An Overview of Nursing Informatics (NI) as a Profession:

How we Evolved Over the Years

Hanan Asiri

Continuous Quality Improvement & Patient Safety Department, Armed Forces Hospitals Southern Region, Khamis

Mushait, Kingdom of Saudi Arabia

Keywords: Nursing Informaics (NI), Definition, History, Role, Competencies, Career Path, Challenges, Opportunities,

Future Direction for Research.

Abstract: Nursing informatics is a relatively new and expanding field. The evolutionary journey it has, that started

more than thirty years ago, marks its rich history. Accordingly, its definition, role, education, competencies

and the career path of its practitioners changed significantly through the years. Also, due to its unique

nature, different issues emerged as challenges that need to be dealt with. On the other hand, some would

view these issues as opportunities which we can benefit from. Nevertheless, the discipline of nursing

informatics continues to evolve and progress rapidly over the years, as a result of the efforts and initiatives

of its practitioners, scholars and organizations. This paper attempts to shed some light on this unique

discipline by briefly examining how it evolved around the world over the past four decades. Yet, some

challenges such as the lack of global NI literature could be considered as the main limitation of the scope of

this review as there are plenty of resources in some parts of the world, while almost the opposite can be seen

in some other regions. Therefore, a comprehensive review of the international historical development of the

discipline of Nursing Informatics is beyond the scope of this paper.

1 INTRODUCTION

“Nursing informatics is a 21st century science with

great potential for improving the quality, safety, and

efficiency of health care”

(McCartney, 2004).

Simply put, nursing informatics is viewed as the

combination of the concepts of three sciences i.e.

cognitive science, information science, and

computer science with an overall focus on nursing

science

(Sackett et al., 2004). The collective efforts

of many scholars have contributed to the increased

exploration and understanding of the field of

Nursing Informatics. The importance of Nursing

Informatics stems from the fact that, as estimated,

nurses spend about 50% of their time in the

“gathering, coordinated, and documenting of

information” (Meadows, 2002). Hence, Nursing

Informatics provides an excellent chance to obtain

the full potential of an organized and well-managed

information by nursing personnel. This paper

attempts to shed light on the definition of nursing

informatics, its history, the role, education and

competencies of its practitioners, their career path,

and the challenges that face it along with the

opportunities available out there for the field to

flourish.

2 THE DEFINITION OF

NURSING INFORMATICS

When it comes to the discipline of Nursing

Informatics, the term itself was proposed in 1976 as

Scholes and Barber elaborated on the computer

technology potentialities for a practice discipline

such as nursing and how it can contribute to the

nursing field in terms of education, service, and

research (Scholes and Barber, 1976). Moreover, it

was further used and defined by Scholes and Barber

again in 1980 in the MEDINFO conference at the

same year in Tokyo (Scholes and Barber, 1980;

Hannah et al., 1999). Yet, Ozbolt and Saba (2008)

tracked the early beginning of NI back to the days of

Florence Nightingale with her vision of

"standardized clinical records that could be analyzed

to assess and improve care processes and patient

outcomes" (Ozbolt and Saba, 2008). However, even

though nurses have done informatics tasks for more

200

Asiri, H.

An Overview of Nursing Informatics (NI) as a Profession: How we Evolved Over the Years.

DOI: 10.5220/0005658202000212

In Proceedings of the 9th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2016) - Volume 5: HEALTHINF, pages 200-212

ISBN: 978-989-758-170-0

than thirty years now, the term “nursing informatics”

was not used in the literature until 1984 as indicated

by Guenther (2006) (Guenther, 2006). Furthermore,

the definition of nursing Informatics itself has

evolved over the years. For instance, in 1985,

nursing informatics was defined by Hannah as the

“use of information technologies in relation to those

functions, within the purview of nursing that are

carried out by nurses when performing their duties”

(Hannah et al., 1985). These duties mentioned in the

definition include all aspects of the information

technology that are used by nurses either related to

the patient care, nursing practice, health care

administration, or nursing education. (Guenther,

2006). Furthermore, Grobe provided another

description of NI in 1988, where he defined it as

“the application of the principles of information

science and theory to the study, scientific analysis,

and management of nursing information for

purposes of establishing a body of nursing

knowledge” (Grobe, 1988). Additionally, in 1989,

another definition by Graves and Corcoran for

nursing informatics was suggested. They define it 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

and Corcoran, 1989). In 1994, the ANA (the

American Nurses Association) published the Scope

of Practice in Nursing Informatics as a pamphlet,

which defined nursing informatics as “the specialty

that integrates nursing science, computer science and

information science in identifying, collecting,

processing and managing data and information to

support nursing practice, administration, education,

research and the expansion of nursing knowledge”

