IWU Ethical Considerations in Healthcare Organizations Discussion

User Generated

ubcr8980

Health Medical

Indiana Wesleyan University

Description

Discussion Post Topic: Social, Legal, and Ethical Considerations

Global communication, social networking, artificial intelligence, sophisticated healthcare technology, electronic storage of information, and numerous decision-support tools present a plethora of social, legal, and ethical considerations for healthcare providers. The assigned readings will help you to explore recommended approaches and initiatives to maintain the integrity, safety, and security of healthcare information when computer technology is used.

Upon successful completion of this discussion, you will be able to:

Examine legal, social, and ethical issues related to computer technology in healthcare.

Resources

Textbook: Applied Clinical Informatics for Nurses (Link to e-book included with Login information will be provided)

File: A Nurse’s Guide to the Use of Social Media (Attached)

File: Evaluating Online Information (Attached)

Instructions

Review the rubric to make sure you understand the criteria for earning your grade.

Read chapter 6 in the textbook Applied Clinical Informatics for Nurses.

Download and read A Nurse’s Guide to the Use of Social Media. (Attached)

Download and view the Evaluating Online Information presentation. (Attached)

Search databases for a current (within the past 5 years), peer-reviewed article that discusses ONE of the following: (a) Social considerations for personal healthcare information (PHI), (b) ethical considerations for PHI, or (c) legal implications for PHI. OCLS resources are preferred sources and can be accessed through IWU Resources. Wikipedia is not permitted, as it is not a peer-reviewed, scholarly source.

Prepare to discuss the following prompts:

Discuss barriers and constraints related to privacy and confidentiality practices in the healthcare setting. Share initiatives that you believe are helpful in addressing these identified barriers to HIPAA compliance. Use scholarly sources to support your discussion.

Share information from your chosen article (see #5 above) with your classmates. Be certain to cite and reference the source.

After completing the assigned readings on this topic, what initiative will you take in your own professional practice to improve on social, legal, and ethical practices? Be specific in describing this initiative.

Unformatted Attachment Preview

Evaluating for Reliable Information from Internet Sources Created by Jeannie Short, MSN, RN For Indiana Wesleyan University Post-licensure (RNBSN) Program © 2012 It is essential that healthcare professionals and healthcare consumers know how to critically evaluate the quality of information found on the Internet. Online information may be evaluated using the following criteria: ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Source or Authorship Accuracy Currency Comprehensiveness Bias Audience Site Accreditation Ease of Navigation (Hebda & Czar, 2009) SOURCE OR AUTHORSHIP Internet sites are not censored, monitored, or reviewed by peers for accuracy. Anyone can publish anything on a web site. Information can reflect the opinion of an author that does not have the knowledge or credibility in regard to subject content. For this reason, the following questions should be considered….. (Young, 2008) SOURCE OR AUTHORSHIP …..Is an author indicated? If so, what are his or her credentials? Do the author’s credentials qualify him or her to fulfill the purpose of the document? Is contact information (email, telephone number, and/or address) included? (Young, 2008) SOURCE OR AUTHORSHIP …. What is the reputation of the sponsoring site? Are there links to affiliation sites? Is there a reputable publisher mentioned? Can information be obtained about sponsorship or affiliations in the site’s footer or header? What domain is indicated in the URL? (Young, 2008) ANATOMY OF THE URL (UNIVERSAL RESOURCE LOCATOR) http://www.nursingcenter.com/continuing/page-1.htm Hypertext Transfer Protocol Host Name Domain Suffix or Extension Folder Name File Name Domain extensions (i.e. “.org” “.com” “.gov” “.edu” “.net”) may indicate the appropriateness of the source for the information or site purpose. (Thede & Sewell, 2010) ACCURACY ….Can information be verified? Are citations given? Is a reference list available for the reader to validate the information? How scholarly are the references? Can information be corroborated from other independent sources? (Hebda & Czar, 2009) CURRENCY …. Is the web site information dated? Can one easily determine when it was written, revised, or reviewed? If timeliness is important for this topic, is the information dated within 5 years? Are links from the web site updated and current? (Hebda & Czar, 2008) COMPREHENSIVENESS …… Does the site discuss all pertinent and relevant aspects of the topic? Does the user need to “go elsewhere to find relevant information” that is needed? Are “broad generalizations” only discussed? (Hebda & Czar, 2009, p. 124) BIAS …… Does the site favor a particular product or service? Does the information reflect impartial views? Are there advertisements either on the web site or linked to the web site? Are the authors or sponsors trying to sell a product, entertain the audience, or persuade the users? Are there frequent “pop-ups”? (Hebda & Czar, 2009) AUDIENCE …… What audience was the web page intended for? Is the audience relevant to the topic being researched? “Are terminology and reading level appropriate for professional use?” (Hebda & Czar, 2009, p. 125) SITE ACCREDITATION …… Does the site display any seal that indicates accreditation or authenticity? Does the information indicate that predetermined standards are met? Does the site comply with formal regulations? Is a seal located on the site to indicate compliance with regulatory bodies? (Hebda & Czar, 2009) EASE OF NAVIGATION …… Is the web site content organized? Has the site used hyperlinks appropriately? Is the reader able to easily find information that is referred to? Are all links current and working? Does supplemental information load easily? Do disclaimers allow users to distinguish between fact and fiction? (Hebda & Czar, 2009) “ The challenge for consumers and healthcare professionals alike is the proliferation of information on the Internet and the need to know how to recognize when information is accurate and meaningful to the situation at hand.” (McGonigle & Mastrian, 2012, p. 353) References Hebda, T., & Czar, P. C. (2009). Handbook of informatics for nurses & healthcare professionals (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge (2nd ed.). Burlington, MA: Jones & Bartlett Learning. Thede, L. Q., & Sewell, J. P. (2010). Informatics and nursing: Competencies and applications (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Young, K. M. (2008). Informatics for healthcare professionals. Philadelphia, PA: Lippincott Williams & Wilkins PA: F. A. Davis. A Nurse’s Guide to the Use of Social Media A Nurse’s Guide to the Use of Social Media T A nurse must understand and apply these guidelines for the use of social media. he use of social media and other electronic communication is expanding exponentially as the number of social media outlets, platforms and applications available continue to increase. Individuals use blogs, social networking sites, video sites, online chat rooms and forums to communicate both personally and professionally with others. Social media is an exciting and valuable tool when used wisely. The very nature of this medium, however, can pose a risk as it offers instantaneous posting opportunities that allow little time for reflective thought and carries the added burden that what is posted on the Internet is discoverable by a court of law even when it is long deleted. Nurses are welcome to use social media in their personal lives. This may include having a Facebook page, a Twitter feed or blogging on various websites. Nurses can positively use electronic media to share workplace experiences, particularly those events that are challenging or emotionally charged, but it is imperative not to mention patients by name or provide any information or details that could possibly identify them in order to protect patients’ right to privacy. The employer’s policies, however, typically do not address the nurse’s use of social media to discuss workplace issues outside of work on home computers, personally-owned phones and other hand-held electronic devices. It is in this context that the nurse may face potentially serious consequences for the inappropriate use of social media. Social Media in the Workplace Social media can benefit health care in a variety of ways, including fostering professional connections, promoting timely communication with patients and family members, and educating and informing consumers and health care professionals. Social media provides nurses with a way to express their feelings, and reflect or seek support from friends, colleagues, peers or virtually anyone on the Internet. Journaling and reflective practice are recognized as effective tools in nursing practice, and the Internet provides an alternative media for nurses to engage in these helpful activities. Without a sense of caution, however, these understandable needs and potential benefits may result in the nurse disclosing too much information, and violating patient privacy and confidentiality. Health care organizations that utilize electronic and social media typically have policies governing employee use of such media in the workplace. Components of these policies often address personal use of employer computers and equipment, personal computing during work hours, and the types of websites that can be accessed from employer computers. Health care organizations also maintain careful control of websites maintained by or associated with the organization, limiting what may be posted to the site and by whom. 4 Jamie has been working in hospice care for the last six years and one of her patients, Maria, maintained a hospital-sponsored communication page to keep friends and family updated on her battle with cancer. One day, Maria posted about her depression. As her nurse, Jamie wanted to provide support, so she posted, “I know the last week has been difficult. Hopefully the new happy pill will help, along with the increased dose of morphine. I will see you on Wednesday.” The site automatically listed the user’s name with each comment. The next day, Jamie was shopping at the local grocery store when a friend stopped her to ask about Maria’s condition. “I saw your post yesterday. I didn’t know you were taking care of Maria,” the friend said. “I hope that new medication helps with her pain.” This is an example of a violation of confidentiality through social media. While Jamie had Maria’s best intentions at heart by trying to offer her words of support, she inadvertently disclosed information about a patient on a social media site. Everyone who read that post now knows about Maria’s medication and increase in morphine, violating her right to privacy and confidentiality. Instances of inappropriate use of electronic media by nurses such as this have been reported to boards of nursing (BONs) and, in some cases, reported in nursing literature and to the media. 5 Confidentiality and Privacy To understand the limits of appropriate use of social media, it is important to have an understanding of confidentiality and privacy in the health care context. Confidentiality and privacy are related, but distinct concepts:    Any patient information learned by the nurse during the course of treatment must be safeguarded by that nurse. Such information may only be disclosed to other members of the health care team for the purpose of providing care for the patient. Confidential information should be shared only with the patient’s informed consent, when legally required or where failure to disclose the information could result in significant harm. Beyond these very limited exceptions, a nurse is obligated to safeguard confidential information. As a licensed practical nurse for more than 20 years, Bob knew the importance of safeguarding a patient’s privacy and confidentiality. One day, he used his personal cell phone to take photos of Claire, a resident in the group home where he worked. Bob received permission from Claire’s brother to take the photo since she was unable to give consent due to her mental and physical condition. That evening, Bob ran into William, a former employee of the group home. While catching up, he showed William the photo of Claire and discussed her condition with him. The administrator of the group home later learned of Bob’s actions and terminated his employment for breach of confidentiality. Bob thought it was okay for him to take Claire’s photo because he had the consent of a family member. He also thought it was acceptable for him to discuss Claire’s condition because William previously worked with Claire. So why was this behavior wrong? Because, first, merely asking Claire’s brother for permission is not obtaining a valid consent. Second, confidential information should not be disclosed to persons no longer involved in the care of a patient. Even though Bob made an honest mistake, confidentiality rules must be strictly enforced to protect a patient’s right to privacy. 6 Privacy relates to the patient’s expectation and right to be treated with dignity and respect. Effective nurse/patient relationships are built on trust. Patients need to be confident that their most personal information and their basic dignity will be protected by the nurse. Patients will be hesitant to disclose personal information if they fear it will be disseminated beyond those who have a legitimate “need to know.” Any breach of this trust, even inadvertent, damages the nurse/patient relationship and the general trustworthiness of the profession of nursing. Privacy is the patient’s expectation to be treated with dignity and respect. Confidentiality is safeguarding patient information. Federal law reinforces and further defines privacy through the Health Insurance Portability and Accountability Act (HIPAA). HIPAA regulations are intended to protect patient privacy and confidentiality by defining individually identifiable information and establishing how this information may be used, by whom and under what circumstances. The definition of individually identifiable information includes any information that relates to the past, present or future physical or mental health of an individual, or provides enough information that leads someone to believe the information could be used to identify an individual. Breaches of patient confidentiality or privacy can be intentional or inadvertent and can occur in a variety of ways. Nurses may breach confidentiality or privacy with information they post via social media sites. Examples may include comments in which patients are described with enough sufficient detail to be identified, referring to patients in a degrading or demeaning manner, or posting videos or photos of patients. 7 Potential Consequences Emily, a 20-year-old junior nursing student, wasn’t aware of the potential repercussions that could occur when she took a photo of Tommy, a 3-year-old leukemia patient in a pediatric unit, on her personal cell phone. When Tommy’s mom went to the cafeteria, Emily asked him if she could take his picture, which Tommy immediately consented to. Emily took his picture as she wheeled him into his room. She posted Tommy’s photo on her Facebook page with this caption: “This is my 3-year-old leukemia patient who is bravely receiving chemotherapy! He is the reason I am so proud to be a nurse!” In the photo, Room 324 of the pediatric unit was visible. Days later, the dean of the nursing program called Emily into her office. A nurse from the hospital found the photo Emily posted of Tommy on Facebook and reported it to hospital officials who also contacted Emily’s nursing program. While Emily never intended to breach the patient’s confidentiality, the hospital faced a HIPAA violation. From Emily’s post, people were able to identify Tommy as a cancer patient and the hospital where he was receiving treatment. School officials expelled Emily from the nursing program for breaching patient confidentiality and HIPAA violations. The nursing program was also barred from using the pediatric unit for their students. Emily’s innocent, yet inappropriate action of posting a patient’s photo had repercussions for her, the nursing program and the hospital. But what if Emily removed the photo hours later? If it’s taken down, no harm, no foul, right? No. Anything that exists on a server is there forever and could be retrieved later, even after deletion; therefore, it would still be discoverable in a court of law. Further, someone could have taken a screen shot of her Facebook page and posted it on a public website. Patient information and photos should never be posted on social media websites. Even after being deleted, the photo is still on a server and possibly posted somewhere else on the Internet. 8 As we’ve seen with Jamie, Bob and Emily, potential consequences for inappropriate use of social and electronic media by nurses vary. Consequences depend, in part, on the particular nature of the nurse’s conduct. Instances of inappropriate use of social and electronic media may be reported to the BON. Laws outlining the basis for disciplinary action by a BON vary between jurisdictions. Depending on the laws of a jurisdiction, a BON may investigate reports of inappropriate disclosures on social media sites by a nurse on the grounds of:  Unprofessional conduct;  Unethical conduct;  Moral turpitude (defined as conduct that is considered contrary to community standards of justice, honesty or good morals);  Mismanagement of patient records;  Revealing a privileged communication; and  Breach of confidentiality. If the allegations are found to be true, the nurse may face disciplinary action by the BON, including a reprimand or sanction, assessment of a monetary fine, or temporary or permanent loss of licensure. Improper use of social media by nurses may violate state and federal laws established to protect patient privacy and confidentiality. Such violations may result in both civil and criminal penalties, including fines and possible jail time. A nurse may face personal liability and be individually sued for defamation, invasion of privacy or harassment. Particularly flagrant misconduct on social media websites may also raise liability under state or federal regulations focused on preventing patient abuse or exploitation. If the nurse’s conduct violates the policies of the employer, the nurse may face employment consequences, including termination. Additionally, the actions of the nurse may damage the reputation of the health care organization, or subject the organization to a lawsuit or regulatory consequences. 9 Social Media’s Impact on Patient Safety and Care Another concern arising from social media misuse is its effect on team-based patient care. Online comments by a nurse regarding co-workers, even if posted from home during nonwork hours, may constitute lateral violence. Lateral violence includes disruptive behaviors of intimidation and bullying, which may be perpetuated in person or via the Internet. This is sometimes referred to as “cyber bullying.” Such activity is a cause for concern for current and future employers, and regulators because they negatively affect team-based care, thus creating patient-safety ramifications. The line between speech protected by labor laws, the First Amendment and the ability of an employer to impose expectations on employees outside of work is still being determined. Nonetheless, negative comments can be detrimental to a cohesive health care delivery team and may result in sanctions against the nurse. Common Myths and Misunderstandings of Social Media While instances of intentional or malicious misuse of social media have occurred, in most cases, inappropriate disclosure is unintentional. A number of factors may contribute to a nurse inadvertently violating patient privacy and confidentiality while using social media, including:      A mistaken belief that the communication or post is private and accessible only to the intended recipient. The nurse may fail to recognize that content once posted or sent can be disseminated to others. A mistaken belief that content deleted from a site is no longer accessible. The moment something is posted, it lives on a server that can always be discoverable in a court of law. A mistaken belief that it is harmless if private information about patients is disclosed if the communication is accessed only by the intended recipient. This is still a breach of confidentiality. A mistaken belief that it is acceptable to discuss or refer to patients if they are not identified by name, but referred to by a nickname, room number, diagnosis or condition. This too is a breach of confidentiality and demonstrates disrespect for patient privacy. Confusion between a patient’s right to disclose personal information about himself or herself (or a health care organization’s right to disclose otherwise protected information with a patient’s consent) and the need for health care providers to refrain from disclosing patient information without a care-related need for the disclosure. The ease of posting and the commonplace nature of sharing information via social media may appear to blur the line between one’s personal and professional lives. The quick, easy and efficient technology enabling use of social media reduces not only the time it takes to post, but also the time to consider whether the post is appropriate and what ramifications may come from posting inappropriate content. 10 11 How to Avoid Disclosing Confidential Patient Information  With awareness and caution, nurses can avoid inadvertently disclosing confidential or private information about patients. The following guidelines are intended to minimize the risks of using social media:       Nurses must recognize that they have an ethical and legal obligation to maintain patient privacy and confidentiality at all times. Nurses are strictly prohibited from transmitting by way of any electronic media any patient-related image. In addition, nurses are restricted from transmitting any information that may be reasonably anticipated to violate patient rights to confidentiality or privacy, or otherwise degrade or embarrass the patient. Nurses must not share, post or otherwise disseminate any information or images about a patient or information gained in the nurse/patient relationship with anyone unless there is a patient-care-related need to disclose the information or other legal obligations to do so. Nurses must not identify patients by name, or post or publish information that may lead to the identification of a patient. Limiting access to postings through privacy settings is not sufficient to ensure privacy.     Nurses must not refer to patients in a disparaging manner, even if the patient is not identified. Nurses must maintain professional boundaries in the use of electronic media. Like in-person relationships, the nurse has an obligation to establish, communicate and enforce professional boundaries with patients in the online environment. Use caution when having online social contact with patients or former patients. Online contact with patients or former patients blurs the distinction between a professional and personal relationship. The fact that a patient may initiate contact with the nurse does not permit the nurse to engage in a personal relationship with the patient.1 Nurses must consult employer policies or an appropriate leader within the organization for guidance regarding work related postings. Nurses must promptly report any identified breach of confidentiality or privacy. Nurses must be aware of and comply with employer policies regarding use of employer-owned computers, cameras and other electronic devices, and use of personal devices in the workplace. Nurses must not make disparaging remarks about employers or co-workers. Do not make threatening, harassing, profane, obscene, sexually explicit, racially derogatory, homophobic or other offensive comments. Nurses must not post content or otherwise speak on behalf of the employer unless authorized to do so and must follow all applicable policies of the employer. Nurses must not take photos or videos of patients on personal devices, including cell phones. Nurses should follow employer policies for taking photographs or videos of patients for treatment or other legitimate purposes using employer-provided devices. 1 12 Nurses may want to consult NCSBN’s “A Nurse’s Guide to Professional Boundaries” for more information on this issue. 13 THE NURSE’S CHALLENGE  Be aware.  Be cognizant of feelings and behavior.  Be observant of the behavior of other professionals.  Always act in the best interest of the patient. Conclusion Social and electronic media have tremendous potential for strengthening personal relationships and providing valuable information to health care consumers, as well as affording nurses a valuable opportunity to interface with colleagues from around the world. Nurses need to be aware of the potential consequences of disclosing patient-related information via social media, and mindful of employer policies, relevant state and federal laws, and professional standards regarding patient privacy and confidentiality and its application to social and electronic media. By being careful and conscientious, nurses may enjoy the personal and professional benefits of social and electronic media without violating patient privacy and confidentiality. 14 15 To find the board of nursing in your state/territory visit https://www.ncsbn.org/contactbon.htm. To order additional copies of this brochure, contact communications@ncsbn.org. 111 E. Wacker Drive, Suite 2900 Chicago, IL 60601-4277 312.525.3600 www.ncsbn.org 11/11 Preview Rubric SARA Discussion Rubric (30 Points) This table lists criteria and criteria group name in the first column. The first row lists level names and includes scores if the rubric uses a numeric scoring method. Criteria Level 5 = 12 points Well-developed post that fully addresses assignment and provides strong evidence of critical thinking. Post is at least four paragraphs with a minimum of three sentences each. Cited sources are scholarly, current, and lend support to post. Required number of sources is used. Level 4 = 11 points (10-11 points possible) Satisfactorily developed post that addresses the majority of the assignment and provides some evidence of critical thinking. Post is three paragraphs with a minimum of three sentences each. Cited sources are not scholarly and/or current. Required number of sources is used. Level 3 = 9 points (8-9 points possible) Weakly developed post that addresses less than the majority of the assignment and provides the beginnings of critical thinking. Post is two paragraphs with a minimum of three sentences each. Required number of current and scholarly sources is not used. Level 2 = 7 points (1-7 points possible) Poorly developed post that addresses some of the assignment and lacks critical thinking. Post is one paragraph in length. No sources are used to support post. Level 1 = 0 points Criterion Score Quality (Initial substantive post) No initial substantive post.
Purchase answer to see full attachment
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.

Explanation & Answer

Attached. Please let me know if you have any questions or need revisions.

