ONE

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

Roy L. Simpson

Chief Nurse Executives Need

Contemporary Informatics
Competencies
EXECUTIVE SUMMARY
Using the informatics Organizing
Research Model (Effken, 2003) to
add context to the information
gieaned from ethnographic interviews of seven chief nurse executives (CNEs) currentiy ieading integrated deiivery systems, the author
conciuded nurse executives can no
ionger depend exciusiveiy on
American Organization of Nurse
Executives (AONE) competencies
as they outsource their responsibiiity for information technoiogy knowiedge to nurse informaticians, chief
information officers, and physicians.
Aithough AONE sets out a specific
iist of recommended information
technoiogy competencies for system CNEs, innovative nursing practice demands a more strategic,
broader ievei of knowiedge.
This broader competency centers
on the reality of CNEs being
charged with creating and implementing a patient-centered vision
that drives heaith care organizations' investment in technoiogy.
A new study identifies and vaiidates
the gaps between seiected CNEs'
self-identified informatics competencies and those set out by AONE
(Simpson, 2012).

ROY L. SIMPSON, DNP, RN, DPNAP,

FAAN, is Vice President, Nursing, Cerner
Corporation, Kansas City, MO.

HE SENTINEL WORK OF C r a v e S

and Corcoran (1989) defines nursing informatics

as "the combination of
computer science, information
science and nursing science designed to assist in the management and processing of nursing
data, information and knowledge
to support the practice of nursing
and the delivery of nursing care"
(para. 1). The American Organization of Nurse Executives (AONE,
2011) sets competencies related to
information technology. These
competencies range from the use
of email, office productivity software, and business analytics tools
to demonstrating an awareness of
societal and technological trends,
issues, and new developments as
they relate to nursing.
The convergence of four environmental factors is setting the
stage for a more rapid deployment
of clinical information systems:
The financial incentives associated with the "meaningful
use" of technology as outlined
in the American Reinvestment
and Recovery Act of 2009.
Technology-based innovations
such as cloud computing and
social media.
Widespread adoption of sophisticated analytical tools for

NURSING ECONOMIC$/November-December 2013A/ol. 31/No. 6

executive decision making.

The inability of most chief
nurse executives (CNEs) to effectively champion nursing's
technology-related needs in
the physician-led and dominated technology evaluation
process.
The unparalleled complexity
of patient care makes nursing
completely dependent on the
instantaneous availability of information to fuel the iterative nature
of decision making central to
patient care. In patient care, it is
information technology that amasses data and turns it into information and, ultimately, the knowledge that advances nursing and
patient care (Simpson, 2012).
Not only are technology evaluations and their related decisions
organizationally transformative,
their impact can be felt for decades.
The life cycle of every technology
investment spans seven distinct
phases, from planning to procurement to deployment to management
to support and disposition, only to
cycle back to planning. With an
ever-present obsolescence engaging at any step in the process creating change, this ever-cycling life
cycle continues. In addition, the
impact of technology's planned
obsolescence cannot be overlooked

Chief Nurse Executives Need Contemporary Informatics Competencies

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when nurse executives make information technology (IT)-related
decisions (The Fconomist, 2009).
Planned obsolescence, a business
strategy embraced by technology
providers worldwide, requires that
designers engineer obsolescence
into their products (The Economist,
2009). Technology providers wholeheartedly embrace the concept to
ensure market demand, and its
associated revenue streams, will be
timed to occur as current products
are phased out or "sunseted" (The
Economist, 2009). That cycling
hack makes each and every health
care facility in a near-constant
process of technology selection,
evaluation, deployment, and replacement knowing ohsolescence
can trump at any time the processes. This practicality differentiates
Simpson's model from Effken's
model.
While the life cycle looks simple enough, its overlay with content, outcomes, nursing informatics intervention, and client factors
makes for a complexity not seen in
other health care executive decision making. These decisions form
inside a context that includes cultural, economic, social, and physical requirements. Adding an outcome orientation to the decision
allows cost, quality, safety, and
satisfaction layers to the discussion. The influence brought to
hear by nursing informatics layers
the decision again as content
structure and information flow
considerations impact the technology under consideration. Finally, the client factor overlays the
decision with considerations pertinent to client or discipline behaviors and characteristics. This
decision-making process mirrors
the one descrihed in the Informatics Research Organizing Model (Fffken, 2003).
The critical decisions required
to organize and prioritize patient
care against a complex backdrop
of quality and patient safety issues
hinges on the use of a wide range
of advanced technologies optimized for nursing. CNEs' respon-

