Ebook: Nursing Informatics

It is indeed a privilege to write the foreword to these proceedings for Nursing Informatics 1997. This, the sixth in a series of international congresses, reflects the evolution of a vibrant discipline in its chosen topic, The Impact of Nursing Knowledge on Health Care Informatics. Today, nursing informatics is affecting the whole of health care. Increasingly, nurses are winning recognition for their critical roles as caregivers and informaticians.

Since first meeting in Tokyo, Japan, in 1980, during Medinfo, the triennial congress held by the International Medical Informatics Association (IMIA), nursing informatics has been one of its most active and vigorous working groups. Recently, IMIA honoured the group's standing as the leading Nursing Informatics organization world-wide by designating it to be the first IMIA special interest group.

Nursing Informatics '97 holds the distinction as being the first meeting sponsored by this new special interest group. It continues in the tradition set by meetings held every three years, first in England, then Canada, Ireland, Australia, the United States, and now in Sweden. New Zealand will host the congress in the year 2000.

Over the years, Nursing Informatics-first the working group and now the special interest group-has benefited from strong and dedicated leadership with Maureen Scholes, followed by Kathryn Hanna, Elly Pluyter Wenting, and now Ulla Gerdin. It has produced seminal proceedings for its congresses and invitational working conferences, and its members have published widely, creating a growing body of Nursing Informatics literature.

Nursing Informatics has changed the practice of health care, defining new roles for nursing in education, research, patient care, and administration and reaching out into industry, government and consultancies.

Today, the field continues to evolve. The range of issues addressed in these Stockholm proceedings is extraordinary, including nursing language, cognitive skills, education and training, nursing research, systems design, decision support, patient records, patient management, standards, and more. Like earlier symposia, Nursing Informatics '97 will clarify values, strategies and practices central to the profession of nursing. Once again, we will see roles emerge as new fields in Clinical Nursing Informatics takes form.

Finally, as has been the case with earlier international nursing informatics meetings, those of us privileged to attend NI '97 are part of a global network, building bridges to our colleagues around the world and creating a lasting bond. We are now all “sisters,” connected in friendship and spirit, and through the Internet. We truly have a worldwide web of lasting relationships, formed in our common quest to improve health care for the patients of the world.

Marion J. Ball, Ed. D.

The development of standardised vocabularies within nursing has been an important research activity for a number of years. Current representations generally take the form of taxonomic vocabularies. These are seen as important as they provide a structure for retrieving and analysing data from automated systems. However, there is increasing evidence to show that traditional taxonomic vocabularies are unsuitable for capturing detailed clinical data. This paper describes how GRAIL (GALEN Representation and Integration Language) is being used within the TELENURSE project to develop a representation of nursing terminology which is sufficiently expressive for documenting detailed clinical data while retaining the benefits of traditional taxonomic vocabularies.

Outcomes research has become increasingly important in the current health care environment and for informatics research efforts. Recent efforts in automating clinical data for use in outcomes studies has focused attention on the need to represent the processes of care in the classic structure-process-outcome models of care. This paper reports on use of the Nursing Intervention Lexicon and Taxonomy for classifying interventions to characterize two process of care variables: intervention intensity and intervention focus. Study results demonstrate that these variables are descriptive and provide promise for describing processes of nursing care for describing clinical care.

Developers of healthcare information systems are challenged by the difficulty of meeting the simultaneous goals of 1) capturing and electronically representing the broad array of data related to healthcare with sufficient expressibility to provide adequate documentation of the patient encounter, and 2) utilizing standardized coding and classification systems to facilitate linkages among computer-based systems. The evaluation studies to date have primarily focused on matching actual clinical data with terms in the recognized classification systems. These studies have provided evidence that the classification systems are relatively domain complete for categorizing patient problems and nursing interventions. Although several of the published criteria for evaluation relate to structure, it is noteworthy that this has not yet been a major focus of study in nursing. There are several areas of critical need that must be addressed. First, additional work is needed to develop and refine a standardized set of atomic-level terms relevant to nursing, including those for assessments, problems, and activities. Second, knowledge representations must be developed to support the building of complex concepts from atomic-level data.

