Nursing Informatics
Nursing Informatics: The Intersection of Nursing, Computer,
And Information Sciences
EXECUTIVE SUMMARY
Nursing informatics (NI) is a well-established special-
ty within nursing.
Background on the birth and evolution of NI, and the
NI scope of practice and certification are explored.
NI has played a vital role in influencing health care
information system features and functions.
Today, nursing informatics has evolved to be an inte-
gral part of health care delivery and a differentiating
factor in the selection, implementation, and evaluation
of health IT that supports safe, high-quality, patient-
centric care.
ITH THIS ISSUE,
NURSING
W Economic$ kicks off a
new “Nursing Informa-
tics” column to keep
nurse executives, managers, and
faculty informed about health
information technology (IT) and
the essential informatics compe-
tencies required to function in
today’s patient-care environment.
In this and subsequent issues, we
Judy Murphy
will explore informatics topics,
issues, and challenges to educate you on the use of IT
to improve the efficiency, safety, and quality of health
care delivery and on the unique role of nursing infor-
matics specialists toward that end.
In this inaugural column, the history of nursing
informatics will be reviewed; looking at its evolution
as a specialty, including the development of scope of
practice, competencies, and certification. In future
columns, we will delve into such topics as the
HITECH Act (Health IT for Economic and Clinical
Health) and “meaningful use,” the TIGER Initiative
(Technology Informatics Guiding Educational
Reform), informatics competencies in our nursing
programs and health care organizations, the patients’
use of personal health records, the importance of IT
JUDY MURPHY, RN, FACMI, FHIMSS, is Vice President,
Information Services, Aurora Health Care in Milwaukee, WI; a
HIMSS Board Member; and a member of the federal HIT
Standards Committee. Comments and suggestions can be sent to
judy.murphy@aurora.org
NOTE: Hear Judy speak on “The Economic$ for Meaningful Use
of Health Information Technology” at the 4th Annual Nurse
Faculty/Nurse Executive Summit, December 13-15, 2010 in
Scottsdale, AZ. Visit www.nursingeconomics.net for Summit pro-
gram and registration information.
204
Judy Murphy
system interoperability and health data exchanges, as
well as the relationship between health IT, quality,
and patient safety. We will also discuss health IT
implementation issues such as IT project governance,
electronic health records, bar-coded medication
administration, online medication reconciliation,
decision support, standardized vocabularies, and evi-
dence-based practice in automated care planning and
documentation. Expect to see guest authors on some
of these topics as well. It will be an exciting journey!
The Birth of Nursing Informatics
In the late 1960s, the first computer systems were
installed in hospitals. These initial systems were gen-
erally financially based, and used to capture orders,
charges, and do patient billing. However, very quick-
ly, the power of computers became known, and they
expanded from being in the hospital basements to a
presence on the nursing units. These monochrome
mainframe terminals, or cathode ray tubes (CRTs),
had small screens and a huge desktop footprint, but
they began to slowly but surely, over the next 40
years, replace much of the paper we all knew so well.
Nurses have contributed to the purchase, design,
and implementation of IT since the 1970s. The term
“nursing informatics” (NI) first appeared in the litera-
ture in the 1980s (Ball & Hannah, 1984; Grobe, 1988;
Hannah, 1985). The definition of NI has been evolv-
ing ever since, molded by maturation of the field and
influenced by health policy. In a classic article that
described its domain, NI was defined as the “combi-
nation of nursing, information, and computer sci-
ences to mange and process data into information and
knowledge for use in nursing practice” (Graves &
Corcoran, 1989). Nurses who worked in NI during
that time were pioneers who often got into the infor-
matics practice because they were good clinicians,
were involved in IT projects as educators or project
team members, or were just technically curious and
willing to try new things. Their roles, titles, and
responsibilities varied, and they often got into NI
“accidentally.” The history of these early pioneers is
preserved in an archive at the National Library of
Medicine started by Dr. Virginia Saba in 1997, and by
34 nursing informatics specialists’ videotaped oral
histories available on the Internet (American Medical
Informatics Association, 2006).