(American Nurses Association, 1994). Furthermore,

in 1995, the ANA published another pamphlet called

Nursing Informatics Standards of Practice. This

publication mainly portrayed “a generalist level of

practice and performance for nursing informatics

that is applied to nurses qualified by experience or

education to practice at that level” (American Nurses

Association, 1995; Guenther, 2006). Ultimately, in

October 2001, the ANA combined these two

pamphlets into one document, which it called the

Scope and Standards of Nursing Informatics, which

was updated in 2008. Nursing informatics was

defined in this publication as “a specialty that

integrates nursing science, computer science and

information science to manage and communicate

data, knowledge and nursing practice” (American

Nurses Association, 2001). Yet, in 1999,

Rognehaugh suggested an additional definition to

nursing informatics which defines it as “the use of

any computer and information technologies that

support any nursing function carried out by nurses in

the performance of their duties” (Rognehaugh,

1999). Moreover, Guenther (2006) indicates that it

is commonly accepted today to have an

understanding of nursing informatics as an

“electronic information combined with nursing and

any aspect of clinical practice, administration,

research, or education” (Guenther, 2006).

Nevertheless, nursing informatics (NI) is considered

as one of the subspecialities of health informatics

and simultaneously nursing. This can explain why,

with substantial efforts, many definitions and

characterizations emerged over time to describe its

unique nature (Staggers et al., 1998; Turley, 1996).

For this reason and after reviewing the literature,

staggers and Thompson (2002) tried to develop an

overarching definition, that combines critical

concepts from the previous work and attempt as well

to add some components such as patients,

information structures, information communication

and decision making that were, and still to some

extent, absent at the time. Therefore, according to

staggers and Thompson (2002), nursing informatics

is defined as “a specialty that integrates nursing

science, computer science, and information science

to manage and communicate data, information, and

knowledge in nursing practice. Nursing informatics

facilitates the integration of data, information, and

knowledge to support patients, nurses, and other

providers in their decision making in all roles and

settings. This support is accomplished through the

use of information structures, information processes,

and information technology” (Staggers and

Thompson, 2002). Additionally, Staggers and

Thompson (2002) highlighted how the definition of

nursing informatics was three themes-oriented.

These themes are; Information Technology-

oriented, Conceptually-oriented, and Role-oriented

definitions. However, a more recent definition of

nursing informatics is offered by IMIA Special

Interest Group on Nursing Informatics i.e. IMIA-NI,

2009 which defines nursing informatics as “science

and practice (that) integrates nursing, its information

and knowledge, with management of information

and communication technologies to promote the

health of people, families, and communities

worldwide."

(IMIA-NI, 2009). Other agencies and

bodies such as he Division of Nursing in the

Department of Health and Human Services and the

National Institute for Nursing Research have

provided other definitions for the discipline that

An Overview of Nursing Informatics (NI) as a Profession: How we Evolved Over the Years

201

added to the previous definitions of Nursing

informatics that were published by the American

Nursing Association (ANA) in 1994, 2001, and in

2008. This clearly reflects how the definition of this

discipline and the role of its practitioners rapidly

changed and evolved over the years. Accordingly,

we can say that, this evolution moved from the

technology-focused orientation in the early 80s to be

more information-focused in 1989 and end up to be

a combination of the four sciences of technology,

information, cognitive and nursing in 1996 (Thede

and Sewell, 2010).

It also integrated the hierarchy of

information i.e. from data, information, knowledge

up to wisdom in the 2008 which is demonstrated by

the ANA 2008 definition, and the international

multifaceted aspects i.e. “to promote the health of

people, families, and communities worldwide” it has

in IMIA Special Interest Group on Nursing

Informatics in 2009 definition.

3 THE HISTORY OF NURSING

INFORMATICS

The term “nursing informatics” was firstly proposed

by Scholes and Barber in 1976 (Scholes and Barber,

1976). Since then, nursing informatics has become

one of the cornerstones of the field of health

informatics. The terms continued to be used in the

80s (Ball and Hannah, 1984; Hannah, 1985; Grobe,

1988) and still is used today by many scholars.

Furthermore, Nursing Informatics was approved as a

nursing specialty by the American Nurses

Association (ANA) in 1992 (American Nurses

Association, 1995). On the other hand, when it

comes to the history of nursing informatics, the

American Medical Informatics Association working

group of nursing informatics (AMIA NI-WG) has

formed a large project in order to preserve and

document the nursing informatics history. This

project consists of three constructs;

• Documenting the pioneers and their

experience in nursing informatics. The

organizations have been encouraged to

preserve their related materials in a national

library of medicine archive which was

started in 1997 by Dr. Saba.

• The AMIA’s website has also maintained the

history of nursing informatics by

videotaping the nursing informatics

pioneers' stories and made them available.

These videos include different themes that

describe the journey and the various topics

that shaped the field of nursing informatics

over the years.

• The informatics evolution as a specialty in

nursing is planned to be documented as a

part of historical research. Use cases are

also incorporated in this project.

