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Nursing Informatics and its Application to Community Health Nursing 1

Ball (2000) stated that 'The strength of nursing profession depends on its
ability to take advantage of the best that technology can offer'. Therefore,
preparing nurses to face the information challenges of the future requires a solid
grounding in information sciences. Simply teaching computer applications in
nursing will provide nurses with the skills to critically appraise their information
needs and utilization of gathering information in patient care (Romano, 1985;
Hannah et al., 1994). Providers of health care as nurses depend on accurate
information in order to accommodate future changes at the lowest possible costs.

The delivery of community health nursing care is an information intensive

industry requiring support systems to collect and analyze data. Nurses recognize
from the beginning of their education that, like the basic sciences, information
science is a supportive discipline for nursing (Grier, 1999). McGuire (2001)
expected that the future of the nursing informatics and telehealth is bright and
promising. Innovations in nursing science combined with advances in information
and communication technologies will provide community health nurse and
planners with tools that will increase their contact with the communities they

As the community health-nursing mission is to improve the health of

communities and populations so the community nursing professionals focus on
(a) preventing, identifying, investigating, and eliminating community health
problems and hazards; (b) assuring that the community has access to competent
personal health care services; and (c) educating and empowering clients to adapt
more healthy behaviors (Landy and Janes, 2001).

Community health nursing incorporates six basic elements: (1) promotion

of healthful living, (2) prevention of health problems, (3) treatment of disorders,
(4) rehabilitation, (5) evaluation, and (6) research. Professional nurses are an
integral part of community health practice. Nurse’s roles and activities are varied
that it is impossible to describe the “typical” community health nurse, their duties
range from examining infants in a well-baby clinic or teaching elderly stroke
victims in their homes, to carrying out epidemiologic research or engaging in
health policy analysis and decision-making.

Community-based nursing refers to both the setting and the practice of the
nursing role. Nursing care that occurs in a setting other than acute care; also
referred to as community health nursing. Population-and community-focused care
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referred to interventions aimed at health promotion and disease prevention that

shape a community’s overall health status. Public health nursing is population-
focused, community-oriented nursing practice and the dominant responsibility is
to the care of the larger community.

In Egypt, much work remains to be done to make nursing informatics a

reality. Through hardware, software and personnel; a multi-facet learning
program that utilizes distance learning, interactive cable TV, and the internet to
connect learning environments to homes, place of work, and the community at
large, and by establishing-updating community nursing resources web sites. The
graduate level nursing informatics educational environment must continue to
strive to become a forum where educator and student meet in an expanded
capacity made possible by an increase in the integration of computer literacy
within the nursing informatics curricula. Using innovative teaching mediums such
as the virtual classroom, distance and continuing education in nursing informatics
can be a reality and should be actively promoted.

Nursing Informatics Definitions

Informatics is derived from the French term informatique, as an area of
nursing specialization; nurses with expertise in informatics are often referred to as
nursing informaticians. Graves and Corcoran (1989) and Nagelkerk (1994)
defined 'nursing informatics as the use of nursing science, computer science and
information science in nursing processes for patient/client care, which provides
data, information and knowledge to the individual and the organization in a way
as to change and influence society and achieve health for all.

The specialty of nursing informatics offers strategies for using information

and communications technologies to collect individual-and community-related
data, store and retrieve this data for clinical decision making (through the process
of converting raw data into nursing information and ultimately into nursing
knowledge), and provide in-depth analysis of data for increasing productive
service delivery while providing quality nursing care.

In addition, Saba and McCormick (1996) explain that nursing informatics

is a branch of informatics particularly concerned with nurse's use of computer
technology and the management of information that facilities nursing practice and
enhances nursing knowledge. Nursing informatics is defined by Simpson (1993)
as “the legitimate access to and use of data, information, and knowledge to
standardize documentation, improve communication, support the decision-
making process, develop and disseminate knowledge, enhance the quality,
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effectiveness and efficiency of health care and empower clients to make health
care choices which contribute to the advancing of the community health nursing
science. Nursing informatics can be accomplished using information structures,
information processes, and information technology (McGuire, 2001).

