#1

In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able
to obtain hospital records fit for any purposes of comparison. If they could be obtained, they would enable us to decide
many other questions besides the ones alluded to. They would show subscribers how their money was being spent, what
amount of good was really being done with it, or whether the money was not doing mischief rather than good."
(Nightingale, 1859)

Informatics Introduction

What is informatics? Isn't it just about computers? Taking care of patients is nursing's primary concern, not thinking about
computers! These are not unusual thoughts for nurses to have. Transitions are always difficult, and a transition to using
more technology in managing information is no exception. This use of information technology in healthcare is known as
informatics, and its focus is information management, not computers. Whether nursing uses informatics effectively or not
will determine the quality of future patient care as well as the future of nursing.

Information is an integral part of nursing. When you are caring for patients, what besides the knowledge that nursing
education and experience has provided do you depend on to provide care? You need to know the patient's history, medical
conditions, medications, laboratory results, and more. Could you walk into a unit and care for a patient without this
information? How this information is organized and presented to you affects the care that you can provide as well as the
time you spend finding it.

The old way is to record and keep the information for a patient's current admission in a paper chart. Today, with several
specialties, consults, medications, laboratory reports, and procedures, the paper chart is inadequate. A well-designed
information system, developed with you and for you, can facilitate finding and using information that you need for patient
care. Informatics skills enable you to participate in and benefit from this process. Informatics does not perform miracles; it
requires an investment by you, the clinician, to assist those who design information systems so the systems are helpful and
do not impede your workflow.

If healthcare is to improve, it is imperative that there be a workforce that can innovate and implement information
technology (AHIMA & AMIA, 2006). There are two roles in informatics: the informatics specialist and the clinician who
must use health information technology. This means that in essence every nurse has a role in informatics. Information, the
subject of informatics, is the structure on which healthcare is built. Except for purely technical procedures (of which there
are few if any), a healthcare professional's work revolves around information. Is the laboratory report available? When is
Mrs. X scheduled for surgery? What are the contraindications for the prescribed drug? What is Mr. Y's history? What
orders did the physician leave for Ms. Z? Where is the latest x-ray report?

An important part of healthcare information is nursing documentation. When information systems are designed for
nursing, this documentation can also be used to expand our knowledge of what constitutes quality healthcare. Have you
ever wondered if the patient for whom you provided care had an outcome similar to others with the same condition? From
nursing documentation, are you easily able to see the relationship between nursing diagnoses, interventions, and outcomes
for your patients? Without knowledge of these chain events, you have only your intuition and old knowledge to use when
making decisions about the best interventions in patient care. Because observations tend to be self-selective, this is often
not the best information on which to base patient care. Informatics can furnish the information needed to see these
relationships and to provide care based on actual patient data.

If Florence Nightingale were with us today, she would be a champion of the push toward more use of healthcare
information technology. Information in a paper chart essentially disappears into a black hole after a patient is discharged.
Because we can't easily access it, we can't learn from it and use it in patient care.

This realization is international. Many countries, especially those with a national health service, have long realized the
need be able to use information buried in charts. In the United States, the strategic plan for wider implementation of
Health Information Technology formulated four goals, all of which will affect nurses and nursing. They are as follows:

1.Inform clinical practice with use of EHRs (Electronic Health Records). The strategies for achieving this goal are:

a. Provide incentives for EHR adoption.

b. Reduce risk of EHR investment
c. Promote the diffusion of EHR in rural and underserved areas.

2.Interconnect clinicians so that they can exchange health information using advanced and secure electronic
communication. The strategies for achieving this goal are:

a. Encourage regional collaborations that reflect the needs and goals of the region.
b. Develop a national health information network.
c. Coordinate federal health information systems.

3.Personalize care with consumer-based health records and better information for consumers by

a. Encourage the use of personal EHRs.

b. Enhance informed consumer choice by providing information about clinicians and institutions.
 c. Promote use of telehealth systems.

