Functional areas for nursing informatics

Application: Informatics Functional Areas

Informatics is one of the most diverse disciplines in health care. Many nurses have been able to capitalize on their informatics knowledge and interests to carve out new roles within their own health care setting. As you embark on your own informatics career path, it is important to be aware of the vast possibilities that await you. One of the best sources to begin your investigation is the American Nurses Association (ANA). The ANA recognizes that nursing informatics titles have little standardization across health care settings. As such, they have categorized the roles of informaticist into nine functional categories:

Administration, leadership, and management
Analysis
Compliance and integrity management
Consultation
Coordination, facilitation, and integration
Development
Educational and professional development
Policy development and advocacy
Research and evaluation (ANA, 2015, pp. 32-34)
In this Assignment, you first consider the various functional areas as outlined by the ANA. You then examine your personal attributes and interests as you consider your future as a nurse informaticist.

To prepare:

Review the nine functional areas for nurse informaticists as identified by the ANA.
Select the functional area in which you are most interested. Then, conduct additional research to identify the general responsibilities and duties associated with nurses working within this area.
Consider your current professional role. How might your personal attributes and interests help you to be successful in your selected functional area? What skills might you wish to develop to better position yourself for success?
To complete:

Submit a 3- to 5-page paper on or before Day 7 of Week 2 that addresses the following:

Identify the nursing informatics functional area in which you are most interested.
Summarize the general responsibilities and duties of nurses who work within this functional area.
Explain how your personal attributes, interests, knowledge, and nursing background will help you thrive within this area.
Propose three overarching skills you could develop to become more effective in this functional area. Justify the importance of each skill by providing applicable examples. Cite your resources as appropriate.
This Assignment is due on or before Day 7 of Week 2.

Reference:
American Nurses Association. (2015). Nursing informatics: Scope and standards of practice (2nd ed.). Silver Spring, MD: American Nurses Association.

computer science, information science and nursing science de - signed to assist in the manage- ment and processing of nursing data, information and knowledge to support the practice of nursing and the delivery of nursing care” (para. 1). The American Organi - zation of Nurse Executives (AONE, 2011) sets competencies related to information technology. These competencies range from the use of email, office productivity soft- ware, and business analytics tools to demonstrating an awareness of societal and technological trends, issues, and new developments as they relate to nursing.

The convergence of four envi- ronmental factors is setting the stage for a more rapid deployment of clinical information systems: • The financial incentives asso-

ciated with the “meaningful use” of technology as outlined in the American Reinvestment and Recovery Act of 2009.

• Technology-based innovations such as cloud computing and social media.

• Widespread adoption of so - phisticated analytical tools for

executive decision making. • The inability of most chief

nurse executives (CNEs) to ef - fectively champion nursing’s technology-related needs in the physician-led and domi- nated technology evaluation process. The unparalleled complexity

of patient care makes nursing completely dependent on the instantaneous availability of infor- mation to fuel the iterative nature of decision making central to patient care. In patient care, it is information technology that amas - ses data and turns it into informa- tion and, ultimately, the knowl- edge that advances nursing and patient care (Simpson, 2012).

Not only are technology evalu- ations and their related decisions organizationally transformative, their impact can be felt for de cades. The life cycle of every technology investment spans seven distinct phases, from planning to procure- ment to deployment to management to support and disposition, only to cycle back to planning. With an ever-present obsolescence engag- ing at any step in the process creat- ing change, this ever-cycling life cycle continues. In addition, the impact of technology’s planned obsolescence cannot be overlooked

EXECUTIVE SUMMARY Using the Informatics Organizing Research Model (Effken, 2003) to add context to the information gleaned from ethnographic inter- views of seven chief nurse execu- tives (CNEs) currently leading inte- grated delivery systems, the author concluded nurse executives can no longer depend exclusively on American Organization of Nurse Executives (AONE) competencies as they outsource their responsibili- ty for information technology knowl- edge to nurse informaticians, chief information officers, and physicians.

Although AONE sets out a specific list of recommended information technology competencies for sys- tem CNEs, innovative nursing prac- tice demands a more strategic, broader level of knowledge.

This broader competency centers on the reality of CNEs being charged with creating and imple- menting a patient-centered vision that drives health care organiza- tions’ investment in technology.

A new study identifies and validates the gaps between selected CNEs’ self-identified informatics compe- tencies and those set out by AONE (Simpson, 2012).

Roy L. Simpson

Chief Nurse Executives Need Contemporary Informatics

Competencies

ROY L. SIMPSON, DNP, RN, DPNAP, FAAN, is Vice President, Nursing, Cerner Corporation, Kansas City, MO.

Instructions for Continuing Nursing Education Contact Hours appear on page 288.