American Nurse Association (2001) indicated nursing informatics as a specialty

♦ Integrates nursing science, computer science, and information
science to manage and communicate data, information, and
knowledge in nursing practice.
♦ Facilitates the integration of data, information, and knowledge to
support patients, nurses and other providers in their decision-making
in all roles and settings.
♦ Accomplishes using the information structures and information

The goal of nursing informatics is to “optimize information management

and communication through the use of information technology and support nurses
as they improve the health of populations, communities, families, and individuals
(Bargstadt, 1998). Simpson (1993) added that advances in information technology
have created new roles for nurses, and emphasized the need for all nurses to
become more knowledgeable about health information concepts and technology
that designed to manage and process information.

Information science encompasses the analysis of information structure,

properties, and organization, information storage and retrieval, information
system and database architecture and design, library science, projects’
management, and organizational issues such as change management and business
process reengineering.

Evolution of Nursing Informatics (American Nurse Association, 2001)

•1992 nursing informatics (NI) first recognized as specialty by the
American Nurses Association (ANA)
• 1994 scope of practice for nursing informatics
• 1995 standards of practice for nursing informatics
• 2001 revised scope and standards of practice of nursing practice
• 5,000 RN’s identify themselves as nurse informaticsit
• 500 RN’s board certified as nurse informaticist
Nursing Informatics and its Application to Community Health Nursing 4

Foundation of Nursing Information

The foundation of nursing information based on the concepts of data,
information, and knowledge as building blocks of nursing communication.
Because information and knowledge are essential for nurses when interpreting
data and making decisions, it is important to know the differences between these
three concepts. Prather (2000) found that data generated during the delivery of
actual patient care are rich in clinical detail. Data are generally associated with
each clinical data element and continuous parameters such as test results and
significant findings are present. Data sets that reflect real-world patients’
experiences and responses can provide valuable insights for clinical knowledge

Data are discrete observations that are not interpreted, organized, or structured.

Examples of Data are age,

blood pressure, weight, number
of workload units of services

Data mining technology was defined by Berry and Linhoff (1997) as “the
semiautomatic exploration and analysis of large quantities of data in order to
discover meaningful patterns and rules.” The identification of meaningful patterns
in data has always been an integral part of scientific discovery, since patterns are
necessary for the construction of scientific hypotheses and causal models
(Brossette, 1998). Data mining as a method for data analysis in nursing research
can contribute to the discovery of causal factors and demonstrate outcome
effectiveness. It is a technology that can turn massive amounts of raw data into
useful information that can improve clinical nursing practice.

Information is data that has been interpreted, organized, or structured to

provide meaning to the data.
Examples of Information;
● Prevalence of clients/ health center by this month
compared by the last year.

● Percentage distributions of workload of

immunization clinic by services and intervention by
activity category by nurses by month.

Information is key to effective decision-making and integral to quality

nursing practice. Much of what nurses do involves information–from assessing
the health care needs of clients, to developing care plans, to communicating client
Nursing Informatics and its Application to Community Health Nursing 5

information to other health professionals, to analyzing staffing and budget

reports. In fact, nurses work in information intensive environment. Advances in
information technology (computers and software) over the last 25 years have
created significant opportunities for nurses to be aware of current information
when making decisions (Canadian Nurses Association, 2001).

Knowledge is the synthesis of information to identify relationships that provide

further insight to an issue or subject area.

Examples of Knowledge
● Referral systems protocols
● Care plans for specific health problem
●Relationship between different nursing
interventions and client outcomes.

While the concepts of data, information, and knowledge are different, the
concepts as a whole are typically referred to generically as information. All the
three concepts are stored in computers and software programs be developed to
assist in the interpretation of the data and the development of nursing knowledge.

Lyman and Varian (2000) stated that the world’s total annual production of
information amounts to approximate Mega Bytes (MB) for each man, woman,
child on earth, and that number is expected to double every year for foreseeable
future. Ninety-three percent of the information that is currently produced each
year is now stored in digital. Increased computing power, decreasing costs, and
advances in data capture and storage technologies have resulted in massive data
sets in many disciplines, including nursing.