Tuning the Definition and Practice Scope of NI
In 1994, the American Nurses Association (ANA)
published their first definition of NI: “Nursing
Informatics is the specialty that integrates nursing sci-
NURSING ECONOMIC$/May-June 2010/Vol. 28/No. 3
ence, computer science, and information science in
identifying, collecting, processing, and managing data
and information to support nursing practice, adminis-
tration, education, research, and the expansion of
nursing knowledge (p. 3).” The ANA expanded their
definition in 2001 when they described it as “…a spe-
cialty that integrates nursing science, computer sci-
ence, and information science to manage and commu-
nicate data, information, and knowledge in nursing
practice. NI facilitates the integration of data, infor-
mation, and knowledge to support patients, nurses,
and other providers in their decision-making in all
roles and settings. This support is accomplished
through the use of information structures, informa-
tion processes, and IT (p. 17).” Finally, in 2008, the
ANA published its current definition of NI. The defi-
nition remained essentially the same as that from
1994, but now includes the additional concept of wis-
dom. “NI is a specialty that integrates nursing science,
computer science, and information science to manage
and communicate data, information, knowledge, and
wisdom in nursing practice (p. 65).” In parallel with
each of these three advancing definitions, ANA pub-
lished three expanding editions of NI Scope and
Standards of Practice (ANA, 1994; 2001; 2008). These
formed the foundation of a discipline-specific infor-
matics practice within the broader category of med-
ical informatics, or more recently called, health infor-
matics.
In 2009, the Nursing Informatics Special Interest
Group of the International Medical Informatics
Association tuned the NI definition by publishing
“Nursing Informatics science and practice integrates
nursing, its information and knowledge and their
management, with information and communication
technologies to promote the health of people, families
and communities world wide.” This is where the
focus turns back toward the use of technology as a
means to an end (using technology to promote health
and quality patient care). There will be more to come
on this in the future as the practice continues to
evolve, as informatics does not only support the
process of care delivery, but also promotes better
patient outcomes and improvement of health.
This maturation of the NI definition gives a hint
as to the evolution of NI practice over the past 25
years. Spawned by a new industry and spurred on by
unparalleled advancements in technology, health care
and informatics has been running to just keep up. Let
me put this in perspective and remind you of some
key historical technical events going on around the
same time. In 1993 alone, consider the introduction of
the Intel Pentium chip, CD burners, digital cameras,
and DVD media. The World Wide Web (www) was
also launched in 1993, with the first free web brows-
er, Mosaic. Netscape came in 1994 and Internet
Explorer in 1995, about the same time that Windows
95 was replacing Windows 3.1. AOL Instant
NURSING ECONOMIC$/May-June 2010/Vol. 28/No. 3
Messaging was born in 1997. All these innovations
occurred in one 5-year time span in the mid-1990s!
Now think of all that has happened in the subsequent
years — small screens, flat screens, laptops, hand-
helds, tablets, wireless, barcodes — in short, ubiqui-
tous computing that we depend on in our everyday
lives. We could talk here about how health care has
lagged other industries in the use of IT and the many
possible explanations for that, but I will save that for
another column.
Nursing Informatics as a Specialty
In 1992, the ANA recognized NI as a specialty. To
be recognized as a specialty within nursing, NI
demonstrated a differentiated practice base, identi-
fied the existence of educational programs, and
showed support from nationally recognized organiza-
tions (Panniers & Gassert, 1995). A description of NI
as a differentiated practice is given in the ANA Scope
of Practice and Standards documents.
Educational programs were slow to start, with
only two graduate-level programs in the late 1980s at
the University of Maryland (Heller, Romano, Moray, &
Gassert, 1989) and the University of Utah (Graves,
Amos, Heuther, Lange, & Thompson, 1995). Federal
funding issues in the early to mid-1990s stunted
development of additional programs. However, new
legislation in 1998 allocated federal monies through
the Division of Nursing and the Health and Human
Services Administration, and funding for the start-up
of NI programs began. Since then, there has been
steady development of programs, and in the last 3-5
years, one could say there has actually been an explo-
sion of new and varied programs, including many dis-
tance learning options. However, as with many parts
of the health care workforce, a shortage of informatics
faculty will throttle additional proliferation of NI pro-
grams.
A final recommendation for a specialty is organi-
zational representation. NI has the support of both
nursing and multidisciplinary organizations. In nurs-
ing, there is support from both NI-specific organiza-
tions at the local, regional, and national levels, as well
as national nursing organizations, such as the ANA,
the American Organization of Nurse Executives, and
the American Academy of Nursing. Multidisciplinary
health care informatics organizations also encouraged
nurses to become actively involved in their organiza-
tions to help solve informatics education and practice
issues, as well as support the policy and advocacy
issues of the organization. Two examples are the
American Medical Informatics Association (AMIA)
and the Healthcare Information and Management
Systems Society (HIMSS). Informatics nurses have
served as president and on the boards for both of
these organizations.
Additionally, 5 years ago, the Alliance for
Nursing Informatics (ANI, 2007) was formed. ANI is a
205
 o begin to identify
collaboration of organiza-
tions, representing a unified
T important system
criteria that supported the
voice for nursing informatics.
Each of the collaborating practice of nursing was a
organizations has its own
established programs, publi- key early step in the
cations, and organizational
structures. However, the uni- development of the health
fied voice is often helpful for
support of national policy IT we know today.
and advocacy issues. ANI,
which is co-sponsored by
AMIA and HIMSS, represents
more than 5,000 nurse infor-
maticists and brings together
25 distinct nursing informatics groups in the United
States. ANI crosses academia, practice, industry, and
nursing specialty boundaries and works in collabora-
tion with the nearly 3 million nurses in practice
today.