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when nurse executives make infor- mation technology (IT)-related decisions (The Economist, 2009). Planned obsolescence, a business strategy em braced by technology providers worldwide, requires that designers engineer obsolescence into their products (The Economist, 2009). Technology providers whole- heartedly embrace the concept to en sure market demand, and its associated revenue streams, will be timed to occur as current products are phased out or “sunseted” (The Economist, 2009). That cycling back makes each and every health care facility in a near-constant process of technology selection, evaluation, deployment, and re - placement knowing obsolescence can trump at any time the process- es. This practicality differentiates Simpson’s model from Effken’s model.

While the life cycle looks sim- ple enough, its overlay with con- tent, outcomes, nursing informat- ics intervention, and client factors makes for a complexity not seen in other health care executive deci- sion making. These decisions form inside a context that includes cul- tural, economic, social, and phys- ical requirements. Adding an out- come orientation to the decision allows cost, quality, safety, and satisfaction layers to the discus- sion. The influence brought to bear by nursing informatics layers the decision again as content structure and information flow considerations impact the tech- nology under consideration. Fi - nally, the client factor overlays the decision with considerations per- tinent to client or discipline be - haviors and characteristics. This decision-making process mirrors the one described in the Infor - matics Research Organizing Mo - del (Effken, 2003).

The critical decisions required to organize and prioritize patient care against a complex backdrop of quality and patient safety issues hinges on the use of a wide range of advanced technologies opti- mized for nursing. CNEs’ respon-

sibility to evaluate, select, and deploy these advanced technolo- gies mandates either a nursing- centric deep knowledge of tech- nology personally or access to that knowledge via a direct reporting structure. For CNEs without per- sonal knowledge of technology considerations, access to an indi- vidual with the knowledge and the criticality of that knowledge to advance the practice of nursing underscores the need for a direct- reporting relationship with the technology-infused individual. Having a nurse informaticist on staff, even in a direct-reporting relationship, while a great help to the CNE, does not remove from the CNE the responsibility for being able to converse, debate, and champion specific technolo- gies and clinical information sys- tems personally. Only that level of knowledge can advance the re - quirements and needs of patient care at the executive table when technology decisions are made.

Two types of IT expertise remain critical to CNEs as they evaluate and select clinical infor- mation systems: process mapping, or discovering how the actual steps of nursing practice unfold during patient care; and workflow design, the mechanical arrange- ment of information, forms, and triggers to capture and document nursing practice. However mech - anical the process of creating and deploying workflows, they cannot be created by engineers and tech- nologists who lack the hands-on experience of delivering patient care at the bedside. Vendor-resi- dent engineers lack the site-specif- ic and nursing practice-specific knowledge required to add the context of the lived experience to the workflow creation process. While evidence in standardization of processes and practices is uni- versal in application goal, what it is not is nursing site specific, requiring some modifications if intended to achieve outcomes of efficiencies for software accept- ance by end users.

In this study, the lack of stan- dardization of nursing processes, procedures, and operations greatly complicated CNEs’ health infor- mation technology (HIT)-related decision making, especially in patient care operations with a high degree of automation. This increasingly complex patient care environment complicates a specif- ic and central HIT-related respon- sibility that falls to the CNE: the design and implementation of overarching nursing workflows. While some aspects of patient care remain resistant to standardiza- tion, the vast majority of these processes can be architected into workflows in much the same way that engineering has codified its processes and procedures. This engineering process cries out for the knowledge that only CNEs and nurse informaticists can provide as seen in the Informatics Re - search Organizing Model by Effken. The criticality of these two elements and their foundational aspects make process mapping and workflow design knowledge essential to CNEs’ evaluation and selection of clinical information systems (Simpson, 2012).

Study Purpose The purpose of this study was

to identify and validate the gaps existing between selected CNEs’ self-ascribed lived experience in - formation technology competen- cies and those laid out by AONE. Technology competencies are not just a part of CNEs’ responsibili- ties; this understanding and its related skills are critical to CNEs’ institutional and organizational leadership. While a thorough un - derstanding of technology’s im - pact on patient care remains the responsibility of nurse informati- cians, CNEs will need to possess a broad, working knowledge of IT to safeguard patient care outcomes. The nurse informatician’s role is to carry the vision of the CNE and nursing leadership team forward to application through technologi- cal innovations. Given the critical

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nature of nursing input to the pur- chase, design, and utilization of sys- tems, baseline information about needed nurse executive competen- cies could inform educators and professional organizations about the needs for nurse executive edu- cation in the IT and nursing infor- matics arena (Cerner, 2010). CNEs may need more sophisticated technology-related competencies and expertise if they are to harness the power of computing to demon- strate the quality and financial- related ad vantages that nursing brings to patient care.

Methodology Before interviewing the CNEs

participating in this study, the author submitted an application for the conduct of research using human subjects, which was ap - proved by the American Sentinel University Institutional Review Board.