Additionally, in her article in 2010, Murphy

explained how the pioneers of nursing informatics

joined the profession. According to Murphy, most of

the nurses, who had a varied age, titles, roles,

experience, and responsibility, got into Nursing

Informatics accidently due to different reasons such

as being “good clinicians, were involved in IT

projects as educators or project team members, or

were just technically curious and willing to try new

things” (Murphy, 2010). However, this doesn’t mean

that some of the pioneers didn’t get into the field

purposefully. On the other hand, in 1982, the

International Medical Informatics Association

(IMIA) recognized the importance of nursing

informatics by establishing Working Group 8

(WG8) in order to represent the nursing interest in

the field. This was followed by a further step of

recognition i.e. transforming this working group into

a Nursing Informatics Special Interest Group that’s

known as the International Medical Informatics

Association – Nursing Informatics (IMIA-NI) in

1994 (Scholes et al., 2000). Nevertheless, globally,

the NI field has and still is going through a constant

process of development in a varied pace around the

world. This section briefly reviews its continuous

international growth by having a concise description

of the evolution of NI discipline in each

continent/region along with providing random

examples as possible from each region. However,

due to the lack of NI literature in some parts of the

world, the author will instead give a brief

introduction about the state of healthcare

information technology in general in that area

because the development of nursing informatics is

tightly connected to the overall progress achieved in

the domain of healthcare information technology

and health informatics. Its worth noting that the

following sections are not intended to be an

exhaustive review of the field historical evolution

and progression.

3.1 NI History in Asia

It wasn’t until the 1970s that the computers were

introduced for the first time to the Asian countries’

healthcare sector such as South Korea, China, Japan,

Taiwan, and Thailand. The main use of computers

back then was concerned with the aspects of billing,

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administration, and insurance. Now, these countries

are in the process of implementing a paperless

electronic health record, yet in a variable rate

(Policarpio, 2014). For instance, in Taiwan,

regardless of the fact that 27% of the hospitals did

implement information systems, 9% are in the

development phase of such process while 24% of

these hospitals are planning to do so, 40% of them

were not planning to invest in any nursing

information systems. However, this doesn’t mean

that Taiwan is not interested in nursing informatics.

Such interest can be evident since 1986 in how the

Taiwanese ministry of education developed specific

instruction programs, i.e. computer- assisted, for

nursing vocational programs (Policarpio, 2014). In

addition, the first formal NI academic association

was founded in 2004, i.e. when the Taiwan Medical

Informatics Association, which was established in

1991, formed a Nursing Informatics working group.

Furthermore, on the behalf of the IMIA-NI i.e.IMIA

Special Interest Group in Nursing Informatics and

under the theme ‘eSmart’, the Taiwan Nursing

Informatics Association (TNIA) along with other

organizations, organized the 12

International

Congress on Nursing Informatics NI2014 in 2014.

When it comes to China, the late 70s of the last

century witnessed the beginning of the development

of the nursing information management systems that

were first used late in 1987. NI is used in the

Chinese clinical practice in the form of nursing

management systems such as nursing information

management, nursing quality management, as well

as staff nurses’ training on clinical skills. NI is also

applied in clinical systems like patient management,

nursing records, pharmacy management etc..(Shi,

2010). Yet, the main weakness the nursing

information management systems face is the

insufficiency of national standards along with the

low level of informatics skills and computer literacy

among the nursing professionals (Li et al., 2008).

Nevertheless, even though there is a lack of any

official statistics about it, many Chinese hospitals

have made progress in the Nursing informatics

implementation as a healthcare standard as many

other of their Asian counterparts did and are using

information systems for the discipline of nursing

nowadays (Jiang et al. , 2002).

3.2 NI History in the Middle East

When examining the environment of health

informatics in general and nursing informatics in

particular in the middle east, one can notice that

there is a variable rate of the adoption of healthcare

technology in this part of the world as well as a lack

of resources of information in general about these

disciplines. We can say that to a certain extent, little

is known about the development of nursing

informatics in the middle east. However, the Middle

East Association for Health Informatics (MEAHI)

was founded in 2002, and approved officially by

IMIA in 2009 as the newest region of IMIA and as a

sign of the increasing interest the health informatics

field is gaining in this area of the world. In its 4

Conference that was held in April 2013, MEAHI had

an inaugural meeting that included MEAHI-Nursing

Informatics (MEAHI-NI ) activities since that it was

one of the conference tracks. Additionally, the

second meeting of MEAHI-NI is planned to be

conducted in Kuwait during MEAHI-STC (MEAHI

Special Topic Conference) in December 2015.