The purpose of this study is to evaluate the utility of the Home Health Care Classification for categorizing patient problems and nursing interventions from the hospital setting. The data set comprised 5,844 problem terms and 20,055 interventions terms. All terms could be categorized using the Nursing Components and Major Categories for Nursing Diagnoses and Interventions. A total of 1,767 (30.2%) patient problem terms could be placed into Major Nursing Diagnosis categories, but not subcategories even though there were subcategories related to the major category. All intervention terms whether they were classified at the Intervention Category or Subcategory could be coded according to Type of Nursing Action. These findings demonstrate that the Home Health Care Classification, at the level of Nursing Components and Major Categories, was domain complete for the data set. The fact that not all terms could be classified according to the existing subcategories suggests some areas for future development, but is also a reflection of the level of detail expressed in the data set itself The results suggest that the Home Care Classification will be adequate and appropriate for categorizing problems and interventions across settings for the next phases of the research project.

A common nursing terminology is essential for outcomes research, data comparability and clinical documentation in an electronic health record. Kaiser Permanente has recognized the need to develop a common nursing and medical terminology across the program. The Interregional Nursing Nomenclature Committee has developed a model for developing a common nursing terminology integrated with other healthcare terminologies.

The Danish Nursing Intervention Classification is the first national nursing intervention classification. Because of the official status of the project it is to be a national standard. It will thus be possible for the system to be in general use nation-wide, which is a necessary condition for an efficient communication in the health care sector in Denmark.

Long a leader in health informatics, nursing faces new challenges. The full and effective use of technology requires an understanding of cognitive processes and organizational behavior. Nursing can play a key role in addressing aims supportive of a new vision of health informatics. The evolving paradigm for knowledge transfer will give rise to new educational models and new institutional entities which will nurture learning and relearning.

This discussion focuses on the importance of nursing intelligence to the organisation, and the nurses' role in gathering and utilising such intelligence. Deliberations with professional colleagues suggest that intelligence can only be utilised fully when the information systems are developed in such a way as to meet the needs of the people who manage and provide nursing care at the consumer level; that is, the activity of nursing itself. If accommodation is made for the recycling of nursing intelligence, there would be a support and furtherance of ‘professional’ intelligence. Two main issues emerge:

- how can nurses support the needs of management to optimise intelligence input?

- how can organisations optimise the contribution of nurses to its information processes and interpretation of intelligence?

The expansion of this ‘professional’ intelligence would promote a generation of constantly reviewed data, offering a quality approach to nursing activities and an organisation's intelligence system.

Two studies of the effects of components of the integrated Nursing Information System VISION, involving five Dutch hospitals, were concluded in 1996. This paper summarises these studies and their results. The studies assessed effects on workload, quality of co-ordination, job satisfaction, patient satisfaction and quality of information supply. In both studies a quasi-experimental approach was followed. The results show significant positive effects with respect to quality of co-ordination, nurses job satisfaction and patient satisfaction. Workload measurements revealed a shift in the nurses' activities, but no change in the amount of time spent on patient care. On the basis of the positive results, 4 of the 5 hospitals have decided to extend the use of the system.

This paper will review and report progress on the development of the International Classification for Nursing Practice. This project, begun in 1990 by the International Council of Nurses, aims to develop a standardised vocabulary and classification of nursing phenomena (nursing diagnoses), nursing interventions, and nursing outcomes which can be used in both electronic and paper records to describe and compare nursing practice across clinical settings. An Alpha Version of the Classification of Nursing Phenomena and Nursing Interventions was released for further development and field testing in 1996 and an outline for a Classification of Nursing Outcomes in 1997. Nurses around the world, and other classification experts, have been invited to participate in the development of the Beta Version which it is hoped will be ready for release in 1999.