The study’s sample population was limited to members of the Health Management Academy (HMA), which includes senior executives working at America’s leading integrated delivery systems (IDSs). No eligible CNE from an IDS using HIT from Cerner Corporation was included in the research.

A Confidentiality Agreement, which was signed by each inform- ant prior to the interview, stipulat- ed the coded data would not be released to anyone and the identi- ty of the informants would not be revealed.

To protect the informants’ pri- vacy, the MP3 files of each inter- view were associated with an alpha-numeric code. This code traveled with the digital file when it was sent to a professional serv- ice for transcription.

To better understand CNEs’ roles in the lived experience of this complex decision making, the in vestigator conducted ethnograph- ic interviews of seven CNE mem- bers of the HMA. Mem ber ship in the academy reflects the CNEs’ affiliation with the country’s lead- ing health systems and corpora-

tions. According to HMA (2012), membership in cludes exe cutives from approximately 90 health sys- tems that account for 55% of the hospital net patient revenue in the country, as well as more than 60 leading health care corporations. The selected CNEs’ professional experience spanned 40 hospitals in integrated health delivery net- works with a total of 8,645 beds located in seven states with an aggregate employee population of 53,735.

Health Management Academy members gain their industry-rec- ognized status not solely from their own body of work, but from the reputation of the IDSs for which they work as well. The combination of HMA’s executive- level contributions to the health care industry and their employers’ reputations as bastions of best practices well qualified them for their role as CNE informants. Each of the member IDSs functioned as a network of health care institu- tions, practices, and organizations to provide or arrange to provide a coordinated continuum of servic- es to a defined population. Each IDS agreed to be held clinically and financially accountable for the clinical outcomes and health status of the population served. IDSs encompass a community and/or tertiary hospital, home health care and hospice services, primary and specialty outpatient care and surgery, social services, rehabilitation, preventive care, health education and financing, and usually using a form of man- aged care (Washington State Hos - pital Association, 2012).

An ethnographic approach to CNE interviewing used iterative questioning based on the tacit information and inferences glean - ed from the early interviews to inform the later conversations, making the cumulative findings richer and more insightful than knowledge gained from consis- tently asking a standard set of questions to all CNE informants (Spradley, 1979).

As each interview was con- ducted, the author reviewed the data collected from that interview independent of the previously gathered information. Once that stand-alone analysis was com- plete, information gleaned from each interview was compared to the data stemming from previous informant interviews. Common and disparate themes were cap- tured for analysis as well.

Research Reveals Common, Disparate Themes

This research set out to an - swer a single pivotal question: “What is the state of CNEs’ HIT- related decision making compared to the competencies outlined in AONE’s recommended informa- tion technology competencies?”

A key part of analyzing the data from informant interviews centered on identifying cultural themes, which defined any princi- ple recurrent in a number of domains, tacit or explicit (Spradley, 1979). These themes pinpointed relationships among subsystems of cultural meaning (Spradley, 1979). Data were scored, key- words were identified and trend- ed, and topics and insights were recorded, with each element being used to reshape the subsequent informant interview questions as themes emerged. For example, informants interviewed early in the research might refer to a “com- puter physician,” while inform- ants speaking in later interviews might refer to the same type of individual as a “chief medical in - formation officer.” If the term evolved in informant sessions, the term “computer nurse” was re - placed with “nurse informatician” in later interviews.

Terminology related to nurses represented a single area of evolu- tion but other subject areas were likely to shift as well. For exam- ple, early interviews probing nurse executives’ data use yielded comments relative to data analy- sis. As the interview process pro- gressed, mentions of the term

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“data analysis” dwindled with more informant comments focus- ing on the use of “statistical data mining and dashboards,” an advanced and more complex form of data analysis.

During the CNEs’ interviews, an 8.5 x 11 inch sheet of ruled paper was divided into two columns. The first column con- sumed the left one-third of the area with the remaining two- thirds forming a second column. Handwritten notes taken during the interviews filled the second column, leaving the left-hand col- umn open for later analysis. These handwritten notes served as a backup resource to the electronic recordings made of each CNE interview.

After each interview, the notes were read and the conversation recalled in terms of a keyword search. As keywords emerged from the conversation, themes came into view. Building on the iterative nature of ethnographic interviewing technique, each pre- vious interview’s keywords and themes were used to enrich subse- quent interviews.

Once all seven interviews were completed, each interview was read completely to scan for content. A second reading focused on context. A third reading pin- pointed keywords and emerging themes, which were captured on sticky notes. The use of reposi- tionable notes proved to be a key element of the analysis process as the review continued over several days. Keywords and trends natu- rally led to trends and patterns of comments.

To conclude the analysis, an exercise that pinpointed evidence of each AONE-recommended in - formation technology was conduct- ed. This analysis showed the CNEs demonstrated competencies in each required area with one excep- tion. As a group, the CNEs did not demonstrate an awareness of socie- tal and technological trends, issues, and new developments as they relate to nursing (AONE, 2011).