1

Social, Legal, and Ethical Considerations
Author
Affiliation
Course
Instructor
Due Date

2
Social, Legal, and Ethical Considerations
Most Health care organizations utilize electronic and social media for various purposes,
including data management and storage. For instance, clinical informatics is a healthcare domain
that entails the acquisition and processing data to support healthcare or patient care. According to
Alexander (2017), clinical informatics entails Nurses. Other HCPs use their education and
experience to assemble data in a clinical context to create information, which gives insight into
patient care. Notably, these systems provide access to personal data or personal health
information (PHI) and are projected to increase, especially with the internet of the future. PHI
contains longitudinal records of wellness, illness, test results, and treatments, among other
human beings' biological attributes. The use of these data raises ethical concerns about privacy
and confidentiality, which breaches disclosures and HIPAA compliance.
One of the barriers and constraints related to privacy and confidentiality practices in the
healthcare setting is the nature of the data. Certain secondary use of PHI makes it almost
inevitable to guarantee confidentiality and privacy in hospital settings. According to Gallagher et
al. (2018), secondary use of PHI entails benevolent causes that support medical research and
public health and hospital operations such as sales, marketing, and financial gain that often
occurs without the knowledge of the patients. Besides, the secondary use of PHI for auxiliary
activities in hospital management sectors such as finances, marketing, system development, or
training makes it almost impossible to justify personal privacy concerns; the patients are not
involved in the critical decisions within these scopes.
Additionally, the privacy laws do not cover most jurisdictions in which PHI is used for
secondary purposes. It implies that there is no issuance of consent to use and disclose PHI
(Gallagher et al., 2018). It shows how PHI in a hospital setting is susceptible to breach to HIPAA

3
compliance as well as ethical thresholds of professional practice that pertain to privacy and
confidentiality of personal information.
Another element of the hospital setting that forms barriers and constraints related to
privacy and confidentiality is the re-identification. Re-identification of anonymous medical
records has been linked back to the identity of the subject patient. It entails the use of deidentification techniques such as The Safe Harbor de-identification process. According to
Gallagher et al. (2018), The Safe Harbor de-identification process involves “removal
(anonymization) or generalization (pseudonymization) of 18 personally identifying elements
associated with the patient” ( p 2). The re-identification process often leads to a breach of PHI
privacy and confidentially, especially with personal identifying information being released to the
public. Gallagher et al. (2018) note that the re-identification process lacks a revision of
anonymization and health data release practices. Therefore, PHI's confidentiality and privacy are
not guaranteed when the re-identification process is called for to support medical procedures or
public health overall.
Additionally, the process of re-identification ethical questions regarding how to allow
patients to intervene and have a solid decision in PHI sharing activities in healthcare settings.
There are no clear-cut edicts of patient privacy to guarantee patients' control over their privacy,
even in unbecoming situations such as re-identification. According to Gallagher et al. (2018),
Patient privacy is a universal edict for all health professionals as it is a fundamental pillar in
establishing trust within the patient-clinician relationship. Often, hospitals rely on The
Hippocratic Oath in which confidentiality is guaranteed based on the patient-clinical relationship
and not the patients' consent. In other words, confidentiality rests on the clinician's edict's
integrity and reliability to not harm (Gallagher et al., 2018). Arguably, it is impossible to provide

4
for confidentiality and privacy in cases such as re-identification. Lastly, the inseparable
relationship between PHI and healthcare technologies, primarily electronic healthcare records
(EHR), creates a significant constraint concerning the provision of confidentiality and privacy in
healthcare settings. EHR records personal identity information, which is accessed by medical
practitioners for various uses in the hospital. The risks of adversaries and other unauthorized
access to these data are very high since the systems are susceptible to malware and other related
adversaries.
Social, legal, and ethical practices are critical in professional practice and determine the
professional's credibility as a whole. Accordingly, as a professional, I should be able to recognize
and abide by the social, ethical, and legal obligations for professional practices. It includes the
responsibility to maintain patient privacy and confidentiality at all times. It means that I should
desist from transmitting by way of any electronic media, primarily that which involves PHI. I
should also be able to resist temptations, such as interests to identify PHI records such as the
patient’s name or any other information that may lead to patient identification. Most importantly,
the essence of patient consent comes to play when it comes to Social, legal, and ethical practices.
It means that I should always ensure that patients are guaranteed their consent when dealing with
PHI.

5
References
Gallagher, T., Dube, K., & McLachlan, S. (2018). Ethical Issues in Secondary Use of Personal
Health Information. Retrieved from https://pambayesian.org/wpcontent/uploads/2019/02/Ethics-IEEE-FutureDir.pdf
Hoy, H., & Frith, K. H. (Eds.). (2017). Applied clinical informatics for nurses. Jones & Bartlett
Learning.

GREETINGS! sorry for that mistake. the reference entry was incomplete. i have attached the book to this mail

1

Social, Legal, and Ethical Considerations
Author
Affiliation
Course
Instructor
Due Date

2
Social, Legal, and Ethical Considerations
Most Health care organizations utilize electronic and social media for various purposes,
including data management and storage. For instance, clinical informatics is a healthcare domain
that entails the acquisition and processing data to support healthcare or patient care. According to
Alexander et al., (2017), clinical informatics encompasses all medical and health specialties,
including nursing. It also addresses the ways information systems such as EHRs, barcode
medication administration systems, radiology imaging system, and patient-care devices as used
in daily in daily operation of patient care. Notably, these systems provide access to personal data
or personal health information (PHI) and are projected to increase, especially with the internet of
the future. PHI contains longitudinal records of wellness, illness, test results, and treatments,
among other human beings' biological attributes. The use of these data raises ethical concerns
about privacy and confidentiality, which breaches disclosures and HIPAA compliance.
One of the barriers and constraints related to privacy and confidentiality practices in the
healthcare setting is the nature of the data. Certain secondary use of PHI makes it almost
inevitable to guarantee confidentiality and privacy in hospital settings. According to Gallagher et
al. (2018), secondary use of PHI entails benevolent causes that support medical research and
public health and hospital operations such as sales, marketing, and financial gain that often
occurs without the knowledge of the patients. Besides, the secondary use of PHI for auxiliary
activities in hospital management sectors such as finances, marketing, system development, or
training makes it almost impossible to justify personal privacy concerns; the patients are not
involved in the critical decisions within these scopes.
Additionally, the privacy laws do not cover most jurisdictions in which PHI is used for
secondary purposes. It implies that there is no issuance of consent to use and disclose PHI

3
(Gallagher et al., 2018). It shows how PHI in a hospital setting is susceptible to breach to HIPAA
compliance as well as ethical thresholds of professional practice that pertain to privacy and
confidentiality of personal information.
Another element of the hospital setting that forms barriers and constraints related to
privacy and confidentiality is the re-identification. Re-identification of anonymous medical
records has been linked back to the identity of the subject patient. It entails the use of deidentification techniques such as The Safe Harbor de-identification process. According to
Gallagher et al. (2018), The Safe Harbor de-identification process involves “removal
(anonymization) or generalization (pseudonymization) of 18 personally identifying elements
associated with the patient” ( p 2). The re-identification process often leads to a breach of PHI
privacy and confidentially, especially with personal identifying information being released to the
public. Gallagher et al. (2018) note that the re-identification process lacks a revision of
anonymization and health data release practices. Therefore, PHI's confidentiality and privacy are
not guaranteed when the re-identification process is called for to support medical procedures or
public health overall.
Additionally, the process of re-identification ethical questions regarding how to allow
patients to intervene and have a solid decision in PHI sharing activities in healthcare settings.
There are no clear-cut edicts of patient privacy to guarantee patients' control over their privacy,
even in unbecoming situations such as re-identification. According to Gallagher et al. (2018),
Patient privacy is a universal edict for all health professionals as it is a fundamental pillar in
establishing trust within the patient-clinician relationship. Often, hospitals rely on The
Hippocratic Oath in which confidentiality is guaranteed based on the patient-clinical relationship
and not the patients' consent. In other words, confidentiality rests on the clinician's edict's

4
integrity and reliability to not harm (Gallagher et al., 2018). Arguably, it is impossible to provide
for confidentiality and privacy in cases such as re-identification. Lastly, the inseparable
relationship between PHI and healthcare technologies, primarily electronic healthcare records
(EHR), creates a significant constraint concerning the provision of confidentiality and privacy in
healthcare settings. EHR records personal identity information, which is accessed by medical
practitioners for various uses in the hospital. The risks of adversaries and other unauthorized
access to these data are very high since the systems are susceptible to malware and other related
adversaries.
Social, legal, and ethical practices are critical in professional practice and determine the
professional's credibility as a whole. Accordingly, as a professional, I should be able to recognize
and abide by the social, ethical, and legal obligations for professional practices. It includes the
responsibility to maintain patient privacy and confidentiality at all times. It means that I should
desist from transmitting by way of any electronic media, primarily that which involves PHI. I
should also be able to resist temptations, such as interests to identify PHI records such as the
patient’s name or any other information that may lead to patient identification. Most importantly,
the essence of patient consent comes to play when it comes to Social, legal, and ethical practices.
It means that I should always ensure that patients are guaranteed their consent when dealing with
PHI.

5
References
Gallagher, T., Dube, K., & McLachlan, S. (2018). Ethical Issues in Secondary Use of Personal
Health Information. Retrieved from https://pambayesian.org/wpcontent/uploads/2019/02/Ethics-IEEE-FutureDir.pdf
Alexander, S., Hoy, H., & Frith, K. H. (Eds.). (2017). Applied clinical informatics for nurses.
Jones & Bartlett Learning.


SECOND EDITION

2

APPLIED CLINICAL
INFORMATICS FOR NURSES
Edited by

Susan Alexander, DNP, ANP-BC, ADM-BC
Associate Professor
College of Nursing
University of Alabama in Huntsville

Karen H. Frith, PhD, RN, NEA-BC
Associate Dean for Undergraduate Programs
Professor
College of Nursing
University of Alabama in Huntsville

Haley Hoy, PhD, ACNP
Associate Dean for Graduate Programs
Associate Professor
College of Nursing
University of Alabama in Huntsville

JONES & BARTLETT
LEARNING

3

World Headquarters
Jones & Bartlett Learning
5 Wall Street
Burlington MA 01803
978-443-5000
info@jblearning.com
www.jblearning.com
Jones & Bartlett Learning books and products are
available through most bookstores and online booksellers.
To contact Jones & Bartlett Learning directly, call 800-8320034, fax 978-443-8000, or visit our website,
www.jblearning.com.

Substantial discounts on bulk quantities of Jones &
Bartlett Learning publications are available to
corporations, professional associations, and other
qualified organizations. For details and specific
discount information, contact the special sales
department at Jones & Bartlett Learning via the above
contact information or send an email to
specialsales@jblearning.com.

Copyright © 2019 by Jones & Bartlett Learning, LLC, an
Ascend Learning Company
All rights reserved. No part of the material protected by
this copyright may be reproduced or utilized in any form,
electronic or mechanical, including photocopying,

4

recording, or by any information storage and retrieval
system, without written permission from the copyright
owner.
The content, statements, views, and opinions herein are
the sole expression of the respective authors and not that
of Jones & Bartlett Learning, LLC. Reference herein to any
specific commercial product, process, or service by trade
name, trademark, manufacturer, or otherwise does not
constitute or imply its endorsement or recommendation by
Jones & Bartlett Learning, LLC and such reference shall
not be used for advertising or product endorsement
purposes. All trademarks displayed are the trademarks of
the parties noted herein. Applied Clinical Informatics for
Nurses, Second Edition is an independent publication and
has not been authorized, sponsored, or otherwise
approved by the owners of the trademarks or service
marks referenced in this product.
There may be images in this book that feature models;
these models do not necessarily endorse, represent, or
participate in the activities represented in the images. Any
screenshots in this product are for educational and
instructive purposes only. Any individuals and scenarios
featured in the case studies throughout this product may
be real or fictitious, but are used for instructional purposes
only.
The authors, editor, and publisher have made every effort
to provide accurate information. However, they are not
responsible for errors, omissions, or for any outcomes
related to the use of the contents of this book and take no
responsibility for the use of the products and procedures
described. Treatments and side effects described in this
book may not be applicable to all people; likewise, some
people may require a dose or experience a side effect that
is not described herein. Drugs and medical devices are
5

discussed that may have limited availability controlled by
the Food and Drug Administration (FDA) for use only in a
research study or clinical trial. Research, clinical practice,
and government regulations often change the accepted
standard in this field. When consideration is being given to
use of any drug in the clinical setting, the health care
provider or reader is responsible for determining FDA
status of the drug, reading the package insert, and
reviewing prescribing information for the most up-to-date
recommendations on dose, precautions, and
contraindications, and determining the appropriate usage
for the product. This is especially important in the case of
drugs that are new or seldom used.
13844-3
Production Credits
VP, Product Management: David D. Cella
Director, Product Management: Amanda Martin
Product Manager: Rebecca Stephenson
Editorial Assistant: Kirsten Haley
Product Assistant: Anna Maria Forger
Production Manager: Carolyn Rogers Pershouse
Director of Vendor Management: Amy Rose
Vendor Manager: Juna Abrams
Senior Marketing Manager: Jennifer Scherzay
Product Fulfillment Manager: Wendy Kilborn
Composition: S4Carlisle Publishing Services
Project Management: S4Carlisle Publishing Services
Cover Design: Scott Moden
Director of Rights & Media: Joanna Gallant
Rights & Media Specialist: Wes DeShano
Media Development Editor: Troy Liston
Cover Image (Title Page, Part Opener, Chapter Opener,
Design Element): © nednapa/Shutterstock
Printing and Binding: Edwards Brothers Malloy
Cover Printing: Edwards Brothers Malloy
6

Library of Congress Cataloging-in-Publication Data
Names: Alexander, Susan, 1969- editor. | Frith, Karen H.,
editor. | Hoy, Haley M., editor.
Title: Applied clinical informatics for nurses/edited by
Susan Alexander, Karen H. Frith, Haley Hoy.
Description: Second edition. | Burlington, Massachusetts :
Jones & Bartlett Learning, [2019] | Includes bibliographical
references and index.
Identifiers: LCCN 2017034523 | ISBN 9781284129175
(pbk. : alk. paper)
Subjects: | MESH: Nursing Informatics
Classification: LCC RT50.5 | NLM WY 26.5 | DDC
610.730285--dc23 LC record available at
https://lccn.loc.gov/2017034523
6048
Printed in the United States of America
21 20 19 18 17 10 9 8 7 6 5 4 3 2 1

7

© nednapa/Shutterstock

8

Contents
Preface
About the Editors
Contributors
Reviewers
SECTION I Concepts and Issues in Clinical
Informatics
Chapter 1 Overview of Informatics in Health Care
Chapter Overview
Informatics in Nursing Practice
History of Clinical Informatics Development
Clinical Informatics and Nursing Informatics Defined
Clinical Informatics Concepts
The Culture of Health Care in the United States
Introducing Information Science
Summary
References

Chapter 2 Information Needs for the Healthcare
Professional of the 21st Century
Chapter Overview
Accessibility to Guidelines, Protocols, and
Procedures
Quality Improvement Techniques and Nursing
Informatics
Interprofessional Collaboration and Practice Workflow
Nursing Workflow
Nursing Curricula and Continuing Education
Ongoing Education and Nursing Informatics
Summary
9

References

Chapter 3 Informatics and Evidence-Based
Practice
Chapter Overview
Introduction to Information and Computer Science
Integrating Evidence-Based Practice
Staying Current in Nursing Practice and Specialty
Areas
Evidence-Based Practice Integrated in Clinical
Decision-Support Systems
Summary
References

SECTION II Use of Clinical Informatics in Care
Support Roles
Chapter 4 Human Factors in Computing
Chapter Overview
Introduction
Human Factors/Ergonomics (HFE)
Standards, Laws, Recommendations, and Style
Guides
Information Processing
Summary
References

Chapter 5 Usability in Health Information
Technology
Chapter Overview
Introduction
Importance of Usability Testing
The Role of Nurses in Usability
User-Centered Design
10

Dimensions of Usability
Planning Usability Testing
Examples of Usability Testing in Health Care
Summary
References

Chapter 6 Privacy, Security, and Confidentiality
Chapter Overview
Introduction
History of Legal Protection for Privacy
Health Insurance Portability and Accountability Act
(Hipaa)
Use of PHI in Marketing, Fund-Raising, and Research
Enforcement of Privacy and Security of PHI
Filing Complaints
Health Information Technology for Economic and
Clinical Health (HITECH) Act
Unresolved Issues of Health Information
Summary
References

Chapter 7 Database Systems for Healthcare
Applications
Chapter Overview
Using Databases in Healthcare Settings
Working with Databases
Creating a Warehouse for Managing Multiple Datasets
Applications in Healthcare Settings
Summary
References

Chapter 8 Using Big Data Analytics to Answer
Questions in Health Care
Chapter Overview
11

Basic Principles of Big Data Analytics
Overview of Algorithms Generated by Data-Mining
Methods
Descriptive Algorithms
Using Data Analytics in Health Care
Challenges in Using Data Analytics Tools in Health
Care
Summary
References

Chapter 9 Workflow Support
Chapter Overview
Need for Workflow Support in Single Hospitals and
Networked Hospital Systems
The Promise of Health IT
Planning for Health IT
Workflow Analysis
Gap Analysis and Workflow Redesign
Workflow to Improve Care Processes and
Organizational Operations
Healthcare Provider Roles in Workflow Analysis
Summary
References

Chapter 10 Promoting Patient Safety with the
Use of Information Technology
Chapter Overview
Health It Used in Patient Care
Patient Safety at the Point of Care
Beyond the Initial Point of Care
Integrating Health IT and Patient Safety Goals
Where, Oh Where, Has My Patient Gone?
Safety of Medical Devices
Summary
12

References

SECTION III Use of Clinical Informatics Tools in
Care Delivery Systems
Chapter 11 The Electronic Health Record
Chapter Overview
Definitions and Descriptions
Benefits of Using EHRs
Challenges of EHR Use
Role of the Nurse and the EHR
Summary
References

Chapter 12 Clinical Decision-Support Systems
Chapter Overview
Introduction
Clinical Decision-Support Systems
Data Capture
Data Quality and Validity
CDSS Applications
Clinical Reasoning
Professional Practice
Summary
References

Chapter 13 Telehealth Nursing
Chapter Overview
Introduction
Definition of Terms
The History of Telehealth
Domains of Telehealth Applications
Privacy, Ethics, and Limitations in Telehealth

13

Utilization of Telehealth
Summary
References

Chapter 14 Mobile Health Applications
Chapter Overview
Introduction
mHealth Benefits
Driving Forces for mHealth
mHealth Systems for HCPs and Researchers
mHealth System in Action: A Case Study of Cardiac
Rehabilitation
mHealth Applications (Apps) for HCPs
mHealth Apps for Consumers
mHealth Challenges
Summary
References

Chapter 15 Informatics and Public Health
Chapter Overview
Concepts in Public Health
Methods of Describing the Health of Communities and
Populations
Applying Informatics Tools to Improve Public Health
Future Directions
Summary
References

Chapter 16 Digital Patient Engagement and
Empowerment
Chapter Overview
Introduction
Engagement and Empowerment
Healthcare Information Revolution
14

Tools Used to Facilitate Patient Engagement
Examples of Patient-Digital Interactions
The Future of E-Health Applications
Summary
References

Glossary
Index

15

© nednapa/Shutterstock

16

Preface

▶ For Whom Is This Text Written?

The text is designed for nurses entering the healthcare
field who must be prepared to apply clinical informatics
knowledge and skills to:
increase quality and satisfaction in patients’ perception of care,
enhance the health of populations,
reduce the cost of health care, and
improve the work life of healthcare providers.

The chapters are written by a diverse group of contributors
with experience in both designing and using health
informatics applications. The content is broad in scope,
beginning with an overview of basic concepts in
informatics and proceeding to a discussion of application
of the concepts in selected healthcare delivery settings.
Though advanced concepts are included in the text, they
are discussed in a manner that is highly readable for
nursing students. The text includes multiple examples and
case studies that will aid students in immediately linking
the content to the clinical environment.
The text begins by introducing concepts and issues
relevant to the field of clinical informatics. A review of the
culture of health care and the use of health information
technology in the United States, with a summary of
information science principles, sets the stage for a
discussion of the nurse’s role in healthcare informatics in
the 21st century. The reader is presented with strategies
to obtain, evaluate, and apply evidence for nursing
practice with the use of informatics tools.
Other chapters contain more isolated concepts, which
could be used “as needed” in multiple areas of the nursing
17

curricula. A brief description of more advanced concepts
will stimulate the interest of the reader, serving as a way to
initiate discussion and interaction between students and
teachers on the enormous possibilities for the use of
healthcare technologies, now and in the future.

▶ Why Is This Text Important for the
Student Nurse?
The text stems from the need for improvements in nurses’
skill sets in using health information technology. Nursing is
an increasingly high-tech field, requiring a wide variety of
competencies that range from basic computer abilities to
advanced skills with medical devices and lifesaving
equipment. Nurses are the largest group of healthcare
providers in the United States, with statistics from the U.S.
Department of Labor, Bureau of Labor Statistics, indicating
that there are more than 2.8 million nurses employed in
the United States (in 2016). The potential impact of nurses
who are prepared to use health information technologies
safely and efficiently to improve patient care cannot be
ignored. Minimum levels of competency in utilizing health
information technologies are needed by nurses regardless
of practice setting.
Perhaps the most appropriate place to begin the
integration of technology and informatics in patient care is
for the prelicensure nurse. If this group of nurses enters
the workforce with the skill sets, clinical experience, and
an expectation to integrate health information technologies
into practice, many of the issues that confound healthcare
organizations now may cease to exist. This is not an
unusual phenomenon. Consider the example of universal
precautions for blood and body fluids. The use of universal
precautions began in response to the HIV and hepatitis B
outbreaks in the 1980s, causing great upheaval in
healthcare practice. Millions of dollars were spent in
reeducating healthcare providers, redesigning hospital
18

rooms and units, and revising nursing curricula to teach
the foundational practice of universal precautions. The
hurdles of adopting universal precautions in health care
have largely been surmounted. Today’s nursing graduates
enter the workforce with the needed training and practice
patterns that prevent transmission of communicable
diseases. Likewise, as informatics knowledge and skills
become more embedded in nursing education and in
practice settings, the more informatics will be accepted as
an indispensable component of nursing practice and
patient care.

▶ What Makes This Text Unique?
Designed with the need for flexibility across curricula, the
text is written primarily for the prelicensure or RN-BSN
student who has experience in the use of diverse
hardware and software applications and who is now ready
to apply those skills in the healthcare setting. While the
text could be used in a focused informatics course, it
would also be pertinent for a nursing program that elects
to teach designated informatics concepts at different
points throughout the program. Course instructors will also
find the text useful due to its inclusion of the competencies
described in the American Association of Colleges of
Nursing’s Essentials of Baccalaureate Education for
Professional Nursing Practice (2008).