Nursing Informatics Certification
As the number of nurses working in NI increased
and the number of graduate NI programs grew, there
was a larger group of informatics nurses interested in
and eligible for certification. In 1995, the American
Nurses Credentialing Center, the largest nurse creden-
tialing organization and a subsidiary of the ANA,
administered the first certification exam, using a com-
puter-based testing method which was somewhat cut-
ting edge at the time. It was a generalist exam based
on the ANA Scope and Standards of NI Practice, as
well as seven focus areas for nursing informatics rec-
ommended by the National Center for Nursing
Research in 1993. Topics included system analysis
and design, system implementation and support, sys-
tem testing and evaluation, human factors, computer
technology, information/database management, pro-
fessional practice trends and issues, and theories.
Today, over 500 nurses hold certification, and there is
interest in developing a specialist level of certifica-
tion for NI, which would expand on the existing gen-
eralist certification.
Information Systems that Support Nursing
Nurses working in informatics have been prolific
in defining what they need in clinical information
systems to support nursing practice. A 1988 ANA
publication entitled Computer Design Criteria for
Systems That Support the Nursing Process (Zielstorff,
McHugh, & Clinton, 1988) began the journey. This
seminal work of the ANA Council on Computer
Applications in Nursing pointed out many computer
system products did not meet nursing’s basic infor-
mation needs. Specific criteria for designing
improved systems were identified. The authors con-
cluded with the hope vendors and nurses would prof-
it from the monograph’s content, leading to informa-
206
tion systems that support effi-
cient and effective nursing
care.
Next-Generation Nursing
Information Systems: Essen-
tial Characteristics for Profes-
sional Practice (Zielstorff,
Grobe, & Hudgings, 1993) is a
second, well-known publica-
tion that synthesized the find-
ings of an Invitational Con-
ference on Nursing Infor-
mation Systems sponsored by
the National Commission on
Nursing Implementation Pro-
ject, the ANA Council on Computer Applications in
Nursing, and the National League for Nursing Nursing
Informatics Forum, as well as other sources of con-
temporary thought about what was then called
Nursing Information Systems. This monograph pro-
vided principles and guidelines to enable nurses and
vendors to design and develop a new generation of
information systems that would support the profes-
sional practice of nursing. Essential characteristics
and functional requirements of these new systems
were described, along with critical information sys-
tems processes. The concept of supporting the deci-
sion making of practicing nurses through improved
information systems was strongly promoted. The
authors envisioned a future in which information sys-
tems contribute to nursing’s and health care’s strategic
goal of cost-effective, quality client care.
Ten years after publication of the Next-
Generation monograph, informatics nurses and clini-
cal nurses still awaited the future proposed by these
two important publications. The energy, enthusiasm,
and knowledge of our colleagues had yet to be trans-
lated into the comprehensive information systems
that supported the professional practice of nursing.
So, as we moved into the second millennium, the
nursing profession in general, and informatics nurses
in particular, recognized the need to revisit and
rethink these original works to complete the compre-
hensive solution advocated by Zielstorff and col-
leagues. This prompted members of the AMIA
Nursing Informatics Working Group to collaborate
with the ANA to craft a new monograph in 2003
(Androwich, Bickford, Hunter, Button, Murphy, &
Sensmeier, 2003). The emphasis of the new work was
to promote the extension of information systems
beyond meeting basic information needs toward pro-
viding support for professional nursing practice to
improve patient outcomes. This included moving
from data-driven systems to workflow-driven sys-
tems, and was a major step toward articulating the
people, process, and technology components of
health IT that we know today (more on that in a future
column, too).
NURSING ECONOMIC$/May-June 2010/Vol. 28/No. 3
 Another significant effort of ANA was to support
the definition and implementation of standards relat-
ed to use of nursing languages in computer-based sys-
tems through the establishment of the Nursing
Information and Data Set Evaluation Center (NID-
SECTM) in 1996. The purpose of NIDSEC was to devel-
op and disseminate standards pertaining to informa-
tion systems that supported the documentation of
nursing practice and evaluate voluntarily submitted
information systems against these standards. The
standards and scoring guidelines used in evaluating
information systems addressed five areas: standards,
nomenclature, clinical content, data repository, and
general systems characteristics (NIDSEC, 1997).
Numerous vendors and software suppliers of the day
voluntarily applied for, and received, NIDSEC
endorsement. The importance of the initiative went
beyond the evaluation of specific clinical information
systems. In the competitive marketplace, hospitals
and health systems demonstrated to consumers qual-
ity was their top priority and their decisions on infor-
mation systems linked nursing data to quality care.