The Data Using keywords and exem-

plars to expand on CNEs’ themes gave context to the data. Themes and associated keywords are sum- marized in Tables 1 and 2. Themes aligned with the keywords and exemplar quotes from the seven interviews are identified in Table 2.

Analysis Interview data. During analysis

of the CNE interviews, five domi- nant and often interwoven themes emerged: technology knowledge, collaboration, HIT selection, execu- tive leadership, and standardization. Each of these themes represented overarching areas of concern for the CNEs, who demonstrated compe- tency in each of the AONE-recom- mended IT competencies with one exception. That exception centered on the CNEs’ lack of awareness about societal and technology trends, issues, and new develop- ments as they related to nursing.

Technology knowledge. CNEs’ lived experience, as expressed through a series of seven ethno- graphic interviews, validated the opinion voiced in the literature that nurse executives lack the foundational knowledge of tech- nology needed to understand, appreciate, and leverage rapidly advancing technically based capa- bilities (Ball et al., 2010). The in - terviews indicated CNEs have chosen to bypass amassing deep technology knowledge, instead relying on emotional intelligence and depen dencies on nurse infor- maticians and chief information officers (CIOs), to exert nursing’s influence into HIT decision mak- ing. CNEs’ lived experience a - ligned with the trend for nurse leaders to look to nurse informati- cians and clinical nurse special- ists (CNSs) to provide the deep technology knowledge they lack (Westra & Delaney, 2008). State - ments such as, “I depend on my nurse informatician to give me the information” flagged this depend- ence.

CNEs said they depended on HIT vendors for their technology education, which gave pause to understanding the various trade- offs vendors make in the system design. Although the research did not ask the question directly, it can be inferred from the CNEs’ responses that their limited tech- nology knowledge renders them unable to champion the collec- tion, analysis, and trending of nursing data in a chief medical officer (CMO)-dominated HIT dis- cussion.

Is it possible the CNEs share an overarching lack of ownership and urgency around the acquisi- tion of technology knowledge? Despite their heavy dependence on HIT vendors for their baseline technology knowledge, only one CNE expressed the need to make technology learning a priority. The CNEs agreed HIT was a priority but not a top priority. They viewed HIT as a tool for nurses in their daily work and as a dash- board for management – not a strategic decision-support tool for their own use.

Collaboration. HIT-related co l - laboration specific to system eval- uation and selection posed a series of challenges for the CNEs. Collectively, they expressed a pre- vailing scenario in which their opinions are not heard and they are unable to counter physician viewpoints in CMO-driven deci- sion making about HIT.

Leadership. CNEs pointed out that when health care organiza- tions employ CIOs from industries outside the health care environ- ment, a particular challenge aris- es. The CIOs’ lack of clinical expertise required the CNE and the CMO to tightly align to lead executive decision making toward improving patient care rather than opting for technology-based oper- ational efficiency.

HIT selection. Collaboration again entered into the CNEs’ inter- views when they spoke about implementing and utilizing the selected HIT systems. The logis-

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tics and expense involved in staff education, a cost which is often overlooked when calculating total cost of ownership, comes into play several times during technol- ogy life cycles: during a system’s initial implementation, as staff turnover occurs, and at regular intervals as system upgrades are made. Each of these intervals demanded the CNEs use their executive leadership positions to collaborate across cross-depart- mental and cross-operational lines especially with CMOs and CIOs. The CNEs’ said their lack of deep

technology knowledge often ham- pered effective collaboration.

Standardization. The lack of standardization of nursing pro - cesses, procedures, and operations greatly complicated the CNEs’ HIT-related decision making, es - pecially in patient care operations with a high degree of automation. This increasingly complex patient care environment complicates a specific and central HIT-related responsibility that falls to the CNE: the design and implementation of overarching nursing workflows. While some aspects of patient care

remain resistant to standardiza- tion, the vast majority of these processes can be architected into workflows in much the same way that engineering has codified its processes and procedures.

Workflow alone is a strategic key only if applied from the view and vision of the nursing practice. One informant said that to suc- ceed in this role “you better have implemented a system before.” Another informant mentioned the care continuum as a prerequisite to understanding of workflow and role as system CNE.

Chief Nurse Executives Need Contemporary Informatics Competencies

SERIES Table 1.

Trending of Themes from CNEs’ Interviews

Theme Interview

1 Interview

2 Interview

3 Interview

4 Interview

5 Interview

6 Interview

7 Frequency of Mention

Technology knowledge X X X X X 5

Collaboration X X X X 4

Executive leadership X X X 3

Health information technology selection X X X 3

Standardization X X 2

Technology vision X 1

Challenges X 1

Chief nursing information officer X 1

Chief information officer X 1

Workflow X 1

Leadership X 1

Benchmarking X 1

Nursing vision X 1

Driving improvement X 1

Working with the board of directors X 1

Technology leadership X 1

Technology priorities X 1

Executive decision making X 1

Technology innovation X 1

Return on investment X 1

Communications X 1

Metrics X 1

Keys to success X 1

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SERIES Table 2.

