BACKGROUND

Historically, technology has been an important part of healthcare delivery as a method to improve the quality of clinical care. In the last 50 years, advances in patient monitoring, resuscitative equipment, surgical techniques, and telemedicine have vastly expanded the options available for interventional treatment. Most recently, information and computer technology has gained attention from a national perspective as insurers, regulatory bodies, and governmental payers have begun to view this technology as an important tool for improving the outcomes of healthcare through data sharing, information accessibility, and decision support. Public attention to technology in healthcare delivery has also grown as consumers are becoming more involved in their own healthcare, seeking information related to care and treatment, accessibility to their health records, and outcome data related to the healthcare facilities where they may seek treatment.

As technology is supported in healthcare institutions, through federal initiatives, and in response to consumer demands, it is changing the way nursing and other healthcare professionals are practicing their craft. Many organizations have become stakeholders in technology adoption by creating initiatives and/or developing mandates to facilitate the assimilation of technology in healthcare delivery. These organizations range from public-reporting initiatives through the Centers for Medicare and Medicaid; quality initiatives supported by the Institute of Medicine; and technology reform through nursing organizations such as the National League of Nursing (NLN), Technology Informatics Guiding Educational Reform (TIGER) Initiative, and the American Association of Colleges of Nursing (AACN). These nursing initiatives have become the vehicle for ensuring that nursing educators and practice work together to develop the knowledge and skills in both the student and practicing nurse to ensure competence in using technology.

DEFINING TECHNOLOGY

One of the challenges to many organizations attempting to implement technology and/or informatics for clinical practice and education is the lack of a common understanding of what this means. In a recent national survey of nursing informatics required in nursing curricula conducted by the NLN, faculty reported integration of informatics into 86% of some or all of their courses.1 The examples cited included computer-related activities, Web-based discussions, and computer-based applications, using computers for information retrieval, electronic health records, clinical documentation systems, and/or documentation and information literacy skills for online courses.2 More importantly, despite the emphasis on evidence-based practice, very few courses used tools to retrieve information, document clinical experiences, or retrieve evidence to support nursing practice. Although this survey was unique to educational practice, similar observations conducted in practice settings show that exposure to informatics tools such as electronic medical records, clinical information systems, intranet, and/or hand-held computers is often high, yet the use of these tools to manage knowledge, promote quality, promote patient safety, and support clinical decision making is of a much lower percentage. There is an incongruity between exposure and integration, which supports a reform in nursing practice. Nursing informatics can be defined as the application of the technology in service to the values of the profession. It is competence in using technology to provide safe and quality care.

In order for this transformation to occur, both those in practice and those in education need to work toward a cultural change that will support the assimilation of technology into clinical practice. Technology needs to become an integral tool of the practicing nurse to support decision making, improve patient outcomes, improve efficiencies, and apply evidence-based practice. This article describes how both those in practice and those in academic settings can work together to meet this goal.

START SMALL

Sometimes, the perceived enormity of a task can freeze the best of intentions right in their tracks. Changing the way nursing is practiced through the use of technology in the future will require millions of individual small changes and the implementation of large projects. Taking small successful steps can quickly help build momentum and win converts. Whether you are in a practice or an academic setting, collaboration is critical to demonstrate the transformation that informatics can bring to clinical care. Find one or two like-minded individuals in your organization and implement a small project. This might initially take the form of an educational offering such as teaching nurses to use the Internet to find evidence-based protocols and then demonstrating how this information can be used to make clinical decisions. Supporting the development of skills and knowledge in data access and decision making will empower them to build this into their practice. As the number of successful projects and participants increases, the more it will become apparent that informatics projects make a positive difference in patient care delivery. Partnering among 0.125 in clinicians, informatics persons, and faculty will help to develop competencies in informatics, and as a consequence, the number and size of informatics initiatives will also grow. As the Nike slogan says, "Just Do It."

CHANGING ATTITUDES

Implementation of any major change requires the cooperation and buy-in of those who will eventually be carrying out the change, and they cannot buy into change if they do not understand the reason behind it. It is important to provide leadership that supports competency in computer literacy, information literacy, and informatics. Partnering of faculty and clinicians in practice settings can set the stage for demonstrating how nursing informatics can improve patient care. Technology is not a panacea for improving the quality of clinical care, but it does offer myriad solutions that can improve sound clinical or educational processes. Again, start small with general educational offerings and opportunities to apply nursing informatics. As interest groups form around different areas, then those with more expertise in the area might be consulted. The use of exemplars in areas where successful transformation has occurred can help to support change.

The use of consultants and/or exemplars in the areas of informatics and technology can provide both presentations and consultation with groups of potential early adopters. Developing special interest groups to work on the development of informatics projects is one method for getting small group buy-in and early acceptance. These experts also have the advantage of being external to the organization and are often perceived as being more credible than those already in the organization. Use your experts to support your leadership position. This approach lends credibility to both you and the expert as reinforcing the same message of change.

Also useful is identifying a core group of champions who can receive advanced training and/or attend national informatics and technology conferences. These champions can then help diffuse this knowledge throughout the organization. Instead of adopting a "build it and they will come" approach, work on growing the need from the bottom up. As the need for informatics and technology grows, the organization will be forced to devote more and more resources to these areas.

GAIN ORGANIZATIONAL COMMITMENT

Successful integration of large technology and informatics projects for both practice and education will require strong organizational commitment. Recognition that an organization needs direction, implementation strategies, evaluation strategies, and methods to ensure implementation across the organization is critical to the acceptance of any change.3 This commitment must be explicit and clearly communicated to the entire organization. This will require the support of key players in the organization. While you are implementing smaller projects related to informatics and technology in your organization, make it a point to meet those in nursing and technology administration. You will need to educate them on the impact that informatics and technology can have on patient care. Work to make the implementation of these projects an organizational priority. Toward this end, specific goals with measurable end points and timelines need to be reflected in the organizations strategic plan. Areas that have been identified as strategic to the future of the organization are more likely to garner both human and financial resources. Also, goals that are formally identified in the organization's strategic plan will be periodically tracked and outcomes will be measured, ensuring that all your hard work will not be a flash in the pan but a sustained effort with solid deliverables.

In summary, incorporating nursing informatics into clinical care requires the commitment and collaboration of both practice and academic settings. Providing leadership that will establish core competencies, providing exemplars that are successful in the community or nursing education to serve as examples for integration, and establishing criteria to evaluate outcomes related to informatics goals will help all nurses practice in an informatics-rich environment.

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