
informationandthenintoknowledge.Forexample,dataderivedfrom
direct
careofanindividualcanbecompiledacrossdiseasestatesandthenagg
regated
fordecision-makingby nurses, nurse administrators,orother
health profes-
sionals.Furtheraggregationcanencompassgeographicalpopulation
s.Nurse
educatorscancreatecasestudiesusingthesedata,andnurseresearche
rscan
accesstheaggregateddataforsystematicstudy.
Theappropriateuseofknowledgeinvolvestheintegrationofempirica
l,ethi-
cal,personal,andaestheticknowledgeintoactions.Theindividualmu
55. stapply
a high level of empirical knowledge in understandingthe current
situation,
applyaprofessionalvaluesysteminconsideringpossibleactions,bea
bleto
predictthepotentialoutcomeoftheseactionswithahighlevelofaccur
acy,and
thenhavethemeanstocarryouttheselectedactioninthegivenenviron
ment.
Wisdomisdefinedastheappropriateuseofknowledgetomanageands
olve
humanproblems.Itconsistsofknowingwhenandhowtoapplyknowle
dge
todealwithcomplexproblemsorspecifichumanneeds(Nelson&Joos
,1989;
Nelson,2002;Nelson&Staggers,2014).Whereasknowledgefocuses
onwhat
isknown,wisdomfocusesontheappropriateapplicationofthatknowl
edge
andanappreciationoftheconsequencesofselectedactions.Forexamp
le,a
knowledgebasemayincludeseveraloptionsformanagingananxiousf
amily;
wisdominvolvesnursingjudgmentaboutwhichoftheseoptionsismos
tappro-
priateforaspecificfamily,anduseofthatoptioninthecareofthatfamil
y.
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
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4 NursingInformatics:ScopeandStandardsofPractice,2ndEdition
The Scope of NurSiNg iNformaTicS pracTice
mustbeabletoplacethesemeasuresinthecontextofaparticularpatien
t’ssitu-
ationinordertointerpretthemeaningofthosevalues.Ifthesevitalsign
swere
obtainedfromanewborn,theymeanonething;iftheywereobtainedfro
man
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The Scope of NurSiNg iNformaTicS pracTice
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6 NursingInformatics:ScopeandStandardsofPractice,2ndEdition
The Scope of NurSiNg iNformaTicS pracTice
Benner(1984)definedtheexperientialstagesofthenursingprofessio
nalin
NovicetoExpert:ExcellenceandPowerinClinicalNursingPractice.
Englebardt
andNelson(2002)alsointegratedwisdomintotheirmodel.Benner,H
ooper-
Kyriakidis, and Stannard (2011) have contributed Thinking-in-
Action as an
approachtoadministrationofcare.Theaddition
ofwisdomraisesnewand
important research questions, challenging the profession to
develop tools
andprocessesfor classifying,measuring,andencoding wisdom as
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NursingInformatics:ScopeandStandardsofPractice,2ndEdition 7
are always concerned with content quality. Nursing informatics
is also con-
cernedwiththecreation,structure,storage,delivery,exchange,inter
operability,
andreuseofnursingandclinicalinformationalongthecontinuumofca
re.As
electronichealthinformation
systemsareintegratedintoeverynursingrole
andsetting, theuseoftechnology atthepoint of care delivery; the
external
useofclinicalinformationforquality,legal,andregulatoryactivities;
andthe
useofanalyticsofdataandmetadatacontributetothecreationofnewn
ursing
knowledge.Suchanevolutioninthehealthcareenvironmentandubiq
uitous
useofdata,information,andknowledgeresourcescontributetotheblu
rring
oftheboundariesbetweentherolesofnurses,infor maticsnurses,andi
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8 NursingInformatics:ScopeandStandardsofPractice,2ndEdition
The Scope of NurSiNg iNformaTicS pracTice
impact of information and applied computer science on
healthcare deliv-
eryandthenursingprocess.Table1illustratesthe connectionbetween
83. the
different foci of nursing and NI. These occur along a continuum
without
distinctboundaries.