Moreover, this Middle Eastern varied adoption rate

might be due to the fact that the implementation of

technology in healthcare in the region is still in its

early stages for many countries here. However, there

are some countries that achieved a remarkable

progress in the area of healthcare technology

adoption such as the case of King Faisal Specialist

Hospital & Research Center (KFSH&RC) in Saudi

Arabia, which become in 2015 the first health

system to attain Ambulatory HIMSS Stage 7

Adoption Model (EMRAMSM) that is provided by

HIMSS Analytics, outside North America. It took

KFSH&RC more than thirteen years to achieve this

level of adoption. Nevertheless, many hospitals

within Saudi Arabia are still struggling when it

comes to the implementation of healthcare

information systems. This example can clearly show

how varied is the state of adopting such technology

within the same country in some cases not to

mention between the different countries in the

region. This could be the result of not having a

national strategy for implementing healthcare

technology in many of these countries, even though

having national healthcare information systems is

one of the strategic goals in many of them, and

leaving such enormous task to the diligence and

discretion of the different sectors that are responsible

for providing healthcare in each country. However,

the Middle East has many opportunities that can

promote the adoption of healthcare technology

adoption. According to Dr. Suzan Ahmad “The

strength of the Middle East region in terms of

informatics lies in its recognition of the importance

of implementing state-of-the-art information

solutions in healthcare. Many initiatives are

underway to promote Health Informatics in

governmental and non- governmental organizations

An Overview of Nursing Informatics (NI) as a Profession: How we Evolved Over the Years

203

that will upgrade the entire healthcare system”

(Ahmad, 2015). Conversely, the indecisiveness that

results from the lack of understanding represents a

major drawback to the adoption of healthcare

information Technology within the region. Such

disadvantage has slowed the adoption of IT and

shown the necessity of a special education about the

benefits as well as the disadvantages of healthcare

technology, which is a fundamental requirement of a

successful adoption of EHR technologies (Simpson

and Stewart, 2010). When viewing Turkey as an

example, Erdemir (2010) illustrates the remarkable

progress Turkey has made in the healthcare

information and management systems arena, which

is largely represented in the Turkish e-Health

Project. Yet, it is noteworthy that even with the

efforts of different disciplines and/or units in

Turkey, the progress in the field of healthcare

information and management systems is still limited

(Erdemir, 2010). Furthermore, since the beginning

of the 1990s, information systems and the electronic

health record have secured a place in the healthcare

agenda in Turkey as well. When it comes to nurses

contribution to this process, Erdemir (2010)

mentions that Turkish executives and policymakers

must recognize the pivotal role of the nursing

profession in the strategic planning of the Electronic

Health Records (EHRs) and information systems in

both their own organization and within the national

Turkish organizations. On the other hand, in

Lebanon for instance, “the use of computer

technology in all sectors including healthcare is still in

its infancy. One of the top hospitals in the country is

planning to implement a fully integrated, networked

hospital information system (HIS) over the next three

years. There are stand-alone systems for the laboratory,

radiology, and billing departments. However, point-of-

service systems, the computer-based patient record, and

other NI applications are not yet available” (Marini,

2000). Until the year of 2000, Marini indicated that

except for the American University of Beirut-School

of Nursing (AUB-SON), NI nor computer literacy

has being taught in any program of nursing in

Lebanon. This incorporation of NI in AUB-SON

curriculum was a subsequent of the recent Lebanese

initiatives to implement Health Information Systems

and computer technology in the healthcare sector

within the country.

3.3 NI History in Africa

In Africa, the association of Health Informatics in

Africa (HELINA) was created in 1993. In 2010,

Cape town in South Africa hosted the first ever

African MEDINFO i.e. the Confernece on Health

Informatics of IMIA. HELINA include almost ten

countries as a full members such as Malawi,

Nigeria..etc, while a number of countries are

considered as corresponding member countries such

as Algeria and Tanzania. When reviewing the

literature about the implementation of healthcare

technology in these countries, it can be clearly seen

that many national healthcare strategies (such as in

South Africa and Ghana for example) have been

influended in one way or another by the 2005

eHealth project’s definition and aims of the 58

World health Assembly of the World Health

Organisation (WHO) in Geneva, which suggested

incorporating the Information and Communication

Technologies (ICT) into the global healthcare

systems to help reach communities like vulnerable

groups (Sarfo and Asiedu, 2013; Department of

Health in the Republic of South Africa, 2012). When

it comes to NI, there are similarities to a certain

extent in the current view of the field of nursing

informatics between the African and the Middle

Eastern visions. We can say that NI is still largely

viewed as a synonym to health informatics, or in the

best cases, as an integral division of it. The

importance of NI as a distinctive discipline has not

yet been understood and realized by many clinicians.

This does not mean that individual efforts are not

being made to help shape the structure and the body

of knowledge of this discipline in these parts of the

world. Nevertheless, in Egypt, technology is

increasingly becoming an integral part of the

healthcare system. The Egyptian Hospitals have

gone through the process of trials and efforts in

order to develop the discipline of nursing

informatics within the country. Some of the

difficulties that faced these efforts are the varied

levels of education for nurses, the low ratio of nurse

to patient, resistance to change and not really

involving nurses in the different phases of the

implementation (Ebrahem et al., 2014). On the other

hand, Nigeria’s history with health informatics

began in the late 80s with a collaborative research

project that was initiated between the Finnish

University of Kuopiom Computer Center and the

Nigerian Obafemi Awolowo University, and

Obafemi Awolowo University teaching Hospital

(OAUTHC) (Idowu, et al., 2003a) as a part of a

long-term research project on the development of

Informatics for Health in Africa, i.e INDEHELA

(Idowu et al., 2008). The result of this joint project

was the production of a very rudimentary hospital

information system (HIS) which was running on a

stand-alone PC that was in use at OAUTHC at that

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time i.e. 1991 and is based on the Admission,

Discharge, and Transfer of the Veterans

Administration (VA) (Idowu et al., 2008; Daini et

al., 1992). Afterwards, the group organized the 1

International Working Conference on Health

Informatics in Africa that was held at Ile-Ife, Nigeria

between the 19-23 of April, 1993 (HELINA, 1993).