▶ Acknowledgments
In this second edition, the editors remain grateful to those
who have played a role in making the text become a
reality. The study of nursing in the 21st century requires
more than learning basic skills of bedside care. Our
students, whose rich blend of backgrounds and talents
make life endlessly interesting, helped us to understand
the need for creating a textbook that could build on
existing computer skills and enhance informatics
competencies to improve patient care. Technology is
19

interwoven into many of the nurses’ tasks, and we applaud
those nurses who realize the importance of competence
with technology and informatics early in their careers. This
is not an easy undertaking, but effective use of health
information technologies will lead to important
advancements in patient care. We are also thankful for
instructors who have adopted the text for use in their
educational programs, providing valuable feedback and
informing us of surprising and unanticipated methods of
using the book’s content for their students. Meeting the
needs of nursing students, who demonstrate great
diversity in technological competence and comfort, is not
an easy task. As editors, we hope that our text can
continue to assist instructors in encouraging students’
interest in the growing field of clinical informatics.
We would like to thank the staff at Jones & Bartlett
Learning for their encouragement and guidance, which
has been consistently displayed in our work to create a
new edition. The production team is a pleasant and
talented group. Special thanks also go to Amanda Martin,
our optimistic and supportive Director of Product
Management, who continues to share our vision of crafting
a book that would integrate informatics content into
nursing curricula in a manner both clinically relevant and
exciting for nursing students. Amanda has been unfailingly
gracious over the development of the first and second
editions, while managing to keep the book on course! We
also acknowledge the numerous other staff members of
Jones & Bartlett Learning who assisted with copyediting,
permissions, and artwork. Bringing a book to print is truly a
team endeavor.
Once again, we are appreciative of the chance to work
with the diverse group of authors who contributed their
expertise to the writing of this text. Though their positions
range from computer scientists to physicians and, of
20

course, nurses, each of our contributors understands the
role that informatics will continue to play in achieving highquality patient care. They also understand the need to
challenge our nursing students to apply more advanced
informatics concepts in varied healthcare settings.
Finally, we must acknowledge the unceasing support from
our families. They remain a positive and calming force in
our lives. Alan, Kendal, Ashley, and Trey—we love you all.
Susan Alexander
Karen H. Frith
Haley Hoy

21

© nednapa/Shutterstock

22

About the Editors
Susan Alexander, DNP, ANP-BC, ADM-BC, is an
Associate Professor of Nursing at The University of
Alabama in Huntsville. With more than 20 years of
experience in nursing, she has extensive clinical
experience in a variety of both inpatient and outpatient
settings, having earned her doctor of nursing practice
degree in 2009. In addition to her faculty responsibilities,
she is certified by the American Nurses Credentialing
Center as an Adult Health Nurse Practitioner and in
Advanced Diabetes Management. She is a member of a
research team that is studying how large datasets can be
used to demonstrate the impact of environmental changes
upon public health and chronic diseases in selected
geographical areas. Dr. Alexander serves as a peer
reviewer for multiple nursing and nonnursing journals, and
is a member of the editorial board for CIN: Computers,
Informatics, Nursing, where she is also the editor of CIN
Plus. She is the column editor for the “Nurse
Entrepreneur” section of CNS: The Journal for Advanced
Nursing Practice. Her publications include articles on
topics including implementation of software applications
for health professionals, the use of online teaching
strategies and mobile applications for healthcare providers
in transplant, and the challenges of using big data in
health care. In addition, she is a contributor to Distance
Education in Nursing, Third Edition (2013, Springer). Dr.
Alexander was the recipient of a 2013 American
Association of Nurse Practitioners State Award for
Excellence. In 2015, she was awarded the Suzanne B.
Smith Mentoring Award by the International Association of
Nurse Editors.

23

Karen H. Frith, PhD, RN, NEA-BC, is a Professor of
Nursing and Associate Dean for Undergraduate Programs
at The University of Alabama in Huntsville. She has been
a nurse educator since 1992 and has an active program of
research in clinical informatics and health services. She
has received nearly $2 million in grants for research and
programs. She is a member of Healthcare Information and
Management Systems Society (HIMSS), Sigma Theta Tau
International, Honor Society of Nursing, and the Southern
Nursing Research Society. She serves as a reviewer (of
grants and articles) for Sigma Theta Tau, Health
Resources and Services Administration, Journal of
Nursing Administration, Online Journal of Issues in
Nursing, Computers, Informatics, Nursing, and Nurse
Educator, among others. She has authored more than 40
articles in peer-reviewed journals, authored the book
Distance Education in Nursing, Third Edition, contributed
chapters to four other books, and presents nationally. Her
previous clinical experience is in cardiovascular surgical
intensive care, coronary intensive care, and orthopedics.
She is board certified by the American Nurses
Credentialing Center as Nurse Executive, Advanced
(NEA-BC).
Haley Hoy, PhD, ACNP, is an acute care nurse
practitioner and Associate Dean of Graduate Programs at
The University of Alabama in Huntsville. She has been a
nurse practitioner for nearly 20 years and has been a
leader in technology and transplant nursing. Her current
research interests include the role of technology and weband mobile-based applications for the transplant
community, in addition to nurse and community attitudes
toward organ donation. She has held research grants from
the North American Transplant Coordinators Organization
(NATCO) and from The University of Alabama in
Huntsville (Faculty Distinguished Research grant
recipient). She is an active member of the American
24

Association of Nurse Practitioners, a board member of the
North American Transplant Coordinators Organization,
and was inducted as a fellow in the American Association
of Nurse Practitioners. She was the recipient of the 2011
American Association of Nurse Practitioners State Award
for Excellence and the Advanced Transplant Provider
Award from the American Society of Transplant Surgeons.
She is board certified by the American Nurses
Credentialing Center and continues to practice as a nurse
practitioner at Vanderbilt Medical Center in the
Department of Lung Transplantation.

25

© nednapa/Shutterstock

26

Contributors
Ellise D. Adams, PhD, RN, CNM
Associate Professor
University of Alabama in Huntsville
Huntsville, Alabama
Marsha Howell Adams, PhD, RN, CNE, ANEF, FAAN
Professor and Dean
College of Nursing
University of Alabama in Huntsville
Huntsville, Alabama
Susan Alexander, DNP, ANP-BC, ADM-BC
Associate Professor
University of Alabama in Huntsville
Huntsville, Alabama
Dorothy Alford, MSN, RN, CEN, CHI
Director of Education
Clear Lake Regional Medical Center
Mainland Medical Center
Houston, Texas
Faye E. Anderson, DNS, RN, NEA-BC
Associate Professor Emeritus
University of Alabama, Huntsville
Huntsville, Alabama
Gennifer Baker, DNP, RN, CCNS
Assistant Professor
Martin Methodist College
Pulaski, Tennessee
Janie T. Best, DNP, RN, ACNS-BC, CNL
Associate Professor
Blair College of Health
Presbyterian School of Nursing
Queens University of Charlotte
Charlotte, North Carolina
Jane M. Carrington, PhD, RN
Assistant Professor
Community & Systems Health Science Division
College of Nursing
University of Arizona
Tucson, Arizona
Heather Carter-Templeton, PhD, RN-BC
Assistant Professor
Capstone College of Nursing
University of Alabama in Huntsville
Huntsville, Alabama
Yeow Chye Ng, PhD, RN
Assistant Professor
College of Nursing
University of Alabama
Huntsville, Alabama
Crayton Fargason, Jr., MD, MBA
Professor
University of Alabama at Birmingham
Medical Director

27

Children’s of Alabama
Birmingham, Alabama
Karen H. Frith, PhD, RN, NEA-BC
Professor
University of Alabama in Huntsville
Huntsville, Alabama
Donna Guerra, EdD, MSN, RN
Assistant Professor
College of Nursing
University of Alabama in Huntsville
Huntsville, Alabama
Joni Hall, MSN, RN
Nurse Informaticist
Children’s of Alabama
Birmingham, Alabama
Diana Hankey-Underwood, MS, WHNP-BC
Nurse Practitioner
Huntsville, Alabama
Haley Hoy, PhD, ACNP
Associate Professor
University of Alabama in Huntsville
Nurse Practitioner
Vanderbilt Medical Center
Nashville, Tennessee
Emil Jovanov, PhD
Associate Professor
Department of Electrical and Computer Engineering
University of Alabama, Huntsville
Huntsville, Alabama
Steffi Kreuzfeld, Dr. Med.
Research Associate
Deputy Director
Institute for Preventive Medicine
University of Rostock
Rostock, Germany
Manil Maskey, MS
Research Scientist
Marshall Space Flight Center
National Aeronauts and Space Administration
Huntsville, Alabama
Aleksandar Milenkovic, PhD
Professor
Department of Electrical and Computer Engineering
University of Alabama in Huntsville
Huntsville, Alabama
Mladen Milosevic, PhD
Senior Scientist
Acute Care Solutions Department
Philips Research North America
Cambridge, Massachusetts
Stephanie Norman-Lenz, MSN, RN
Director of Nursing Informatics
Children’s of Alabama
Birmingham, Alabama
Louise C. O’Keefe, PhD, CRNP, RN
Assistant Professor

28

College of Nursing
University of Alabama in Huntsville
Huntsville, Alabama
Pamela V. O’Neal, PhD, RN
Associate Professor
College of Nursing
University of Alabama in Huntsville
Huntsville, Alabama
Rahul Ramachandran, PhD
Research Scientist
Informatics and Data Management
National Aeronautics and Space Administration
George C. Marshall Space Flight Center
Huntsville, Alabama
Ron Schwertfeger, MLIS
Instruction, Outreach & Assessment Librarian/Lecturer
M. Louis Salmon Library
University of Alabama in Huntsville
Huntsville, Alabama
Kimberly D. Shea, PhD, RN
Associate Clinical Professor of Nursing
Community & Systems Health Science Division
College of Nursing
University of Arizona
Tucson, Arizona
Darlene Showalter, DNP, RN, CNS
Clinical Associate Professor
College of Nursing
University of Alabama in Huntsville
Huntsville, Alabama
Regina Stoll, Dr. Med. Habil.
Director
Institute of Preventive Medicine
University of Rostock
Rostock, Germany
Brenda Talley, PhD, RN, NEA-BC
Associate Professor
College of Nursing
University of Alabama, Huntsville
Huntsville, Alabama
Xiaohua Sarah Wu, MSN, RN, FNP-BC
University of Rochester Medical Center
Strong Memorial Hospital
Rochester, New York

29

© nednapa/Shutterstock

30

Reviewers
Kim Siarkowski Amer, PhD, RN
Associate Professor
School of Nursing
DePaul University
Chicago, Illinois
Judith Bailey, MS, RN
Cedar Crest College
Allentown, Pennsylvania
Lehigh Valley Health Network
Allentown, Pennsylvania
Margaret Benham-Hutchins, PhD, RN
Texas Woman’s University
College of Nursing
Denton, Texas
Ann M. Bowling, PhD, RN, CPNP-PC, CNE
Wright State University
Miami Valley College of Nursing and Health
Dayton, Ohio
Deborah Cheater, MS, RN, CNE
Nursing Instructor
Carl Albert State College
Poteau, Oklahoma
Mary Anne Blum Condon, PhD
Chair and Professor
Averett University
Danville, Virginia
David J. Crowther, PhD, RN, CNS
Associate Professor
Angelo State University
San Angelo, Texas
Kathleen Dunemn, PhD, APRN, CNM
Associate Professor
University of Northern Colorado
Greeley, Colorado
Tresa Kaur Dusaj, PhD, RN-BC, CNE, CHSE, CTN-A
Monmouth University
Long Branch, New Jersey
Beth Elias, PhD, MS
Assistant Professor
University of Alabama, Birmingham
School of Nursing
Birmingham, Alabama
Sally K. Fauchald, PhD, RN
The College of St. Scholastica
Department of Graduate Nursing
Duluth, Minnesota
Rebecca Hill, DNP, MSN, FNP-C
Assistant Professor
Massachusetts College of Pharmacy and Health Sciences
Boston, Massachusetts

31

Janice M. Jones, PhD, RN, CNS
Clinical Professor
University at Buffalo School of Nursing
Buffalo, New York
Lynn M. Klima, MSN, RN
Faculty
School of Nursing
Siena Heights University
Adrian, Michigan
Barbara A. Miller, PhD, RN, ACNS-BC
Assistant Professor
Darton State College
Albany, Georgia
Catherine S. Moe, MS, RN, CNE
Assistant Professor
Lakeview College of Nursing
Danville, Illinois
Angela Mountain, RN, MS, CMSRN
Assistant Professor
Texas A&M Health Sciences Center
Colleen Neal, MS, RN
Assistant Professor
Texas A&M Health Science College of Nursing
Anita K. Reed, MSN, RN
Department Chair Adult and Community Health Practice
Saint Joseph’s College
St. Elizabeth School of Nursing
Lafayette, Indiana
Tina Reinckens, RN, MA
Coppin State University
Baltimore, Maryland
Annette M. Weiss, PhD, RN, CNE
Assistant Professor and RN to BSN Program Director
Misericordia University
Dallas, Pennsylvania
Marisa L. Wilson, DNSc, MHSc, RN-BC
University of Maryland School of Nursing
Baltimore, Maryland

32

33

34

© nednapa/Shutterstock

35

SECTION I
Concepts and Issues in
Clinical Informatics
CHAPTER 1 Overview of Informatics in Health
Care
CHAPTER 2 Information Needs for the
Healthcare Professional of the 21st
Century
CHAPTER 3 Informatics and Evidence-Based
Practice

36

© nednapa/Shutterstock

37

CHAPTER 1
Overview of Informatics in
Health Care
Haley Hoy, PhD, ACNP
Susan Alexander, DNP, ANP-BC, ADM-BC

LEARNING OBJECTIVES

1. Review the history of the development of clinical informatics in
the United States.
2. Define and discuss key concepts relating to clinical informatics
and information science.
3. Describe the present culture of health care in the United States.
4. Describe the role of clinical informatics in contemporary health
care in the United States.

KEY TERMS

Clinical informatics
Communication
technologies

Healthcare providers
(HCPs)
Information

Data (datum)

Information systems

Fragmentation

Knowledge

38

Nursing
informatics (NI)
Wisdom

▶ Chapter Overview
The purposes of this chapter are to provide an overview of
health information technology (IT) used in contemporary
nursing practice and briefly describe the history of clinical
informatics using the culture of health care in the United
States as a framework. Clinical informatics can provide
possible solutions to existing problems in the U.S.
healthcare system including fragmentation, access to
care, and care of special populations. Nurses who
understand clinical informatics will likely improve
healthcare delivery and patient safety.

39

▶ Informatics in Nursing Practice
The role of the 21st century nurse is complex, requiring
interaction with multiple medical devices and health IT.
Nurses at all levels of educational preparation and in all
healthcare settings use technology every day in practice.
In addition to becoming expert users, it is increasingly
likely that nurses, because of their rich experience in
patient care, will be called on to participate in the design of
new clinical systems for delivering high-quality and
efficient care. The case study that follows illustrates how
technology is integral to all parts of healthcare delivery for
healthcare providers (HCPs), patients, and healthcare
settings (see BOX 1-1).
BOX 1-1 Case Study
Cody arrives for her scheduled 12-hour hospital shift as a circulating
surgical registered nurse (RN). After she swipes her name badge at the
double doors, the doors slowly swing open for her to proceed to the
same-day surgery unit. Another swipe of her badge through the time
clock yields a “beep,” and Cody knows her day has officially begun. At the
desk, Cody greets her coworkers and glances at the large monitor
hanging on the wall in the nurses’ station where the day’s schedule of
patients, procedures, their providers, and other notes are posted.
The day’s first case is a tonsillectomy for a 3-year-old boy. Proceeding to
the child’s room, she introduces herself to the little boy and his parents
and begins preparations needed for the surgical procedure. After
scanning the child’s barcoded wrist band and barcodes on the admission
paperwork, Cody transmits the codes to the patient’s gurney, so that the
staff can track the patient’s movement throughout the surgical suite and
recovery area. She offers additional wristbands to the parents. These
wristbands are coded to allow movement in and out of the same-day
surgical unit and have a unique six-digit identification number that will
allow the parents to watch their son’s progress through pre-op, the
operating room (OR), and recovery, without breaching privacy rules.
She begins to interview the parents about the child’s health and family
history and to reconcile the child’s medications with the computerized list.
Once completed, she uses the computer’s touch screen to notify
anesthesia services that the patient is ready for the anesthesiologist’s
exam.
After the anesthesiologist enters the room and introduces herself, she
scans the child’s wristband, comparing it with the barcoded anesthesia
assessments and surgical consent she has collected. Once she has
completed her interview and examination, she taps a button on the
computer screen in the patient’s room, notifying the OR staff that the
patient is ready for the surgical procedure. Thirty minutes later, the
patient’s name begins to blink on the screen, letting the staff and the

40

parents know that the patient will soon be moved to the OR suite.
At the patient’s bedside, the transport staff and anesthetist once again
compare the code on the child’s wristband with their coded documents,
confirming the child’s name and date of birth verbally with the parents.
Releasing the brakes on the patient’s gurney, they slowly move the
patient to the OR, followed by the child’s parents. Along the way, the
transport staff points out the location of large monitor screens on which
the parents can track their child’s progress as they wait for the procedure
to conclude. As the child’s gurney moves into the OR, a transponder that
is embedded in the gurney is detected by a scanner immediately inside
the OR door. This information on the patient’s location is imported directly
into the electronic health record (EHR) and used to update the monitor in
the nurses’ station. In the OR, the patient is transferred to the OR table,
which is again synchronized with barcodes on the wristband and
documents, as the OR staff comfort the patient. The anesthesiologist
begins her work, and as the child sleeps, he is intubated, intravenous
access is obtained, and the surgery begins.
Less than 40 minutes later, the surgery is complete, and the patient is
returned to the gurney, which registers movement to the recovery room.
Prior to transport, a blanket made of smart fabric, able to monitor vital
signs and communicate wirelessly with recovery room monitors, is placed
over the child. The child’s vital signs, oxygen saturation, and heart rhythm
will be monitored until he is awake and able to be discharged later in the
day.
Three hours later, the patient is awake and ready for discharge. As orders
are again reconciled with the patient’s wristband, and the discharge
status is updated on the patient’s gurney. The child leaves the same-day
surgery unit in the arms of his father, along with further instructions and a
follow-up appointment already scheduled with the surgeon.
Check Your Understanding
1. How can the use of informatics make the daily work of a nurse
easier or harder?
2. Does the addition of informatics and technological tools have
an impact on patient care and satisfaction? How? What other
tools and devices commonly used by nurses could be
integrated into a seamless system to improve the quality of
patient care or the efficiency of processes?

41

▶ History of Clinical Informatics
Development
In the 21st century, it is difficult to imagine providing
patient care in any setting without the use of computer
technology. It is surprising that the word “computer” can
be traced to 1646, meaning “one who computes”
(Merriam-Webster, 2013). In the 19th century, the word
“computer” was used to describe the activities of humans
who labored to create tables of numerical values used in
science, mathematics, and engineering. Despite
painstaking work, the tables contained a high rate of
errors, a phenomenon recognized by Charles Babbage,
an English mathematician and scholar. In 1821, Babbage
began construction of the first mechanical computer,
known as the “Analytical Engine” (The Great Idea Finder,
1997–2007), designed to compute the values of
polynomial functions, which eventually earned him the title
of “Father of Computing” (Hyman, 1982). Babbage’s
colleague, Augusta Ada Lovelace (Countess Lovelace), a
mathematician, is attributed with the first efforts at
programming a computer when she authored the first
algorithm intended to be processed by a computer (San
Diego Computer Science Center, 1997). Though the
Analytical Engine did not have the capability for practical
daily use, it possessed many features found in modern
computers such as the ability to read data from punch
cards, store data, and perform arithmetic operations (The
Great Idea Finder, 1997–2007). The Analytical Engine
helped users begin to understand the potential value of
more sophisticated means of collecting and using data.
Over time, the value of computers and technology in the
collection and manipulation of data became readily
apparent. Through its work in establishing and maintaining

42

ongoing population records, the United States (U.S.)
Census Bureau recognized the ability of digital computers
to process large amounts of information. The Universal
Automatic Computer (UNIVAC) was designed especially
for the Census Bureau’s needs (see FIGURE 1-1). The
first version of UNIVAC (UNIVAC I) was used to conduct a
portion of the population census in 1950 and then the
entire economic census in 1954 (U.S. Census Bureau,
n.d.). UNIVAC is widely viewed as the first successful
civilian computer, ushering in the dawn of the computer
age in information processing.