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
Thefollowingtenetsofnursinginformatics formaframeworkthatcha
racter-
izesthethinkingandactionsofinformaticsnursesinallaspects
ofpractice
andineverysetting.Nursinginformatics
88. The Scope of NurSiNg iNformaTicS pracTice
NursingInformatics:ScopeandStandardsofPractice,2ndEdition 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.
89. nursing, the nursing Process, and Vocabularies
“Nursing is the protection, promotion, and optimization of
health and
abilities,preventionofillnessandinjury,alleviationofsufferingthro
ugh
the diagnosis and treatment of human response, and advocacy in
the
careofindividuals,families,communities,andpopulations”(ANA,2
010).
Furtherexplicationofnursingpracticeanditscomplexityisfoundinth
e
establishedstandardsofprofessionalnursingpracticethatincorporat
ethe
nursing process of assessment, diagnosis, outcomes
identification, plan-
ning,implementation,andevaluation.Delineatedcompetenciesacco
mpany
eachstandard.
Theimportance oflanguages, vocabularies, and terminologies
cannot be
overstatedwhendescribingnursingpractice.Nursingleadershaveide
ntified
many different vocabularies and ways of organizing data,
information, and
knowledgepertinenttonursingthroughnumerousestablishedresearc
hinitia-
tivesthathavespanneddecades.Intheearly1990s,ANAbegantoform
ally
recognizetheselanguages,vocabularies,andterminologies(listedin
Table2)
asvaluablerepresentationsofnursingpracticeandtopromotetheinte
gration
ofstandardizedterminologiesintoinformationtechnologysolutions
.Todate,
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10 NursingInformatics:ScopeandStandardsofPractice,2ndEdition
The Scope of NurSiNg iNformaTicS pracTice
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
94. 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
95. 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
99. U.
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NursingInformatics:ScopeandStandardsofPractice,2ndEdition 11
Standardizedterminologieshavebecomeasignificantvehicleforfaci
litat-
ing interoperability between different concepts, nomenclatures,
and infor-
100. mationsystems.Continuedevolution,mapping,andintegrationofco
ncepts,
aswellasresearchefforts,characterizetoday’sterminologyenviron
mentin
light of passage of the Health Information Technology for
Economic and
ClinicalHealth(HITECH)Actof2009.HITECH’saccompanyingfun
ding
resources continue to stimulate more rapid movement toward
electronic
datacaptureandhealthinformationexchanges(HIEs)(HealthIT.gov,
2009).
Twoexamplesfollow.
TheInternationalClassificationfor NursingPractice(ICNP®),devel
-
opedandmaintainedbytheInternationalCouncilofNurses(ICN),
provides a global cross-map of nursing terminologiesto 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).
TheSystematizedNomenclatureofMedicine,orSNOMEDCT®(http
://
www.ihtsdo.org/snomed-ct/), is a comprehensive universal
health-
care referenceterminologyand
messagingstructure.SNOMEDCT®
enables multiple nursing terminology systems to be mapped to
one
anotherthroughharmonizedconcepts.Releasedin2011,theNursing
101. ProblemListSubsetofSNOMEDCT®istheprimarycodingterminol-
ogyfornursingproblemsusedinclinicaldocumentationandbased
onnursingconceptsfoundwithintheNationalLibraryofMedicine’s
Unified Medical Language System (UMLS) Metathesaurus. The
UMLS Metathesaurus includes more than 100 source
vocabularies
and isresponsible for managing the nursing terminologies
mapped
toSNOMEDCT®.Othermappinginitiativesareunderway.