Furthermore, Idowu and colleagues (2008) identify

several obstacles that hinder the implementation of

health Informatics and the use Information and

Communication Technology (ICT) in Nigeria such

as government’s attitude, cost of ICT peripherals,

resistance to new technology..etc. These obstacles

are the result of three factors, namely, people,

government and ICT infrastructure as indicated by

and Idowu and colleagues (2008). When it comes to

nurses’ knowledge of nursing informatics in Nigeria,

a study in 2014 by Olajubu, Irinoye, & Olowokere

revealed that the knowledge of NI in this sample of

nurses in primary, secondary, and tertiary healthcare

facilities was just fair, and the majority described

themselves as ‘not competent’ when it comes to the

use of NI. The limited computer access was the most

perceived barrier among the thirteen barriers that

were identified by the same study (Olajubu et al.,

2014).

3.4 NI History in Australia and New

Zealand

When tracing back the nursing informatics’

early beginnings in New Zealand, it can be

seen that the early 1980s witnesses the early

inception of the discipline, even though it took

New Zealand about ten years to establish the

first national organization in 1991 (Appleton et

al., 2000). In 1989, the New Zealand

government funded Jan Hausman to develop a

national curriculum of nursing informatics.

Nursing informatics competencies were

identified by this curriculum along with the

associated attitudes, skills, and knowledge

which still currently relevant for the most part

(Honey and Baker, 2004). Each school of

nursing in New Zealand is being supplied with

a NI curriculum document along with a set of

teaching resources and packages. However, a

great variation in the introduction of nursing

informatics is present (Honey, & Westbrooke,

2012). Additionally, Nursing Informatics New

Zealand (NINZ), which was the first

informatics group for health professional

formed in New Zealand, hosted in 2000 the 7th

International Nursing Informatics Conference

(NI’2000) in Auckland, New Zealand (Honey

and Westbrooke, 2012). In Australia, at the 7th

National Conference of the College of Nursing

Australia which had a theme of ‘Information

Processing: Challenges and Choices for

Nurses’, a nursing group was founded in 1985

‘to promote improvement in nursing care

through the use of information technology and

to provide a forum for sharing knowledge and

experiences’

”

(Griffin, 1989). Late in the same

year of 1985, the Nursing Computer Group

Victoria was established. Two years later in

1987, the group won the bid to host IMIA’s

WG8, which is known now as IMIA-NI, 4

International Conference on Nurses’ use of

Information Science and Computers that was

held in Melbourne in 1991 (Hovenga, 1997).

After this successful conference, the Nursing

Computer Group Victoria changed its name in

order to mirror its growing national

membership to become the Australian Nursing

Informatics Association. About the same time

in other Australian states, other similar groups

were created. All these groups decided in 1994

to work together by forming the Australian

Nursing Informatics Council (ANIC), with a

representative and territory group from each

state.

3.5 NI History in Europe

In 1993, EuroMISE i.e. European Education in

Medical Informatics, Statistics and Epidemiology, a

joint European project was started under the aegis of

the European TEMPUS-PHARE programme. The

idea of this project was to teach health informatics to

teachers in among others. The programme involved

Faculty from various European countries while

students came from countries in the central and

eastern European (Zvarova, 1998). Furthermore, the

outcomes of other European funded projects such as

EDUCTRA, the EuroMISE, the ERASMUS MSc

Programme, etc.. were the starting point of the

Information Technologies EDUCation and

TRAining project known as IT EDUCTRA which

was approved in the 4th EU Framework programme

in 1995 (Hasman, 1998). The IT EDUCTRA

programme main goal was “to create a training

program for healthcare professionals in the basics of

information technology and IT medical applications”

while the ultimate production of this program was “a

CD-ROM containing the teaching materials and

tools and used new information technologies for the

dissemination of knowledge and skills required for

An Overview of Nursing Informatics (NI) as a Profession: How we Evolved Over the Years

205

new health care systems” (Hasman et al.,

2014).When specifically tracking the NI education

in Europe, a 1997 survey which included five

European countries revealed that NI education

differs widely within and between these countries

nursing curricula in terms of intensity, length and

equipment used. Furthermore, the results of the

questionnaire revealed that there are NI identifiable

course in 59% of these nursing schools.

Nevertheless, there are numerous initiatives in

Europe that promote the education of NI such as the

project of NIGHTINGALE EU (Nursing Informatics

Generic High-level Training in Informatics for

Learning & Education), another EU-Financed

project that was approved in 1995 (Mantas, 1997).