4.Improve public health through advanced biosurveillance methods and streamlining the collection of data for quality
measurement and research. This requires the collection of detailed clinical information and will be accomplished by

a. Unify public health surveillance architectures by making the systems able to exchange information.
b. Streamline quality and health status monitoring to provide the ability to look at quality at the point of care and in
real time.
c. Provide tools to accelerate research and dissemination of evidence into clinically useful products, applications,
and knowledge.

To fulfill these goals, information, which is the structure on which healthcare is built, can no longer be managed with
paper. If we are to provide evidence-based care, the mountains of data that are hidden in medical records must be made to
reveal their secrets. Bakken (2001) told us that there are five components needed to provide evidence-based care:

1. standardization of terminologies and structures used in documentation.

2. the use of digital information.
3. standards to permit healthcare data exchange between heterogeneous entities.
4. the ability to capture data relevant to the actual care provided, and
5. competency among practitioners to use this data. All of these are part of informatics.

Information is a capital good with a value the same as labor and materials (National Advisory Council on Nurse Education
and Practice, 1997). The financial health of organizations depends on effective and efficient information management.
Today, healthcare organizations are waking up to the fact that how information is handled and processed has a great effect
on both the outcomes for those who purchase services and the economics of healthcare. Manual recording and filing of
information are inadequate to manage today's healthcare information. We have made some attempts to use technology to
manage information, but these efforts often fall short as a result of our inexperience in grasping the schemes of where
information originates, how it is used clinically and administratively, and how it can be used to improve practice.

The complexity of today's healthcare milieu, added to the explosion of knowledge, makes it impossible for any clinician
to remember everything needed to provide high-quality patient care. Additionally, healthcare consumers today want their
healthcare providers to integrate all known relevant scientific knowledge in providing their care. We have passed the time
when the unaided human mind can perform this feat: Modern information management tools are needed as well as a
commitment by healthcare professionals to change practices when more knowledge becomes available.

#2

Definitions

Informatics is about managing information. The tendency to relate it to computers comes from the fact that the ability to
manage large amounts of information was born with the computer and progressed as computers became more powerful
and commonplace. It is, however, human ingenuity that is the crux of informatics. The term "informatics" originated from
the Russian term "informatika" (Sackett & Erdley 2002). A Russian publication, Oznovy Informatiki (Foundations of
Informatics), published in 1968 is credited with the origins of the general discipline of informatics (Middle East Technical
University, n.d.). At that time it was described within the context of computers. "Medical informatics" was the first term
used to identify informatics in healthcare. It was defined as the information technologies that are concerned with patient
care and the medical decision making process. Another definition stated that medical informatics is complex data
processing by the computer to create new information. As with many healthcare enterprises, there was debate about
whether "medical" referred only to informatics focusing on physician concerns, or if it refers to all healthcare disciplines.
Increasingly, it is seen that other disciplines have a body of knowledge separate from medicine, but part of healthcare, and
the term healthcare informatics is becoming more commonly used. In essence, informatics is the management of
information, using cognitive skills and the computer.

HEALTHCARE INFORMATICS

Healthcare informatics focuses on managing information in healthcare. It is an umbrella term that describes the capture,
retrieval, storage, presenting, sharing, and use of biomedical information, data, and knowledge for providing care,
problem solving, and decision making (Shortliffe & Blois, 2001). The purpose is to improve the use of healthcare data,
information, and knowledge in supporting patient care, research, and education (Delaney, 2001). The focus is on the
subject, information, rather than the tool, the computer. The distinction is not always obvious as a result of the need to
master computer skills to enable one to manage this information. The computer is used in acquiring, organizing,
manipulating, and presenting the information. It will not produce anything of value without human direction in how,
when, and where the data is acquired, how it is treated, interpreted, manipulated, and presented. Informatics provides that
human direction.