FIGURE 1-1 A UNIVAC 1105 used in the 1960 census, at
the Census Bureau.
Courtesy of U.S. Census Bureau. Retrieved from
http://www.census.gov/history/www/innovations/technology/univac_i.html

Although a full history of the development of computers
into the handheld models we use today is not within the
scope of this text, a brief review of significant changes in
the use of computers and technology in health care is
warranted. Radiology is one of the first healthcare fields in

43

which informatics concepts were adopted. Robert Ledley,
a dentist who also studied physics, is credited with
inventing the first full-body computed tomography (CT)
scanner. Dr. Ledley had a deep interest in how the fields
of pattern recognition and image analysis could be applied
to patient care through the use of computers and founded
the National Biomedical Research Foundation in 1960, a
nonprofit organization dedicated to the promotion of
computing methods among biomedical scientists. He was
also a founding fellow of the American College of Medical
Informatics. Dr. Ledley foresaw the role of technology in
issues of patient care such as record keeping, imaging,
and diagnosis in settings ranging from private office
practices to acute care facilities. Today, the use of
technologically driven devices such as electrocardiogram
machines, ventilators, and intravenous pumps
necessitates a degree of technical skill in every clinician.
The increasing incorporation of technology into health care
quickly resulted in an accumulation of data as HCPs
realized that not only could computers be used at the point
of patient care, but could collect and store data useful for
determining the impact of many factors on patient care.
The field of clinical informatics is an example of a specialty
field developed by those with interests in manipulation and
application of data to patient care. Data storage and
maintenance are also of interest to the federal government
because huge databases containing billions of data points
on patients are available for researchers to answer clinical
questions.
A review of the history of clinical informatics would not be
complete without a discussion of nursing’s contribution to
the field and to the development of nursing informatics (NI)
as a science in the public and private sectors. In the late
1950s, Harriet Werley became the first nurse researcher at
the Walter Reed Army Research Institute and was asked
44

to join a small group of people who were consulting about
the possibilities of using computers in health care. Werley
was instrumental in promoting research on what would
later emerge as the field of NI (Ozbolt & Saba, 2008). The
American Medical Informatics Association (AMIA)
recognizes many important nurse leaders as NI pioneers.
While this text cannot highlight all, it is important to
understand the contributions that have shaped the
discipline of NI.
Dr. Patricia Abbott, who might be best known for her work
in helping to develop NI as a specialty field, was a member
of the team of authors who crafted the initial American
Nurses Association Scope and Standards of Practice for
Nursing Informatics (AMIA, n.d.). Dr. Abbott also worked
with the American Nurses Credentialing Center to develop
the first certification exam in NI. Dr. Virginia Saba, another
pioneer of NI, actively participated in initiating academic
technology programs and healthcare IT systems (AMIA,
n.d.). Dr. Saba has coordinated distance learning projects
for nurses and served on national healthcare standards
committees. Dr. Kathleen McCormick has been a clinical
trial researcher and NI scientist within the National
Institutes of Health Clinical Center and the National
Institute on Aging, and she is an elected member of the
National Academy of Sciences, Institute of Medicine (IOM)
now called the National Academy of Medicine (AMIA,
n.d.).
Activities of NI pioneers are not limited to the field of
nursing. Dr. Marion Ball has provided service to the public
sector as a member of the National Academy of Medicine
and on the Board of Regents of the National Library of
Medicine (AMIA, n.d.). She has worked with multiple
national and international committees, including serving as
president of the International Medical Informatics
Association and as a board member of the AMIA. Dr. Ball
45

was also invited to serve as an international advisor to the
Board of the China Hospital Information Management
Association. Roy L. Simpson, vice president, NI, Cerner
Corporation, worked with colleagues to develop the
Nursing Minimum Data Set and to develop online nursing
administration and NI master’s programs (AMIA, n.d.).
NI pioneers are also active in the areas of educating and
fostering the NI workforce of tomorrow. Dr. Linda Thede is
professor emeritus at the College of Nursing at Kent State
University, where she has developed and taught NI
programs (AMIA, n.d.). Dr. Susan K. Newbold, a
healthcare informatics consultant based in Franklin,
Tennessee, worked to found CARING, an NI group that
was established in 1982. She also participates in teaching
NI to nursing students at multiple curricular levels (AMIA,
n.d.). Dr. Susan J. Grobe developed the Nursing
Education Module Authoring System, which consists of a
set of software programs that faculty can use to create
modules on the nursing process. Dr. Grobe was one of the
first of two nurse fellows elected to the American College
of Medical Informatics (AMIA, n.d.).

46

▶ Clinical Informatics and Nursing
Informatics Defined
Clinical informatics is a broad term that encompasses all
medical and health specialties, including nursing, and
addresses the ways information systems (e.g., EHRs,
barcode medication administration systems, radiology
imaging system, and patient-care devices) are used in the
day-to-day operations of patient-care. The domains of
clinical informatics include health systems, clinical care,
and information and communication technologies (see
FIGURE 1-2). The purpose of clinical informatics is to
improve patient care by using methods and technologies
from established disciplines such as computer science
and information science.

FIGURE 1-2 Domains of clinical informatics.

47

Data from Gardner, R. M., Overhage, J. M., Steen, E. B., Munger, B. S.,
Holmes, J. H., Williamson, J. J., & Detmer, D. E., for the AMIA Board of
Directors. (2009). Core content for the subspecialty of clinical informatics.
Journal of the American Medical Informatics Association, 16(2), 153–157.

Nursing informatics is a specialty in the discipline of
nursing, and it is classified as a special interest group in
professional organizations whose focus is clinical
informatics. NI is defined by the International Medical
Informatics Association’s Nursing Informatics Special
Interest Group (2009) as the “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.” Because of the emphasis on
promoting health, the study of NI is a natural fit for nurses
who are dedicated to quality care for patients. As
described in this book, the understanding of NI concepts is
not a “nice to know” set of knowledge, skills, and values;
rather, it is a requirement for effective nursing practice
(Thede, 2012).
The role of clinical informatics is becoming increasingly
important and can be seen in almost every aspect of
patient care, from the bedside to the patient’s bill. The use
of powerful clinical informatics tools can support processes
of care, such as promoting the flow of information between
those who are involved in the delivery of care across
HCPs in large delivery systems. At the macro-system
level, clinical informatics tools can be used to assess
specific outcomes of care for groups, such as the efficacy
of annual influenza vaccinations or fall prevention
programs.

48

▶ Clinical Informatics Concepts
Informatics is a multidisciplinary science, with its
beginnings in how data are processed and communicated
between systems. What are data? Data are values or
measurements, bits of information that can be collected
and transformed, allowing a person to answer a question
or to create an end product, such as an image. In health
care, data may be created with every patient encounter.
Nurses and other HCPs use their education and
experience to assemble data in a clinical context to create
information, which gives insight about patient care.
Information can then be used to plan care for patient
aggregates, increase the efficiency of organizations,
improve quality of care, prevent medical errors, increase
efficiency of care, and potentially reduce unnecessary
costs. Knowledge creation concerns the ways that nurses
and HCPs use the data and information they create to
better understand and manage their practice. Graves and
Corcoran provided a classic definition of knowledge as
“information that has been synthesized so that
relationships are identified and formalized” (1989, p. 230).
For example, information is a trend of a patient’s vital
signs and lab results after surgery, and knowledge is
recognition that elevation in a patient’s temperature and
white blood cell count could mean a post–operative
infection is developing. The proper use of knowledge to
solve real-world problems and aid continuous
improvement is what is known as wisdom (McGonigle &
Mastrian, 2012).
Many different systems support the movement from data
to information, information to knowledge, or knowledge to
wisdom. Systems that support the transfer from data to
information are known as information systems. Systems

49

that support the transition from information to knowledge
are decision-support systems, and those that apply
knowledge through wisdom are known as expert systems
(McGonigle & Mastrian, 2012). At each level, these
systems contain computer, communications, and human
elements.
Principles of informatics can apply to many different fields,
from economics to health care. However, in clinical
informatics, people with a background in health care use
informatics tools, such as health information databases,
medical imaging software, or point-of-care technologies to
capture information and present it to other members of
healthcare teams. The implementation of clinical
informatics tools has the potential to create vast
improvements in patient care by improving efficiency and
reducing errors, which is a top priority for the United
States.

50

▶ The Culture of Health Care in the
United States
The United States spends more per capita on health care
than any other country in the world. Health expenditures in
the United States neared $3.2 trillion in 2015—accounting
for 17.8% of the overall share of the economy (Centers
for Medicaid and Medicare Services [CMS], Office of
the Actuary, National Health Statistics Group, 2015).
While the intent of the Affordable Care Act (ACA), enacted
in 2010, was to reduce healthcare spending, the ACA is
typically associated with the expansion of health care to
underserved individuals. Though cost containment has
been demonstrated in areas of health care, costs continue
to rise at a rate of 5.4% annually through 2024 (Altarum
Institute, 2017).
Despite continued increases in healthcare spending, a
public opinion poll on the quality of health care in the
United States would yield a variety of responses. A report
from the IOM (2011) draws attention to the poor health of
U.S. citizens. Though the United States has the highest
rate of per capita spending on health care, comparing our
population of citizens under the age of 75 to those of peer
countries finds that ours have higher rates of chronic
diseases and disabilities (IOM, 2011). According to the
Commonwealth Fund, the United States ranks poorly, and
frequently last, when compared with 11 other
industrialized countries on factors of health care including
healthy lives, access to care, healthcare quality, efficiency,
and equity (The Commonwealth Fund, 2014). On
measures of quality, the United States ranks near the top
in two of four aspects of quality, effective care, and
patient-centered care, but ranks much lower in providing
safe and coordinated care (2014). Fragmentation,

51

occurring when healthcare professionals focus on
momentary issues with patients and failing to look at the
“big picture” is a serious issue in today’s healthcare
environment.

The Impact of Fragmentation
Missing medical information can be a detriment to care in
many settings, but perhaps more so in areas of high
acuity, in which HCPs may be forced to make rapid
decisions that may be challenging to patient safety. A
retrospective review of 3.6 million patient visits to acute
care sites in Massachusetts from 2002 to 2007 revealed
that 56.5% of the patients were multisite users or had
used more than one acute care site within the 5-year
period (Bourgeois, Olson, & Mandl, 2010).
Fragmentation of care ultimately places patients at greater
risk for poor outcomes, particularly if those patients have
multiple or chronic conditions. Patients with chronic
diseases such as type 2 diabetes mellitus (T2DM) are at
risk for multiple complications that often necessitate
management by subspecialists such as ophthalmologists,
nephrologists, podiatrists, and cardiologists. Initiating such
referrals and follow ups for patients with T2DM, while
consistent with evidence-based guidelines, can be an
arduous task for an HCP. Patients who do not receive
needed referrals for treatment of complications may be
forced to seek care in settings that are more expensive
and less appropriate for chronic management, such as an
emergency department (ED). Liu, Einstadter, and Cebul
(2010) studied the effects of care fragmentation on a
group of 683 adult patients with diabetes and chronic
kidney disease. The primary outcome variable was the
number of ED visits made during a 2-year period. Findings
from the study revealed that patients who had fewer visits
to primary HCPs had higher numbers of ED visits.

52

For optimal protection against transmissible diseases such
as measles, mumps, and pertussis, childhood
immunizations must be given at specified intervals and
ages. Tracking the administration of childhood
immunizations for each child, which may total 24 timed
vaccinations during the first 18 months of life, is another
area at risk for fragmentation and subsequent elevation in
risk of acquiring childhood diseases (Centers for Disease
Control and Prevention [CDC], 2013). The effects of
fragmented health care have also been studied in
immunization rates of children aged 19–35 months
residing in four geographical areas (northern Manhattan,
San Diego, Detroit, and rural Colorado), which have
received federal designation as health professional
shortage areas (Yusuf et al., 2002). HCPs must have
reliable information in order to offer necessary
immunizations; otherwise children may miss opportunities
for vaccinations if providers decide to delay based on
inaccurate or incomplete records from parents or other
HCPs. Incomplete information from recent HCPs was
associated with both overimmunization and
underimmunization in this study (Yusuf et al., 2002). The
utilization of community-wide immunization registries,
containing information from all immunization providers in a
community, was suggested as a solution to the dilemma of
clinical questions regarding vaccinations (Yusuf et al.,
2002).
Inaccurate or incomplete transfer of information, another
example of the fragmentation that permeates health care
today, can put vulnerable patients at risk of adverse
events, hospital readmission, and even death in the
transition from inpatient to home care (Davis, Depoe,
Kansagara, Nicolaidis, & Englander, 2012). HCPs have
identified the need for improved communication between
healthcare systems, particularly for those patients who
have conditions that have been identified as high risk for
53

hospital readmission. In a qualitative study of 75
healthcare professionals, representing physicians, nurses,
pharmacists, and other allied health professionals, poor
cross-site communication was noted as a major gap in
helping patients to transition from hospital to home (Davis
et al., 2012). These gaps were amplified by the lack of
interoperability between EHR systems of the facility and
outpatient practice, and this was especially troubling to
primary care providers who cited:
A patient’s there in front of me [after
discharge], they’ve had a life changing
event, and I’m sitting there without the
information. You feel like an idiot. . . . I would
think, “What kind of system do you guys
have here? I almost died, and you don’t even
have the information.” . . . That’s
embarrassing and I don’t think it engenders
a lot of confidence for your patients. (Davis
et al., 2012, p. 1653)

54

▶ Introducing Information Science
The Promises of Clinical Informatics
Systems
The adoption of clinical informatics systems has the
potential to address issues of fragmentation by integrating
healthcare delivery across groups of HCPs, health
systems, and insurers. The full potential of clinical
informatics tools remains to be realized. Improving
efficiency of care for specific disease states, care settings,
and populations is an area in which clinical informatics
tools can make a positive impact. For example, a survey of
40 hospital infection preventionists suggests that
expansion of the hospital EHR’s capabilities, in order to
provide clinical decision prompts on patients who need
closer inspection, would be of benefit in detecting and
providing timely care for patients with hospital-associated
infections. Improved awareness of regional health
initiatives and public health reporting capabilities would
increase communication and earlier detection (McKinney,
2013).

Improved Efficiency
Defragmentation, a strategy long used in fields such as
engineering, computer science, and manufacturing, is a
means of managing limited resources while improving the
performance of a system. A myriad of applications for
health IT and informatics systems incorporating
defragmentation can be used to improve efficiency, even
in the office environment, where millions of patients
schedule appointments with HCPs every day.
Conventional appointment scheduling, in which a block of
time is scheduled to accommodate a patient’s needs, is a
trade-off between the need to maximize the productivity of
an HCP while minimizing the wait time for a patient. A

55

ranked list of most preferred to least preferred
appointment time slots for providers was created for
schedulers, designed to offer guidance on how to best
schedule patient appointments to prevent provider
schedule fragmentation (Lian, Distefano, Shields,
Heinichen, Giampietri, & Wang, 2010). A computer
model was developed to measure efficiency using two
metrics: “acceptance rate (the number between the
number of accepted appointments and the total number of
appointment requests), and the utilization rate (the health
care provider’s actual service time divided by the total
work time)” (Lian et al., 2010, p. 128). The advanced
appointment scheduling process was tested in four
different specialty and primary care clinics. The
aggregation of open time slots for HCPs that resulted from
the implementation of the process was utilized in various
ways, including the addition of new patient appointments
in the open blocks of time.

Improving the Health Care of Older Adults
Older adults bear a higher burden of illness and frailty, and
may transition frequently between healthcare systems,
leading to both increased economic costs and physical
risk. More than 125 million Americans had at least one
chronic disease diagnosis in 2000, and this number is
expected to grow to 157 million by the year 2020 (Wu &
Green, 2000). A disproportionately large number of older
adults are dealing with chronic illnesses. Potentially
avoidable hospitalizations in older adult clients often result
in poor outcomes, which are unnecessary and create
excessive expenditures. By improving communication
across systems, clinical informatics may assist HCPs in
meeting the challenges of caring for older adults. For
example, the Regenstrief Medical Record System
(RMRS), housed at the University of Indiana and serving
the Indianapolis area, contains records from more than 1.3
million patients. As early as 1974, the RMRS began to
56

deliver automatic reminders in the form of paper reports,
creating reminders for preventive services such as fecal
occult blood testing, mammography, and vaccinations—
topics pertinent to the care of older adults. In a 2-year
randomized trial involving 130 providers and more than
12,000 patients, investigators found that older adult
patients of physicians who received reminders for
influenza vaccinations were twice as likely to receive the
vaccination as patients of physicians who did not receive
electronically generated reminders (Weiner et al., 2003).

Challenges in Clinical Informatics
Clinical informatics technologies have multiple purposes—
to improve health of people, aggregates, communities,
and populations. However, several barriers must be
overcome if technology can really improve the U.S.
healthcare system. The first and biggest barrier is the lack
of system interoperability, which restricts the flow of data
from one information system to others (Thede, 2012).
There are many reasons for the interoperability problem,
including the purchase of “best of breed” systems for
specialty practices, the use of legacy systems that cost too
much to upgrade, and integration processes that are too
difficult to implement. Poor usability of health IT is the
second barrier (Thede, 2012). When nurses and other
HCPs are burdened with technology rather than helped by
it, the health IT has been improperly designed for the user
experience and for the workflow. A related and important
third barrier is the failure to design health IT for human
factors to prevent errors (Thede, 2012). The interaction of
humans with technology is studied in other fields and
applied in the design of technology and processes. In
clinical informatics, attention to human factors is emerging
and will become more prominent as a strategy to improve
patient safety.

The Role of the Nurse
57

Nurses will play key roles in the redesign of healthcare
delivery systems, with expanded roles, knowledge, and
skill sets, to address problems facing the health IT world,
such as lack of interoperability. The challenges of working
with specific populations, complex comorbidities, and
multiple healthcare systems, along with the increasing
need to incorporate evidence-based practice make it
necessary for nurses at all levels of educational
preparation to master essential informatics competencies.
In addition to familiarity with basic computer skills, nurses
will need proficiency with patient-care technologies and
“an attitude of openness to innovation and continual
learning, as information systems and patient care
technologies are constantly changing” (American
Association of the Colleges of Nursing, 2008, p. 19).

Bridging the Gap Between Development and
Clinical Use
With their experience in multiple aspects of patient care,
nurses have the capacity to be far more than end users.
Participating in the design, testing, and launch of
informatics technologies can help to increase the
accuracy, ease of use, and adoption of valuable tools,
such as the EHR. Previous studies have reported an 83%
increase in the success of entry of history of present
illness and review of systems data into an electronic chart
when the task was assigned to a nurse (EHR Intelligence,
2012). Nurses have often found themselves serving as
translators for patients, families, and other healthcare
professionals. Many nurses will find a natural extension of
this talent in their work with assisting other HCPs to
efficiently use health IT technologies.

58

▶ Summary

© nednapa/Shutterstock

HCPs recognized the impact of informatics to improve
outcomes for patients more than 100 years ago. New
applications for informatics-based tools continue to
emerge, offering nurses and other HCPs a valuable
mechanism of improving delivery and outcomes of care for
patients. While not every nurse will require more formal
education in informatics, every nurse must realize that
health IT technology is simply another tool to be used in
nursing care. As nursing students acquire familiarity with
technically complex tasks such as gaining intravenous
access or inserting Foley catheters, it is reasonable to
include the attainment of familiarity with health IT
technologies as an expectation. Understanding informatics
concepts, which is the basis for development of
sophisticated health IT tools, will provide a groundwork for
nurses to develop their skills in a growing aspect of health
care.

59

References

Altarum Institute (2017). Health sector economic
indicators: Insights from monthly national health
spending data through December 2016. Retrieved
from
http://altarum.org/sites/default/files/uploadedrelated-files/CSHS-SpendingBrief_February_2017.pdf
American Association of the Colleges of Nursing. (2008).
The essentials of baccalaureate nursing education for
professional nursing practice. Retrieved from
http://www.aacn.nche.edu/educationresources/BaccEssentials08.pdf
American Medical Informatics Association. (n.d.). Video
Library 1: Nursing informatics pioneers. Retrieved
from http://www.amia.org/programs/workinggroups/nursing-informatics/history-project/videolibrary-1
Bourgeois, F. C., Olson, K. L., & Mandl, K. D. (2010).
Patients treated at multiple acute health care facilities:
Quantifying information fragmentation. Annals of
Internal Medicine, 170(22), 1989–1995.
Centers for Disease Control and Prevention. (2013). 2013
Recommended immunizations for children from birth
through 6 years old. Retrieved from
http://www.cdc.gov/vaccines/parents/downloads/parentver-sch-0-6yrs.pdf
Centers for Medicare and Medicaid Services, Office of
the Actuary, National Health Statistics Group. (2015).
National health expenditures 2015 highlights.
Retrieved from https://www.cms.gov/ResearchStatistics-Data-and-Systems/Statistics-TrendsandReports/NationalHealthExpendData/downloads/highlights.pdf
The Commonwealth Fund. (2014). U.S. health system
ranks last among eleven countries on measures of
access, equity, quality, efficiency, and healthy lives.
Retrieved from
http://www.commonwealthfund.org/publications/pressreleases/2014/jun/us-health-system-ranks-last
Davis, M. M., Devoe, M., Kansagara, D., Nicolaidis, C., &
Englander, H. (2012). “Did I do as best as the system
would let me?” Healthcare professionals’ views on

60

hospital to home care transitions. (2012). Journal of
General Internal Medicine, 27(12), 1649–1656.
EHR Intelligence. (2012). Adoption and Implementation
News. Nurse involvement, acceptance is critical to
successful EHR use. Retrieved from
https://ehrintelligence.com/news/nurseinvolvement-acceptance-is-critical-to-successfulehr-use/
Graves, J., & Corcoran, S. (1989). The study of nursing
informatics. Journal of Nursing Scholarship, 21(4),
227–231.
The Great Idea Finder. (1997–2007). Ada Lovelace.
Retrieved from
http://www.ideafinder.com/history/inventors/lovelace.htm
Hyman, A. (1982). Charles Babbage: Pioneer of the
Computer. Princeton, NJ: Princeton University Press.
Institute of Medicine. (2011). Health IT and patient safety:
Building safer systems for better care. Washington,
DC: Committee on Patient Safety and Health
Information Technology, Board on Health Care
Services.
International Medical Informatics Association, Nursing
Informatics Special Interest Group. (2009). Definition.
Retrieved from http://imia-medinfo.org/ni/node/28
Lian, J., Distefano, K., Shields, S. D., Heinichen, C.,
Giampietri, M., & Wang, L. (2010). Clinical
appointment process: Improvement through schedule
defragmentation. IEEE Engineering in Medicine and
Biology Magazine, 29(2), 127–134. doi:
10.1109/MEMB.2009.935718
Liu, C. W., Einstadter, D., & Cebul, R. D. (2010). Care
fragmentation and emergency department use among
complex patients with diabetes. American Journal of
Managed Care, 16(6), 413–420.
McGonigle, D., & Mastrian, K. G. (2012). Nursing
informatics and the foundation of knowledge (2nd
ed.). Burlington, MA: Jones & Bartlett Learning.
McKinney, M. (2013). Study: EHRs underutilized by
preventionists. Retrieved from
http://www.modernhealthcare.com/article/20130225/NEWS/302259955

Merriam-Webster. (2013). Computer. Retrieved from
61

Merriam-Webster. (2013). Computer. Retrieved from
http://www.merriamwebster.com/dictionary/computer
Ozbolt, J. G., & Saba, V. K. (2008). A brief history of
nursing informatics in the United States. Nursing
Outlook, 56, 199–205.
San Diego Computer Science Center. (1997). Ada Byron,
Countess of Lovelace. Retrieved from
http://www.sdsc.edu/ScienceWomen/lovelace.html

Thede, L. (2012). Informatics: Where is it? OJIN: The
Online Journal of Issues in Nursing, 17(1). Retrieved
from
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANA
Informatics/Informatics-Where-Is-It.html

U.S. Census Bureau. (n.d.). UNIVAC I. Retrieved from
http://www.census.gov/history/www/innovations/technology/univac_i.htm
Weiner, M., Callahan, C. M., Tierney, W. M., Overhage,
M., Mamlin, B., Dexter, P. R., & McDonald, C. J.
(2003). Using information technology to improve the
health care of older adults. Annals of Internal
Medicine, 139, 430–436.
Wu, S., & Green, A. (2000). Projection of chronic illness
prevalence and cost inflation. Santa Monica, CA:
RAND Corporation.
Yusuf, H., Adams, M., Rodewald, L., Pengjun, L.,
Rosenthal, J., Legum, S., & Santoli, J. (2002).
Fragmentation of immunization history among
providers and parents of children in selected
underserved areas. American Journal of Preventive
Medicine, 23(2), 106–112.