^Q

sibility to evaluate, select, and

deploy these advanced technologies mandates either a nursingcentric deep knowledge of technology personally or access to that
knowledge via a direct reporting
structure. For CNEs without personal knowledge of technology
considerations, access to an individual with the knowledge and
the criticality of that knowledge to
advance the practice of nursing
underscores the need for a directreporting relationship with the
technology-infused individual.
Having a nurse informaticist on
staff, even in a direct-reporting
relationship, while a great help to
the CNE, does not remove from
the CNE the responsihility for
heing able to converse, debate,
and champion specific technologies and clinical information systems personally. Only that level of
knowledge can advance the requirements and needs of patient
care at the executive tahle when
technology decisions are made.
Two types of IT expertise
remain critical to CNFs as they
evaluate and select clinical information systems: process mapping,
or discovering how the actual
steps of nursing practice unfold
during patient care: and workflow
design, the mechanical arrangement of information, forms, and
triggers to capture and document
nursing practice. However mechanical the process of creating and
deploying workflows, they cannot
he created hy engineers and technologists who lack the hands-on
experience of delivering patient
care at the bedside. Vendor-resident engineers lack the site-specific and nursing practice-specific
knowledge required to add the
context of the lived experience to
the workflow creation process.
While evidence in standardization
of processes and practices is universal in application goal, what it
is not is nursing site specific,
requiring some modifications if
intended to achieve outcomes of
efficiencies for software acceptance hy end users.

In this study, the lack of standardization of nursing processes,

procedures, and operations greatly
complicated CNFs' health information technology (HIT)-related
decision making, especially in
patient care operations with a
high degree of automation. This
increasingly complex patient care
environment complicates a specific and central HIT-related responsihility that falls to the CNF: the
design and implementation of
overarching nursing workflows.
While some aspects of patient care
remain resistant to standardization, the vast majority of these
processes can he architected into
workflows in much the same way
that engineering has codified its
processes and procedures. This
engineering process cries out for
the knowledge that only CNFs and
nurse informaticists can provide
as seen in the Informatics Research Organizing Model by
Fffken. The criticality of these two
elements and their foundational
aspects make process mapping
and workflow design knowledge
essential to CNFs' evaluation and
selection of clinical information
systems (Simpson, 2012).
Study Purpose
The purpose of this study was
to identify and validate the gaps
existing between selected CNFs'
self-ascrihed lived experience information technology competencies and those laid out by AONF.
Technology competencies are not
just a part of CNFs' responsibilities; this understanding and its
related skills are critical to CNFs'
institutional and organizational
leadership. While a thorough understanding of technology's impact on patient care remains the
responsihility of nurse informaticians, CNFs will need to possess a
broad, working knowledge of IT to
safeguard patient care outcomes.
The nurse informatician's role is
to carry the vision of the CNF and
nursing leadership team forward
to application through technological innovations. Given the critical

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nature of nursing input f o the purchase, design, and ufilization of systems, baseline information abouf
needed nurse executive competencies could inform educators and
professional organizations about
the needs for nurse executive education in the IT and nursing informatics arena (Cerner, 2010). CNEs
may need more sophisticated
tecimology-relafed competencies
and expertise if they are to harness
the power of computing to demonstrate the quality and financialrelated advantages that nursing
brings to patient care.
Methodology
Before interviewing the CNEs
participating in this study, the
author submitted an application
for the conduct of research using
human subjects, which was approved by the American Sentinel
University Institutional Review
Board.
The study's sample population
was limited to members of the
Health Management Academy
(HMA), which includes senior
executives working at America's
leading integrated delivery systems
(IDSs). No eligible CNEft-oman IDS
using HIT from Cerner Corporation
was included in the research.
A Confidentiality Agreement,
which was signed by each informant prior to the interview, stipulated the coded data would not be
released to anyone and the identity of the informants would not be
revealed.
To protect the informants' privacy, the MP3 files of each interview were associated with an
alpha-numeric code. This code
traveled with the digital file when
it was sent to a professional service for transcription.
To better understand CNEs'
roles in the lived experience of
this complex decision making, the
invesfigator conducted ethnographic interviews of seven CNE members of the HMA. Membership in
fhe academy reflects fhe CNEs'
affiliation with the country's leading health systems and corpora-

tions. According to HMA (2012),

membership includes executives
from approximately 90 health systems that account for 55% of the
hospital net patient revenue in the
country, as well as more than 60
leading health care corporations.
The selected CNEs' professional
experience spanned 40 hospitals
in integrated health delivery networks with a total of 8,645 beds
located in seven states with an
aggregate employee population of
53,735.
Health Management Academy
members gain their industry-recognized status not solely from
their own body of work, but from
the reputation of the IDSs for
which they work as well. The
combination of HMA's executivelevel contributions to the health
care industry and their employers'
reputations as bastions of best
practices well qualified them for
their role as CNE informants. Each
of the member IDSs functioned as
a network of health care institutions, practices, and organizations
to provide or arrange to provide a
coordinated continuum of services to a defined population. Each
IDS agreed to be held clinically
and financially accountable for
the clinical outcomes and health
status of the population served.
IDSs encompass a community
and/or tertiary hospital, home
health care and hospice services,
primary and specialty outpatient
care and surgery, social services,
rehabilitation, preventive care,
health education and financing,
and usually using a form of managed care (Washington State Hospital Association, 2012).
An ethnographic approach to
CNE interviewing used iterative
questioning based on the tacit
information and inferences gleaned ftom the early interviews to
inform fhe later conversations,
making the cumulative findings
richer and more insightful than
knowledge gained from consistently asking a standard set of
questions to all CNE informants
(Spradley, 1979).