NURSING INFORMATICS

Healthcare has many disciplines, thus it is not surprising that healthcare informatics has many specialties of which nursing
is one. Nursing informatics is also a subspecialty of nursing which the American Nurses Association (ANA) recognized in
1992, with the first informatics certification examination being given in the fall of 1995 (Newbold, 1996). Nursing
informatics has as its focus managing information pertaining to nursing. Specialists in this area look at how nursing
information is acquired, manipulated, stored, presented, and used. Informatics nurses work with practicing nurses to
identify the needs of nurses for information and support, and with system developers in the development of systems that
work to complement the practice needs of nurses. Nursing informatics specialists bring to system development and
implementation a viewpoint that supports the needs of the clinical end user. The objective is an information system that is
not only user friendly for data input, but presents the clinical nurse with needed information in a manner that is timely and
useful. This is not to say that nursing informatics stands alone, it is an integral part of the interdisciplinary field of
healthcare informatics, hence related to and responsible to all the healthcare disciplines.

DEFINITIONS OF NURSING INFORMATICS

The term "nursing informatics," was probably first used and defined by Scholes and Barber in 1980 in their address that
year to the MED-INFO conference in Tokyo. There is still no definitive agreement on exactly what the term nursing
informatics means. As Simpson once said (Simpson, 1998), defining nursing informatics is difficult because it is a moving
target. The original definition said that nursing informatics was the use of computer technology in all nursing endeavors:
nursing services, education, and research. (Scholes & Barber, 1980) Another early definition that followed the broad
definition of Scholes and Barber was written by Hannah, Ball & Edwards (1994). They defined nursing informatics as any
use of information technologies in carrying out nursing functions. Like the Scholes and Barber definition, these
definitions focused on the technology and could be interpreted to mean any use of the computer from word processing to
the creation of artificial intelligence for nurses as long as the computer use involved the practice of professional nursing.

The shift from a technology orientation in definitions to one that is more information oriented started in the mid 1980s
with Schwirian (Staggers & Thompson, 2002). She created a model to be used as a framework for nursing informatics
investigators (Schwirian, 1986). The model consisted of four elements arranged in a pyramid with a triangular base. The
top of the pyramid was the desired goal of the nursing informatics activity and the base was composed of three elements:
1) users (nurses and students), 2) raw material or nursing information, and 3) the technology, which is computer hardware
and software. They all interact in nursing informatics activity to achieve a goal. The model was intended as a stimulus for
research.

The first widely circulated definition that moved away from technology to concepts was from Graves and Corcoran
(Staggers & Thompson, 2002). They defined nursing informatics as "a combination of computer science, information
science and nursing science designed to assist in the management and processing of nursing data, information and
knowledge to support the practice of nursing and the delivery of nursing care" (Graves & Corcoran, 1989)(p. 227). This
definition secured the position of nursing informatics within the practice of nursing and placed the emphasis on data,
information, and knowledge (Staggers & Thompson, 2002). Many consider it the seminal definition of nursing
informatics.

Turley (Turley, 1996), after analyzing previous definitions, added another discipline, cognitive science, to the base for
nursing informatics. Cognitive science emphasizes the human factor in informatics. Its main focus is the nature of
knowledge, its components, development, and use. Goossen (1996), thinking along the same lines, used the Graves and
Corcoran definition as a basis and expanded the meaning of nursing informatics to include the thinking that is done by
nurses to make knowledge-based decisions and inferences for patient care. Using this interpretation, he felt that nursing
informatics should focus on analyzing and modeling the cognitive processing for all areas of nursing practice. Goossen
also stated that nursing informatics should look at the effects of computerized systems on nursing care delivery

The first ANA definition in 1992 added the role of the informatics nursing specialist to the Graves and Corcoran
definition. The 2001 ANA definition stated that nursing informatics combines nursing, information and computer sciences
for the purpose of managing and communicating data, information, and knowledge to support nurses and healthcare
providers in decision making (American Nurses Association, 2001). Information structures, processes, and technology are
used to provide this support. In the latest ANA Scope and Standards this definition was reiterated, albeit in slightly
different wording (American Nurses Association, 2008) and with the addition of wisdom to the data, information, and
knowledge conceptual framework. This most recent definition emphasized again that the goal of nursing informatics is to
optimize information management and communication to improve the health of individuals, families, populations, and
communities.