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
HITStandardsCommitteewithitsroletorecommendtheclinicalvoca
bu-
lariestobeusedintheelectronicspecificationprocess(Table3).Clini
cal
vocabularies define the concepts used to measure clinical
processes and
patient outcomes. Harmonization between the different
vocabularies is
necessarytoensureappropriateimplementationoftheelectronicmea
sures
across all electronic health record (EHR) systems. This table
does not
Nursing Informatics.indd 11 11/6/14 4:06 PM
Co
py
ri
gh
t
105. 12 NursingInformatics:ScopeandStandardsofPractice,2ndEdition
The Scope of NurSiNg iNformaTicS pracTice
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
106. 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
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NursingInformatics:ScopeandStandardsofPractice,2ndEdition 13
iso-639
International Organization for
Standardization Standard 639
Nursing and other Representation
of languages and
language groups
LoinC®
Logical Observation Identifiers,
111. 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
includerecognitionoftheimportantcodesreflectedintheFifthEditio
n
of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5)
releasedin2013.
Suchdiversityanddisparityconfirmthatinformaticsnursesmustseek
a
broader picture of the implicationsof 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 mustsee beyond thetechnical aspect ofthe
116. 14 NursingInformatics:ScopeandStandardsofPractice,2ndEdition
The Scope of NurSiNg iNformaTicS pracTice
Concepts and tools from information science
and Computer science
Toolsandmethodsfrominformationandcomputersciencesarefunda
mental
toNI,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–
computerinteraction(HCI),ergonomics,andhumanfactors
havelongbeenoverlappingconceptsoffundamentalinteresttotheinf
ormatics
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NursingInformatics:ScopeandStandardsofPractice,2ndEdition 15
ProgressTowardaHealthcareUsabilityMaturityModel (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, DesigningUsableClinicalInformationSystems:
RecommendationsfromtheTIGERUsabilityandClinicalApplicatio
n
DesignCollaborativeTeam, available at
http://www.thetigerinitiative.
org/docs/TigerReport_Usability_000.pdf
122. ■ 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/
HCIexamineshowpeople,softwareapplications,andcomputertechn
ology
interactandinfluenceeachother.ElementsofHCIarerootedinpsycho
logy,
cognitivescience,sociology,computerscience,andinformationscie
nce.HCI
addressesthedesign,development,procurement,implementation,a
ndevalu-
ationofapplicationsaswellasothercomponentsassociatedwiththesy
stem
lifecycle.Forexample,aninformaticsnursewouldassessabar -
codemedica-
tionadministrationsystembeforepurchasetodeterminewhetherthed
esign
and operation complement the way nurses cognitively process
medication
administrationanddocumentthataction.
The IOM’s 2012 report, Health IT and Patient Safety: Building
Safer
Systems for Better Care, identifiestheimportanceofHCI inthe
integration
ofapplicationsandtechnologywithhealthcaredelivery.Suchintegra
tioninto
everyday life has contributed to the empowerment of patients,
now often
designated as e-patients, and the promotion of interprofessional
collabora-
tionthroughmobiletechnology(m-
health).ThisrequirestheINandINSto
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16 NursingInformatics:ScopeandStandardsofPractice,2ndEdition
The Scope of NurSiNg iNformaTicS pracTice
(Huang,Chen,&Chung,2005),andaging(Sibley,2008).Inthefuture,
the
convenienceoftechnologiesavailableincommercialproductscanbe
expectedto
drivesimilarfunctionalityinhealthcaretechnologyandwillincreaset
hescopeof
HCIfactors.Finally,theeffectofnaturallanguageprocessing(Zhou,
2007)and
implantablemonitoringdevices(Topol,2011)onHCIisyettobedeter
mined.
127. Thetermergonomicsreferstoattributesofphysicalequipmentortopri
n-
ciples of arrangement of equipment in the work environment.
For instance,
aninformaticsnursemayhavearoleinensuringthatsoundergonomics
prin-
ciplesareusedinclinicalsettingstoguidetheselectionandarrangeme
ntof
variousdevicestosupportworkflowforinterprofessionalproviders,
patients
andtheirfamilies,andotherendusers.