The main goal of the NIGHTINGALE project was

to “bring to the surface, by means of a series of

workshops, the user needs of the nursing profession

with respect to telematics, to develop a nursing

informatics curriculum for European nurses, and to

develop educational tools and software assisting the

educational process in nursing informatics” (Hasman

et al., 2014). This project was considered extremely

important and fundamental for planning and

therefore implementing a strategy to train the

nursing professionals in using and applying

healthcare information systems. Moreover, the

project was grounded on the previous experiences

that were obtained in the Telenursing AIM project as

well as on the EDUCTRA Concerted Action that

partially touched the subject of the education of the

nursing professionals and their training. A number

of Health Telematics Education in European

conferences were organized and a ‘health

informatics for nurses’ textbook was compiled as a

result (Mantas and Hasman, 2002). Additionally,

another distinctive movement towards developing

the discipline in Europe is manifested by the

creation of the European Federation of Medical

Informatics EFMI WG5 of nursing informatics in

Europe which is known as NURSIE in EFMI

Council meeting at MIE’88 in Oslo, Norway.

Moreover, the 13

International Congress in Nursing

Informatics (NI2016) will be held in Geneva,

Switzerland.

3.6 NI History in North America

When reviewing the history of NI in North America,

it can be seen that the discipline is better

documented, especially in the States, than in other

parts of the globe. Ozbolt ans Saba (2008) pointed

out how in the late 1950s, Werley was one of the

few who were consulted about the possible computer

uses in healthcare by IBM as " the ﬁrst designated

nurse researcher at the Walter Reed Army Research

Institute" (Ozbolt and Saba, 2008). In turn, Werley

was also able to convince the committee appointed

by the American Nurses’ Association in 1960 "to

include a focus on nurses’ use of information in

communicating and decision-making "(Ozbolt and

Saba, 2008; ANA Committee on Research and

Studies, 1962). Additionally, the first computer

applications in the nursing profession reports

appeared in the literature both scholarly and

professionally in the early 1970’s. In the 70s,

nursing informatics was supported by the

development of some of the early HIS by many

agencies/parties in the US. These HIS included

nursing care planning and documentation.

Furthermore, nurses were involved in these

interdisciplinary efforts which aimed at developing

and implementing applications that support health

care. Through the 80’s, NI practice, education, and

scholarship flourished and grew in the US. For

instance, in 1981, the National Institutes of Health

Clinical Center hosted its ﬁrst national conference

on Computer Technology and Nursing, with the

TRIMIS project of the Department of Defense and

the Division of Nursing of HRSA as co-sponsors.

Nursing schools and professional associations also

organized conferences and offered workshops.

Furthermore, in the schools of nursing, NI leaders

were introducing informatics courses. In 1984 and

1985 respectively, a Council and a Forum on

Computer Applications in Nursing were established

by the American Nurses Association and the

National League for Nursing. Furthermore, In 1988,

the ﬁrst NI graduate education program was opened

at the University of Maryland. The field gained more

recognition and many advancement have been

achieved through the 90s in the States such as, but

not limited to, the publications of the American

Nurses Association, the basic nursing informatics

certiﬁcation established by the American Nurses

Credentialing Center, additional NI graduate

programs etc.. The 2000s were largely revolving

around developing the standards needed for

achieving interoperability as well as nursing

Terminology models by many American parties

such as the American Health Information

Community (AHIC) and the Nursing Terminology

Summit Conference. Research was conducted to

distinguish the informatics competencies’ different

levels needed for all nurses and from those who are

identified as informatics nurses. On the other hand,

during the early to mid 1980’s in Canada, hospitals

began implementing HIS i.e. Hospital Information

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206

Systems, which included clinical applications such

as entering order and reporting results in which

nurses were expected to use. Accordingly, the

Canadian Information Systems Departments realized

that implementing such systems can not be done

without some kind of knowledge of the clinical

operations and input from its practitioners/users and

consequently started hiring nurses to bridge this

clinical-technical gap. Many titles described the job

of these nurses such as “Nurse Analyst”, “Nursing

Systems Coordinator,” and “Nursing Coordinator-

Computer Project” (National NI Project Discussion

Paper, 2007). On the other hand, the Canadian

Nursing Informatics Association (CNIA) received in

2001 the status of emerging group from the

Canadian Nursing Association (CAN) and afterward

the affiliate status in 2003. Now, the CNIA has full

associate status with the CNA. In addition, since

2003, there has been a noticeable increase in the

Canadian nursing informatics courses at both

graduate and undergraduate levels in nursing

schools. When it comes to education, in 2012,

CASN i.e. the Canadian Association of Schools of

Nursing, and Canada Health Infoway created and

developed Nursing Informatics Competencies for

Registered Nurses at Entry-to-practice level (Nagle

et al., 2012) along with learning resources and tools

that can help faculty in teaching undergraduate

students in nursing informatics. Additionally, CASN

is also “actively involved in supporting faculty in a

peer to peer network to help faculty master nursing

informatics competencies and integrate them into

nursing curricula across the country. Peer leaders are

engaging nursing faculty across the country”

(Madsen et al., 2015; CASN, 2015). Moreover, in

2012, the 11th International Congress on Nursing

Informatics was held in Montreal, Canada.