Staggers and Thompson (2002), who believe that the evolution of definitions will continue, pointed out that in all of the
current definitions, the role of the patient is under emphasized. Some early definitions included the patient, but as a
passive recipient of care. With the advent of the Internet, more and more patients are taking an active role in their
healthcare. This factor changes not only the dynamics of healthcare, but permits a definition of nursing informatics that
recognizes that patients as well as healthcare professionals are consumers of healthcare information and that patients may
be participating in keeping their medical records current. Staggers and Thompson also pointed out that the role of the
nurse as an integrator of information has been overlooked and should be considered in future definitions.

Despite these definitions, the focus of much of today's practice informatics is still on capturing data at the point of care
and presenting it in a manner that facilitates the care of an individual patient. Although this is a vital first step, when
designing patient care information systems, thought needs to be given to secondary data analysis, or analysis of data for
purposes other than for which it was originally collected. Using aggregated data, or the same piece(s) of data, for example,
outcomes of a given intervention for many patients, you can make decisions based on actual patient care data.
Understanding how informatics can serve you as an individual nurse, as well as the profession, puts you in a position to
work with informatics specialists to make retrievable data needed to improve patient care.

#3

Computers and Healthcare: History

In 1850, it was possible for all the medical knowledge known to the Western world to be put into two large volumes
making it possible, for one person to read and assimilate all this information. The situation today is dramatically different.
The number of journals available in healthcare and the research that fills them have increased many times over. Even in
the early 1990s, if physicians read two journal articles a day, by the end of a year they would be 800 years behind in their
reading (McDonald, 1994). A healthcare clinician may be expected to know something about 10,000 different diseases
and syndromes, 3,000 medications, 1,100 laboratory tests and the information in the more than 400,000 articles added to
the biomedical information each year (Davenport & Glaser, 2002). Additionally, current knowledge is constantly
changing: one can expect much of their knowledge to be obsolete in five years or less.

In healthcare, the increase in knowledge has led to the development of many specialties such as respiratory therapy,
neonatology, and gerontology, and subspecialties within each of these. As these specialties have proliferated and spawned
the development of many miraculous treatments, healthcare has too often become fractionalized, resulting in difficulty in
gaining an overview of the entire patient. The pressure of accomplishing the tasks necessary for a patient's physical
recovery usually leaves little time for perusing a patient's record and putting together the bits and pieces so carefully
charted by each discipline. Even if time is available there is simply so much data, in so many places, that it is difficult to
merge the data with the knowledge that a healthcare provider has learned, as well as with new knowledge needed to
provide the best patient care. We are drowning in data but lack the time and skills to transform it to useful information or
knowledge.

The development of the computer as a tool to manage information can be seen in its history. The first information
management task "computerized" was numeric manipulation. Although not technically a computer by today's terminology,
the first successful computerization tool was the abacus, which was developed about 3000 BC. Although when one
developed skill, real speed in these tasks was possible, the operator of the abacus still had to mentally manipulate data. All
the abacus did was store the results step by step. Slide rules came next in 1632, but like the abacus required a great deal of
skill on the part of the operator. The first machine to add and subtract by itself was Blaise Pascal's "arithmetic machine,"
built in 1542. The first "computer" to be a commercial success was Jacquard's weaving machine built in 1804. Its
efficiency so frightened workers at the mill where it was built that they rioted, broke apart the machine, and sold the parts.
Despite this setback, the machine proved a success because it introduced a cost-effective way of producing goods.