Inthepast,HCI,usability,andergonomicshavetypicallybeensubsum
ed
undertherubricofhumanfactors,orhowhumansinteractwithtools,in
clud-
ingtechnology.TheHumanFactorsandErgonomicsSociety(HFES)i
denti-
fiesergonomics(orhumanfactors)as“thescientificdisciplineconcer
nedwith
the understanding of interactions among humans and other
elements of a
system,andtheprofessionthatappliestheory,principles,dataandmet
hods
to design in order to optimize human well-being and overall
system perfor-
mance”(https://www.hfes.org/web/educationalresources/hfedefi
nitionsmain.
html#profsoc).Theconceptsofefficiency,effectiveness,andsa fetya
reintegral
andapplytotheclient,consumer,andothers.
The term user experience encompasses all aspects of users’
interactions.
The International Organization for Standardization (ISO) 9241-
11 defines
132. The Scope of NurSiNg iNformaTicS pracTice
NursingInformatics:ScopeandStandardsofPractice,2ndEdition 17
influencehealthmaintenanceandthehealingprocess.Nurses,usingt
heiredu-
cation,intellect,andexperientialknowledge,placethesedataintocat
egories
tocreateinformation.Finally,usingcriticalthinkingandwisdom,the
nurse
isabletoformulateaplanandprioritizeinterventionsoractionsthateff
ect
themostpositiveoutcomepossibleforthesituation.
Nursesmakedecisionsfromtheiruniqueperspectivesbasedontheire
du-
cation,experience,andspecialty.Decision-
makingistheprocessofchoosing
amongalternatives.Thedecisionsthatnursesmakecanbecharacteriz
edboth
by the quality of decisions and by the impact of the actions
resulting from
thosedecisions.Asknowledgeworkers,nursesmakenumerousdecisi
onsthat
affect the lives and well-being of individuals, families, groups,
communities,
andpopulations.Theprocessofdecision-
makinginnursingisguidedbythe
conceptofcriticalthinking.Criticalthinkingistheintellectuallydisci
plined
process of actively and skillfully searching out the best
evidence and using
thatknowledge toconceptualize, apply,analyze,
synthesize,and/or evaluate
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The Scope of NurSiNg iNformaTicS pracTice
Thenursingprocessofassessment,diagnosis,outcomesidentificatio
n,plan-
ning,implementation,andevaluationcanbeenhancedthroughtheutil
ization
137. of technology. Technology, when properly developed and
applied, has been
showntoenhancethehealthcareteam’sabilitytocollect,categorize,i
nterpret,
manage, evaluate, and share relevant information. This also
enhances the
team’sabilitytomanageclientcareinamoreefficientandproductive
manner.
Inmostcases,theutilizationoftechnologyhasdecreasedthenurse’sw
orkload
associatedwithcollectingandcategorizingdata,whileenablingande
nhancing
thesharingofrelevantinformationwithothermembersofthehealthca
reteam.
Whenthecomplexityofinformationsharingisdecreased,enhancedsh
aringof
relevantinformationwithinthehealthcareteamtheoreticallyimprov
esquality
andsafetyandresultsinimprovedpatientoutcomes.Theinformaticsn
urse
is ideally suited to evaluate how technology can assist the nurse
and other
membersofthecaredeliveryteamtomanagedataandshareinformatio
nto
achievedesiredoutcomes.
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-
basedpracticemodelscanbedevelopedthroughthisresearch.
Models of practice that generate positive patient outcomes can
then be rep-
138. licatedand supportedby systemsoptimizedto allowseamlessdata
capture,
intuitivedatadisplay,andexpertsystemprocessing.
Nursingisfocusedonoptimizingthehealthstatusofindividuals,famil
ies,
groups,communities,andpopulations.Eachoftheseentitiesisaffecte
dbythe
environmentinwhichitresides.Technology,whenproperlydesigned
andimple-
mented,enhancestheabilitytotrackandtrenddatatohelpdeterminew
hat,
where,when,how,andwhyresourcescouldbeallocatedtoachievethe
greatest
good.Informaticsnursesareuniquelyqualifiedtoassistinthedevelop
mentand
optimizationofsystemsthatcapture,categorize,share,andevaluated
ataand
informationwhilekeepingthenursingprocessasthefoundationofpra
ctice.