62

© nednapa/Shutterstock

63

CHAPTER 2
Information Needs for the
Healthcare Professional of
the 21st Century
Haley Hoy, PhD, ACNP
Susan Alexander, DNP, ANP-BC, ADM-BC
Gennifer Baker, DNP, RN, CCNS

LEARNING OBJECTIVES

1. Describe the importance of informatics related to the nurse’s
role in clinical guidelines, protocols, procedures, and
accessibility for all clinicians.
2. Recognize the importance of clinical informatics to achieve
efficient quality improvement techniques within a complex
healthcare system.
3. Discuss the application of clinical informatics in optimizing the
nurse’s role in interprofessional collaboration and practice
workflow through nursing leadership in information technology.
4. Describe the importance of clinical informatics in nursing
curricula and continuing education.

KEY TERMS

Clinical
guidelines
Continuing
education
Continuous

Fast healthcare
interoperability
resources (FHIR)
Health information
exchange (HIE)

quality

64

Interprofessional
collaboration
Procedures
Protocols

improvement
(CQI)

65

▶ Chapter Overview
Clinical informatics is evident throughout the healthcare
system. Nurses are expected to enter the field with a
baseline knowledge of clinical informatics as well as an
understanding of its application to clinical guidelines,
protocols, and procedures. Moreover, many quality
improvement (QI) techniques aimed at preventing medical
errors involve informatics and are necessary to achieve
cost reduction as well as patient and clinician satisfaction.
The role of the nurse in informatics related to
interprofessional practice, practice workflow, and
leadership in information technology (IT) will be discussed
in this chapter. Finally, nursing education curricula and
their alignment with the expectations of a complex
healthcare system related to clinical informatics will be
described.

66

▶ Accessibility to Guidelines,
Protocols, and Procedures
Clinical informatics as it applies to clinical guidelines,
protocols, and procedures may be the most easily
understood application for nurses. A struggle for clinicians
prior to the 21st century was maintaining awareness of
current guidelines as many of these groups update their
guidelines every few years as new evidence evolves.
Through clinical informatics, and the advent of handheld
devices, the most up-to-date clinical guidelines are at
every clinicians’ fingertips.
Handheld devices and applications make readily available
the most current guidelines and clinical protocols (see
FIGURE 2-1; Moorman, 2002). Guidelines, primarily
evidence-based recommendations, are usually generated
from an authority group consisting of experts in the field
and are published regularly. A well-known example is the
set of guidelines published annually by the American
Diabetes Association (2017). A council of experts
assesses, critiques, and updates the clinician guidelines
for care of the patient with diabetes. In years past,
clinicians who regularly care for patients with diabetes
would carry these guidelines in their lab coat for easy
reference. Today, these guidelines are updated with new
recommendations to safeguard patients with regard to the
physical and psychological health of people with diabetes.
Clinicians now have the ability to access these updated
guidelines because of the work in the field of informatics.
Other common clinical guidelines are the National Heart,
Lung, and Blood Institute (NHBLI) for the management of
asthma and hypertension published by the Joint National
Committee (JNC) and colorectal screening guidelines

67

released periodically by the U.S. Preventive Services Task
Force (TABLE 2-1).

FIGURE 2-1 Today’s nurses must possess competence in
patient care, communication, and data management.
© hocus-focus/iStockphoto.com

TABLE 2-1 Examples of Commonly Used Clinical Resources
Topic

Release
Date

URL

Colorectal
Cancer
Screening

2016

http://jamanetwork.com/journals/jama/
fullarticle/2529486

Diabetes

2017

https://professional.diabetes.org/sites/professional.
diabetes.org/files/media/
dc_40_s1_final.pdf

Hypertension

2014

http://jamanetwork.com/journals/
jama/fullarticle/1791497

68

Asthma

2007

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

Protocols are usually evidence-based but tend to be
team-based approaches to practices in a locale or region.
Through shared drives and web-based applications, teams
of clinicians can share and access protocols to improve
uniformity and best practices germane to a particular
practice. Common protocols encountered by nurses are
treatment protocols and procedure protocols. Procedures
are commonly performed skills in practice setting. These
procedures can be accessed, shared, and easily updated
with the emergence of new evidence with the use of
clinical informatics. The application of clinical informatics
allows the nurse to review procedures prior to performing
them and also adds to the uniformity of procedures
performed within a given practice. Common medical
applications, such as Epocrates and UpToDate, offer a

69

centralized repository of many guidelines, protocols, and
procedures and are discussed further in a later chapter.

70

▶ Quality Improvement Techniques
and Nursing Informatics
QI and patient safety are intimately related to clinical
informatics in health care. Healthcare organizations and
practice settings create data from detailed records of
patient histories, diagnoses, treatments, and the outcomes
of treatments. With the help of health IT, the data can be
used to create a wealth of knowledge that improves the
quality and efficiency of care.
The transformation of data into knowledge and wisdom is
the foundation of informatics. It is a continuous process
that requires the tools provided by IT and the expertise
and interpretive skills of the healthcare provider (HCP).
The efficacy of knowledge is directly related to the breadth
of the data from which it is derived. As time progresses
and the adoption of technologies such as the electronic
health record (EHR) continues, this process will become
more important and more efficacious, and the skills
required for knowledge creation will become more and
more integral to the nursing practice.
The National Academy of Medicine, formerly the Institute
of Medicine, highlights six main aims of HCPs:
effectiveness, safety, efficiency, patient-centeredness,
timeliness, and equitability (Agency for Healthcare
Research and Quality [AHRQ], 2016). The QI system,
then, must develop measures of quality that reflect these
aims. Because of the complex and unpredictable nature of
health care, measuring quality can be difficult; it is
particularly hard to attribute the outcomes of treatment to
any one particular cause. Another factor contributing to the
complexity of QI is that errors and adverse events should
be rare, exceptional events (Hughes, 2008). Several

71

groups have attempted to address this issue by
researching, vetting, and endorsing measures of quality
that are valid and reliable and more proximal to the actual
care provided rather than a long-term measurement.
AHRQ is the primary provider of these vetted quality
measures, and a breakdown of these measures can be
found on its National Quality Measures Clearinghouse
website (http://www.qualitymeasures.ahrq.gov).
Using clinical guidelines, HCPs can begin to assess
quality through benchmarking. With internal
benchmarking, HCPs compare their current performance
to their past performance. This benchmarking is helpful in
identifying best practices within an organization. In
external benchmarking, performance is compared to other
HCPs outside the organization. External benchmarking is
important to ensure that HCPs and organizations are not
isolated and have quality equivalent to others regardless
of geographic location. Sources for comparative data for
external benchmarking include the AHRQ’s annual
National Healthcare Quality Report and National
Healthcare Disparities Report. There are also other more
nursing-specific sources, such as the American Nurses
Association (ANA)’s National Database of Nursing Quality
Indicators (Hughes, 2008).
Quantitative measures of quality are useful, but they do
not provide the entire picture. In order to use them to their
fullest potential, a thorough understanding of the
structures and processes that make up the workflow of the
organization and an open and collaborative team
approach to QI are vital. This is where continuous quality
improvement (CQI) systems come in. With CQI systems,
the belief is that there is always room for improvement in
every aspect of the process. Organizations that use CQI
set up holistic systems that focus on every aspect of an
organization and strive to make improvement the primary
72

purpose of the organization. This holistic approach
includes defining processes, honing organizational
management, working in teams, gathering and assessing
data, and translating those assessments into changes in
the function of the practice (Hughes, 2008). The
continuous nature of these types of systems means
constantly reevaluating and assessing the changes made
in the past. These systems are some of the most teamoriented, requiring a large commitment from the
organization’s leadership and its constituents, but they can
produce amazing results if implemented by a willing and
committed staff. A detailed list of QI strategies and tools
can be found at the AHRQ’s website
(https://innovations.ahrq.gov/qualitytools/qualityimprovement-quality-toolbox).

73

▶ Interprofessional Collaboration and
Practice Workflow
Clinical informatics impact the ability of professionals to
interact and build upon one another’s contribution to
patient care. In years past, interprofessional
collaboration was limited to verbal encounters, phone
calls, and facsimiles. With the application of clinical
informatics, clinicians now routinely collaborate through
portals and electronic medical records (EMRs), review and
attest one another’s patient notes, and make referrals
conveying critical information to other clinicians through
informatics (Oyler & Vinci, 2008). In fact, in 2017, fast
healthcare interoperability resources (FHIR), a
standard for electronically sharing healthcare information,
released an update and will soon move from a trial version
to its final version. The primary goals of FHIR are to
improve interoperability among healthcare systems
through health information exchanges (HIEs) and
improve access to healthcare information on multiple
devices including computers, tablets, and cell phones
(Munro, 2014). HIEs are high-level systems that are
designed to promote the rapid sharing of data across
facilities. Although technological factors are certainly
essential in the success of an HIE, understanding how the
HIE impacts users is also important. Unertl, Johnson, and
Lorenzi (2012) conducted a 9-month qualitative,
ethnographic study, gathering data from six emergency
departments (EDs) and eight ambulatory clinics in the
Southeastern United States. They found that HIEs were
incorporated into the workflow in user-specific roles; for
example, nurses reported frequent access of HIEs to
confirm patients’ reports of care at other facilities within the
exchange (Unertl, Johnson, & Lorenzi, 2012). Additional
positive impacts of HIEs on workflow were noted by

74

participants in other ways, such as how they assist in
medical decision making by supplying essential
information when laypersons were unable to do so and
facilitate referrals and transfers to other facilities.

75

▶ Nursing Workflow
Health IT has a profound effect on the way that nurses
provide care for patients, regardless of the location of that
care. In many cases the effects may be negative, by
reducing the efficiency of nursing care processes, also
called nursing workflow. Because workflow issues are so
important, an entire chapter is devoted to the topic later in
the book. However, a short description is warranted here
to emphasize the role that nurses have when using health
IT.
Quantitative research methods are often used to evaluate
the implementation of informatics tools in nursing workflow
because these methods can describe details such as cost,
time, and other factors that are often associated with
health IT use in organizations. However, a more
comprehensive understanding of the scope of health IT
implementation in nursing workflow requires an
assessment of the attitudes and perceptions of the nurses
who will work directly with the technology (see FIGURE 22). This type of information may be better captured with
the use of qualitative research methods. In complex
bedside procedures, such as the administration of
intensive insulin therapy (IIT) in the patient with diabetes
who is experiencing a hyperglycemic crisis, the use of a
computer-assisted clinical decision-support system may
be helpful. In a qualitative ethnographic study of 49
instances of nurses who used such a system embedded in
a provider order-entry system to administer IIT to patients,
researchers found that nurses felt that the documentation
associated with the use of the system presented a
hindrance to patient care, but valued its ability to
recommend insulin dosages based on their data input
(Campion, Waitman, Lorenzi, May, & Gadd, 2011).

76

FIGURE 2-2 Describing the impact of health IT
implementation on nursing workflow necessitates
assessment of nurses’ attitudes and perceptions about the
use of technology in patient-care settings.
© EricHood/iStockphoto.com

77

Due to the importance of clinical informatics related to QI,
interprofessional collaboration, and nursing workflow, it is
imperative that nurses remain leaders in health IT (see
case study in BOX 2-1). Chief Nursing Officer (CNO) must
understand informatics concepts and the needs of the
nursing staff to engage successfully with the Chief
Information Officer (CIO) of the organization (American
Organization of Nurse Executives, [AONE], 2015). Too
often lack of communication between the CNO and CIO
leads to poor technology selection or flowed
implementation. Lack of this critical relationship can lead
to an implementation of health IT solutions that is met with
resistance or fails to address specific needs of the nursing
discipline. Introduction of clinical informatics early in
nursing curricula is a first step in creating nurses who are
prepared to be leaders in IT.
BOX 2-1 Case Study: Establishment and Utilization of the IT/Nursing
Workflow Group
When change is inevitable for an organization such as in a product,
process, or pathway, it is in the best interests of the organization to
include in the process of change those who would be defined as end
users. The end user is someone who actually touches or uses whatever
is being addressed in an ongoing basis. Involvement of end users assists
in streamlining changes and creates an environment of appreciation and
ownership that yields a greater volume of interest and increased morale.
In turn, the EHR would become end-user friendly and have the possibility
to decrease time and effort in charting workflow and allowing for more
direct patient care.
Shannon’s hospital is planning to upgrade the EHR admission
assessment and charting workflow for nurses, and he is charged with
getting direct care nurses involved in the process. Collaborative
communication with a senior IT applications analyst resulted in a formal
meeting for direct care nurses, held in a location away from the nursing
units. Shannon schedules monthly meetings, allotting 4–5 hours for each,
in order to provide an opportunity for the direct care nurses to voice
concerns with the current charting, make suggestions to streamline
electronic workflow, and help make decisions regarding desired
upgrades.
Several months before the scheduled upgrade, Shannon requested the
nursing directors to ask each nursing manager to recruit a staff nurse to
participate in the monthly meeting. The goal was to have an adequate
representation of nursing staff who delivered direct care to patients
representing multiple disease processes, range of acuity, and throughout
the life span. Desired participants were described as direct care nurses
who would be willing to speak up in a group of their peers and give
honest input. Each would need to be proficient with EHR charting.
Each month the senior applications analyst worked with Shannon to

78

establish an agenda for the meeting to coincide with the upgrade timeline.
It was imperative that this group remained on task in order to meet the
overall goal for the organization. Participation flourished in the beginning
as workflow was redefined.
During the meetings prior to the upgrade, Shannon and the direct care
nurses validated there were several ways in which to chart multiple data
elements. Identification of these multiple elements became a high priority,
along with streamlining charting by nursing within the EHR. Duplication
and cumbersome charting in the EHR were identified as nursing
dissatisfiers, and as such, became of high importance to nursing and
hospital administration. The direct care nurses were glad to see their
concerns were heard and that they were trusted to work toward problem
resolution.
Over the period of 9 months, Shannon was able to lead the direct care
nursing workflow group in offering invaluable input into how the nursing
staff charts in the EHR. They minimized and streamlined charting
pathways and gave input on the training materials for the upgrade roll out.
Over time, staff nurse participation decreased, and those who persisted
brought vital worth to the project. These individuals also stepped up to
assist in facilitating the education of their peers throughout the
organization. This well-organized group created an improved charting
path that was embraced by other bedside nurses throughout the hospital.

79

▶ Nursing Curricula and Continuing
Education
The American Association of Colleges of Nursing (AACN,
2008), in The Essentials of Baccalaureate Education for
Professional Nursing Practice, summarizes the need for
informatics content in curricula: “Knowledge and skills in
information management and patient care technologies
are critical in the delivery of quality patient care” (p. 4).
TABLE 2-2 lists the specific competencies that nurses
should possess when they graduate from any Bachelor of
Science in Nursing program.
TABLE 2-2 AACN Essentials of Baccalaureate
Education for Professional Nursing Practice. Essential
IV: Information Management and Application of PatientCare Technology
Demonstrate skills in using patient-care technologies, information
systems, and communication devices that support safe nursing practice.
Use telecommunication technologies to assist in effective communication
in a variety of healthcare settings.
Apply safeguards and decision-making support tools embedded in
patient-care technologies and information systems to support a safe
practice environment for patients and healthcare workers.
Understand the use of clinical information systems to document
interventions related to achieving nurse-sensitive outcomes.
Use standardized terminology in a care environment that reflects
nursing’s unique contribution to patient outcomes.
Evaluate data from all relevant sources, including technology, to inform
the delivery of care.
Recognize the role of information technology in improving patient-care
outcomes and creating a safe care environment.
Uphold ethical standards related to data security, regulatory
requirements, confidentiality, and patients’ right to privacy.
Apply patient-care technologies as appropriate to address the needs of a
diverse patient population.
Recognize that redesign of workflow and care processes should precede
implementation of care technology to facilitate nursing practice.
Participate in evaluation of information systems in practice settings
through policy and procedure development.
Reproduced from American Association of Colleges of Nursing. (2008).
The Essentials of Baccalaureate Education for Professional Nursing
Practice. Retrieved from http://www.aacn.nche.edu/educationresources/baccessentials08.pdf

80

Nursing education programs are working to implement
health informatics education into present curricula, but this
can be a difficult process. Time constraints and a shortage
of nursing faculty with health informatics expertise have
been cited as barriers to the full integration of health
informatics content in programs of study in the United
States and abroad (Bartholomew, 2011). In a study of
186 students enrolled in healthcare professions in the
United Kingdom, 61% reported that they desired more
training in the use of clinical information systems
(Bartholomew, 2011). It is essential that students
understand that working with health IT tools is a
meaningful component of the professional nurse’s skill set.
Exposure to an academic EHR and repeat opportunities to
develop competency in the use of the EHR have been
cited as important throughout the curricula. These
exposures may be important approaches in assisting
nursing students to meet the evolving health IT
expectations in healthcare settings (Gardner & Jones,
2012).

81

▶ Ongoing Education and Nursing
Informatics
Continuing education is required for all nurses to stay
current in practice, meet their state-mandated continuing
education units (CEUs), and fulfill requirements for
certification/recertification in specialty practice. For
example, 30 states in the United States require CEUs for
renewal of the registered nurse (RN) license. Some states
have special requirements for CEUs including education
on human immunodeficiency virus/acquired immune
deficiency syndrome, professional practice, pain
management, bioterrorism, domestic violence, and
reporting to public health authorities (ANA, 2013). For
nurses with national certification in specialized nursing
areas or in advanced practice roles, CEU requirements
are more extensive and vary by the certification. As clinical
evidence rapidly evolves, an efficient means to gain
access to education is available through online programs
offering CEUs (see TABLE 2-3).
TABLE 2-3 Resources
Resource

Internet Address

Agency for
Healthcare
Research and
Quality: Quality
Measures
Website

http://www.qualitymeasures.ahrq.gov

Agency for
Healthcare
Research and
Quality: Patient
Safety Website

http://www.patientsafety.gov

American
Library
Association
Information
Literacy

http://www.ala.org/ala/mgrps/divs/acrl/standards/informationliteracycompetency.

82

Competency
Standards for
Higher
Education
American
Nurses
Association
States Which
Require
Continuing
Education for
RN Licensure

http://nursingworld.org/MainMenuCategories/Policy-Advocacy/State/LegislativeAgenda-Reports/NursingEducation/CE-Licensure-Chart.pdf

ECDL
Foundation,
which is an
international
organization
whose mission
is to raise
digital
competence in
the workforce,
education, and
society
(European
Computer
Driving
License
Qualifications,
2013)

http://www.ecdl.org/programmes/ecdl_icdl

Technology
Informatics
Guiding
Education
Reform(TIGER)
Initiative
(Health
Information
and
Management
Systems
Society, 2017)

http://www.himss.org/professionaldevelopment/tiger-initiative

Many professional nursing organizations, for-profit
companies, and universities offer quality educational
material online (see the companion website to this text for
resources). Nurses who wish to take CEUs by using online
resources need to make sure that the CEUs will meet the
requirements of state licensure or certification.

83

Online CEU offerings can take different forms: text
documents with examination questions returned to the
CEU provider by email, fax, or U.S. mail; asynchronous
webinars with embedded examination questions that
upload to CEU providers; synchronous webinars with
question-and-answer sessions; and interactive tutorials
with embedded questions that upload to a CEU provider.
The ANA hosts Twitter chats occasionally found at
#ANAChat; nurses who tweet can participate in the
discussion and earn free CEUs. Podcasts are also
methods by which nurses can obtain CEUs.
Even complete certificate programs are available online
from organizations such as the Institute for Healthcare
Improvement’s (2012) Open School. Completion of a
series of asynchronous tutorials in patient safety and QI
provide, at the time of this writing, 26 hours of continuing
education with a certificate of completion for nurses and
other HCPs. Certainly, universities offer certificate
programs online such as post-master’s certificates in
nursing education, nursing informatics, and geriatrics.
Other methods of professional development may not
provide CEUs, but they can help clinicians stay abreast of
developments in their areas of interest. For example, webconferencing or voice over Internet with Skype or other
methods can connect nurses to specialists in their areas of
interest. With smartphones and/or Internet access, nurses
can follow Twitter feeds from universities, federal
agencies, and well-respected healthcare organizations.
From this simplest form to more complex adaptations, IT
will remain an important means for nursing collaboration
and maintaining continuing education.

84

▶ Summary

© nednapa/Shutterstock

Nurses and other HCPs use health IT in all aspects of
providing patient care. There is no choice about being
competent with basic computer skills and with information
management skills. Nursing informatics competencies are
identified in The Essentials of Baccalaureate Education for
Professional Nursing Practice, by the TIGER Initiative, and
the Nursing Informatics: Scope and Standards of Practice
(2nd ed.). Informatics competencies are required to
improve nursing workflow and care delivery processes.
Nurses who are competent users of technology can also
keep themselves abreast of changes in practice by
engaging in continuing education using interactive
Internet- or mobile-based education.