Themes and Associated Keywords from CNEs’ Interviews

Theme Keywords Exemplar Quotes

Technology vision Vision, egalitarian “[The CNE]…needs the acumen and the expertise to be an egalitarian partner with the physician and the medical staff.”

Technology knowledge

Schooled, schooling, current knowledge, staff education, physician leader, dependence on others, competency

“There is simply not a vehicle here where people are schooled [in technology] within the organization.”

“I pulled the nursing team together and we trained 10,500 people. It cost more than $2,000,000.”

“…there is more focus around understanding from a chief nursing officer’s perspective what it takes to deliver care to patients, what the organization’s and nursing’s plans are for changing that care delivery and then understanding the points at which technology helps to assist in that process and facilitate the care.”

“I’m not very technically competent. As I look at the things I would have done differently, I would have recognized that I needed to be smarter [about technology] sooner.”

HIT selection Chief medical information officer (CMIO)

“They strategize with me and we get what we need into the strategic plan but the overarching power comes from the CMIO and what the doctors want.”

“[I am] the person most influential in impacting what our strategic future is using technology for care, and for nurse and patient safety.”

Challenges Bad processes, misunderstandings, physician-centered

“One of the big challenges is that we have really bad processes within organizations. We think implementation of a technology will fix a bad process.”

“As a CNE, one of my struggles has been is that we’re going to not just adopt [technology]. I find I have to insert myself into groups who think they understand what that process or system might need to look like when they really don’t understand it.”

Chief nursing information officer

Partnered “We were able to develop nursing informatics roles in this organization and develop a career ladder that never existed. It wouldn’t have existed if we hadn’t partnered to be to that…”

Chief information officer (CIO)

Chief information officer change

“We recently changed the CIO. [The] prior CIO was someone who centrally believed he could make all the decisions…and he partnered with no one.”

Workflow Common goals “The way the work gets done is we have an agreed upon set of structures and processes that are inclusive of nursing and ancillary and physician leaders in the organization. We have those discussions that we need to have around our common goal which is caring for patients.”

Leadership Aggressive, knowledge base, politics

“You have to be forceful, assertive, and sometimes really aggressive.”

Benchmarking Data-driven, payers “You have to be data-driven. You have to be able to turn the data into information.”

Nursing vision Quality indicators, quality improve - ment, engagement

“[My] vision of nursing… [is to be able to] trace back quality indicators [to show] how the nurses and the assistant personnel either helped or didn’t help in the delivery of that care.”

“[The] CNE engages end users at all levels to help understand the care and processes that need to be delivered, in setting that vision for what they need and then [accounting for] outside forces that end users may not truly understand. You take the information from those who pay us and who set other expectations…and then transfuse that into your organization by sharing that knowledge.”

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SERIES Table 2. (continued)

Themes and Associated Keywords from CNEs’ Interviews

Theme Keywords Exemplar Quotes

Health information technology selection

Implementation, rollout, evaluation

“When I was at a freestanding hospital, I was very involved in the selection process.”

“You’ve got to do more build. You’ve got to revise based on end users’ feedback…we are not ready to implement this.”

“I, myself, do not spend time evaluating. I depend completely on my staff…to make recommendations.”

Driving improvement

Inquisitive “As a chief quality officer, I was very inquisitive about how to get data out of the system and use it to drive improvement.”

Collaboration Data analysis, governance, physician- dominated, strategic plan, CIO, strategic plan, change initiatives

“…chief patient safety officer who has become very involved in analyzing the work that’s going on and how it might contribute to errors. He measures adverse events related to anything in the electronic health record.”

“We have a department of qualitative sciences…that helps us quantify issues. We have an executive steering team of electronic health records, and we have an information services governments council. He and I both sit on these councils.”

Working with the board of directors

Rollout “It really took standing up to the board members…and saying, ‘It’s [the system] not ready. We will have potential patient safety issues if we roll this out.’”

“Part of the dilemma has been in a multi-hospital system [is around] who is really making the [rollout] decision.”

Standardization Baseline “They [multiple hospitals in the IDS] all want something different…The standards and processes have to be the same.”

Technology leadership

Development, learning, teaching, informatics

“We’ve had two major developments related to nursing and patient care, and the creation of the patient engagement and education record that reflects the multidisciplinary aspects of…learning across the continuum. We led the [pre- development] conversations…”

Technology priorities

Triage, shared priorities, continuum of care, risk stratification

“We are getting increasingly interested in risk stratification. If you have X number of changes in your orders in a shift or in an hour, then we see something is going wrong…If you don’t have an identified discharge date, we’re not planning to get you to the next point of disposition…”

Executive decision making

Governance, lobbying, emotional intelligence

“I would want to make sure that [the CNE candidate] had a very high score in terms of emotional intelligence. [That would be]… critical in a place like this.”