Functional Areas of Nursing Informatics
Informaticsnurses,informaticsnursespecialists,andotherstakehold
ersare
helpingtransformhealthcarethroughtheuseofinformaticsprocesses
,tools,
andstructures.Acrossallhealthcareenvironments,INsandINSsmost
com-
monlypracticeininterprofessionalhealthcareenvironmentsandinte
ractwith
information technology (IT) professionals during all phases of
the system
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NursingInformatics:ScopeandStandardsofPractice,2ndEdition 19
lifecycle.INsandINSsusescientificandinformaticsprinciplesande
mploy
creative strategies in informatics solutions. They bring the
perspectives of
nursing,andveryoftenthepatients,tointerprofessionalworkthrough
asolid
understandingofoperationalprocessesandthevalueofconsumeradv
ocacyto
informaticsfunctions.INsandINSsmayneedadditionaleducationor
other
typesofadvancedpreparationtomanagetheinformaticsprojectsatha
nd.
Becauseofthetendencytoconfuseroleswithtitles,thissectiondescri
bes
thefollowingdynamicandevolvingfunctionalareasofnursinginfor
matics:
■ Administration, leadership, and management
■ Systems analysis and design
■ Compliance and integrity management
■ Consultation
143. ■ 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
Thelastdiscussioninthissectiondescribesadditionalintegratedfunc
tions,
especiallythosecrossingclinicalpracticeandinformatics.INsandIN
Ssmay
beinpositionsthatfocusprimarilyononefunctionalarea;morefreque
ntly,
though,severalfunctionalareasarecombinedwithinaparticularNIpo
sition.
Administration, Leadership, and Management
Asistrueofadministrationingeneral,leadershipandmanagementfun
ctionsin
nursinginformaticsincorporatebothhigher-levelandmid-
leveladministrative
functions.Increasingly,INSsareattainingseniorleadershipposition
s.Positions
may be titled Chief Nursing Informatics Officer (CNIO), Chief
147. aw
.
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20 NursingInformatics:ScopeandStandardsofPractice,2ndEdition
The Scope of NurSiNg iNformaTicS pracTice
Officer(CIO),director,orsimilarleadershiptitles(AmericanOrgani
zationof
NurseExecutives[AONE],2012;Hodges&Wierz,2012).Inthisfunct
ional
capacity,nursinginformaticsleadersareexpectedtobevisionaryand
establish
the direction of large-scale informatics solutions. The nursing
informatics
leader often serves as a catalyst for developing strategic plans
and creating
nationalorsystempoliciesandprocedures,whileservingasthec hamp
ionfor
integratedprojectsandsystems.
Inmid-
levelmanagement,INSsmaysuperviseresourcesandactivitiesfor
allphasesofthesystemlifecycle.Theseactivitiesmayincludeneedsa
nalysis,
requirementsgathering,design,development,selectionandpurchas
e,testing,
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NursingInformatics:ScopeandStandardsofPractice,2ndEdition 21
these efforts reflect concerns and actions of interprofessional
stakeholders.
153. The Interprofessional Education Collaborative Expert Panel
(2011, p. 14)
described multiple core competencies for interprofessional
teamwork that
included“21st-
centurytechnologiesforcommunicationandcoordination(i.e.,
informatics),”emphasizinghowvitalitisforallinformaticsnurselea
dersto
workcollaborativelywithallmembersofthehealthcareteam.
systems Analysis and Design
Datacanbeaggregatedandanalyzedinanumberofwaystosynthesizek
nowl-
edge,informdecisionsupportandoutcomesmanagement,advanceth
escience
ofnursinginformatics,andsupportreimbursement.TheINandINSma
yuse
anumberoftoolsandresourcestoaccomplishtheseends,suchasdatafl
ow
diagrams,entity-
relationshipmodeling,taxonomies,clinicalvocabularies,and
qualityindicators.Meta-analysiscanidentifylarge-
scaletrendsacrossmultiple
groupsofdata.Systemsrequirementsanalysiscantracktheflowofdat
aina
processorsystemtoaidincustomizationforend-userneeds.