85

References

Agency for Healthcare Research and Quality. (2016). The
six domains of health care quality. Retrieved July 23,
2017, from
https://www.ahrq.gov/professionals/qualitypatientsafety/talkingquality/create/sixdomains.html
American Association of Colleges of Nursing. (2008). The
essentials of baccalaureate education for professional
nursing practice. Retrieved from
http://www.aacn.nche.edu/educationresources/baccessentials08.pdf
American Diabetes Association (2017). Standards of
medical care in diabetes 2017. Diabetes Care: The
Journal of Clinical and Applied Research and
Education, 1, (supplement).
American Nurses Association. (2013). States which
require continuing education for RN licensure.
Retrieved from
http://nursingworld.org/MainMenuCategories/PolicyAdvocacy/State/Legislative-AgendaReports/NursingEducation/CE-LicensureChart.pdf
American Organization of Nurse Executives. (2015).
AONE Nurse Executive Competencies. Chicago, IL:
Author. Retrieved from
http://www.aone.org/resources/nurse-leadercompetencies.shtml
Bartholomew, N. (2011). Is higher education ready for the
information revolution? International Journal of
Therapy and Rehabilitation, 18(10), 558–566.
Campion, J. R., Waitman, L. R., Lorenzi, N. M., May, A.
K., & Gadd, C. S. (2011). Barriers and facilitators to
the use of computer-based intensive insulin therapy.
Journal of International Medical Informatics, 80, 863–
871.
European Computer Driving License Qualifications.
(2013). About ECDL Foundation. Retrieved from
http://www.ecdl.org/index.jsp?
p=93&n=94&a=3235
Gardner, C. L., & Jones, S. J. (2012). Utilization of
academic electronic medical record in undergraduate
86

nursing education. Online Journal of Nursing
Informatics (OJNI), 16(2). Retrieved from
http://ojni.org/issues/?/p=1702
Health Information and Management Systems Society.
(2017). The TIGER initiative. Retrieved from
http://www.himss.org/professionaldevelopment/tigerinitiative.
Hughes, R. G. (2008). Tools and strategies for quality
improvement and patient safety. In R. G. Hughes
(Ed.), Patient safety and quality: An evidence-based
handbook for nurses. Rockville, MD: Agency for
Healthcare Research and Quality. Retrieved from
http://www.ahrq.gov/professionals/cliniciansproviders/resources/nursing/resources/nurseshdbk/nurseshdbk.pdf
Institute for Healthcare Improvement. (2012). How to
improve. Retrieved from
http://www.ihi.org/knowledge/Pages/Howtolmprove/default.aspx
Moorman, L. P. (2010, January). Nurse leaders discuss
the nurse’s role in driving technology decisions.
American Nurse Today. Retrieved from
https://www.americannursetoday.com/nurseleaders-discuss-the-nurses-role-in-drivingtechnology-decisions/
Munro, D. (2014, March 30). Setting healthcare interop
on fire. Forbes. Retrieved from
https://www.forbes.com/sites/danmunro/2014/03/30/settinghealthcare-interop-on-fire/#23585d40f2ba
Oyler, J., & Vinci, L. (2008). Teaching internal medicine
residents quality improvement techniques using the
ABIM’s practice improvement modules. Journal of
General Internal Medicine, 23(7), 927–930.
Unertl, K. M., Johnson, K. B., & Lorenzi, N. M. (2012).
Health information exchange technology on the
frontline of healthcare: Workflow factors and patterns
of use. Journal of the American Medical Informatics
Association, 19, 392–400. doi:10.1136/amiajnl-20110004
U.S. Preventive Services Task Force, Bibbins-Domingo,
K., Grossman, D. C., Curry, S. J., Davidson, K. W.,
Epling J. W. Jr., . . ., Siu. A. L. (2016). Screening for
colorectal cancer: US Preventive Services Task Force
recommendation statement. JAMA, 315(23), 2564.

87

© nednapa/Shutterstock

88

CHAPTER 3
Informatics and EvidenceBased Practice
Janie T. Best, DNP, RN, ACNS-BC, CNL
Karen H. Frith, PhD, RN, NEA-BC
Ron Schwertfeger, MLIS

LEARNING OBJECTIVES

1. Distinguish between the hardware and software components of
computer systems.
2. Search electronic resources for evidence-based practice (EBP),
including databases, journals, and professional organizations,
efficiently to find current nursing research, systematic reviews,
and clinical practice guidelines.
3. Discuss methods of integrating EBP into electronic health
records or other health information technology.
4. Apply knowledge of EBP to patient care.
5. Discuss the role of health information technology standards in
EBP.

KEY TERMS

Agency for
Healthcare
Research and
Quality (AHRQ)
Boolean
operators
Centers for
Disease Control

Cochrane Databases

Google Scholar

Cumulative Index to

Interlibrary loan

Nursing and Allied
Health Literature
(CINAHL)
Directory of Open
Access Journals

Literature search
Medical Subject
Headings
(MeSH)
National Center

(DOAJ)

for

89

and Prevention
(CDC)

Evidence-based
practice (EBP)

Biotechnology
Information
(NCBI)

Clinical decisionsupport
systems
(CDSS)

National
Guideline
Clearinghouse
National Library
of Medicine
(NLM)
Open access

Plan-Do-Study-Act
(PDSA)

PubMed LinkOut
PubMed sidebar

PubMed

filters

PubMed Advanced
Search Builder
PubMed Clinical
Queries

Rich Site
Summary (RSS
feeds)
Zotero

90

▶ Chapter Overview
Since the passage of the Affordable Care Act in 2009, and
with the opportunity to capture incentive monies from the
Centers for Medicare and Medicaid Services (CMS), the
use of technology has exploded as healthcare
organizations have accepted the challenge to convert their
paper records to an electronic health record (EHR) (Duffy,
2015). Gugerty and Delaney (2009) describe how the
Technology Informatics Guiding Education Reform
(TIGER) initiative addressed this explosion of technology
in health care and the need for nurses to be prepared to
effectively use technology to provide evidence-based care.
TIGER competencies include: (a) basic computer
proficiency; (b) the ability to identify a clinical question,
find, evaluate, and apply information on the question
(information literacy); and (c) the ability to appropriately
collect, process, and communicate data (information
management). The TIGER report encourages inclusion of
all three areas in nursing programs as these are key skills
of evidence-based practice (Cheeseman, 2012; Gugerty
& Delaney, 2009).
Successful use of technology by nurses to implement
evidence-based practice and thus to improve patient care
requires a basic understanding of computer architecture,
computer terminology, and data and file management
(Cheeseman, 2012). Developing the skill of finding and
appraising current evidence from research, systematic
reviews of literature, and clinical practice guidelines may
be difficult as the nurse moves from the academic to
practice settings. However, evidence-based practice
(EBP) is a core skill necessary to improve nursing care
and enhance the safety of patients. This chapter provides
basic computer information, a synopsis of EBP, describes

91

the major steps associated with EBP, and supplies
readers with resources to conduct literature searches for
evidence. Finally, this chapter gives an overview of health
information management technology standards as they
apply to clinical practice.

92

▶ Introduction to Information and
Computer Science
Computer Architecture
Computers are used to find, manipulate, and store data in
an electronic format. In recent years, computers have
become more complex and mobile, and they are
increasingly essential to individuals in their personal and
professional lives (Kaminski, 2015). Desktop devices,
laptops, tablets, cell or smartphones, and a wide variety of
medical and household equipment use computer software
to perform their functions (Dainow, 2016). A basic
understanding of how computers operate provides the
nurse with the first step to exploring the evidence as it
relates to clinical practice (Cheeseman, 2012).
A computer system has four main functions: collection,
processing, storage, and retrieval of data (Cheeseman,
2011), and consists of input devices, the central
processing unit (CPU), memory, and output devices. Two
main components of a computer are its hardware (physical
components) and software (applications). Physical
components include the casing (desktop, laptop, or
mobile) and the internal mechanisms (CPU, motherboard,
power supply, hard disc, and memory). External hardware
includes touch screens, keyboards, a mouse to control
screen position, and a monitor that displays information on
a screen. Additional hardware is available to help the user
print information or enhance listening (Kaminski, 2015).
Computers are further categorized on the basis of size
and use. Supercomputers are large and only run a few
programs at a high processing speed. Their specific uses
range from animations and simulations, or training to
weather forecasting. Mainframe computers have large

93

memory capacity, work at a high speed, and have the
ability for many users to operate the computer system at
the same time. Healthcare and university computer
systems are examples of mainframe computers. The
smallest computers, microcomputers or personal
computers, are designed for single users, can be
connected as a network, and are small and affordable to
most individuals (Cheeseman, 2011).

Data Organization, Representation
and Structure
A computer’s work begins with input of information via an
external or touch-screen keyboard to a CPU where a
processor chip collects data and makes decisions based
on the software’s program code (instructions). The
memory of a computer is divided into random-access
(RAM) and read-only (ROM). RAM provides temporary
storage of data during the creation of work before it is
stored in a more permanent location, either in the
computer’s hard drive or other storage location. Unless
saved to a more permanent location, RAM storage is lost
when the program is closed or the computer is turned off.
ROM is located in the motherboard (circuit boards) and
saves data in a more permanent way after the computer is
turned off. During work, data are uploaded in the RAM
and, when directed by the user, stored in ROM on the
hard drive, on a USB flash drive, or in other external
locations. (Cheeseman, 2011; Kaminiski, 2015).
The ability to store information is based on the capacity of
the device. The basic (smallest) unit of memory is a bit; a
byte consists of eight bits of data. From these small units,
storage can be expanded in increments of 1,000 to
kilobytes (KB), megabytes (MB), gigabytes (GB), and
terabytes (TB). Decisions about the amount of storage
needed in a computer system is based on the amount of
data to be processed and stored, and on estimated
94

storage time. Data can be collected, organized, and stored
in a database where it can be retrieved easily and in a way
that is meaningful to the user. Commonly used databases
in health care include electronic medical records,
databases that support mobile applications, and many
more, which are described in chapters that follow. In
academic settings, bibliographic and citation databases
are commonly used. Synthesized databases allow the
user to search for information from practice guidelines,
systematic reviews, and meta-analysis documents
(Cheeseman, 2011). Directions for how to conduct a
literature search using large databases are discussed later
in this chapter.
Software applications are internal programs that can be
modified without changes to the external hardware of the
computer (Dainow, 2016). These applications are
categorized as productivity, creative, or communication
programs. Productivity software includes a variety of
programs including databases, email, presentations,
spreadsheets, and word processing applications to
support a wide variety of information processing needs.
Creative software can be used to create drawings, music,
or digital photography/videos. Communication software
includes email programs, Internet browsers, instant
messaging, and a variety of conferencing programs
(Dainow, 2016; Kaminski, 2015).

Networking and Data Communication
Computer networks are formed when two or more
computers are linked in a way that allows them to share
information. A local area network (LAN) is confined to a
single site, a metropolitan area network (MAN) connects
regional areas, and a wide area network (WAN) reaches
far beyond the single location to connect many LANs
together. Connections to the Internet are available through
cable or digital subscriber lines (DSL) or through dial-up
95

telephone services (Cheeseman, 2011; Dainow, 2016).
To connect to the Internet, the computer has to be
connected to an Internet service provider (ISP) through a
modem and a unique Internet protocol (IP) address
(Dainow, 2016). Each website is identified by a unique
uniform resource locator (URL) protocol. Two types of
URL addresses are commonly used to reach web
resources: hypertext transfer protocol (HTTP) or hypertext
transfer protocol—secure (HTTPS). There are also URL
addresses for email and file transfers (FTP) (Cheeseman,
2011; Dainow, 2016; TechTarget, 2016).
Computer networks allow knowledge to be shared in
multiple ways. The World Wide Web (www) is a network
program that is familiar to most Internet users. A collection
of documents, images, and web pages, the World Wide
Web makes it possible to gather information from many
resources, as well as to share information around the
globe. Smartphones add another layer of information
gathering and storage via telephone and global positioning
system (GPS) technology, preserving the ability to access
and disseminate information, no matter where we are, 24
hours a day (Cheeseman, 2011; Dainow, 2016;
Kaminiski, 2015).
Another use of the Internet is to store large amounts of
information in a cloud. This method of storage allows an
organization to achieve cost savings in many areas
(maintenance, infrastructure, use of less expensive
computers). For an organization that requires fast and
consistent access to the cloud storage, loss of, or a slow,
Internet service connection will be a disadvantage of this
method of data storage (Cheeseman, 2011).
Health care has benefited from recent computer advances
in software programming, including educational packages
for online instruction through courses, simulation
96

experiences (avatars, high-fidelity mannequins, and online
student resources), artificial intelligence/robotics to
improve life for individuals with disabilities, and research
(e.g., the Human Genome Project to map DNA). Social
networking applications (also known as social media) are
software programs that encourage communication with
others. Individuals can set up blogs or join social networks
like Facebook or Twitter to share information with friends,
family, or others with similar health conditions (Dainow,
2016). Social media has become a way that patients,
families, and caregivers gain information and support from
one another, particularly with chronic illnesses or lifelimiting illnesses (Rupert et al., 2016).

Basic Terminology of Computing
Understanding basic computer terminology is the first step
to effective computer use. Many Internet sites have
compiled comprehensive lists of computer terms and
definitions that can be easily accessed and used for
teaching and learning basic computer language. One list,
created specifically for the older population, has been
developed by the National Institute on Aging and can be
found at
https://nihseniorhealth.gov/toolkit/toolkitfiles/pdf/Glossary.pdf.
Having a common terminology is essential to the effective
use of retrieved computer data to improve patient care and
outcomes. Nurses must be able to capture their work in a
way that is meaningful and allows for evaluation of the
effectiveness of nursing interventions (Rutherford, 2008).
The American Nurses Association (2012) published 12
approved standardized terminologies that support nursing
work. The International Council of Nurses (2015)
developed a framework for nursing practice that allows for
inclusion of different terminologies that support the work of
nurses. The goals of these two documents are similar and
support the use of common nursing language to raise
97

awareness of nursing work, communication within the
healthcare team, ease of data retrieval and analysis for
evaluation of nursing work, and increased ability to
incorporate and adhere to evidence-based standards of
care (Rutherford, 2008). Use of standard terminologies
ensures that communications are understood and
interpreted in the same way by all members of the
healthcare team (Halley, Sensmeier, & Brokel, 2009).

98

▶ Integrating Evidence-Based
Practice
Introduction
EBP is a process that has developed from a need to
improve the quality and manage the economics of
healthcare delivery (Salmond, 2007). The components of
EBP include a systematic and critical evaluation of the
current literature, the nurse’s clinical expertise and
available resources, and patients’ values and preferences.
This information is used to make deliberate clinical
decisions based on theory and relevant research that
guide patient care (Ahrens & Johnson, 2013; Ingersoll,
2000; Melnyk & Fineout-Overholt, 2011). The expected
results of these carefully considered decisions are
improved outcomes for patients, efficiency, and costeffective care delivery for organizations (Melnyk &
Fineout-Overholt, 2011; Salmond, 2007).

Cultivating a Spirit of Inquiry
The process of EBP is best learned in sequence with
distinct steps. The preliminary step, cultivating a spirit of
inquiry (Melnyk, Fineout-Overholt, Stillwell, &
Williamson, 2010, p. 51), means to be curious about the
effectiveness of nursing interventions, to take interest in
changing nursing practice or questioning practice, and to
try new approaches. Nurses with a spirit of inquiry
understand EBP as a way of thinking, not an additional
burden to their practice. Nurses who are passionate about
EBP will likely become informal leaders, or be promoted to
leadership positions, and can influence others to grow
support for EBP. Those who have a spirit of inquiry will
have questions and a desire to find the best evidence to
support their practice (Melnyk, Fineout-Overholt,
Stillwell, & Williamson, 2009).

99

Writing the Question
Nurses who use the steps of EBP to formalize their
questions about practice should use the PICOT format
(Lawson, 2005; Melnyk & Fineout-Overholt, 2011). The
term PICOT identifies the patient or population (P), issue
or intervention (I), what will be compared (C), the expected
outcome (O), and the time (T) that it will take to achieve
and evaluate the outcome (Melnyk & Fineout-Overholt,
2011). The PICOT format is a systematic method of
question writing and helps decrease the time and effort it
takes to find evidence specific to the topic being
investigated. Consistently using a set format to write the
question ensures that all components of the question are
addressed before the literature search begins (Stillwell,
Fineout-Overholt, Melnyk, & Williamson, 2010).
It takes time and practice to learn how to write questions in
the PICOT format. Melnyk and Fineout-Overholt (2011)
suggest that it takes “practice, practice, practice” to
become proficient in writing PICOT questions (p. 31).
Questions may be written following a template and may
focus on interventions, predictions or prognosis of
outcomes for a specific patient population, comparison of
diagnosis or diagnostic tests, etiology and associated risk
factors for a specific condition, or meaning within a
situation (Melnyk & Fineout-Overholt, 2011; Stillwell et
al., 2010).
Nurses who embrace EBP may find support in forming
groups interested in certain topics. Lawson (2005)
suggests that getting other nurses involved helps to clarify
clinical issues and to write clear and specific clinical
questions. Once a group is assembled and the individuals
are comfortable in identifying issues and writing questions,
the second step, searching for evidence, can begin.

Finding the Evidence Using Library
100

Sources
In order to use evidence in EBP, a nurse must locate and
review the evidence found in research articles as
published in reliable sources. This process begins with
using appropriate electronic databases and performing
effective online searches. Using appropriate databases
can be easier for nursing students during their coursework
and for nurses at university-affiliated hospitals and clinics,
with their many research database subscriptions, but other
options are available.
Nurses should use databases and websites that have
valid and reliable information. PubMed and Cumulative
Index to Nursing and Allied Health Literature (CINAHL)
are two databases that index a comprehensive body of
healthcare literature. The Cochrane Databases and the
National Guideline Clearinghouse support EBP by
including systematic reviews and current practice
guidelines. Government sources for reliable information
include the Centers for Disease Control and Prevention
(CDC) and the Agency for Healthcare Research and
Quality (AHRQ). Many professional organizations have
their journals and evidence-based guidelines available
electronically for members or individuals who have
subscribed online (Fineout-Overholt, Berryman,
Hofstetter, & Sollenberger, 2011; Hoss & Hanson,
2008). Information about additional resources is
addressed later in this chapter.

Searching for Evidence in Research
Literature
Searching the literature may seem like a daunting task,
and overwhelming to those who have not had experience
with electronic databases. While lack of access to an
onsite library or computer database applications can be a
major barrier to conducting a search for evidence, the
inability of a nurse to effectively use the computer to
101

search the literature adds an additional barrier to
embracing EBP (Hoss & Hanson, 2008; Wells, Free, &
Adams, 2007). Nurses without computer skills or
experience in data searches can seek assistance from a
university or hospital librarian, or other experienced
professionals (Fain, 2009). Time spent with a librarian who
loves to teach others how to find these treasure troves of
information is priceless, and will return a lifetime of
information power. Links to tutorials and videos for using
commonly accessed databases can be found in the
companion website for this book.
One of the greatest skills that nurses learn in their
academic program is the ability to find relevant research
on clinical topics. To begin the search in one of these
research databases, nurses should select key terms from
the PICOT question. These terms are entered using
Boolean operators (and, or, not) to combine multiple
search terms. In addition, many databases allow the use
of quotation marks to search for phrases of multiple words.
A good search technique is to set limits on the search, to
narrow down the results to articles that are more suitable.
For example, limiting a search to English-language, peerreviewed journals and articles published within the last 5
years can help in the selection of valid findings that may
be applicable to the topic (Hoss & Hanson, 2008; Melnyk
& Fineout-Overholt, 2011).

Systematic Reviews and Clinical
Practice Guidelines
Systematic reviews are literature reviews that follow a
certain methodology to standardize the critique of
research findings. Two excellent sources of systematic
reviews are McMaster Plus Nursing+ and the Cochrane
Collaboration. McMaster Plus has three functions: (1) it
serves as a database of peer-reviewed articles that have
been rated by nursing professionals, (2) it contains an
102

email alert system for selected topics of interest, and (3) it
provides links to abstracts of systematic reviews of
research literature. The Cochrane Collaboration is a library
built by healthcare professionals who author Cochrane
Reviews, which are the gold standard for preappraised
research evidence. Only a few Cochrane reviews are free;
most are contained in the Cochrane Database of
Systematic Reviews and available with a subscription.
Nurses can join the Cochrane Journal Club and other
electronic notifications of systematic reviews and clinical
practice guidelines at no cost. TABLE 3-1 provides a list of
resources and Internet addresses for these sites.
TABLE 3-1 Resources to Learn About EBP
Tutorials

Internet Address

Appraising
the
Evidence

http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Imp
Your-Practice/Research-Toolkit/Appraising-the-Evidence

American
Nurses
Association
(ANA) list of
online
tutorials
about EBP

http://ana.nursingworld.org/research-toolkit/Education

University of
North
Carolina
EBP
tutorials

http://www.hsl.unc.edu/Services/Tutorials/EBM/welcome.htm

Academic
Center for
EvidenceBased
Practice at
the
University of
Texas
Health
Science
Center at
San Antonio
Basic
Modules
Intermediate

http://acestar.uthscsa.edu/modules/Basic.htm
http://acestar.uthscsa.edu/modules/Intermediate.htm

103

Modules

Clinical guidelines are valuable because they contain
preappraised research. Authors of clinical practice
guidelines rate the research for the quality of evidence and
the strength of making a recommendation for change
based on the findings. The federal government provides at
least three sources of free clinical practice guidelines at
the Agency for Healthcare Quality and Research, the
National Guidelines Clearing House, and the PubMed
Clinical Queries. TABLE 3-2 provides the Internet
addresses for the free resources for clinical practice
guidelines.
TABLE 3-2 PubMed Tutorials and Videos: Learn How to Search Efficiently
for Articles
Tutorials

Internet Address

PubMed Tutorial

http://www.nlm.nih.gov/bsd/disted/pubmedtutorial/

Medical Subject
Headings (MeSH)
in
MEDLINE/PubMed:
A Tutorial

http://www.nlm.nih.gov/bsd/disted/meshtutorial/introduction/index.html

Branching Out: The
MeSH Vocabulary

http://www.nlm.nih.gov/bsd/disted/video/

Videos
My NCBI—National
Center for
Biotechnology
Information

http://www.youtube.com/watch?v=ks46w3mNAQE

PubMed Simple
Subject Search

http://www.nlm.nih.gov/bsd/viewlet/search/subject/subject.html

PubMed Author
Search

http://www.nlm.nih.gov/bsd/viewlet/search/author/author.html

Getting Full-text
Articles from
PubMed

http://www.youtube.com/watch?v=V0NYKFSphKY

104

Using Sidebar
Filters to Limit
Results

http://www.youtube.com/watch?v=696R9GbOyvA&feature=youtu.be

Advanced PubMed
Search Builder

http://www.youtube.com/watch?v=dncRQ1cobdc&feature=relmfu

Save Search
Results in
Collections,
Including Favorites

http://www.youtube.com/watch?v=iXSttEKntCE

Searching by Using
the MeSH
Database

http://www.youtube.com/watch?v=uyF8uQY9wys

Search for Journal
in PubMed

http://www.nlm.nih.gov/bsd/viewlet/search/journal/journal.html

Retrieving Citations
from a Journal
Issue

http://www.nlm.nih.gov/bsd/viewlet/search/scm/scmissue.html

Selecting Outside
Tool Preference

http://www.nlm.nih.gov/bsd/viewlet/myncbi/pref_otool.html

Using Free Resources
After students leave their colleges and universities, access
to subscription databases, such as CINAHL, depends on
resources available in their places of employment. For
those in academic medical centers, access to databases
may be assured; those in community hospitals or
ambulatory settings will likely find themselves
disconnected from the very lifeline of evidence-based
practice—a library.
There are ways to access libraries free or at low costs for
individual nurses. The best place to start is PubMed, which
is freely available online. Some of the research journals
published online are available as open access journals—if
those journals are indexed in PubMed, then those results
will link to the article. Google Scholar can also be a useful
tool.