The difference and analytical engines, early computers designed by Charles Babbage in the mid 19th century, although
never built, laid the foundation for modern computers (Analytical Engine, 2007). The first time that an automatic
calculating machine was successfully used was in the 1900 census. Herman Hollerith (who later started IBM) used the
Jacquard loom concept of punch cards to create a machine that enabled the 1900 census takers to compile the results in
one year instead of the 10 (Herman Hollerith—Punch Cards) required for the 1890 census. The first computer by today's
perception was the Electronic Numerical Integrator and Computer (ENIAC) built by people at the Moore School of
Engineering at the University of Pennsylvania in partnership with the U.S. Government. When completed in 1946, it
consisted of 18,000 vacuum tubes, 70,000 resistors, and 5 million soldered joints. It consumed enough energy to dim the
lights in an entire section of Philadelphia (Moye, 1996). The progress in hardware since then is phenomenal; today's
"Palmtop" computers have more processing power than ENIAC did.

The use of computers in healthcare originated in the late 1950s and early 1960s as a way to manage financial information.
This was followed in the late 1960s by the development of a few computerized patient care applications (Saba & Erdeley
2006). Some of these hospital information systems included patient diagnoses and other patient information as well as
care plans based on physician and nursing orders. Because of the lack of processing power then available, these systems
were unable to deliver what was needed and never became widely used.

EARLY HEALTHCARE INFORMATICS SYSTEMS

One of the interesting early uses of the computer in patient care was the Problem-Oriented Medical Information System
(PROMIS) begun by Dr. Lawrence Weed at the University Medical Center in Burlington, VT (McNeill, 1979) in 1968.
The importance of this system is that it was the first attempt at providing a total, integrated system that covered all aspects
of healthcare, including patient treatment. It was patient oriented and used as its framework the problem-oriented medical
record (POMR). The unit featured an interactive touch screen and was known for fast responsiveness (Problem-Oriented
Medical Information System, n.d.). At its height, it consisted of over 60,000 frames of knowledge.

PROMIS was designed to overcome four problems that are still with us today: lack of care coordination, reliance on
memory, lack of recorded logic of delivered care, and lack of an effective feedback loop (PROMIS: The Problem-Oriented
Medical Information System, 1980). The system provided a wide array of information to all healthcare providers. All
disciplines recorded their observations and plans, and related them to a specific problem. This broke down barriers
between disciplines, making it possible to see the relationship between conditions, treatments, costs, and outcomes.
Unfortunately, this system did not have wide acceptance. To embrace it meant a change in the structure of healthcare,
something that did not begin to happen until the 1990s, when managed care in all its variations reinvigorated a push
toward more patient-centered information systems, a push that is continuing as you read this.

Another early system that became functional in 1967 and is still functioning, is the Help Evaluation Logical Processing
(HELP) system developed by the Informatics Department at the University of Utah School of Medicine. It was first
implemented in a heart catheterization laboratory and a post open heart intensive care unit. It is now hospital wide and
operational in many hospitals in the Intermountain Healthcare system (Gardner, Pryor, & Warner, 1999). This is not only a
hospital information system but integrates a sophisticated clinical decision support system that provides information to
clinical areas. It was the first hospital information system that collected data for clinical decision making and integrated it
with a medical knowledge base. It is well accepted by clinicians and has demonstrated that a clinical support system is
feasible and that it reduces healthcare costs without sacrificing quality.

PROGRESSION OF INFORMATION SYSTEMS

As the science of informatics has progressed, there have been changes in information systems. Originally computerized
clinical information systems were process oriented. That is, they were implemented to computerize a specific process, for
example, billing, order entry, or laboratory reports. This led to the creation of different software systems for different
departments, which unfortunately could not share data, creating a need for clinicians to enter data more than once. An
attempt to share data by integrating data from disparate systems is a difficult and sometimes impossible task. Even when
possible, the results are often disappointing and can leave negative impressions of computerization in users' minds. These
barriers are being slowly overcome with the introduction of data standards, both in terminology and in protocols for
passing data from one system to another.