Technology innovation

Engineering “I’d like to go back to engineering school because I think it’s a gap in my knowledge as a nurse executive…”

Executive leadership

Integrity, executive secession, informal dialogue, visibility

“My nurse informatician and I have mutual integrity. I completely trust that what the people are reporting to me is accurate.”

Keys to success Relationships “[CNEs] may have the knowledge and be superb…but where they fail is in creating relationships that are effective…whether it’s [with] finance…or…IT…or the person in charge of facilities.”

Standardization Leading, informatics infrastructure

“Much of the work that I’ve been involved in [is] leading…around standardization of practice and elimination of variation. [We are] pushing toward role clarity and [seeing] how that gets expressed through the use of technology.”

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Gap Analysis A gap analysis of the CNEs’

HIT-related competencies and AONE’s recommended IT compe- tencies were conducted. The major- ity of CNEs self-described their technology competencies as ali - gned with the AONE-recommend- ed competencies. Six of the seven CNEs lacked a critically important recommended competency: being able to demonstrate awareness of societal and technological trends, issues, and developments as they relate to nursing. This overarching deficiency, when coupled with CNEs’ lack of historical technology knowledge, prevented CNEs from fully engaging in HIT-related deci- sion making. Table 3 shows the CNEs’ alignment with AONE’s rec- ommended information technolo- gy competencies.

Key Findings The CNEs pointed out two

ways they are marginalized in the evaluation and selection of clini- cal information systems. First, the CNEs found their review responsi- bilities limited to the functional level; that is, looking at the sys- tems’ features, rather than their ability to advance nursing prac- tice. Second, the CNEs explained that a CMO-led physician contin- gent guided IT decision making,

relegating CNEs to a “specifier/ recommender” role. CNEs found themselves limited in their ability to advocate effectively for technol- ogy needed to support nursing practice during the evaluation and selection of clinical information systems. As a result, there is no one at the executive decision- making table to advocate for the needs of patient care during all- important technology discussions (Simpson, 2012).

Another point emerging for CNEs is to use CNSs to stay abreast of current research and technology capabilities to support CNE strategy for amassing tech- nology knowledge in specific fields of practice. This delegation of HIT expertise significantly expands the traditional role of the CNS, which is to be competent in the practice and the technologies that support the domain of the individual practice (Simpson & Somers, 1991). For example, a car- diac CNS would also be responsi- ble for the knowledge of EKG monitors, echo, and other cardiac devices used in conjunction with cardiac care. The literature does not describe such attributes attached to the CNS nor does the American Nurses Association. However, this expectation, which could direct the advancing role of the CNS, could be the salvation of

CNSs’ future as well because it clearly differentiates their practice from that of the nurse practitioner. No one will know the machine- specific domain knowledge better than the CNS who is focused and mastered in the domain specific to that patient condition.

Impact of Social Media Although the CNEs demon-

strated knowledge of technology- fueled innovation in nursing prac- tice, two substantial gaps exist between the CNEs’ knowledge and AONE’s stated competency. The first gap pertains to CNEs’ aware- ness of societal and technological trends, issues, and new develop- ments as they relate to nursing, a stated AONE competency. The second disconnect occurs bet - ween CNEs’ knowledge and the AONE competency requiring pro- ficient awareness of legal and eth- ical issues related to client data, information, and confidentiality. Nurses’ use of social media lies at the intersection of both these gaps.

In the lived experience, for example, nurses routinely use social media to communicate nurse to nurse, nurse to patient, and nurse to patient family, nurse to physician, nurse to interdisci- plinary team, etc. (Black, Light, Paradise Black, & Thompson, 2013). It is troubling that this per-

Chief Nurse Executives Need Contemporary Informatics Competencies

SERIES Table 2. (continued)

Themes and Associated Keywords from CNEs’ Interviews

Theme Keywords Exemplar Quotes

Return on investment (ROI)

Cost of ownership, achieving ROI

“The executive group and the executive steering group of informatics look at ROI…That discussion happens both at the steering committee level and the senior executive level.”

Communications Alignment, social media, listening, needs

“Our metrics are showing that at the VP, AVP, and director levels, we have very good alignment in terms of the staff understanding the strategic direction and the purpose behind it. But we have a drastic falloff at the supervisor and below level.”

“We’re using social media [to communicate] more effectively with our employees. We’re now segmenting and tailoring our message, so that some of our communication [about nursing and technology] can be global.”