Timothy (2001) who is an informatics specialist at Communicable Disease

Control says that even though the field is often associated with applications and
programs, packages, or tools, it actually encompasses a larger process of what he
calls the “data progression pathway.” This pathway represents the process of
moving from data to information, information to knowledge, knowledge to
decisions, and decisions to outcomes.

Knowledge-Based Services
Knowledge networks not only allow scholars and scientists to work
together more effectively, across distance, but also offer completely new
approaches to investigating and analyzing concepts and phenomena. Knowledge
Discovery in Databases (KDD) is a process that includes data selection, data
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preprocessing, data transformation, data mining, interpretation, and evaluation

(Wright (1998). Knowledge-based systems are recent but will expand with the
spread of informatics and telemetric supports. These systems provide expert
advice on health-scientific issues. For example; diagnostic support, suggest
additional tests or propose a treatment. Such systems often include a combination
of literature data (from journals articles and textbooks) and factual data (Thiru et
al, 2003).

Wright (1998) mentioned that knowledge-based information services consist of

systems, resources, and services to:

• help health care professionals acquire and maintain the knowledge and
skills they need to care for clients/patients
• support clinical and management decision-making (computerized decision
support systems should be developed for nurses and decision makers).
• support performance improvement
• satisfy research-related needs
• educate clients/patients and families

Benefits of Informatics Application

All health care organizations use information technology in one form or
another. Discussion has been for a long time as to what are the direct and indirect
benefits of information technology in medical/nursing or health care. The ability
to maximize information technology benefits and the associated return on
investment is becoming an integral part of the executive management information
technology skill set. Thiru, Simon, Sullivan, Brew, and Cooper (2003) added that
there are three categories of potential benefits that can be identified in relation to
the quantitative, qualitative, and strategic benefits use of computers and electronic
data processing in the health care sector. These are;

• Quantitative benefits. For example the use of electronic data

interchange technology to transmit surveillance data in real time or to
electronically submit medical claims, which results in time and labor cost

• Qualitative benefits. These benefits measured only in terms of the

impact of technology on the performance of health systems and their
efficiency. Accurate data, fast transfer of data, wider accessibility, and
linking of data elements are benefits that are not easily quantified.
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• Strategic benefits. Data collection and analysis bring immediate benefit

to an organization, but in the long term, these data constitute the basis for
health research and strategic planning.

In addition, Zielstorff (1998) stated that clinical information systems in

current health care environment, including long-term care, provide five functions.
These five functions include providing the legal record of care, supporting
clinical decision-making, capturing costs for financial purposes, accumulating a
database for administrative queries assurance/research, and supporting data
exchange between systems.

Benefits of Nursing Informatics

For Community Health Nursing
The combination of nursing and information systems management
produces several benefits for nurses practicing in the community. These benefits
include; management of client-level data, the use of standardized nursing
language, provision of care in an efficient and productive manner and the use of
information systems for research, health promotion, and illness prevention in the
community. These benefits are explored as follow;

I. Standardized Nursing Language

Concepts that are common across disciplines and across the continuum of
health services need to be structured and defined in a standard or common way.
This means that not only do nurses need standards for common concepts, but
nurses also need standards that are compatible across information systems that
can be used by different health professionals, across the continuum of health
service delivery, and within and across provinces and territories.

The International Organization for Standardization (IOS, 2004) defines

standards as; documented agreements containing technical specifications or other
precise criteria to be used consistently as rules, guidelines, or definitions of
characteristics to ensure that materials, products, process, and services are fit for
their purpose. Today, there are many different types of health information
standards including technical standards for computer hardware and software,
data standards to enable the development of quality and comparable information,
and information exchanging standards or protocols to facilitate the sharing of

Lundy and Janes (2001) mentioned that the development and

implementation of computer health information systems or automated health
information systems requires some form of structured vocabulary or terminology
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with common definitions for common terms to enable the effective management
and processing of data. Over the last decade, there has been significant progress
in development of health information concepts and standards.

At the international level, the International Council of Nurses (ICN) is

leading the development of universal language for defining and describing
nursing practice – the International Classification for Nursing Practice
(ICNP). ICNP provides nursing with a common framework that facilitates cross
mapping of existing nursing vocabularies and classification to enable comparison
of nursing data across organizations, health sectors, and countries. The alpha
version of ICNP was released in 1996 for review and feedback and significantly
revised beta version was released in 1999 and has been translated into more than
20 languages (ICN, 1999).