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As each interview was conducted, the author reviewed the

data collected ftom that interview
independent of the previously
gathered information. Once that
stand-alone analysis was complete, information gleaned from
each interview was compared to
the data stemming ftom previous
informant interviews. Common
and disparate themes were captured for analysis as well.
Research Reveals Common,
Disparate Themes
This research set out to answer a single pivotal question:
"What is the state of CNEs' HITrelated decision making compared
to the competencies outlined in
AGNE's recommended information technology competencies?"
A key part of analyzing the
data ftom informant interviews
centered on identifying cultural
themes, which defined any principle recurrent in a number of
domains, tacit or explicit (Spradley,
1979). These themes pinpointed
relationships among subsystems
of cultural meaning (Spradley,
1979). Data were scored, keywords were identified and trended, and topics and insights were
recorded, with each element being
used to reshape the subsequent
informant interview questions as
themes emerged. Eor example,
informants interviewed early in
the research might refer to a "computer physician," while informants speaking in later interviews
might refer to the same type of
individual as a "chief medical information officer." If the term
evolved in informant sessions, the
term "computer nurse" was replaced with "nurse informatician"
in later interviews.
Terminology related to nurses
represented a single area of evolution but other subject areas were
likely to shin as well. Eor example, early interviews probing
nurse executives' data use yielded
comments relative to data analysis. As the interview process progressed, mentions of fhe term

^Q

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"data analysis" dwindled with
more informant comments focusing on the use of "statistical data
mining and dashboards," an
advanced and more complex form
of data analysis.
During the CNEs' interviews,
an 8.5 x 11 inch sheet of ruled
paper was divided into two
columns. The first column consumed the left one-third of the
area with the remaining twothirds forming a second column.
Handwritten notes taken during
the interviews filled the second
colunm, leaving the left-hand column open for later analysis. These
handwritten notes served as a
backup resource to the electronic
recordings made of each CNE
interview.
After each interview, the notes
were read and the conversation
recalled in terms of a keyword
search. As keywords emerged
from the conversation, themes
came into view. Building on the
iterative nature of ethnographic
interviewing technique, each previous interview's ke}rwords and
themes were used to enrich subsequent interviews.
Once all seven interviews
were completed, each interview
was read completely to scan for
content. A second reading focused
on context. A third reading pinpointed keywords and emerging
themes, which were capttired on
sticky notes. The use of repositionable notes proved to be a key
element of the analysis process as
the review continued over several
days. KeyTvords and trends naturally led to trends and patterns of
comments.
To conclude the analysis, an
exercise that pinpointed evidence
of each AOI^-recommended information technology was conducted. This analysis showed the CNEs
demonstrated competencies in
each required area with one exception. As a group, the CNEs did not
demonstrate an awareness of societal and technological trends, issues,
and new developments as they
relate to nursing (AONE, 2011).

The Data
Using keywords and exemplars to expand on CNEs' themes
gave context to the data. Themes
and associated keywords are summarized in Tables 1 and 2. Themes
aligned with the keywords and
exemplar quotes from the seven
interviews are identified in Table 2.
Analysis
Interview data. Dvixing analysis
of the CNE interviews, five dominant and often interwoven themes
emerged: technology knowledge,
collaboration, HIT selection, execufive leadership, and standardization.
Each of these themes represented
overarching areas of concern for the
CNEs, who demonstrated competency in each of the AONE-recommended IT competencies with one
exception. That exception centered
on the CNEs' lack of awareness
about societal and technology
trends, issues, and new developments as they related to nursing.
Technology knowledge. CNEs'
lived experience, as expressed
through a series of seven ethnographic interviews, validated the
opinion voiced in the literature
that nurse executives lack the
foundational knowledge of technology needed to understand,
appreciate, and leverage rapidly
advancing technically based capabilities (Ball et al., 2010). The interviews indicated CNEs have
chosen to bypass amassing deep
technology knowledge, instead
relying on emotional intelligence
and dependencies on nurse informaticians and chief information
officers (CIOs), to exert nursing's
influence into HIT decision making. CNEs' lived experience aligned with the trend for nurse
leaders to look to nurse informaticians and clinical nurse specialists (CNSs) to provide the deep
technology knowledge they lack
(Westra & Delaney, 2008). Statements such as, "I depend on my
nurse informatician to give me the
information" flagged this dependence.