Metrics Drowning, process focus, outcome focus

“…nurses want to measure process rather than outcome. Getting that change in view pushed through the entire organization is critical. Process measures are great but you’ve really got to focus on outcomes and pushing that down to the unit level.”

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vasive communication violates The Health Insurance Portability and Accountability Act regula- tions (U.S. Department of Health and Human Services, 1996) and happens in the majority of facili- ties, even where CNEs have “banned” social media. Recently, researchers from the University of Florida examined 15 days worth of anonymous network utilization records for 68 workstations locat- ed in the emergency department (ED) of an academic medical cen- ter, comparing data from the ED workstations to work index data from the hospital’s information systems. Throughout the 15-day study period, health care workers spent 72.5 hours browsing Face - book, visiting the social network- ing site 9,369 times, and spending

12 minutes per hour on the site. The amount of time spent on Facebook, while significant, was overshadowed by a second re - search finding: the time spent on Facebook actually increased as patient volume in the ED rose. As a result, the researchers recom- mended future studies look at the impact of using Facebook in break rooms only and other non-work parts of the hospital (Narsi, 2013).

This real-life example shows CNEs cannot claim naiveté when it comes to the use of social media in their facilities. In this example, the lived experience does not support CNEs’ beliefs that they have been successful in protecting the confi- dentiality of vitally important health information. Policies that eliminate or restrict the use of

social media in their facilities must be equitable for compliance. Of course, this creates another set of dynamics which must be addressed. Plus it speaks to the def- inition and knowledge of “cloud computing” which lies at the core of confidentiality and security being that information on devices used could possibly be uploaded to the cloud. Unbe known to the user or CNE, these actions have the potential to breach confidence and privacy. If the knowledge of cloud were present, each informant would have equitably known infor- mation was uploaded from devices and security breached.

This research concluded that while the CNEs applied the major- ity of AONE-recommended infor- mation technology competencies

Chief Nurse Executives Need Contemporary Informatics Competencies

SERIES Table 3.

CNEs’ Alignment with AONE’s Recommended Technology Competencies

Competency CNE 1 CNE 2 CNE 3 CNE 4 CNE 5 CNE 6 CNE 7

Demonstrate basic competency in email, common word processing, spreadsheet and Internet programs.

X X X X X X X

Recognize the relevance of nursing data for improving practice. X X X X X X X

Recognize the limitations of computer applications. X X X X X X X

Use telecommunications devices. X X X X X X X

Utilize hospital database management, decision support, and expert systems programs to access information and analyze data from disparate sources for use in planning patient care processes and systems.

X X X X X X X

Participate in change management processes and utility analysis. X X X X X X X

Participate in the evaluation of information in practice settings. X X X X X X X

Evaluate and revise patient care processes and systems. X X X X X X X

Use computerized management systems to record administrative data (billing data, quality assurance data, workload data, etc.). X X X X X X X

Use applications for structured data entry (classification systems, acuity level, etc.). X X X X X X X

Recognize the utility of nursing involvement in planning, design, choice, and implementation of information systems in the practice environment.

X X X X X X X

Demonstrate awareness of societal and technological trends, issues, and developments as they relate to nursing. X

Demonstrate proficient awareness of legal and ethical issues related to client data, information, and confidentiality. X X X X X X X

Read and interpret benchmarking, financial, and occupancy data. X X X X X X X

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to their executive decision making, most did not demonstrate an awareness of societal and techno- logical trends, issues, and new developments as they relate to nursing. Considering the CNEs cited technology knowledge, or more precisely, a lack of technolo- gy knowledge, as their top concern, it was particularly disconcerting to see they did not demonstrate an awareness of technology direction and trends related to nursing.

AONE’s list of IT competen- cies offered CNEs a point from which to begin amassing baseline technology knowledge. For exam- ple, the competencies, such as being able to use email, word pro- cessing, spreadsheet and Internet- based programs, demonstrate only baseline knowledge. Baseline com- petencies do not indicate the level of knowledge and technical so - phistication the CNEs needed to evaluate, select, deploy, and uti- lize evidence-based HIT in system CNE roles of IDSs.

The AONE baseline compe- tencies do not address key aspects of executive decision making rela- tive to HIT, such as science-based workflow, evidence-based archi- tecture, and utility corporations. The complexity of modern nursing care requires a much deeper under- standing of technology capabilities and options if CNEs are to actively participate and lead or influence executive-level decisions related to the evaluation, selection, deployment, and utilization of HIT in IDSs (Nurse.com, 2011). The research did not attempt to gauge the nursing informatics expertise of nurses outside the CNE ranks. Nor did the research examine nurse informaticists knowledge of CNEs em ployed in settings other than multihospital network IDSs. The study did not address the fre- quency or appropriateness of CNEs’ decisions to delegate deci- sion making, responsibility, and/or ac countability to the integrated de - livery systems’ IT organization.