Newer systems, however, are organized by data and are designed to use the same piece of data many times, thus requiring
that the entry be made only once. The primary design is based on how data is gathered, stored, and used in an entire
institution rather than on a specific process such as pharmacy or laboratory. For example, when a medication order is
placed, the system can have access to all the information about a patient including his diagnosis, age, weight, allergies,
and eventually genomics, as well as the medications he is currently taking. The order and patient information can also be
matched against knowledge such as what drugs are incompatible with the prescribed drug, the dosage of the drug, and the
appropriateness of the drug for this patient. If there are difficulties, the system can deliver warnings at the time the
medication is ordered instead of requiring clinician intervention either in the pharmacy or at the time of administration.
Another feature in a data-driven system is the ability to make the same information available to the dietician planning the
patient's diet and the nurse providing patient care and doing discharge planning, thus enabling a more complete picture of
a patient than one that would be available when separate systems handle dietetics and nursing.

Evidence-based practice will result not only from research and practice guidelines, but also from unidentifiable (data
minus any patient identification) aggregated data from actual patients. It will also be possible to see how patients with a
given genomics react to a drug, thus helping the clinician in prescribing drugs. This same aggregated data will help
clinicians make decisions by providing information about treatments that are most effective for given conditions,
replacing the current system, which is too often based on "what we have always done" rather than empirical information.
These systems will use computers that are powerful enough to process data so that information is created "on the fly," or
immediately when requested. Systems that incorporate these features will require a new way of thinking. Instead of
having all one's knowledge in memory, one must be comfortable both with needing to access information and with
changing one's practice to accommodate the new knowledge.

Computerization will affect healthcare professionals in other ways. Some jobs will change focus. As nurses we may find
that our job as a patient care coordinator has shifted from transcribing and checking orders to accessing this information
on the computer. To preserve our ability to provide full care for our patients, and as an information integrator for other
disciplines, we will need to make our information needs known to those who design the systems. To accomplish this we
all need to be aware of the value of both our data and our experience and to be able to identify the data we need to
perform our job, as well as to appreciate the value of the data that others and we add to the healthcare system.

#4

Benefits of Informatics
The information systems described previously will bring many benefits to healthcare. These benefits can be seen in the
ability to create and use aggregated data, prevent errors, ease working conditions, and provide better healthcare records.

FOR HEALTHCARE IN GENERAL

One of the primary benefits of informatics is that data that was previously buried in inaccessible records becomes usable.
Informatics is not just about collecting data, but about making it useful. When data is captured electronically in a
structured manner, it can be retrieved and used in many different ways, both to easily assimilate information about one
patient and as aggregated data. Aggregated data is the same piece or pieces of data for many patients. Table 1-1 shows
some aggregated data for postsurgical infections sorted by physician and then by the organism. Because infections for
some patients are caused by two different pathogens in Table 1-1, you see two entries for some patients, however, this is
all produced from only one entry of the data. With just a few clicks of a mouse, this same data could be organized by unit
to show the number of infections on each unit. This is possible because data that is structured as in Table 1-1 and
standardized can be presented in many different views.

When aggregated data is examined, patterns can be seen that might otherwise take several weeks or months to become
evident, or might never become evident. When patterns, such as the prevalence of infections for Dr. Smith emerge (Table
1-1), investigations into what these patients have in common can begin. Caution, however, should be observed. The
aggregated data in Table 1-1 are insufficient for drawing conclusions; the data only serves as an indication of a problem
and clues to where to start investigating. Aggregated data is a type of information or even knowledge, but wisdom says
that it is incomplete. If this data were shared outside of an agency, or with those who don't need to have personal
information about a patient, it would be de-identified, that is, there would be no patient names and probably no physician
names. Deciding who can see what data is one of the current issues in informatics.

Informatics through information systems can improve communication between all healthcare providers, which will
improve patient care as well as reduce stress. Additional benefits for healthcare include making the storage and retrieval of
healthcare records much easier, quicker retrieval of test results, printouts of needed information organized to meet the
needs of the user, and fewer lost charges as a result of easier methods of recording charges. The computerization of
administrative tasks such as staffing and scheduling also saves time and money.