In Canada, Nursing Components Working Group has continued to build on

the work started in early 1990s to develop a standardized minimum data set for
nursing. There is now a national consensus that critical nursing care data elements
include client status, nursing interventions and client outcomes. While nurses
have reached a consensus on the kinds of data elements required, they now must
begin moving these concepts to implementation by ensuring that they are
included within information systems. This involves nurses assessing the health
needs of clients and collecting client-specific interventions in a standardized way
in order to gain a better understanding of the impact of those interventions on
client outcomes (Simon, 2003).

II. Classification of Client-level Data

International Classification of Diseases and Related Health Problems;

Canadian Classification for Health interventions also enhanced the new
version of the International statistical Classification of Diseases and Related
Health Problems. Nurses provided input to the development of Canadian
International Health Intervention plans to maintain both classifications and utility
to the field nurses should play a key role in ensuring that changes and
enhancements to the classification are relevant to nurses information needs
(Canadian Nurses Association, 2000).

Classification standard for client-nursing data

The classification contains a comprehensive list of nursing diagnostic,
therapeutic, support and nursing interventions, allowing for the standard
collection of health interventions, regardless of the service provided or service
setting (NANDA, American Nurse Association, 2004).
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III. Identification of Client Outcomes

With regard to the identification of client outcomes that are relevant to the
work that nurses do, the Ontario Nursing and Health Outcomes Project (1997) has
done significant work in identifying client outcomes that are sensitive to nursing.
The client outcomes that have been identified include; functional status, self-care,
symptom control, and client satisfaction with nursing care. Plans include
developing pilot projects in acute, long-term and community care (Canadian
Nurses Association, 2000).

IV. Client Information Management

The management of client-level data provides the community health nurse
with an accurate assessment of clients and their caregivers’ situation for the
purpose of planning, implementing, and evaluating care. Information systems
allow for the organization of data collected during an individual’s admission to a
community health care facility. This information can be stored for future retrieval,
and the aggregation of this information can be analyzed for the benefit of the
community (Wright, 1998).

V. Efficiency and Time Benefits

The use of nursing information systems can provide community health
nurse managers and staff with efficiencies in productivity. The collection of
client-and caregiver-centered information is often a time-consuming endeavor
and uses financial and personnel resources. Savings in time are often
demonstrated by the use of computer systems for communicating information
over distance, over time, and to multiple users of the data and clinical information
can be shared with several users at the same time (Smith, 2000).

VI. Privacy, confidentiality and security of health information

With rapid advances in information technology, nurses need basic
knowledge of concepts relating to privacy, confidentiality, and security of health
information, especially if they are involved in the development of health
information systems. The United Kingdom (UK) Data Protection Act of 1998 has
presented challenges for those engaged in epidemiological research using patient
data. However, the precise meaning of this Act, and others that flow from
European Human Rights Legislation, is still very much open to interpretation
(Tom and Frank, 2004).
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Privacy: It is the right of an individual to determine, when, how and to what

extent they will share information about themselves with others (Tom and Frank,

Confidentiality: It refers to the obligations of one person to protect the personal

information of another person. The protection of the confidentiality of personal
health information has always been a fundamental principle of health care system
(Tom and Frank, 2004).

In addition, Canadian Nurses Association (1997) added that the code of

ethics for registered nurses determined that nurses safe guard the trust of the
clients that health information linked with the context of a professional
relationship and can be shared outside the health care team only with the client’s
permission or as legally needs.

Security; it refers to the procedures and technologies that are used to restrict
access to, and maintain the integrity of health information. McGuire (2001) stated
that the establishment of various standards related to privacy, confidentiality and
security have evolved over the years. Finally, in implementing operational
guidelines, various procedures and security systems are used; each is based on
specific technical standards.

McGuire (2001) mentioned that there are too many technical standards
related to information systems security to be done, and explains some examples
that are relevant to nurses such as:
● Identification (e.g., passwords) and authentication (e.g., digital signature) of
users of health information.
● Provision of audit trails or records of access activity relating to health
● Protection from unauthorized access (e.g., firewall) to health information.