Each of the CNEs participating in the research demonstrated com-

petency in and applied the majori- ty of the AONE capabilities to their IT-related decision making. How - ever, those competencies corre- sponded to older, more established types of technology, such as email, office productivity software, and business analysis tools. The gaps in CNEs’ technology-related knowl- edge, as identified via ethnograph- ic interviews, pertained to the AONE competencies requiring: (a) an awareness of societal and tech- nological trends, issues, and new developments as they relate to nursing; and (b) proficient aware- ness of the legal and ethical issues related to client data, information, and confidentiality. It is imperative CNEs keep their technology-related competencies current to be able to anticipate how new technologies, such as social media, can be used to strengthen patient care and to evaluate if these same technologies hold any potential for harm to patients.

Recommendations for Future Research

Further research is needed to better understand how CNEs make decisions about the evaluation, selection, deployment, and uti- lization of HIT across the continu- um of patient care settings. Emo - tional intelligence ranks high on the scale for skills used today in the life cycle of HIT, but that will not suffice for knowledge in abili- ty to advocate for patient care. For example, hospitals and health care organizations not affiliated with an IDS were omitted from this research as were for-profit hospitals. It would be interesting to see if the same issues that affect HIT-related decision making in IDSs have relevance in for-profit institutions, smaller health care facilities, and stand-alone hospi- tals. Additionally, follow-up re - search could examine the role structured committees of corpo- rate-based CNEs play in technolo- gy education and life cycle. This could be the differentiating com- petency from operational site-spe-

cific CNEs and clarifying the role of the corporate CNE of IDSs. Additionally, studies centering on CNEs’ contribution to the automa- tion of key nursing processes, such as the development of nursing sci- ence-based workflows, would be useful. Another pressing need re - volves around the dissemination of new knowledge in computer science, information science, and nursing science to CNEs at health care organizations of all sizes.

Given the exhaustive patient care and operational requirements placed on the system-wide CNE, one can debate the value of man- aging skill sets versus becoming a technical content expert. Thanks to the powerful effect of Moore’s law on technologies of all types, nursing informatics quickly be - comes a core competency for CNEs in organizations of all sizes. As the CNE role expands to take on more organizational and financial res - ponsibility for patient outcomes, HIT becomes a key clinical and operational enabler of quality pa - tient care across all settings. As such, technology competencies specific to the CNE role will need to be studied, not only from a functional perspective as it is today, but from a strategic per- spective as well. Focusing on how CNEs leverage HIT to meet their organizations’ business goals should be a research imperative.

Conclusions Despite the fact that few tradi-

tional graduate programs in nurs- ing and business teach these fun- damental deep technology-related competencies, CNEs sit at the executive table during technology evaluations and routinely find themselves ill prepared to debate with their physician counterparts the functions of the clinical infor- mation systems. Specifically, CNEs must view these advanced tech- nologies from a strategic and oper- ational perspective that fine-tunes the systems’ architectural design, workflow, and processes for de - ployment in the patient care envi-

Chief Nurse Executives Need Contemporary Informatics Competencies

SERIES

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ronment. Additionally, CNEs need to go “toe to toe” in physician-led technology discussions. Simply put, CNEs must function as the “voice of patient care” in these debates because there is no one else at the table who will advocate for patients. As a result, the largest user population in the health care organization – nurses – find their requirements falling to a second- ary position behind the require- ments delineated and champion - ed by physicians.

This research asked a single, pivotal question: “What is the state of CNEs’ HIT-related deci- sion making compared to the com- petencies outlined in AONE’s rec- ommended information technolo- gy competencies?” The answer to that question was two-fold. CNEs demonstrated competency in and applied the majority of the AONE competencies to their decision- making process related to the eval- uation, selection, deployment, and utilization of HIT. However, the majority of the CNEs did not demonstrate a competency specif- ic to AONE’s call to “demonstrate an awareness of societal and tech- nological trends, issues and new developments as they relate to nursing” (AONE, 2011, p. 10).

In recognition of the critical need for CNEs at hospitals of all sizes to acquire and maintain cur- rent knowledge of HIT, it is time for the profession to enlist the help of academic leaders and reg- ulators in the effort to build a learning infrastructure capable of building a wide and deep HIT competency for CNEs in America.

Credentialing organizations and accreditation agencies, such as AONE Certification Center, National League for Nursing Accrediting Commission, Ameri - can Nurses Credentialing Center, and the Commission on Collegiate Nursing Education, would be well served to crystallize educational content to address CNEs’ lack of technology knowledge in curricula and certification. No longer can nurse executives at the highest lev- els depend exclusively on AONE competencies as they outsource their responsibility for information technology knowledge to nurse informaticists, chief information officers, and physicians. To do so would be to relegate the legions of nurses they lead to a subservient position in the value chain of health care providers, marginaliz- ing the profession. $