BENEFITS TO THE NURSING PROFESSION

Each healthcare discipline will benefit from its investment in informatics. In nursing, informatics will not only enhance
practice, but also allow nursing science to develop (Fitzpatrick, 1988). Informatics will improve documentation and, when
properly implemented, can reduce the time spent in documentation. It is believed by many nurses that they spend over
50% of their time doing paperwork (Womack et al, 2004). Entering vital signs both in nursing notes and on a flow sheet,
wastes time and invites errors. In a well-designed clinical documentation system, this data will be entered once, retrieved,
and presented in many different forms to meet the needs of the user.

Paper documentation methods create other problems such as inconsistency and irregularity in charting as well as the lack
of data for evaluation and research mentioned above. An electronic clinical information system can remind users of the
need to provide data in areas apt to be forgotten and provide a list of terms that can be clicked to enter data. The ability to
use patient data for both quality control and research is vastly improved when documentation is complete and electronic.
Despite Florence Nightingale's emphasis on data, for much of nursing's history, nursing data has not been valued. It is
either buried in paper patient records that make retrieving it economically infeasible or, worse, discarded when a patient is
discharged, hence unavailable for building nursing science. With the advent of electronic clinical documentation, nursing
data can be made a part of the EHR and become available to researchers for building evidence-based nursing knowledge.
The recent Maryland report on the use of technology to address the nursing shortage demonstrated that informatics can be
used to improve staff morale and patient care (Womack et al., 2004). For example, paper request forms can be eliminated,
work announcements can be more easily communicated, the time for in-services can be reduced, and empty shifts can be
filled using Internet software.

In understanding the role and value that informatics adds to nursing, it is necessary to recognize that the profession is not
confined to tasks, but that it is cognitive. Providing the data to support this is a joint function of nursing informatics and
clinicians. Identifying and determining how to facilitate its collection is an informatics skill that all nurses need.

#5

Nursing Informatics Competencies and Information Literacy

The need to manage complex amounts of data in patient care demands that nurses, regardless of specialty area, have
informatics skills (Gaumer, Koeniger-Donohue, Friel, & Sudbay, 2007; Nelson, 2007; Wilhoit, Mustain, & King, 2006).
Informatics skills require basic computer skills as one component (Staggers, Gassert, & Curran, 2002). A recent survey of
hospital administrators in three states in the southeastern United States revealed that one of the competencies that they
wanted from nurses dealt with the use of the computer (Uttley-Smith, 2004). This supports an earlier study by Gravely,
Lust, & Fullerton (1999) that found that 83% of hospital recruiters indicated the importance of computer skills. Another
skill needed for proficiency in informatics is information literacy. Both these skills have also been identified by the ANA
and National League for Nursing (NLN) as necessary for evidence-based practice.

COMPUTER FLUENCY

The term "computer literacy" is used broadly to mean the ability to perform various tasks with a computer. Given the
rapid changes in technology and in nursing, perhaps a better perspective on computer use can be gained by thinking in
terms of computer fluency rather than literacy. The term "fluency" implies that an individual has a lifelong commitment to
acquiring new skills for the purpose of being more effective in work and personal life (Committee on Information
Technology Literacy, 1999). This necessitates a goal of gaining sufficient foundational skills and knowledge to enable one
to independently acquire new skills. Thus, computer literacy is a temporary state, whereas computer fluency involves
being able to increase one's ability to effectively use a computer when needed.

A perusal of Listserv archives in informatics reveals periodic requests for instruments to measure the computer
competency of staff. Unfortunately, there is little agreement on specific competencies needed, let alone an instrument to
measure this, but there is a consensus that it involves a positive attitude toward computers, knowledge and understanding
of computer technology, computer hardware and software skills, and the ability to visualize the overall benefits to nursing
from this technology (Hobbs, 2002). Simpson (1998) pointed out the need for nurses to master computers to avoid
extinction. A computer is a mind tool that frees us from the mental drudgery of data processing, just as the bulldozer frees
us from the drudgery of digging and moving dirt. Like, the bulldozer, however, the computer must be used intelligently, or
damage can result.