In 1981, the Council of Europe enacted its Convention for the Protection of
Individuals with regard to automatic processing of personal data. Data should be:

1. Obtained and processed fairly and lawfully.

2. Stored for specified and legitimate purposes and not used in a way
incompatible with those purposes.
3. Adequate, relevant, and not excessive in relation to the purposes
for which they are stored.
4. Accurate and, where necessary, kept up to date.
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5. Preserved in a form, which permits identification of the data

subjects for no longer than is required for the purpose for which
those data are stored.

With the atmosphere of uncertainty about data protection, Tom and Frank
(2004) stated that there is a threat to informatics research in primary care and it
should serve as an extra motivation for community nurses to develop effective
ethical processes for managing information that justify the trust of the
community. Uncertainty is a challenge, but a positive response to that challenge
will bring a stronger system for managing individual data in health researches.

Code of ethics and legality for Electronic Health (e-health) were developed
by Mediterranean Region Countries through the World health Organization
(2004) about the following topics: definitions, confidentiality, honesty, quality,
sustainability, privacy, sharing, and accountability of the electronic health
(Appendix ◄1► Arabic Version).

In the Eastern Mediterranean region, nurses have also laid some important
groundwork for cross border cooperation in regulation. There is reported to be a
wide variation in regulatory laws, policies and practices governing nursing in this
region, and the goals of current activity include one relating to inter-linked or
integrated systems for registration and licensing. Standards for nursing education
and prototype criteria have been developed, with support from both ICN and

Sample Application Model of Nursing Informatics

McCloskey and Bulechek (2002) provide a framework of a theoretical
model from which to expand nursing knowledge and conduct research on nursing
intervention and outcomes. This application sample consists of the following
● Analysis of reports generated from a spreadsheet software application
● Review of outcomes indicators using a decision-support software application
● Recording of workload and interventions as a by-product of electronic charting

Clinical Practice
● Recording of client assessment data in an electronic health record
● Recording of workload and interventions as a by-product of electronic charting
Nursing Informatics and its Application to Community Health Nursing 12

● Distance learning/teaching via the internet
● Recording of workload and interventions as a by-product of electronic charting

● Evaluation of nurse-sensitive outcomes measures using a standard minimum
data set
● Use of knowledge bases via the internet
● Recording of workload and interventions as a by-product of electronic charting

Therefore, Nursing Informatics can be viewed through a number of

different lenses. The most common ones include the standard areas of nursing:
nursing practice, nursing education, nursing research, and nursing administration.
Nursing Informatics can also be viewed through the sociological lens of
hegemony, empowerment, dialogue, synthesis, and creative expression.

Physical Infrastructure/Architecture
The infrastructure consists of both the telecommunication media used to
actually transmitting information—such as phone lines, fiber-optic cables,
satellites, and microwave systems—and the media used as input/output devices—
such as telephones, video cameras, monitors, fax machines, and computers—that
are needed to send and receive data. One set of media cannot be used without the
other in informatics but various combinations of use are essential.

Communication systems include small citizens band (CB), high-frequency

(HF), very-high-frequency (VHF), and ultra-high-frequency (UHF) radio
systems; a public switched telephone network; data and private networks; public
broadcasting networks; and satellites—including low and medium earth-orbiting
satellites—with variable capabilities and geographic coverage. The core network
links telecommunication service providers and international gateway exchanges
and provides all the trunk transmission, switching, and other network capabilities.
Other communication capabilities such as mobile telecommunication systems,
intelligent network products, and integration of overlay networks (such as an
integrated services digital network and data networks) are being added (Simpson,
The infrastructure consists of a combination of both land-based and air-
based communication networks and systems, each offering various bandwidths—
from a single telephone line using copper wire, which is adequate for voice,
facsimile, and text-based data transmission, to broadcast television cable and
Nursing Informatics and its Application to Community Health Nursing 13

satellite networks. Convergence of these technologies makes it possible to

combine audio, data, and video communication by means of personal computer
access to telecommunication networks that include access to high-speed
computers with CD-ROM drives and local-call access to an Internet service
provider in order to take advantage of what the Internet, the World Wide Web,
and educational CDs have to offer (Salazar-Riera, 2002).