CNEs said they depended on

HIT vendors for their technology
education, which gave pause to
understanding the various tradeoffs vendors make in the system
design. Although the research did
not ask the question directly, it
can be inferred from the CNEs'
responses that their limited technology knowledge renders them
unable to champion the collection, analysis, and trending of
nursing data in a chief medical
officer (CMO)-dominated HIT discussion.
Is it possible the CNEs share
an overarching lack of ownership
and urgency around the acquisition of technology knowledge?
Despite their heavy dependence
on HIT vendors for their baseline
technology knowledge, only one
CNE expressed the need to make
technology learning a priority. The
CNEs agreed HIT was a priority
but not a top priority. They
viewed HIT as a tool for nurses in
their daily work and as a dashboard for management - not a
strategic decision-support tool for
their own use.
Collaboration. HTT-related collaboration specific to system evaluation and selection posed a
series of challenges for the CNEs.
Collectively, they expressed a prevailing scenario in which their
opinions are not heard and they
are unable to counter physician
viewpoints in CMO-driven decision making about HIT.
Leadership. CNEs pointed out
that when health care organizations employ CIOs from industries
outside the health care environment, a particular challenge arises. The CIOs' lack of clinical
expertise required the CNE and
the CMO to tightly align to lead
executive decision making toward
improving patient care rather than
opting for technology-based operational efficiency.
HIT selection. Collaboration
again entered into the CNEs' interviews when they spoke about
implementing and utilizing the
selected HIT systems. The logis-

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Table 1.
Trending of Themes from CNEs' Interviews
Theme
Technology knowledge

Interview
1

Interview
2

Collaboration
Executive leadership
Heaith information
technology selection

Interview
4

X
X

Interview
5
X

Interview
6
X

Interview
7

Frequency
of Mention
5

Standardization
Technology vision

Interview
3

3
X

Chailenges

Chief nursing
information officer

Chief information officer

Woricfiow

Leadership

Benchmarking

Nursing vision

Driving improvement

Working with the

board of directors

Technoiogy leadership

Technology priorities

Executive decision making

Technoiogy innovation

Return on investment

Communications

Metrics

Keys to success

tics and expense involved in staff

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

technology knowledge often hampered effective collaboration.

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

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remain resistant to standardization, the vast majority of these

processes can be architected into
workflows in much the same way
that engineering has codified its
processes and procedures.
Workflow alone is a strategic
key only if applied from the view
and vision of the nursing practice.
One informant said that to succeed in this role "you better have
implemented a system before."
Another informant mentioned the
care continuum as a prerequisite
to imderstanding of workflow and
role as system CNE.

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Table 2.
Themes and Associated Keywords from CNEs' Interviews
Theme

Keywords

Exemplar Quotes

Technology vision Vision, egalitarian

"[The CNE].. .needs the acumen and the expertise to be an egalitarian partner with
the physician and the medical staff."

Technology
knowledge

'There is simply not a vehicle here where people are schooled [in technoiogy] within
the organization."

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

"1 pulled the nursing team together and we trained 10,500 people. It cost more than
$2,000,000."
".. .there is more focus around understanding from a chief nursing officer's
perspective what it takes to deliver care to patients, what the organization's and
nursing's plans are for changing that care deiivery and then understanding the points
at which technology heips to assist in that process and facilitate the care."
"i'm not very technically competent. As 1 look at the things 1 would have done
ditferentiy, 1 wouid have recognized that 1 needed to be smarter [about technology]
sooner."

HIT selection

Challenges

Chief medical
information officer
(CMIO)

Bad processes,
misunderstandings,
physician-centered

"They strategize with me and we get what we need into the strategic pian but the
overarching power comes from the CMiO and what the doctors want."
"[1 am] the person most influential in impacting what our strategic future is using
technology for care, and for nurse and patient safety."
"One of the big challenges is that we have reaiiy bad processes within organizations.
We think implementation of a technology will fix a bad process."
"As a CNE, one of my struggies has been is that we're going to not just adopt
[technology]. 1 find 1 have to insert myself into groups who think they understand
what that process or system might need to look like when they reaiiy don't
understand it."

Chief nursing
Partnered
information officer

"We were abie to deveiop nursing informatics roles in this organization and deveiop
a career ladder that never existed. It wouldn't have existed if we hadn't partnered to
be to that..."

Chiet information
officer (CIO)

Chief information
officer change

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

Workflow

Common goals

'The way the work gets done is we have an agreed upon set of structures and
processes that are inciusive of nursing and anciiiary and physician leaders in the
organization. We have those discussions that we need to have around our common
goal which is caring for patients."

Leadership

Aggressive,
knowledge base,
politics

"You have to be forcefui, assertive, and sometimes reaiiy aggressive."

Benchmarking

Data-driven, payers

"You have to be data-driven. You have to be able to turn the data into information."