105

PubMed
As a service of the National Center for Biotechnology
Information (NCBI) at the U.S. National Library of
Medicine (NLM), PubMed is an extensive index of
published medical literature with over 22 million citations.
Nursing literature is indexed in this service too. However,
unlike CINAHL and other subscription databases, it does
not provide full-text access to those articles. While articles
can be accessed with the LinkOut functionality, they may
not be housed within the PubMed database.
PubMed offers several noteworthy features. Rather than
using keywords, the most effective way to search in
PubMed is by using Medical Subject Headings (MeSH).
MeSH is a thesaurus of controlled-vocabulary terms. Once
MeSH terms are found for the topic, a more fruitful yield
will result from searches of PubMed. Figure 3-1 shows a
MeSH tree for obstructive sleep apnea. Other features of
PubMed are the PubMed Advanced Search Builder,
sidebar filters, LinkOut, and My NCBI.

106

FIGURE 3-1 MeSH tree of obstructive sleep apnea
produced from a search of PubMed.
Courtesy of National Center for Biotechnology Information. Available at
http://www.ncbi.nlm.nih.gov/pubmed

107

The MeSH terms selected are entered into the PubMed
Advanced Search Builder, the open boxes in PubMed.
The drop-down menus are then set to MeSH terms, and
Boolean operators (and, or, not) should be used as
needed. If the yield is too high for a reasonable review of
articles, then the sidebar filters can be added including
article types (clinical trials, systematic reviews, practice
guidelines, to name a few), text availability (abstract
available, free full text available, or full text available), and
publication dates. The filters will limit the search to a
number that is more manageable. When the desired
articles are selected, some full-text articles may be freely
available using the LinkOut service. LinkOut is found in
the upper right-hand corner of the screen. To find the
desired reference material, the LinkOut icon should be
clicked. Icons change depending on the source of the
reference material. If full text is not available, nurses can
order the articles from their hospitals or from public
libraries using interlibrary loan services. Typically, a
public library will have a nominal charge for an interlibrary
loan.
Searches of PubMed should be managed such that the
MeSH terms and the yields from searches can be
retrieved if needed. PubMed provides a cloud-based folder
called My NCBI (My National Center for Biotechnology
Information) for searching and storing the history of
searches. Up to 6 months of search histories can be
stored in My NCBI. Registration and use is free. Written
tutorials and short videos provide excellent help for nurses
who are new to PubMed. Some of the most helpful
tutorials and videos are listed in TABLE 3-3.
TABLE 3-3 Electronic Alerts for Systematic Reviews
and Clinical Practice Guidelines
Resource

Internet Address

108

McMaster Plus,
British Medical
Journal Updates

https://plus.mcmaster.ca/EvidenceAlerts/

PubMed

https://www.ncbi.nlm.nih.gov/pubmed/

Knowledge
Finder from the
National Library
of Medicine

http://www.kfinder.com/kfinder/Default.htm

Cochrane Library
Journal Club
Scroll to bottom
to find sign-up
form

http://www.cochranejournalclub.com/selfmonitoring-and-self-management-oralanticoagulation-clinical/default.asp?moreinfo1#moreinformation

National
Guideline
Clearinghouse
Email Alerts

http://www.guideline.gov/subscribe.aspx

Google Scholar
Google Scholar is a web-based search engine for
scholarly literature across a broad range of disciplines. Its
index includes literature from both free and paid
repositories, professional societies, academic publishers,
and other sources across the web. The primary focus is to
index all academic papers on the web (Google). While
there is no doubt of the value of the service for
researchers of all kinds, it also has its shortcomings.
Google takes articles from everywhere it can access on
the web, and users must be careful to vet the articles they
find using Google Scholar, because the articles may or
may not be peer reviewed. One particularly celebrated and
useful feature of Google Scholar is the “cited by” feature.
The “cited by” feature allows users to view a list of later
works that have cited the original paper. This ability to
connect literature through citations has historically only
been available through paid services. A particularly
pervasive shortcoming of the service is that it strengthens
the Matthew Effect, a term coined by sociologist Robert
Merton to refer to the way in which starting advantages
109

tend to build on themselves (Rigney, 2010). With Google
Scholar this is seen in the way that articles with more
citations are more likely to be at the top of the search
results, and newer articles with fewer citations are more
likely to be lower on the page and thus less likely to be
read and used (Beel & Gipp, 2009). Google Scholar is a
valuable resource for researchers of all kinds, but, as is
true with all research tools, it is the responsibility of
researchers to verify the veracity of any sources they use.

Open Access Journals
Freely available articles are provided by publishers who
offer open access. The rationale for providing free, online
access to scholarly articles and research is to advance
scientific thought, particularly for individuals in developing
countries who cannot afford the high prices of journal
subscriptions (Carroll, 2011). The cost of publication is
shifted to the authors, rather than the readers. While this
makes research available, nurses must ensure that they
are selecting articles from peer-reviewed journals.
Journals that are open access can be found by searching
online for the Directory of Open Access Journals
(DOAJ). A particular advantage of the DOAJ is that it
gives smaller publications a way to expand their reach.
Nurses should always be vigilant about the quality of their
sources, but they should not neglect open access journals,
as they often have research from more varied sources and
in smaller research niches.

Analyzing the Literature
Not all evidence is equal; nor will all evidence be
applicable to a particular clinical setting. When searching
for evidence, it is prudent to look for clinical practice
guidelines, systematic reviews, meta-analyses of
evidence, or randomized controlled trials relevant to the
particular clinical question. Single studies or case studies
can be used to demonstrate how evidence is put into
110

practice, and textbooks can be used as resources for
information on a particular condition. Most nursing
research and evidence-based practice textbooks will have
guides to help evaluate the quality of quantitative and
qualitative research studies (Levin, 2013; FineoutOverholt et al., 2011). The American Nurses Association
has developed a list of resources to help nurses evaluate
the quality of research studies. These tools address the
validity of the study, reliability of the results, and the
applicability to the particular patient care setting (see
Table 3-1).

Putting the EBP Process into Practice
Once the literature is analyzed using a systematic
approach, nurses working on an EBP project will need to
decide if a change in practice is needed. If so, then
creating enthusiasm for the project and soliciting input
from all stakeholders early in the planning stages will be
critical. Early and frequent communication by email or
other innovative strategies such as Twitter, Facebook, or
blogging can keep stakeholders involved.
As with any change, a plan needs to be prepared. A
theoretical model or process, such as Plan-Do-Study-Act
(PDSA), can be used as a framework to plan and
implement the project. A timeline for the project is
essential to keep it on track. Even strategies to overcome
barriers to the planned change need to be included.
Selecting an evaluation strategy as part of the initial
project plan is also necessary (Melnyk & FineoutOverholt, 2011). The plan must address any ethical
issues and protected health information issues by seeking
Institutional Review Board approval for the project (Levin,
2013). The project plan can be made using an Excel
spreadsheet or using specific software for project planning
such as Microsoft Project. Following the timeline and
sharing the project results during implementation will help
111

other nurses and stakeholders remain engaged in the
practice change (Lawson, 2005).

Communicating the Findings
Once the practice change is stable, the final step of EBP is
to share the results with others. Failure to share the
outcomes of EBP projects may lead to unwarranted
duplication and delay in getting evidence into practice
throughout the practice setting and beyond. Results can
be disseminated in the organization at staff meetings, in a
nursing newsletter, as a blog posting, or as a poster
presentation. Findings should be presented at local
specialty group meetings or at regional or national
conferences (Melnyk et al., 2010). Nurses can also
partner with local schools or colleges of nursing to create
an Evidence-Based Practice Day, in which nurses from
various clinical settings can share the results of their
projects.

Evaluating EBP
Standardized computer terminology and databases
provide the opportunity to evaluate EBP. Outcome data
are available from the EHR, disease-specific registries,
and other quality care databases. In order for these data
to be useful, they must be entered correctly, processed in
a meaningful way, and retrieved and analyzed using
appropriate statistical tools (Tymkow, 2016).

Finding More About EBP Online
Because this chapter provides a brief overview of EBP,
Internet-based resources can be used to supplement
knowledge of EBP. The American Nurses Association
(ANA) provides a list of online tutorials that can assist
nurses in learning more about EBP, and the University of
North Carolina also has free EBP tutorials available for
nurses who seek information about the EBP process.

112

These resources can be found in the companion website
for this book.

Using Reference Manager Software to
Store and Use Sources
Nurses who plan to carry out formal EBP projects need to
learn how to manage the results of their searches using
software. This is particularly critical if the nurse plans to
communicate findings in poster sessions or in published
articles. Without software, the research articles, systematic
reviews of literature, and clinical practice guidelines can
become stacks of paper with little or no organization.
Fortunately, there are free software solutions: Zotero and
Mendeley, among others. Each of these citation
management programs (sometimes called citation
managers or reference managers) has different computer
requirements and installation instructions.
As one example, Zotero can be installed either as a plugin for the Mozilla Firefox Internet browser or as a
standalone desktop program. (If the standalone desktop
program is installed, a browser plug-in for Google Chrome,
Apple Safari, and/or Firefox should also be installed.)
Once Zotero is installed, databases such as PubMed,
CINAHL, or Google Scholar can be searched as normal.
Any relevant search results can easily be saved into the
Zotero library on the computer. Researchers can also
create a free online account with Zotero, in order to save
their desktop/laptop citation library online (in order to have
access to their library when working at another computer).
In addition to storing references, many citation managers
(including Zotero) can be integrated into Microsoft Word
(or other word-processing programs). This add-in feature
is the real magic of reference software. When a reference
is selected in the Zotero library, with the click of one icon
the reference is cited in the narrative and added to a
reference list in the word-processing document. Any
113

changes are automatically reflected in the in-text citations
and reference list. Finally, references in Zotero can be
shared with other Zotero users; this feature is helpful for
teams of nurses focused on EBP.
There are multiple choices for reference managers, in
addition to Zotero. (Mendeley works in a similar manner, is
fully compatible with Windows and Mac operating
systems, and can work with any Internet browser.) In most
cases, a researcher will only need to select and use one
reference manager (e.g., Zotero or Mendeley, but not
necessarily both). In selecting which reference manager to
use, it may help to check with colleagues. (If sharing a
citation library with colleagues, it is helpful for all the team
members to use the same reference manager.) Note that
free programs like Zotero and Mendeley provide users
with the option to pay for upgraded levels of online cloud
storage. On the other hand, EndNote is an example of a
reference manager with an up-front cost, but which
includes greater levels of online storage and free online
training (along with other resources).
TABLE 3-4 Repositories of Clinical Practice Guidelines
Resource

Internet Address

Agency for
Healthcare Research
and Quality (AHRQ)

http://www.ahrq.gov/clinic/cpgsix.htm

AHRQ Innovations
Exchange

https://innovations.ahrq.gov/

National Guideline
Clearinghouse

http://www.guideline.gov/

PubMed Clinical
Queries

https://www.ncbi.nlm.nih.gov/pubmed/clinical

National Institute for
Health and Care
Excellence (NICE)
Organization

http://www.nice.org.uk/

114

McMaster Plus
Nursing+

http://plus.mcmaster.ca/np/Default.aspx

115

▶ Staying Current in Nursing Practice
and Specialty Areas
Email Notifications
It is impossible to read enough journals to stay current with
the short shelf-life of most research. Using technology to
stay current is a smart decision. With registration at journal
publisher websites, email notifications will be sent when
new content is available. Publishers send a table of
contents with every issue of the journal. Links from the
table of contents often provide an abstract. If an
interesting journal article is in the table of contents, then
the nurse can order the article using interlibrary loan if it is
not available from other sources. TABLE 3-5 lists journal
publishers who provide free email notifications.
TABLE 3-5 Electronic Subscriptions to Journal Email Notifications
Resource

Internet Address

RSS
Feeds for
Nursing
Journals

http://journals.lww.com/ajnonline/_layouts/15/oaks.journals/feeds.aspx

Mobile
CINAHL

https://health.ebsco.com/products/the-cinahl-database

Lippincott
Williams &
Wilkins
Email
Alerts

http://journals.lww.com/pages/login.aspx?
ContextUrl=%2fsecure%2fpages%2myaccount.aspx

Sage
Publishers
Email
Alerts

http://www.sagepub.com/emailAlerts.sp?
_DARGS=/common/components/extras_big.jsp.1_A&_DAV=Dummy&_dynSessConf=1994759084613409176

Springer
Publishing
Email
Alerts

http://www.springerpub.com/products/Journals/Nursing#.UdjEufnVCQo

116

Rich Site Summary
Rich Site Summaries (RSS), often called RSS feeds, are
simplified summaries of the information provided on whole
websites. For example, an RSS feed of the CNN website
would show a list of all the stories on the page. RSS feeds
provide a clear and easy way of tracking information from
a large number of sources, and nurses should be aware of
the wealth of information available to them through RSS
feeds. Some notable sources of feeds include the National
Institutes of Health, the Food and Drug Administration, the
CDC, and the AHRQ. The U.S. government web portal
provides a large index of these feeds on their website
(https://www.usa.gov).

Social Media
Social media includes Facebook, Twitter, LinkedIn, and all
the other similar services. In health care, social media has
not been a widely used tool, but that may be changing.
Social media services help people to connect, share their
experiences, develop groups, and communicate more
effectively. For a healthcare provider (HCP) that might
mean instant-messaging services between patients and
nurses or doctors, or video-conference-based
appointments. It could also mean social networks specific
to nurses and doctors where opportunities, research, and
wisdom could be shared. A free EHR system called Hello
Health is used by a Brooklyn-based practice that provides
a model for this type of integration (Hawn, 2009). The
practice has developed a patient management platform
where patients can communicate with their HCP via
private instant messaging, schedule video-chat
appointments, renew prescriptions, and access their own
personal health record (Hawn). As the landscape
continues to develop and these tools evolve, nurses must
adapt. By focusing on the improved communication
enabled by social media, nurses will be able to build
communities and share their experiences and wisdom.
117

Webinars and Teleconferences
Communication technology, particularly Internet-based
communications, have opened up new ways for nurses to
engage with one another to learn about the best practices
in patient care. Technologies such as Skype, Google
Hangouts, and join.me offer low-cost or free services to
connect multiple people with audio, video, and desktop
sharing. When used as continuing education or webinars,
nurses can participate with experts on clinical topics
anywhere Internet service is available. Sortedahl (2012)
developed an online journal club for school nurses and
assessed nurses’ satisfaction with the method after 3
months. Sortedahl found that the nurses valued three key
elements: having well-informed knowledgeable
moderators, getting research articles in advance, and
discussing the application of findings to nursing practice.
The researcher also found that using Internet-based
technology allowed the journal club to invite the author of
a research article to the club meeting, which benefited the
researcher and nurses. There were issues with slow
Internet connections, firewalls and other security
measures, and operating system incompatibilities. Despite
the technical issues, the nurses liked the method and
wanted even more interaction with each other between
journal club meetings (Sortedahl).

118

▶ Evidence-Based Practice Integrated
in Clinical Decision-Support Systems
The most efficient means for integrating EBP in clinical
processes is to have clinical decision-support system
(CDSS) embedded in health information technology
(health IT). Clinical decision-support systems are
computer systems designed to impact clinical decision
making about individual patients at the moment those
decisions are made (Berner & La Jande, 2007) by
presenting contextually appropriate information. CDSSs
bring the available, applicable knowledge and research
together into systems that clinicians can use throughout
the decision-making process. The key aspect is that the
usefulness comes from the interaction of the human and
the computer. Modern CDSSs are not designed as black
boxes that interpret information and deliver concrete
answers, but as tools that provide the clinician with the
best possible evidence relevant to the patient’s
assessment data and laboratory results to ensure the
patient receives the best possible care (Berner & La
Jande, 2007).
Most CDSSs are made up of three essential components:
the knowledge base, the reasoning engine, and a
mechanism to communicate with the user (Berner & La
Jande, 2007). The knowledge base contains all the
relevant knowledge expressed as if-then rules. The
reasoning engine contains a set of instructions that tell the
computer how to apply the rules to real patient data. The
communication mechanism provides the means for patient
data to be entered into the system and for any pertinent
findings to be relayed to the user. Many CDSSs rely on
the user to input data manually, but the continued
acceptance of EHRs and improved interoperability among

119

systems will enable more systems to input data
automatically from multidisciplinary team members
(Berner & La Jande, 2007).
Commercially available EHRs typically have CDSSs, but
the system may need to be customized for use in the
particular healthcare setting. Nurses and other HCPs need
to be involved in the development of the CDSS because
the system should reflect the best clinical decisions, and
HCPs are equipped to translate clinical research into
clinical processes through a reasoning engine in the EHR
(Brokel, 2009). In a very basic way, order sets and
nursing plans of care in EHRs represent clinical decision
support because the predetermined orders are used to
simplify the cognitive processes necessary for planning
care. When order sets and nursing plans of care are
developed, nurses can influence the process by serving
on a task force to develop the CDSS by bringing research
evidence and clinical practice guidelines to this decisionmaking group. In this way, nurses contribute to the
implementation of evidence-based practice (Brokel,
2009).

Health Information Technology and
EBP
Health information includes all the information related to
the interactions of patients, HCPs, and the health
information management (HIM) team. Beginning with the
registration process, health information is captured,
categorized, stored, and retrieved to use in making
decisions related to the delivery of health care. Managing
health information through the life span of EHRs is the
responsibility of HIM professionals (ITI Planning
Committee, 2015).
BOX 3-1 Case Study: Searching for, Evaluating, and Managing Research
Articles

120

Beth works at the OB/GYN clinic in a medium-sized hospital. She has
noticed that many of her patients develop diabetes during their
pregnancy, even though they do not have a previous history of diabetes.
Beth wants to use EBP to help improve the care these patients receive.
As her first step, Beth wants to look in a reputable online resource for
evidence-based research in medicine and nursing. She decides to use
PubMed.
When Beth begins her research in PubMed, she searches for “diabetes,”
but she finds a lot of the results do not seem relevant; many of the
research articles describe older patients, or teenagers, or males. In order
to perform a more effective search for evidence-based research on her
topic, Beth uses the MeSH database option within PubMed. When she
searches in the MeSH database for diabetes and pregnancy, she finds
the term “Diabetes, Gestational.”
When Beth adds the MeSH term “Diabetes, Gestational” to her search in
PubMed, she finds thousands of articles that are specific to diabetes
during pregnancy. After beginning to scan through the articles in this list,
she uses filters to narrow down her search to articles from the last 5
years that are about clinical trials. She still finds hundreds of articles, so
she starts reading the following article:
Karamali, M., Heidarzadeh, Z., Seifati, S. M., Samimi, M.,
Tabassi, Z., Hajijafari, M., . . . Esmaillzadeh, A. (2015). Zinc
supplementation and the effects on metabolic status in
gestational diabetes: A randomized, double-blind, placebocontrolled trial. J Diabetes Complications, 29(8), 1314–
1319.
Beth decided to start with this article, because the citation indicates that
this research article is relevant to her area of research, it is recent, and it
reports on clinical trials with human patients. After she reviews this article
and saves it, she continues looking for other similar articles.
As Beth continues her research for recent articles about clinical trials with
human patients, she begins to save the article citations into a personal
“library.” In order to easily review these articles, she begins to use Zotero,
saving her articles on her laptop and online. This has several added
benefits: she can save citations from PubMed as well as articles that she
finds in other research databases, she can access those citations from
other computers, she can share her library of references with her
colleagues, and she can build a bibliography from these articles, if she
wants to document the EBP at her clinic.
Check Your Understanding
1. When Beth starts her research, she decided to start in PubMed.
For what possible reasons might she have started in PubMed
(over another medical database, such as CINAHL)? What
advantages would PubMed have over another resource, such
as Google Scholar?
2. In Beth’s first PubMed search, she found a lot of results for
older patients or males. What benefits does she gain from using
a MeSH term?
3. In the results that Beth found, she started with the 2015 article
“Zinc supplementation and the effects on metabolic status in
gestational diabetes.” Why would she choose this article? What
information in this citation indicates that it might meet her
needs?
4. When Beth starts to save a personal library of her references,
she has several reasons to use Zotero. How can a citation

121

manager like Zotero (or Mendeley, or EndNote, etc.) help you
with your research?