3.7 NI History in Latin America and

Carribean

As indicated by Jhon (n.d.), the activities of

individuals have been viewed and considered as the

base of NI in South America more than

governmental policies or any national efforts.

Additionally, in each South American country, there

is a variation rates and levels of development and

implementation of technological resources (Jhon,

n.d.). Jhon also mentioned that the growth in

information technology in the region of Latin

America and the Caribbean has been consistently

reported as the world highest for the past 20 years.

Moreover, the countries of Latin America and the

Caribbean are rank third in information technology

expenditure (Panis, 2015). Consequently, guidelines

and protocols have been published by the Pan

American Health Organization (PAHO) to orient

and guide the development and deployment of ICT

within the region. When speaking about the motives

behind starting NI initiatives in South America, Jhon

says that administrative and financial concerns were

the initial motivation for developing computer

systems in the area of healthcare. Countries like

Mexico, Brazil, Argentina, Chile, Colombia, and

Paraguay have clinical information systems in

hospitals/health institutes. He also indicates that

"National and International software become more

represented in South America health care workers(

"Jhon, n.d.). Furthermore, workshops, conferences,

congresses, education and training programs are

being arranged in order to share NI experiences in

these countries. Accordingly, in order to meet the

education and training need of the nursing

workforce, programs have been initiated by nursing

schools and hospitals to prepare nurses on how to

use computers. For instance, the Federal University

of São Paulo started the first center to offer the

specialization degree certificate in NI in South

America i.e. Nucleo de Informatica em Enfermagem.

Jhon concluded that NI is considered as an integral

part of healthcare that result from the advancement

achieved in the entire health informatics sector.

Additionally, the NI development is carried out on a

case by case basis that take into account each region-

specific needs and requirements (Jhon, n.d.). On the

other hand, ongoing discussions at many levels,

including federal, about implementing computer

systems for managing health information are noticed

in a number of these countries such as in Brazil

(National Education Council (BR). n.d.; Sanches et

al., 2011). Sanches, Jensen, Monteiro, and Lopes

(2011) indicated that Brazilian public initiatives are

supporting the notion of implementing and

integrating such systems to be used at various levels

of healthcare. As a result, the Unified Health System

(SUS) National Information and Health Informatics

Policy (PNIIS) was proposed (Sanches et al., 2011).

Furthermore, Sanches and colleagues identified in

their study about the teaching of Informatics in

undergraduate nursing programs at Brazilian public

institutions that “in Brazil, only 35 undergraduate

nursing programs at federal and state higher

education institutions offered informatics-related

subjects in their curriculum, available on the

Internet, in 2010” (Sanches et al., 2011).

An Overview of Nursing Informatics (NI) as a Profession: How we Evolved Over the Years

207

4 THE EDUCATION AND

COMPETENCIES OF NURSING

INFORMATICS

The education of NI witnessed a somehow slow start

as only two graduate-level programs were

established in the late 80s in the United States of

America (Heller et al., 1989; Graves et al., 1995).

Nevertheless, with a proper funding that is started in

1998, a steady increase in the number of the NI

programs continues and result in a numerous

programs in the States alone, even though a shortage

in the informatics faculty was reported as an

obstacle to the proliferation of these programs

(Murphy, 2010). Another paper, however, identified

the earliest NI curriculum initiatives that occurred in

1977 in a nursing program by Ronald and Skiba at

the state University of New York at Buffalo (Sackett

and Erdley, 2002). During the late 70s and through

the 80s of the last century, courses were mainly

focused on three components; “computer basics,

informatics related to the research process, and

software applications related to education,

administration, and clinical practice” (Sackett et al.,

2004). When it comes to the standardization of the

NI competencies at different levels of education,

many scholars have contributed to these efforts such

as Staggers et al. (2001) and (2002) who tried to

provide a framework that divide the NI personnel

according to their competencies into levels from

novice to expert practitioners. Other researchers

defined particular competencies that are needed for

nurses once joining the nursing workforce

(McCannon and O’Neal, 2003). Nevertheless, even

though many scientific publications of NI

competencies began in the late 80s and continued

until our current times, “the first master list of

discrete NI competencies” was only published in

2002 (Goncalves et al., 2012; Staggers et al., 2002).

An analysis of the latest research in this regard was

provided by Goncalves and colleagues in 2012.

5 THE ROLE AND CAREER

PATH OF NURSE

INFORMATICIANS

Only in 1992, NI was recognized as a distinguished

specialty in the US by the American Nurses

Association as one of its newest specialties. This

might explain why different specification for the NI

role exists, even though the general description

always include information organizing, managing

and providing nurses’ input into the implementation

process. However, an informatics nurse specialists

role specification was provided by staggers and

Thompson (2002) (Staggers and Thompson, 2002).