Nursing vision

Quaiity indicators,
quality improvement, engagement

"[My] vision of nursing... [is to be abie to] trace back quality indicators [to show] how
tiie nurses and the assistant personnei either helped or didn't help in the delivery of
that care."
"[The] CNE engages end users at ail levels to help understand the care and
processes that need to be delivered, in setting that vision for what they need and
then [accounting for] outside forces that end users may not truly understand. You
take the information from those who pay us and who set other expectations...and
then transfuse that into your organization by sharing that knowledge."
continued on next page

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Table 2. (continued)
Themes and Associated Keywords from CNEs' interviews
Theme
Health
information
technology
selection

Keywords
Implementation,
rollout, evaluation

Exemplar Quotes
"When 1 was at a freestanding hospital, 1 was very involved in the selection process."
"You've got to do more build. You've got to revise based on end users'
feedback...we are not ready to implement this."
"1, myself, do not spend time evaluating. 1 depend completely on my staff...to make
recommendations."

Driving
improvement

Inquisitive

"As a chief quality officer, 1 was very inquisitive about how to get data out of the
system and use it to drive improvement."

Collaboration

Data analysis,
governance,
physiciandominated, strategic
plan, CIO, strategic
plan, change
initiatives

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

Rollout

"It really took standing up to the board members...and saying, 'It's [the system] not
ready We will have potential patient safety issues if we roll this out.'"

Working with the

board ot directors

"We have a department of qualitative sciences...that helps us quantify issues. We

have an executive steering team of electronic health records, and we have an
information services governments council. He and 1 both sit on these councils."

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

Baseline

'They [multiple hospitals in the IDS] all want something different.. .The standards
and processes have to be the same."

Technology
leadership

Development,
learning, teaching,
informatics

"We've had two major deveiopments related to nursing and patient care, and the
creation of the patient engagement and education record that reflects the
multidiscipiinary aspects of...iearning across the continuum. We led the [predevelopment] conversations..."

Technoiogy
priorities

Triage, shared
priorities, continuum
of care, risk
stratification

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

Executive
decision making

Governance,
lobbying, emotional
intelligence

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

Technology
innovation

Engineering

"I'd like to go back to engineering school because 1 think it's a gap in my knowledge
as a nurse executive..."

Executive
leadership

Integrity, executive
secession, informal
dialogue, visibility

"My nurse informatician and 1 have mutual integrity. 1 completely trust that what the
people are reporting to me is accurate."

Keys to success

Relationships

"[CNEs] may have the knowledge and be superb...but where they fail is in creating
relationships that are effective...whether it's [with] finance...or...IT...or the person in
charge of facilities."

Standardization

Leading, informatics "Much of the work that I've been involved in [is] leading...around standardization of
infrastructure
practice and elimination of variation. [We are] pushing toward role clarity and
[seeing] how that gets expressed through the use of technology"
continued on next page

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Tabie 2. (continued)
Themes and Associated Keywords from CNEs' Interviews
Theme

Keywords

Exemplar Quotes

Return on
investment (ROI)

Cost of ownership,
achieving ROI

"The executive group and the execufive steering group of informatics look af
ROI...Thaf discussion happens both at fhe steering committee level and the senior
executive level."

Communications

Alignment, social
media, listening,
needs

"Our metrics are showing that at the VP, AVP, and director levels, we have very good
alignment in terms of fhe staff understanding the sfrafegic direction and the purpose
behind if. But we have a drastic falloff at the supervisor and below level."
"We're using social media [fo communicafe] more effectively wifh our employees.
We're now segmenting and tailoring our message, so that some of our
communication [about nursing and technology] can be global."

Metrics

Drowning, process
focus, outcome
focus

Gap Analysis

A gap analysis of the CNEs'

HIT-related competencies and
AONE's recommended IT competencies were conducted. The majority of CNEs self-described their
technology competencies as aligned with the AONE-recommended competencies. Six of the seven
CNEs lacked a critically important
recommended competency: being
able to demonstrate awareness of
societal and technological trends,
issues, and developments as they
relate to nursing. This overarching
deficiency, when coupled with
CNEs' lack of historical technology
knowledge, prevented CNEs from
fully engaging in HIT-related decision making. Table 3 shows the
CNEs' aligrmient with AONE's recommended information technology competencies.
Key Findings

The CNEs pointed out two

ways they are marginalized in the
evaluation and selection of clinical information systems. First, the
CNEs found their review responsibilities limited to the functional
level; that is, looking at the systems' features, rather than their
ability to advance nursing practice. Second, the CNEs explained
that a CMO-led physician contingent guided IT decision making.