As outlined in the ITI Planning Committee white paper
(2015), responsibilities and requirements for HIM
professionals include ensuring the integrity, protection,
and availability of health information. HIM professionals
work in a variety of roles to capture, validate, maintain,
and analyze data as well as providing decision support for
health professionals. HIM practice by these professionals
support the life cycle of health information from capture or
input of data into the computer system to the disposal of
health information data. Principles governing health
information have been developed by the American Health
Information Management Association (AHIMA) and are
focused on integrity, protection, transparency,
accountability, compliance, and the timely availability,
retention, and disposition of health information (ITI
Planning Committee, 2015). Standards governing the
use of health information are focused on the
interoperability of information technology systems to
support distribution of patient information by authorized
users (Halley et al., 2009). Incorporation of clinical
practice guidelines and nursing terminology into the EHR
provides a common language and interventions that
support data collection and evaluation of clinical outcomes
(Barey, Mastrian, & McGonigle, 2016).
The use of sophisticated CDSS, developed by
multidisciplinary teams, is an efficient way to translate
research evidence into everyday practice. However, the
steps involved in the appraisal of evidence cannot be
missed. It would be irresponsible to take current practice
and automate the clinical decisions based on status quo.
Likewise, it would be imprudent to base care on a single
research article. Nurses and other HCPs need to take the
122

time to examine their current practices with respect to best
practices when EHRs or other health IT are implemented.

123

▶ Summary

© nednapa/Shutterstock

While moving from academia to nursing practice based on
evidence may seem daunting, nurses should transform
traditional practices into ones supported by the best
scientific evidence. Nurses can get access to primary
research, systematic reviews, and clinical practice
guidelines by using information technology effectively.
Information management strategies are essential including
subscribing to RSS feeds, registering for email alerts from
journal publishers and from government resources, and
purchasing subscriptions to services that provide EBP
support. Finally, nurses should advocate for the selection
of health information technology that has best practices as
an integrated feature. Technology can make the practice
of EBP more seamless for nurses and fulfill the need to
improve patient care.

124

References

Ahrens, S., & Johnson, C. S. (2013). Finding the way to
evidence-based practice. Nursing Management,
44(5), 23–27. doi:
10.1097/01.NUMA.0000429009.93011.ea
Alexander, S., Hoy, H., Maskey, M., Conover, H.,
Gamble, J., & Fraley, A. M. (2013). Initiating
collaboration among organ transplant professionals
through web portals and mobile applications. Online
Journal of Issues in Nursing, 18(3). doi:
10.3912/OJIN.Vol18No02PPT03
American Nurses Association. (2012). ANA recognized
terminologies that support nursing practice. Retrieved
from:
http://www.nursingworld.org/npii/terminologies.htm
Barey, E. B., Mastrian, K., & McGonigle, D. (2016). The
electronic health record and clinical informatics. In S.
M. DeNisco & A. M. Barker (Eds.), Advanced practice
nursing: Essential knowledge for the profession (3rd
ed., pp. 349–367). Burlington, MA: Jones & Bartlett
Learning.
Beel, J., & Gipp, B. (2009). Google Scholar’s ranking
algorithm: An introductory overview. In B. Larse & J.
Leta (Eds.), Proceedings of the 12th International
Conference on Scientometrics and Informetrics (ISSI
’09), 1, 230–241, Rio De Janeiro (Brazil). International
Society for Scientometrics and Informetrics. Retrieved
from http://www.sciplore.org/publications/2009Google_Scholar%27s_Ranking_Algorithm_-_An_Introductory_Overview_--_preprint.pdf
Berner, E., & La Jande, T. (2007). Overview of clinical
decision support systems. In E. Berner (Ed.), Clinical
decision support systems: Theory and practice (2nd
ed., pp. 4–18) New York: Springer.
Best, J., Frith, K., Anderson, F., Rapp, C. G., Rioux, L., &
Ciccarello, C. (2011). Implementation of an evidencebased order set to impact initial antibiotic time
intervals in adult febrile neutropenia. Oncology
Nursing Forum, 38(6), 661–668.
doi:10.1188/11.ONF.661-668
Brokel, J. M. (2009). Infusing clinical decision support
interventions into electronic health records. Urologic
Nursing, 29(5), 345–353.

125

Carroll, M. W. (2011). Why full open access matters.
PLoS Biol, 9(11), e1001210.
doi:10.1371/journal.pbio.1001210
Centers for Disease Control and Prevention. (2016).
Meaningful use. Retrieved from
http://www.cdc.gov/ehrmeaningfuluse/introduction.html
Cheeseman, S. E. (2011). Mastering basic computer
competencies one byte at a time. Neonatal Network,
30(6), 413–419.
Cheeseman, S. E. (2012). Information literacy: Using
computers to connect practice to evidence. Neonatal
Network, 31(4), 253–258.
Dainow, E. (2016). Understanding computers,
smartphones and the Internet. Retrieved from
https://www.smashwords.com/books/view/630245
Duffy, M. (2015). Nurses and the migration to electronic
health records. American Journal of Nursing, 115(12),
61–66.
Fain, J. A. (2009). Reading, understanding, and applying
nursing research (4th ed.). Philadelphia: FA Davis.
Fineout-Overholt, E., Berryman, D. R., Hofstetter, S., &
Sollenberger, J. (2011). Finding relevant evidence to
answer clinical questions. In: B. M. Melnyk & E.
Finout-Overholt, (Eds.), Evidence-based practice in
nursing & healthcare: A guide to best practice. (2nd
ed.). Philadelphia: Lippincott Williams & Wilkins.
Google Scholar. About. Retrieved from
http://scholar.google.com/intl/en/scholar/about.html
Gugerty, B., & Delaney, C. (2009). Technology
Informatics Guiding Educational Reform (TIGER).
TIGER Informatics Competencies Collaborative
(TICC) final report. Retrieved from
http://tigercompetencies.pbworks.com/f/TICC_Final.pdf
Halley, E. C., Sensmeier, J., & Brokel, J. M. (2009).
Nurses exchanging information: Understanding
electronic health record standards and
interoperability. Urologic Nursing, 29(5), 305314.
Hawn, C. (2009). Take two aspirin and tweet me in the
morning: How Twitter, Facebook, and other social
media are reshaping healthcare. Health Affairs, 28(2),
361–368. Retrieved from
126

http://content.healthaffairs.org/content/28/2/361.full#sec6
Health RSS Feeds. USA Government Web Portal.
Retrieved from
http://www.usa.gov/Topics/ReferenceShelf/Libraries/RSS-Library/Health.shtml
Hello Health Patient Information. Hello Health. Retrieved
from
https://hellohealth.com/telemedicine/overview/
Hoss, B., & Hanson, D. (2008). Evaluating the evidence:
Web sites. AORN Journal, 87(1), 124–141.
Ingersoll, G. L. (2000). Evidence-based nursing: What it
is and what it isn’t. Nursing Outlook, 48(4), 151–152.
doi:10.1067/mno.2000.107690

ITI Planning Committee. (2015). Integrating the health
care infrastructure white paper: Health IT standards
for 10 health information management practices.
Retrieved from
http://ihe.net/uploadedFiles/Documents/ITI/IHE_ITI_WP_HITStdsforHIMPr
09-18.pdf

International Council of Nurses. (2015). International
classification for nursing practice (ICNP) information
sheet. Retrieved from
http://www.icn.ch/images/stories/documents/pillars/Practice/icnp/ICNP_F
Kaminski, J. (2015). Computer science and the
foundation of knowledge model. In D. McGonigle & K.
G. Mastrian (Eds.), Nursing informatics and the
foundation of knowledge (2nd ed., pp. 33–56).
Burlington, MA: Jones & Bartlett Learning.
Karamali, M., Heidarzadeh, Z., Seifati, S. M., Samimi, M.,
Tabassi, Z., Hajijafari, M., . . . Esmaillzadeh, A.
(2015). Zinc supplementation and the effects of
metabolic status in gestational diabetes: A
randomized, double-blind placebo-controlled trial.
Journal of Diabetes Complications, 29(3), 1314–1319.
Lawson, P. (2005). How to bring evidence-based practice
to the bedside. Nursing 2005, 35(1), 18–19.
Levin, R. F. (2013). Searching the sea of evidence: It
takes a library. In: R. F. Levin & H. R. Feldman (Eds.),
Teaching evidence-based practice in nursing (2nd
ed., pp. 103–118). New York: Springer.

127

Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidencebased practice in nursing & healthcare: A guide to
best practice (2nd ed.). Philadelphia: Lippincott
Williams & Wilkins.
Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., &
Williamson, K. M. (2010). The seven steps of
evidence-based practice. American Journal of
Nursing, 10(1), 51–53.
Rigney, D. (2010). What is the Matthew Effect? The
Matthew Effect: How advantage begets further
advantage. New York: Columbia University Press.
Retrieved from http://cup.columbia.edu/book/9780-231-14948-8/the-matthew-effect/excerpt
Rupert, D. J., Gard Read, J., Amoozegar, J. B., Moultrie,
R. R., Taylor, O. M., O’Donoghue, A. C., . . .
O’Donoghue, A. C. (2016). Peer-generated health
information: The role of online communities in patient
and caregiver health decisions. Journal of Health
Communication, 21(11), 1187–1197.
doi:10.1080/10810730.2016.1237592
Rutherford, M. (2008). Standardized nursing language:
What does it mean for nursing practice? OJIN: The
Online Journal of Issues in Nursing, 13(1). doi:
10.3912/OJIN.Vol13No01PPT05
Salmond, S. W. (2007). Advancing evidence-based
practice: A primer. Orthopaedic Nursing, 26(2), 114–
123.
Sortedahl, C. (2012). Effect of online journal club on
evidence-based practice knowledge, intent, and
utilization in school nurses. Worldviews on EvidenceBased Nursing, 9(2), 117–125. doi: 10.1111/j.17416787.2012.00249.x
Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., &
Williamson, K. M. (2010). Asking the clinical question:
A key step in evidence-based practice. American
Journal of Nursing, 110(3), 58–61.
TechTarget. (2016). URL. Retrieved from
http://searchnetworking.techtarget.com/definition/URL
Tymkow, C. (2016). Clinical scholarship and evidencebased practice. In S. M. DeNisco & A. M. Barker
(Eds.), Advanced practice nursing: Essential
knowledge for the profession (3rd ed., pp. 495–552).
Burlington, MA: Jones & Bartlett Learning.

128

Wells, N., Free, M., & Adams, R. (2007). Nursing
research internship: Enhancing evidence-based
practice among staff nurses. Journal of Nursing
Administration, 37(3), 135–143.

129

130

131

© nednapa/Shutterstock

132

SECTION II
Use of Clinical Informatics in
Care Support Roles
CHAPTER 4 Human Factors in Computing
CHAPTER 5 Usability in Health Information
Technology
CHAPTER 6 Privacy, Security, and
Confidentiality
CHAPTER 7 Database Systems for Healthcare
Applications
CHAPTER 8 Using Big Data Analytics to Answer
Questions in HealthCare
CHAPTER 9 Workflow Support
CHAPTER 10 Promoting Patient Safety with the
Use of Information Technology

133

© nednapa/Shutterstock

134

CHAPTER 4
Human Factors in Computing
Steffi Kreuzfeld, Dr. med.
Regina Stoll, Dr. med. habil.

LEARNING OBJECTIVES

1. Define ergonomics and associated concepts as applied in
healthcare settings.
2. Describe the importance of understanding human factors in
healthcare settings.
3. Know the key International Organization for Standardization
(ISO) standards for ergonomic principles and design of work
settings.
4. Comprehend the influence of work systems on the nurses’
physical and psychological health.
5. Analyze information systems and computer applications with
regard to human–computer interactions.

KEY TERMS

Anthropometry

Information processing

Task design

Dialogue

Interactivity

User interface

Ergonomics

International Organization

Visual display

Graphical user
interface (GUI)
Hardware
ergonomics

for Standardization (ISO)
Natural user interfaces
Selective attention
Software ergonomics

Human–computer
interaction
(HCI)

135

terminal
(VDT)
Voice user
interfaces
Work systems

▶ Chapter Overview
Computer systems and computer applications are used in
all areas of life, from leisure to work. The systems range
from computer workstations, notebooks, and
smartphones, to networked household appliances and
medical devices. To allow humans to comfortably interact
with the various applications in a safe and efficient
manner, ergonomic principles must be applied. This
chapter describes the physiological, psychological, and
social aspects of human interaction with computer
systems and the effects of computer technology on people
at work, particularly in healthcare settings.

136

▶ Introduction
Humans and computers form a complex sociotechnical
work system. If they are to distribute their workloads in a
meaningful manner, the different qualities and abilities of
human and machine must be considered. The human
recognizes problems and can draw on wide-ranging
general and specific knowledge in various areas to
combine knowledge with experience to creatively apply
them to problem solving. The human is capable of
complex decisions and accepting the resulting
responsibility. For example, nurses have knowledge, skills,
and values developed by completing collegiate education
in nursing, participating in continuing education, and by
practicing in work settings. Nurses, equipped with
education and experience, make complex decisions in
noisy, fast-paced work environments that have
consequences for the safety of patients in their care.
In contrast, computer systems can process huge amounts
of data quickly and error free, repeat similar tasks multiple
times without fatigue, extract important information, and
exclude irrelevant data. Computers can function under
extreme conditions and endure factors that would be
detrimental to human health (Dul & Weerdenmeester,
2008).
The conditions under which humans work constitute
significant factors that influence health and wellbeing, as
well as productivity and successful outcomes of work. The
individual performance of the human is determined, on
one hand, by external performance-shaping factors such
as work environment, assigned task, technical feasibilities,
time constraints, and modes of cooperation. On the other
hand, it is also influenced by internal performance-shaping

137

factors, such as physical and psychological states of the
human. Computer applications that are well suited to
humans can ease and enrich human performance.
Standards, laws, and recommendations can be used to
create a framework to prevent humans from sustaining
lasting harm by their work.

138

▶ Human Factors/Ergonomics (HFE)
In 2000, the International Ergonomics Association (IEA,
2000) defined ergonomics as follows:
Ergonomics (or human factors) is the
scientific discipline concerned with the
understanding of the interactions among
humans and other elements of a system,
and the profession that applies theory,
principles, data and methods to design in
order to optimize human well-being and
overall system performance. Practitioners of
ergonomics and ergonomists contribute to
the design and evaluation of tasks, jobs,
products, environments and systems in order
to make them compatible with the needs,
abilities and limitations of people.
The term ergonomics derives from the Greek words ergon
(work) and nomos (law) and describes the systematic
study of all aspects of human activity as it relates to work.
Ergonomics is a dynamic, interdisciplinary field of study
that continuously evolves through new insights into the
interaction between humans and work (Wilson, 2000). It
differentiates itself from other fields of study through its
direct applicability. Ergonomics is central to safety
programs in many different fields including manufacturing,
aerospace, and health care. The application of
ergonomics in health care is gaining attention in the United
States as a result of reports by the Institute of Medicine
(IOM, 1999, 2004, 2011).
As new knowledge is applied, it should lead to greater
humanization of work. This implies that the human is at the

139

center and that the work is being adapted to human
needs, not the other way around. Besides increased
safety, health, and comfort for the worker, there are also
economic considerations included among the target
parameters of applied ergonomics. Productivity, quality,
and efficiency can be improved by applying ergonomic
production processes, and costs can be lowered by
decreasing work-related illnesses and illness-related
absences from work (Dul et al., 2012). For example, in the
United States, the economic influence of properly applied
ergonomics can result in better reimbursement from the
Centers for Medicare and Medicaid Services (CMS)
because adverse events, many of which are caused by
the mismatch of technology to human factors, can be
reduced (Amarasingham, Plantinga, Diener-West, Gaskin,
& Powe, 2009; CMS, 2008).
The second part of the IEA definition of ergonomics
indicates the breadth of the spectrum of research in
ergonomics: It spans from capturing work content and
organizational aspects of work, to environmental factors,
to consideration of physical and psychological factors and
limitations that humans face as they interact with various
work equipment. Ergonomics requires specialized
education. The disciplines involved are primarily
occupational science, human and social sciences, the
humanities, computer and design science, and industrial
engineering. In the United States, a subspecialty called
human factors engineering contributes to knowledge
generation through research and improvements in work
environments by application of research to healthcare
settings.
There are different areas of ergonomics, each with its own
focus. For example, in physical ergonomics, the health
consequences of working posture and repetitive motions
are studied as the origins of musculoskeletal disorders.
140

Organizational ergonomics deals with the optimization of
work processes and structures, such as time
management, teamwork, communication within an
organization, telecommuting, and quality control. In
contrast, the area of cognitive ergonomics focuses on
such issues as cognitive and memory processes in the
human brain, decision making, recognition and elimination
of work-related stress, reliability of human actions, and
human–computer interactions (HCIs).

141

▶ Standards, Laws,
Recommendations, and Style Guides
A part of the ergonomic knowledge has been summarized
and recorded by way of standards, laws, and
recommendations. International standards are issued by
the International Organization for Standardization
(ISO). They are based on firmly established scientific
principles and are determined on an international level,
frequently in lengthy discussions, and adopted by majority
decision. They form the lowest common denominator on
which representatives from politics, economics, and
science can agree and constitute a framework for their
practical application and careful “should do”
recommendations. The disadvantage of such generally
accepted standards is that they are frequently too
nonspecific and new scientific findings are often not
considered.
Likewise, laws are frequently nonspecific and provide only
minimal standards for occupational safety. They also do
not adapt well to the current state of knowledge in the
short term. In contrast, recommendations in books or
publications incorporate current findings more easily and
promote more concrete applications. However, they may
be open to interpretation, and extensive prior knowledge
may be required of the user. Style guides are guidelines
for standardizing designs of user interfaces. Generally,
they are published by the manufacturer as part of the
documentation for computer operating systems (e.g.,
Microsoft Windows). They frequently are based on the
principles of software ergonomics. BOX 4-1 lists pertinent
international ISO standards on ergonomics.
BOX 4-1 Examples of International ISO Standards on Ergonomics

142

ISO
6385:

Ergonomic principles in the design of work systems

ISO
9241:

The ergonomics of human system interaction

ISO
9355-2:

Ergonomic requirements for the design of displays and
control actuators— Part 2: Displays

ISO/TR
16982:

Ergonomics of human–system interaction—Usability methods
supporting human-centered design

ISO
100753:

Ergonomic principles related to mental workload

ISO 6385: Ergonomic Principles in the
Design of Work Systems
This international standard contains the significant findings
and definitions in ergonomics; it explains relevant basic
terms and provides an occupational science framework for
all specialists who are involved in the wide-ranging design
of work systems. Technical, economic, organizational, and
social aspects must all be considered. The standard also
applies to the design of products that are not associated
with work.
A work system provides a super structure for the
cooperation of individuals or groups of employees (or
users) that allows them to complete their tasks using their
tools and equipment within their occupational domain. To
create a work system based on ergonomic principles and
ISO standards, the following subcategories of the system
must be considered: organization of work, task design,
design of activity, design of work environment, design of
tools and equipment, and design of workplace and work
station.

ISO 9241: The Ergonomics of Human
System Interaction
143

ISO 9241 is a multipart international standard that initially
consisted of 17 parts making demands on office work
(“Ergonomic requirements for office work with visual
display terminals”). Meanwhile, these recommendations
do not only apply to office work. Thus, the 2006 standard
has been given the more general title “Ergonomics of
human system interaction.” It has been revised and
extended since then. Three chapters of the original ISO
9241 structure remain (part 1, 2, and 11), while the rest
will be rearranged in series, structured in “hundreds,” in
order to facilitate the standard’s handling and readability.
Chapter 20 has been added. An overview of the thematic
priorities of ISO 9241 can be found in BOX 4-2.
BOX 4-2 ISO 9241, Old and New Parts
Ergonomic requirements for office work with visual display terminals
(VDTs)
Part 1:

General introduction

Part 2:

Guidance on task requirements

Part 5:

Workstation layout and postural requirements

Part 6:

Guidance on the work environments

Part 11:

Guidance on usability

Part 12:

Presentation of information

Part 13:

User guidance

Part 14:

Menu dialogues

Part 15:

Command dialogues

Part 16:

Direct manipulation dialogues

Part 17:

Form-filling dialogues

Ergonomics of human–system interaction
Part 20:

Accessibility guidelines for ICT equipment and services

144

100 series:

Software ergonomics

200 series:

Human–system interaction processes

300 series:

Displays and display-related hardware

400 series:

Physical input devices—ergonomics principles

500 series:

Workplace ergonomics

600 series:

Environment ergonomics

700 series:

Application domains—control rooms

900 series:

Tactile and haptic interactions

ICT = Information/Communication Technology
Data from ISO. (2010). ISO 9241-210: 2010(en). Ergonomics of humansystem interaction: Part 210: Human-centred design for interactive
systems. Retrieved from
https://www.iso.org/obp/ui/#iso:std:iso:9241:-210:ed-1:v1:en

The comprehensive collection of recommendations
regarding the design of the workplace, hardware, and
software aims at reducing health risks caused by displaybased work and facilitating the user’s job demands. ISO
9241 is used particularly by those who work on planning,
design, and usability of office workstations, office layouts,
information/communication technology equipment, the
development of software platforms, software applications,
and display technologies, or the evaluation of usability
goals of a computer system.

Organization of Work
Organization of work is defined as the systematic
organization and design of workflow under consideration
of task-specific, content-specific, and time-specific
aspects. It is important to analyze how individual
workplaces and activities within a work system (e.g., a

145

hospital), depend on or limit each other, or work
synergistically or antagonize each other. A typical
organization in an acute care hospital in the United States
has functional departments, such as nursing, respiratory
therapy, physical therapy, laboratory, radiology, surgery,
dietary, housekeeping, and administration. However,
employees in the distinct departments must work
cooperatively to move patients through an inpatient
experience. For example, a patient seen in an emergency
department is evaluated by a healthcare provider, treated
by nurses and other ancillary providers, and admitted for
inpatient treatment. Movement of the patient to a hospital
room (task-specific aspects) depends on availability of
transfer equipment and personnel, communication
between the healthcare providers in the two different
treatment areas, and transfer of health information from
one area to another (content-specific aspects). The
transfer may also be dependent on the availability of a
receiving nurse, which can be delayed during shift
changes or when nurses have urgent tasks to ...


Anonymous
Great! Studypool always delivers quality work.

Studypool
4.7
Trustpilot
4.5
Sitejabber
4.4

Similar Content

Related Tags