Informatics is developing in all of the disciplines related to healthcare. There are many aspects to informatics development which frequently appear to be unrelated and to lack cohesion. This paper builds on the development of a model for nursing informatics and proposes how the components of that model can interact to provide an outline for the development of informatics as a discipline. A understanding of the disciple allows us to organize the existing research and more importantly to understand the areas where research is lacking as the discipline is evolving.

Institution wide use of an intensive care bedside information system creates the opportunity to make available vast amounts of clinical data to support research and quality improvement activities. Acting on this opportunity has required the development of several innovative approaches to transform this raw data into usable information. The process described herein uses commercially available software and hardware tools to extract on a daily basis, process and archive data for 7 intensive care units. Once this procedure is complete, attention is turned to using individual and combinations of data elements to build a higher level of information that more directly relates to the kinds of inquiries that help to address questions of outcome, and care quality.

There has been little study on how nurse managers collect, store, process and retrieve quality management data, yet nearly every nursing department has an existing program to provide these functions. We investigated our current paper-based system and found several deficiencies. Guided by structured interviews, task analysis, and focus groups we developed a networked computerized quality management database to provide more timely data reporting and consistency of analysis. This paper describes the development and implementation of the system with discussion on how it will be evaluated in the future.

This paper describes a system which allows the patient to answer a structured questionnaire in private, at their own speed and without pressure using a touch-screen personal computer. A clinical report is generated immediately and used to help guide a clinician in a face to face consultation with the patient. Trials in a clinical setting have shown a positive response by both patients and clinicians.

The patient classifications done by nurses for all adult patients (n=15,500) discharged from an urban teaching hospital in one year were retrieved and analyzed by discharge status. Classification results were summarized by physical functional, psychological-social, and dependence categories and were associated with discharge disposition; patients discharged home were less dependent than others discharged to nursing homes or those who died in the hospital. Diagnosis related group (DRG) payment weights were somewhat independent of the patient classification scores and were not associated with adverse outcomes.

In response to increasing economic and political pressures, administrators and other health-care professionals have become increasingly concerned with health-related outcomes management. The categories of outcomes in health care have been identified within administrative, economic, and clinical realms. Great emphasis has been placed in the literature on the importance of measuring and using outcome data for decision making. Despite this emphasis, little progress has been made in either the science or the art of outcomes management. Furthermore, integrating the art and science into systematic processes for outcomes management has been done with limited success. This paper focuses on the state of outcome concepts, measurement, collection, and evaluation. Strategies will be offered to move the conceptualization and operationalization of outcomes management forward.

Oftentimes when models of information systems are developed, outcomes are either left out or described as an end product of treatment alone. However, in research demonstrating outcomes,evaluating whether outcomes are achieved can best be accomplished when the outcomes are integrated into the entire care process. This paper describes a model for nursing to consider when integrating outcomes during several components of nursing care delivery, and several nursing domains for achieving outcome of care.

Information technology has been taught as part of nursing curricula for several years. With computer literacy now a basic requirement in clinical nursing practice, it is important to look more seriously at the standards and methods of teaching information technology at nursing colleges. In this study the objectives of teaching information technology and the content of information technology studies were evaluated by nurse educators (n=162) and by an expert panel (n=15). Nurse educators and the expert panel had more or less identical views on what those objectives should be. The quality and outcomes of information technology teaching in nurse education have never been measured in Finland before. In order to find out the consumers' point of view, student nurses were asked to assess their knowledge and skills in computer use. The student nurses (n=373) felt that they had a reasonable command of the theoretical knowledge in information technology. However, their keyboard skills were confined to the use of word processors.

Organizational diagnosis views the organization as a single entity with problems and challenges that are unique to the organization as a whole. This paper describes the process of establishing organizational diagnoses related to computer and information learning needs within a clinical or academic health care institution. The assessment of a college within a state-owned university in the U.S.A. is used to demonstrate the process of organizational diagnosis. The diagnoses identified include the need to improve information seeking skills and the information presentation skills of faculty.