"...nurses want to measure process rather fhan oufcome. Getting that change in
view pushed through fhe entire organization is critical. Process measures are greaf
but you've really gof to focus on outcomes and pushing that down to the unit level."

relegating CNEs to a "specifier/

recommender" role. CNEs found
themselves limited in their ability
to advocate effectively for technology needed to support nursing
practice during the evaluation and
selection of clinical information
systems. As a result, there is no
one at the executive decisionmaking table to advocate for the
needs of patient care during allimportant technology discussions
(Simpson, 2012).
Another point emerging for
CNEs is to use CNSs to stay
abreast of current research and
technology capabilities to support
CNE strategy for amassing technology knowledge in specific
fields of practice. This delegation
of HIT expertise significantly
expands the traditional role of the
CNS, which is to be competent in
the practice and the technologies
that support the domain of the
individual practice (Simpson &
Somers, 1991). Eor example, a cardiac CNS would also be responsible for the knowledge of EKC
monitors, echo, and other cardiac
devices used in conjunction with
cardiac care. The literature does
not describe such attributes
attached to the CNS nor does the
American Nurses Association.
However, this expectation, which
could direct the advancing role of
the CNS, could be the salvation of

CNSs' future as well because it

clearly differentiates their practice
ftom that of the nurse practitioner.
No one will know the machinespecific domain knowledge better
than the CNS who is focused and
mastered in the domain specific to
that patient condition.
Impact of Social Media

Although the CNEs demonstrated knowledge of technologyfueled innovation in nursing practice, two substantial gaps exist
between the CNEs' knowledge and
AONE's stated competency. The
first gap pertains to CNEs' awareness of societal and technological
trends, issues, and new developments as they relate to nursing, a
stated AONE competency. The
second disconnect occurs between CNEs' knowledge and the
AONE competency requiring proficient awareness of legal and ethical issues related to client data,
information, and confidentiality.
Nurses' use of social media lies at
the intersection of both these gaps.
In the lived experience, for
example, nurses routinely use
social media to communicate
nurse to nurse, nurse to patient,
and nvu-se to patient family, nurse
to physician, nurse to interdisciplinary team, etc. (Black, Light,
Paradise Black, & Thompson,
2013). It is troubling that this per-

NURSING ECONOMIC$/November-December 2013A/ol. 31/No. 6

Chief Nurse Executives Need Contemporary Informatics Competencies

SERIES
Table 3.
CNEs' Alignment with AONE's Recommended Technology Competencies
Competency

| CNE 11 CNE 21 CNE 31 CNE 41 CNE 51 CNE CNE

6
7

Demonstrate basic competency in email, common word processing,

spreadsheet and Internet programs.

Recognize the relevance of nursing data for improving practice.

Recognize the limitations of computer applications.

Use teiecommunications devices.

Utilize hospital database management, decision support, and expert

systems programs to access information and anaiyze data from
disparate sources for use in planning patient care processes and
systems.

Participate in change management processes and utility analysis.

Participate in the evaluation of information in practice settings.

Evaluate and revise patient care processes and systems.

Use computerized management systems to record administrative data

(billing data, quality assurance data, workload data, etc.).

Use applications for structured data entry (classification systems,

acuity level, etc.).

Recognize the utility of nursing involvement in planning, design,

choice, and implementation of information systems in the practice
environment.

Demonstrate awareness of societal and technological trends, issues,

and developments as they relate to nursing.

Demonstrate proficient awareness of legal and ethical issues related

to client data, information, and confidentiality.

Read and interpret benchmarking, financial, and occupancy data.

vasive communication violates

The Health Insurance Portability
and Accountability Act regulations (U.S. Department of Health
and Human Services, 1996) and
happens in the majority of facilities, even where CNEs have
"banned" social media. Recently,
researchers from the University of
Florida examined 15 days worth
of anonymous network utilization
records for 68 workstations located in the emergency department
(ED) of an academic medical center, comparing data from the ED
workstations to work index data
from the hospital's information
systems. Throughout the 15-day
study period, health care workers
spent 72.5 hours browsing Facebook, visiting the social networking site 9,369 times, and spending

12 minutes per hour on the site.

The amount of time spent on
Facebook, while significant, was
overshadowed by a second research finding: the time spent on
Facebook actually increased as
patient volume in the ED rose. As
a result, the researchers recommended future studies look at the
impact of using Facebook in break
rooms only and other non-work
parts of the hospital (Narsi, 2013).
This real-life example shows
CNEs cannot claim naivete when it
comes to the use of social media in
their facilities. In this example, the
lived experience does not support
CNEs' beliefs that they have been
successful in protecting the confidentiality of vitally important
health information. Policies that
eliminate or restrict the use of

NURSING ECONOMIC$/November-December 2013/Vol. 31/No. 6

social media in their facilities must

be equitable for compliance. Of
course, this creates another set of
dynamics
which
must be
addressed. Plus it speaks to the definition and knowledge of "cloud
computing" which lies at the core
of confidentiality and security
being that information on devices
used could possibly be uploaded to
the cloud. Unbeknown to the user
or CNE, these actions have the
potential to breach confidence and
privacy. If the knowledge of cloud
were present, each informant
would have equitably known information was uploaded ftom devices
and security breached.
This research concluded that
while the CNEs applied the majority of AONE-recommended inf^ormation technology competencies