Though NIDSEC evaluation criteria are no longer
used, this was an important step for NI as a profes-
sion. In addition to clarifying their own specialty and
scope of practice, it was important to describe how
this made an impact on the health care industry and
the systems being developed and used. To begin to
identify important system criteria that supported the
practice of nursing was a key early step in the devel-
opment of the health IT we know today.
Summary
I have taken some liberties in my “trip down
memory lane,” and hope you found some of it inter-
esting and/or instructive. In summary, NI is a well-
established specialty within nursing. I have provided
background on the birth and evolution of NI, and
explored the NI scope of practice and certification. I
have talked about the NI influence on information
system features and functions. My hope is that by
replaying some of these key events in the history of
NI, nurse leaders will see how much of a solid foun-
dation was laid over the past 25 years, and under-
stand the work of the pioneers, whose shoulders on
which our NI specialists of today stand.
Today, nursing informatics has evolved to be an
integral part of health care delivery and a differentiat-
ing factor in the selection, implementation, and eval-
uation of health IT that supports safe, high-quality,
patient-centric care. In future columns, I will explore
the why’s and how’s of that bold statement, and what
you need to know about IT in today’s health care envi-
ronment. Please stay tuned. $
NURSING ECONOMIC$/May-June 2010/Vol. 28/No. 3
REFERENCES
Alliance for Nursing Informatics (2007). About ANI. Retrieved
from http://www.allianceni.org
American Medical Informatics Association. (2006). Nursing infor-
matics history project. Retrieved from http://coursedocs.
umaryland.edu/Projects/amia/pioneers.htm
American Nurses Association (ANA). (1994). The scope of prac-
tice for nursing informatics. Washington DC: American
Nurses Publishing.
American Nurses Association (ANA). (2001). Scope and stan-
dards of nursing informatics practice. Washington DC:
American Nurses Publishing.
American Nurses Association (ANA). (2008). Nursing informat-
ics: Scope and standards of practice. Silver Spring, MD:
Nursebooks.org.
American Nurses Credentialing Center. (n.d.). Nursing informatics
certification. Retrieved from http://www.nursecredentialing.
org/NurseSpecialties/Informatics.aspx
Androwich, I., Bickford, C., Hunter, K., Button, P., Murphy & J.,
Sensmeier, J. (2003). Clinical information systems: A frame-
work for reaching the vision. Washington, DC: American
Nurses Publishing.
Ball, M., & Hannah, K. (1984). Using computers in nursing.
Reston, VA: Reston Publishers.
Graves, J., & Corcoran, S. (1989). The study of nursing informat-
ics. Image: Journal of Nursing Scholarship, 21(4), 227-231.
Graves, J., Amos, L., Heuther, S., Lange, L., & Thompson, C.
(1995). Description of a graduate program in clinical nursing
informatics. Computers in Nursing, 13(2), 60-70.
Grobe, S. (1988). Nursing informatics competencies for nurse edu-
cators and researchers. In Petersen, H.E. & Gerdin-Jelger, U.
(Eds.), Preparing nurses for using information systems:
Recommended informatics competencies. New York:
National League for Nursing.
Hannah, K. (1985). Current trends in nursing informatics:
Implications for curriculum planning. In Hannah, K.J.,
Guillemin, E.J., & Conklin, D.N. (Eds.), Nursing uses of com-
puters and information science. Amsterdam, Netherlands:
Elsevier.
Heller, B., Romano, C., Moray, L., & Gassert, C. (1989). Special fol-
low-up report: The implementation of the first graduate pro-
gram in nursing informatics. Computers in Nursing, 7(5),
209-213.
International Medical Informatics Association. (2009). Definition.
Retrieved from http://www.imiani.org/index.php
National Center for Nursing Research. (1993). Nursing informat-
ics: Enhancing patient care: A report to the NCNR priority
expert panel on nursing informatics/national center for
nursing research. NIH Publication No. 93-2419. Bethesda,
MD: U.S. Department of Health and Human Services.
Nursing Information and Data Set Evaluation Center (NIDSEC).
(1997). Standards and scoring guidelines. Washington, DC:
American Nurses Publishing.
Panniers, T., & Gassert, C. (1995). Standards of practice and prepa-
ration for certification. In B. Heller, M. Mills, & C. Romano
(Eds.), Information management in nursing and healthcare.
Springhouse, PA: Springhouse Corporation.
Zielstorff, R., McHugh, M., & Clinton, J. (1998). Computer design
criteria for systems that support the nursing process.
Washington, DC: American Nurses Association Publications.
Zielstorff, R., Grobe S., & Hudgings, C. (1993). Next-generation
nursing information systems: Essential characteristics for
professional practice. Washington, DC: American Nurses
Publishing.
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