Given the forces moving healthcare toward more use of informatics, it is important for nurses to learn the skills associated
with using a computer for managing information. Additionally, knowing how to use graphical interfaces and application
programs such as word processing, spreadsheets, databases, and presentation programs is as an important an element in a
professional career as mastering technology skill (McCannon & O’Neal, 2003). Just as anatomy and physiology provide a
background for learning about disease processes and treatments, computer fluency skills are necessary to appreciate more
complex informatics concepts (McNeil & Odom, 2000) and for learning clinical applications (Nagelkerk, Ritolo, &
Vandort, 1998).

Ronald and Skiba (1987) were the first to look at computer competencies required for nurses. In the late 1990s and early
part of this century this issue was revisited, but the focus became the use of computer skills as part of informatics skills
(McCannon & O'Neal, 2003; McNeil et al., 2003; Pew Health Professions Commissions, 1998; Staggers, Gassert, &
Curran, 2001; Staggers et al., 2002; Uttley-Smith, 2004). One of the more thorough studies is by Staggers, Gassert, and
Curran (2001). They defined four levels of informatics competencies for practicing nurses. The first two pertain to all
nurses, the last two to informatics nurses.
  The beginning nurse should possess basic information management and computer technology skills.
Accomplishments should include the ability to access data, use a computer for communication, use basic desktop
software, and use decision support systems.
 Experienced nurses should be highly skilled in using information management and computer technology to
support their major area of practice. Additional skills for the experienced nurse include being able to make
judgments on the basis of trends and patterns within data elements and to collaborate with nursing informatics
nurses to suggest improvements in nursing systems.
 The informatics nurse specialist should be able to meet the information needs of practicing nurses by integrating
and applying information, computer, and nursing sciences.

 The informatics innovator will conduct informatics research and generate informatics theory.

INFORMATION LITERACY

Information literacy, or the ability to know when one needs information and how to locate, evaluate, and effectively use it
(National Forum on Information Literacy, 2004) is an informatics skill. Although it involves computer skills, like
informatics, it requires critical thinking and problem solving. Information literacy is part of the foundation for evidence-
based practice and provides nurses with the ability to be intelligent information consumers in today's electronic
environment (Jacobs, Rosenfeld, & Haber, 2003).

The level of computer fluency needed by nurses to be both information literate and informatics capable in their practice is
what is expected of any educated nurse. In this course, the lessons addressing basic computer skills will emphasize
concepts that promote the ability to learn new applications. These lessons provide information underlying the use of
informatics in professional life both on and off a clinical unit, and to adapt to changes in technology. In future lessons
these principles will be built upon to allow the reader to start to develop beginning informatics skills, including the ability
to find and evaluate information from electronic sources. Additional lessons will allow the reader to develop skills
necessary to work with nursing informatics specialists in providing effective information systems and the use of nursing
data.

Summary

Healthcare is in transition and nursing is being affected by these changes. Part of these changes involves informatics.
Whether the change will be positive or negative for patient care and nursing depends on nurses. For the change to be
positive, nurses need to develop skills in information management, known in healthcare as informatics. To gain these
skills, a background in both computer and information literacy skills is necessary.

As knowledge continues to expand logarithmically, data and information can no longer be managed solely by the human
mind. The use of tools to aid the human mind has become mandatory. Although healthcare has been behind most
industries in using technology to manage its data, there are many forces, both at the governmental and private levels that
are working to change this. With these pressures, healthcare informatics is rapidly expanding. There are many
subspecialties in informatics, of which nursing is one. Embracing informatics will allow nurses to assess and evaluate
practice just as a stethoscope allows the evaluation and assessment of a patient.

The use of computers in healthcare started in the 1960s, mostly in financial areas, but with the advance in computing
power and the demand for clinical data, computers are being used more and more in clinical areas. With this growth has
come a change in focus for information systems from providing solutions for just one process, to an enterprise-wide
patient-centered system that focuses on data. This new focus provides the functionality that allows one piece of data to be
used in multiple ways. To understand and work with clinical systems, as well as to fulfill other professional
responsibilities, nurses need to be computer fluent, information literate, and informatics knowledgeable.