GNE

Chief Nurse Executives Need Contemporary Informatics Competencies

SERIES
to their executive decision making,
most did not demonstrate an
awareness of societal and technological trends, issues, and new
developments as they relate to
nursing. Considering the CNEs
cited technology knowledge, or
more precisely, a lack of technology knowledge, as their top concern,
it was particularly disconcerting to
see they did not demonstrate an
awareness of technology direction
and trends related to nursing.
AGNE's list of IT competencies offered CNEs a point from
which to begin amassing baseline
technology knowledge. For example, the competencies, such as
being able to use email, word processing, spreadsheet and Internetbased programs, demonstrate only
baseline knowledge. Baseline competencies do not indicate the level
of knowledge and technical sophistication the CNEs needed to
evaluate, select, deploy, and utilize evidence-based HIT' in system
CNE roles of IDSs.
The AGNE baseline competencies do not address key aspects
of executive decision making relative to HIT, such as science-based
workflow, evidence-based architecture, and utility corporations.
The complexity of modem nursing
care requires a much deeper imderstanding of technology capabilities
and options if CNEs are to actively
participate and lead or influence
executive-level decisions related
to the evaluation, selection,
deployment, and utilization of HIT
in IDSs (Nurse.com, 2011). The
research did not attempt to gauge
the nursing informatics expertise
of nurses outside the CNE ranks.
Nor did the research examine
nurse informaticists knowledge of
CNEs employed in settings other
than multihospital network IDSs.
The study did not address the frequency or appropriateness of
CNEs' decisions to delegate decision making, responsibility, and/or
accountability to the integrated delivery systems' IT organization.
Each of the CNEs participating
in the research demonstrated com-

^ ^

petency in and applied the majority of the AGNE capabilities to tJieir

IT-related decision making. However, those competencies corresponded to older, more established
types of technology, such as email,
office productivity software, and
business analysis tools. The gaps in
CNEs' technology-related knowledge, as identified via ethnographic interviews, pertained to the
AGNE competencies requiring: (a)
an awareness of societal and technological trends, issues, and new
developments as they relate to
nursing; and (b) proficient awareness of the legal and ethical issues
related to client data, information,
and confidentiality. It is imperative
CNEs keep their technology-related
competencies current to be able to
anticipate how new technologies,
such as social media, can be used
to strengthen patient care and to
evaluate if these same technologies
hold any potential for harm to
patients.
Recommendations for Future
Research
Eurther research is needed to
better understand how CNEs make
decisions about the evaluation,
selection, deployment, and utilization of HIT" across the continuum of patient care settings. Emotional intelligence ranks high on
the scale for skills used today in
the life cycle of HIT, but that will
not suffice for knowledge in ability to advocate for patient care. Eor
example, hospitals and health
care organizations not affiliated
with an IDS were omitted from
this research as were for-profit
hospitals. It would be interesting
to see if the same issues that affect
HIT-related decision making in
IDSs have relevance in for-profit
institutions, smaller health care
facilities, and stand-alone hospitals. Additionally, follow-up research could examine the role
structured committees of corporate-based CNEs play in technology education and life cycle. This
could be the differentiating competency from operational site-spe-

cific CNEs and clarifying the role

of the corporate CNE of IDSs.
Additionally, studies centering on
CNEs' contribution to the automation of key nursing processes, such
as the development of nursing science-based workflows, would be
useful. Another pressing need revolves around the dissemination
of new knowledge in computer
science, information science, and
nursing science to CNEs at health
care organizations of all sizes.
Civen the exhaustive patient
care and operational requirements
placed on the system-wide CNE,
one can debate the value of managing skill sets versus becoming a
technical content expert. Thanks
to the powerful effect of Moore's
law on technologies of all types,
nursing informatics quickly becomes a core competency for CNEs
in organizations of all sizes. As the
CNE role expands to take on more
organizational and financial responsibility for patient outcomes,
HIT becomes a key clinical and
operational enabler of quality patient care across all settings. As
such, technology competencies
specific to the CNE role will need
to be studied, not only from a
functional perspective as it is
today, but from a strategic perspective as well. Eocusing on how
CNEs leverage HIT to meet their
organizations' business goals should
be a research imperative.
Conclusions
Despite the fact that few traditional graduate programs in nursing and business teach these fundamental deep technology-related
competencies, CNEs sit at the
executive table during technology
evaluations and routinely find
themselves ill prepared to debate
with their physician counterparts
the functions of the clinical information systems. Specifically, CNEs
must view these advanced technologies from a strategic and operational perspective that ne-tunes
the systems' architectural design,
workflow, and processes for deployment in the patient care envi-