AmajorresponsibilityoftheINorINSistounderstandworkflowproce
sses,
particular informatics solutions, and how these affect each
other. Workflow
analysis(identifyingtheindividualtasksofaworkprocess),coupled
withan
understandingoftheclinicalprocess,isessentialtoenhancesafetyan
dreduce
inefficiencies in a healthcare environment. Processes must be
154. designed for
successfulinteractionsbetweenusersandcomputers.Competencein
formal
systemsanalysistechniquespermitscomparisonofsystems’capabili
tiesand
limitationsandisrequiredtodesign(orredesign)applicationsforsucc
essful
computer–userinteractionsoruserexperiences.
INs and INSs may also engage in the process of knowledge
discoveryin
databases (KDD).Usingsound methodologies andpractical
evidence-based
recommendations,theINScandiscoverinformationandknowledger
elatedto
diverseareasofnursingpractice.Knowledgediscoverymethods (data
mining
andmachinelearningmethods)incombinationwithstatisticalanalysi
sand
data visualizationtechniqueshelp identifyand
understandpatternsin very
largedatastores,suchasenterprisedatawarehouses.
Analysisisalsorequiredfortheuseofclinicalvocabularies,language
s,and
taxonomies. Nursing languages must be periodically re-
evaluated for their
applicability andcurrency. Analysis ofa meta-database, such as
the Unified
MedicalLanguageSystem(UMLS),requiresknowledgeofnursingan
dmedical
vocabulariesinordertoanalyzegroupsoftaxonomiesandmapthemto
simi-
larterms.AnexampleistheefforttomapSNOMEDCTtotheInternatio
nal
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The Scope of NurSiNg iNformaTicS pracTice
ClassificationofDiseases,TenthRevision,ClinicalModification(IC
D-10-CM)
toaidinmeetingandattestingtomeaningfuluserequirements.INandI
NS
expertiseshouldbeincludedintheseeffortstosupportthecollection,r
eport-
ing,andanalysisofnursing-sensitivedata.
Outcomes analysis may be related to any domain of nursing
practice:
clinical,education,research,oradministration.Thecomplexityandl
evelsof
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,suchasheuristicsandcognitivewalk-
through,toevaluatethematch
ofsystemstousers,tasks,andcontexts.
159. Analysts use other tools to (1) maintain data integrity and
reliability,
(2)facilitatedataaggregationandanalysis,(3)identifyoutcomes,(4)i
dentify
organizational barriers, and (5) develop performance measures.
These tech-
niquesallownursestocontributetobuildingaknowledgebaseconsisti
ngof
thedata,information, theories, andmodelsusedby nurses and
other stake-
holdersindecision-
makingthatsupportsqualityhealthcare.Thefollowing
areexamplesofanalysisactivities:
■ 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
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NursingInformatics:ScopeandStandardsofPractice,2ndEdition 23
monitorcomplianceandintegrityoftheirinformationandreportingac
tivities,
infrastructures,employees,and
businesspartners.Alongwithdevelopingorga-
nizationalculturesthatencourageethicalconductandregulatorycom
pliance,
mechanismsmustbeinplacetopreventanddetectcriminalconduct.
164. Computerized information systems must support compliance
with the
1996 Health Insurance Portability and Accountability Act
(HIPAA) efforts
bylimitingaccesstopersonallyidentifiablehealthinformationtoonl
ythose
whorequireandareauthorizedaccess.Auditingsystemsthatdetectre
dflags,
reporting systemsthatwill preserveconfidentiality oranonymity,
and enter-
prise risk management (ERM) allow reporting of risks by
everyone in an
organization.ERMbreaksdownsilosandprovidestimelyreportingof
risks
andopportunitiesatahighlevelforimmediateattentionthroughrisksc
oring
andmapping(Carroll&Nakamura,2011).