They describe the nurse informatics role

specification as “to employ informatics theories,

concepts, methods, and tools to analyze information

and information system requirements; design, select,

implement, and evaluate information systems, data

structures, and decision-support mechanisms that

support patients, nurses, and their human–computer

interactions within health care contexts; and to

facilitate the creation of new nursing knowledge”.

This role for NI was the result of the successive

advances in information technology arena. For nurse

informaticians, the career path typically starts when

the hospital come to a decision to implement a

clinical information system. A nurse will be hired to

bridge the gap between the nurses and the

implementation team and to bring a nursing

perspective to the table. They also ensure that the

nurses’ needs are considered when designing and

purchasing an automated system. The career options

expand as the nurse informatician’s knowledge,

skills, and experience grow. Some of them may join

a consulting firm, information systems vendor

(Rosen and Routon, 1998), or pursue further

education in the discipline and turn to academia

while the rest may continue working as a nurse

informatics specialist in hospital settings.

6 NURSING INFORMATICS

CHALLENGES AND

OPPORTUNITIES

Over the years, the NI profession has witnessed

many challenges as well as opportunities, and still is,

to evolve to the current state that we see it in today.

This progression has been in different rates and

patterns around the world. The background of those

involved in this profession that is varied as well

might contribute to these issues. The unique nature

of NI itself might also be one of the reasons of all of

these challenges and opportunities. Nevertheless,

many issues have been considered as challenges that

could be turned into opportunities in the field of NI.

These matters include accessibility of information,

lack of privacy, and freedom of use vs. security of

information (Baker, 2012). Designing and

implementing nursing information systems that can

improve patient care efficiency and effectiveness

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208

and, simultaneously, track patient outcomes and

preparing the nursing workforce to manage the

challenges that might accompany this process is also

viewed as one of the most significant challenges that

faces nurse informaticians (NagelKerk et al., 1998).

Another study in 1994 identified six fundamental

factors that affect nurses during a computerized

process implementation. These factors include

established time frame, strong leadership, carefully

planned training, effective communication, proper

choice of software, and planned change process with

leadership as the most important factor among all

(Adaskin et al., 1994). The low number of NI staff

could also be considered as another obstacle.

Furthermore, in terms of education, many obstacles

still face the incorporation of core informatics

courses into the curricula of nursing schools. The

lack of well-prepared faculties to teach these courses

is considered as another drawback that hinder the

accomplishment of this goal. On the other hand,

there are many associations/ unions around the

world that act as an umbrella for nursing

informaticians in different countries such as the

Alliance for Nursing Informatics (ANI), American

Nursing Informatics Association (ANIA), Canadian

Nursing Informatics Association (CNIA), and the

International Medical Informatics Association

Nursing Informatics Special Interest Group (AMIA

NI). This can be seen as a significant advantage that

has the potential to help better shape and

professionalize the discipline. Have an established

accreditation system in the states for the nurse

informaticians can also greatly serve this cause if

transferred to other countries for instance. Also, a

number of initiatives that have the same goal such as

Technology Informatics Guiding Educational

Reform (TIGER), the Health Information

Technology for Economic and Clinical Health

(HITECH) Act, and the Quality and Safety

Education for Nurses (QSEN) have also positively

contributed to these efforts.

7 CONCLUSION,

RECOMMENDATIONS AND

FUTURE DIRECTION FOR

RESEARCH IN NI

NI is one of the newest specialties in the nursing

profession and is as well a distinctive subspecialty of

the interdisciplinary field of health informatics. Its

unique nature significantly contributed to its

evolution in different aspects in terms of its

definition, history, and its practitioner role,

education and competencies. Nevertheless, thanks to

the efforts of many scholars and associations in the

field, NI continues to steadily expand and grow

around the world. Globally though, it can be seen

that remarkable advancement has been achieved in

some countries or even in some parts of the same

country, while other regions/countries are still

lagging behind in this aspect of healthcare. Carefully

creating and clearly defining the body of knowledge

for the discipline of NI is imperative because nurses

constitute the majority of healthcare professional

and are already using technology in healthcare

education, practice, and research. More research is

indeed still needed to clearly develop the education,

competencies, and job description of NI

professionals. An active international body that act

as an umbrella that regulates NI activities around the

world can help properly utilize the lessons of the

past and benefit from the valuable experience of the

NI pioneers who can be an active participants in

achieving the aforementioned goals. From a clinical

practice point of view, the role of nurses in all the

phases of the HIT implementation should be clearly

defined to encourage more nurses to confidently

participate in the implementation process by

supplying them with the needed resources and

materials to facilitate such involvement. In order to

do that, more research is certainly needed to

identify what core skills should be incorporated in

the future basic nursing education and training

curricula and the best way to integrate them in the

nursing schools. In addition, with the emergence of

concepts such as telehealth, telemedicine and

telenursing, more research is needed to assess these

processes and identify their pros and cons in terms

of patient care, clinical practice and education.

(Vernic, 2012).

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