NURSiNG ECONOiVIICS/November-December 2013/Vol. 31/No. 6

Chief Nurse Executives Need Contemporary Informatics Competencies

CNE
SERIES

NEs sit at the executive table during technology

evaluations and routinely find themselves ill
prepared to debate with their physician counterparts
the functions of the clinical information systems.
ronment. Additionally, CNEs need
to go "toe to toe" in physician-led
technology discussions. Simply
put, CNEs must function as the
"voice of patient care" in these
debates because there is no one
else at the table who will advocate
for patients. As a result, the largest
user population in the health care
organization - nmrses - find their
requirements falling to a secondary position behind the requirements delineated and championed by physicians.
This research asked a single,
pivotal question: "What is the
state of CNEs' HIT-related decision making compared to the competencies outlined in AONE's recommended information technology competencies?" The answer to
that question was two-fold. CNEs
demonstrated competency in and
applied the majority of the AONE
competencies to their decisionmaking process related to the evaluation, selection, deployment,
and utilization of HIT. However,
the majority of the CNEs did not
demonstrate a competency specific to AONE's call to "demonstrate
an awareness of societal and technological trends, issues and new
developments as they relate to
nursing" (AONE, 2011, p. 10).
In recognition of the critical
need for CNEs at hospitals of all
sizes to acquire and maintain current knowledge of HIT, it is time
for the profession to enlist the
help of academic leaders and regulators in the effort to build a
learning infrastructure capable of
building a wide and deep HIT
competency for CNEs in America.

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

American Organization of Nurse Executives (AONE). (2011). The AONE

nurse executive competencies, information management and technology.
Retrieved from http://www.aone.org/
resources/leadership%20tools/PDFs/
AONE^NEC.pdf
Ball, M.J. Douglas, ).V., Hinton Walker, P.,
DuLong, D., Gugerty, B., Hannah, B.,
... Troseth, M.R. (Eds). (201). Nursing
informatics - Where technology and
caring meet (4th ed.). New York, NY:
Springer.
Black, E., Light, )., Paradise Black, N., &
Thompson, L. (2013). Offline social
network use by health care providers
in a high traffic patient care environment, lournal of Medical Internet
Research, 25(5), e94. doi:10.2196/
jmir.2421
Cerner Corporation. (2010). Informatics
and the executive nurse leader Findings from Cerner Nursing Forum
Invitational. AUentown, N): Author.

NURSING ECONOMIC$/November-December 2013/Vol. 31/No. 6

Effken, J.A. (2003). An organizing framework for nursing informatics research.

CIN: Computers, Informatics, Nursing, 23(6), 316-323. Retrieved from
http://at.phcc.edu/NUR2820/PDFs/
MOD2/Nursing_Infonnatics.pdf
Graves, ).R., & Corcoran, S. (1989). An
overview of nursing informatics.
Image: Journal of Nursing Scholarship, 21, 227-231. Retrieved from
http://www.csulb.edu/~dkumrow/
ov.html
Health Management Academy (HMA).
(2012). Ahout us. Retrieved from
http://www.hmacademy.com/about
us.html
Narsi, S. (2013, May 22). Are your hospital's employees spending too much
time on Facebook? Healthcare
Business and Technology. Retrieved
from http://www.healthcarebusiness
tech.com/healthcare-workers-on-facebook/
Nurse.com. (2011, November 1). Survey
examines roles of CNOs in IT decisions. Retrieved from http://news.
nurse.com/article/20111115/
NATIONAL02/111280003/1003#.U1W
h6Chh420
Simpson, R.L., & Somers, I.B. (1991). The
role of the clinical nurse specialist in
information
systems
selection.
Clinical Nurse Specialist, 5(3), 159163.
Simpson, R.L. (2012). State of contemporary informatics competencies for
chief nurse executives. Capstone
Requirements for Doctorate of Nursing Practice, American Sentinel
University.
Spradley, J.P. (1979). The ethnographic
interview. Belmont, CA: Wadsworth
Publishing Go.
The Economist. (2009, March 23). Idea:
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U.S. Department of Health and Human
Services. (1996). Summary of the
HIPAA privacy rule. Retrieved from
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a/understanding/summary/
Washington State Hospital Association.
(2012). Board manual: Definition of
integrated delivery system. Retrieved
from http://www.wsha.org/files/62/
Gov_Board_Manual_integrated.pdf
Westra, B.L., & Delaney, C.W. (2008).
Informatics: Competencies for nursing and healthcare leaders. AMIA
Annual Symposium Proceedings.
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nlm.nih.gov/pmc/issues/1777327
ADDITIONAL READING

American Nurses Association (ANA).

(2011). Nurses' involvement with the
EHR: Advocating patient safety.
Retrieved from http://www.nursing
world.org/draft-position-nursesinvolvement-ehr

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