TheINandINSmusthaveandmaintaintheknowledgetoeffectivelyap
ply
current ethical standards and regulatory requirements to help
healthcare
organizationsto:
■ Revise operational procedures for staff.
■ Establish technical processes to maintain compliance.
■ Meet new regulatory mandates at local, state, national, and
global levels.
Thesestandards,directives,guidelines,ormandatesmayincludethos
efrom
governmentagencies,suchastheCentersforMedicare&MedicaidSe
rvices,
the Food and Drug Administration (FDA), the Centers for
165. Disease Control
andPrevention(CDC),theNationalInstitutesofHealth(NIH),andacc
redita-
tionorganizations,suchasTheJointCommission(TJC),HealthcareF
acilities
Accreditation Program(HFAP),DetNorske VeritasHealthcare,
Inc. (DNV),
andtheWorldHealthOrganization(WHO).
Ethicalissuessurroundtheuseofnewproducts,suchasembeddedtech
-
nologiesandradio-
frequencyidentification(RFID),whichcanbeusedincar-
ingforpersonswithAlzheimer’sdiseaseandotherdementias.Asthesc
ience
matures,someoftheseissueswillberesolvedandstandardswillbeesta
blished.
Requirementswillcontinuetoevolve.Thefollowingareexamplesofc
ompli-
anceandintegritymanagementactivities:
■ 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 NursingInformatics:ScopeandStandardsofPractice,2ndEdition
The Scope of NurSiNg iNformaTicS pracTice
■ 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
Informaticsnursesandinformaticsnursespecialistsapplyinformatic
sknowledge
andskillstoserveastransformationalleadersandresourcesforclients
,both
formallyandinformally,inexternalandinternalsettings.Informatics
nurse
consultantsareexpectedtohavesolidexpertiseinclinicalnursingand
areas
suchasprocessredesign,strategicITplanning,systemimplementatio
n,writ-
ingforinformaticsandotherpublications,evaluatingclinicalsoftwar
eproducts,
174. op
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NursingInformatics:ScopeandStandardsofPractice,2ndEdition 25
followsthenursingprocessofassessment,diagnosis,outcomesidenti
fication,
planning,implementation,andevaluation(ANA,2010).TheINorIN
Smay
serveasprojectcoordinator,facilitatingchangemanagementandinte
grating
theinformation andtechnology totransform processes. Inthis
role, project
managementknowledgeandskillsareessentialtothes uccessofthepr
oject.
Project coordination can range from small, department-centered
efforts to
enterprise-wideinitiatives.Examplesinclude:
■ Coordinating installations, system upgrades, and optimization
175. 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.
TheINandINSfrequentlyserveasahubforinterprofessionalcommun
i-
cationandasabridgeandcommunicationliaisonbetweenandamongi
nfor-
maticssolutionusers,clinicalandnonclinicalendusers,andITexpert
sand
staff. The IN and INS often serve as translators and integrators
addressing
systemrequirementsandimpacts.
Informaticsnursesfrequentlyserveastheliaisonbetweenengineersa
nd
endusers.Inthiscapacity,theinformaticsnurseensuresthatnecessar
ytest-
ingorresearchisperformedtodeterminetheenduser’sneedsandthati
nfor-
mationisconveyedappropriately.Theinformaticsnursewillalsopla
yakey
roleinthedevelopmentandtestingofnewapplicationsorenhancemen
tsto
179. tt
ed
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nd
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S.
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The Scope of NurSiNg iNformaTicS pracTice
180. ■ 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
Adeveloperisresponsiblefortranslatinguserrequirementsintoeffec
tiveinfor-
maticssolutions.Informaticsnursesareinvolvedinavastarrayofdev
elopment
activities,fromconceptualizingmodelsforapplications,tosoftware
andhard-
waredesign,tothedesignofeducationmanualsandmedia,tothedesig
nof
complextechnologynetworks.Aspartofthisfunction,INsandINSsp
articipate
181. intheprocessofdesign,iterativedevelopment,testing,anddissemina
tionof
quality informatics solutions for nurses, other healthcare
professionals, and
consumers.Anunderstandingoftheinformationneedsofnursesandth
enurs-
ingprofession,consumersandconsumercareprocesses,bestbusiness
practices,
clientservices,projectedmarketdirections,productdesignanddevel
opment
methods,marketresearch,contemporaryprogramming,systemsdesi
gn,and
modelinglanguageareessentialforpracticinginadevelopmentenvir
onment.
Adherence to national standards and regulatory requirements is
also
essentialtoanydevelopmentwork.Toensureinteroperabilitybetwee
nsys-
tems, INs and INSs involved in system development must be
knowledge-
ableaboutinternationalstandardsrequirements.Existingstandardsi
nclude
HealthLevelSeven(HL7),InternationalOrganizationforStandardiz
ation
(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
wellasSection508accessibilitystandards.Anunderstandingofthecu
rrent
workonstandardsismandatory.Thefollowingareexamplesofdevelo
pment
responsibilities:
185. .
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NursingInformatics:ScopeandStandardsofPractice,2ndEdition 27
■ 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
186. docu-
menting diabetic education.
education and Professional Development
EducationisacriticalcomponentofmanyNIfunctionsandmaydirectl
yaffect
thesuccessorfailureofanynewormodifiedITsolution.Vendorsofinf
orma-
tionsystemsfrequentlyusethetermtrainingwhenreferringtocliented
ucation.
Innursing,however,thebroaderlabelofeducationisused.Adherence
tosolid
educationalprinciplesisanecessarycomponentofeducationandprof
essional
development.Teaching nursesand nursingstudents,
healthcareconsumers
andfamilies,andmembersoftheinterprofessionalhealthcareteamab
outthe
effectiveandethicalusesofinformationtechnology,aswellasNIconc
eptsand
theories, is essential for the optimal use of informatics solutions
in nursing
practice.Ever-
changingrequirementsinhealthinformationtechnologymake
continuingeducationessentialaswell.INsandINSsinthiscapacityde
velop,
implement,andevaluateeducationalcurriculaandeducationaltechn
ologies
tomeetlearners’needs.
Inthisrole, educatorsand trainers assessand evaluate informatics
skills
andcompetencieswhileprovidingfeedbacktothelearnerregardingth
eeffec-
tivenessoftheactivityandthelearner’sabilitytodemonstratenewlya
cquired
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28 NursingInformatics:ScopeandStandardsofPractice,2ndEdition
The Scope of NurSiNg iNformaTicS pracTice
Theinformaticsnursemustevaluatetheusers’levelofinformationlite
racy
as well as their computer literacy. Computer literacy is a core
competency
neededinhealthcareandnursingpractice,andshouldbetaug htinnursi
ng
curriculaatalllevels.Inaddition,informationliteracymustbeintegra
tedinto
196. The Scope of NurSiNg iNformaTicS pracTice
NursingInformatics:ScopeandStandardsofPractice,2ndEdition 29
■ 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
Advancesin mappingthehumangenomeand
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30 NursingInformatics:ScopeandStandardsofPractice,2ndEdition
The Scope of NurSiNg iNformaTicS pracTice
wellasinformatics.Infact,genomicscompetenciesandcurriculargui
delines
are available online (ANA & ISONG, 2011;
http://www.genome.gov/Pages/
Health/HealthCareProvidersInfo/Grad_Gen_Comp.pdf ).
Withtheincreasedamountofresearchregardingtheimpactofgenomi
c
variation on health and its increasing relevance to clinical
practice, infor-
maticsnursesneedtobuildtheirgenetics/genomicsknowledgebases
othat
they maysupport this expanding practice area. This involves
developing an
understandingofgenomicbioinformatics,thetypesofgenomicinfor
mation
available,andhowsuchinformationcanbestoredandabstractedwithi
nthe