The infrastructure required for high-quality information and health service

delivery is far from universally available or reliable. It is extremely costly in
sparsely populated or distant areas, although ultimately its absence may be more
costly. It is needed to prepare communities now to exercise their rights, be
informed and have their preferences considered when they need health care. Also
the administrators of health services have to consider the financial cost of health
care in rural and remote areas, and they must encourage professional excellence
by providing continuing education to nurses and other health workers so that they
can adequately work with informed consumers and deliver care in accordance
with the best available practice guidelines (Canadian Institute for Health
Informatics, 1997).

Governments must have the will and the fiscal objectives to resource the
necessary telecommunication infrastructure for their citizens irrespective of
location. In addition, the information and telecommunication technology
infrastructure needs to be accommodated with many and varied applications
which required for the support of rural and remote communities. The
disadvantaged in rural and remote areas can benefit significantly from these
technologies. This is feasible only when the technologies can be fully utilized for
a variety of purposes.

Nursing informatics system needs to develop people who have the

necessary computer and information literacy skills to benefit from using
technologies. Professional and regulatory bodies also need to devise and
implement competencies and standards to ensure adequate preparation of nurses
before they embark on “adventurous” practice in nursing informatics and its
application in community health nursing (Yasnoff, et al., 2001).

Sparks (1993) emphasized the necessity of introducing nursing staff to the

three major international electronic networks (Internet, Fidonet, and Bitnet) that
will enhance their information access. These electronic highways link academic,
research, governmental and commercial organizations. These systems provide
access to multiple computer bulletin boards that provide information and
networking. Electronic mail provides instantaneous transmittal of messages to
Nursing Informatics and its Application to Community Health Nursing 14

and from nurses. Also providing library materials on client care units is another
issue to encourage the development of computer skills. Nursing journals, such as
Computer in Nursing, basic computer books, periodicals, or manuals can provide
basic, useful news for nursing staff.

Computer Applications in Community

Health nursing
Computer technology has made it possible not only to explore health care
dilemmas, but has opened up the universe as a laboratory for possible answers
(Cox, Harsanyi and Dean, 1987). Computer technology gives nurses the tools to
develop and implement systems. Informatics addresses such issues, as the impact
computerization will have on data collection, analysis, information dissemination,
communication, and even on the understanding of public health issues. The use of
the internet is an example of how informatics differs from computer science.
Internet technology is a powerful tool, but informatics specialists must be
employed in deciding how this tool should be used to better meet the goals of
public health (Yasnoff, et al., 2001).

A prerequisite to the widespread use of powerful new information

applications is the pervasive deployment throughout the community health system
of modern computers that interconnected through a standards-based network. In
recent years, substantial progress has been made toward this goal. Beginning with
the Information Network for Public Health Officials (INPHO) and continuing with
the Health Alert Network, CDC has made systematic efforts to improve the
nation’s public health telecommunications, information, and distance-learning
infrastructure by promoting internet connectivity and other information
infrastructure for nation and local community health workers (Richard, 1998).

Offering basic computer classes that assist nurses to acquire keyboarding

and word processing skills, and basic computer terminology provides a base for
further expertise. Understanding basic computer terms such as personal
computers, word processing, mainframe equipment, software and hardware
applications, modems, and databases can become an important foundation on
which expertise and skills are built (Todd, 1998).

The use of computer application such as e-mail, databases, and

spreadsheets can provide community health nurses with tools to increase their
productivity and knowledge. E-mails can be used to coordinate communication
among health care providers in the community. Databases have been used to
collect and organize massive amounts of client-and community related data to be
used in research and analysis. Spreadsheets can be used to perform complicated
Nursing Informatics and its Application to Community Health Nursing 15

mathematical or statistical calculations that support clinical decision making

(McPeck, 2001).

Decision support and expert systems are beginning to emerge in nursing

and are useful to clinicians, educators, and administrators. Decision support
systems can prompt and help make clinical decisions by providing typical data
and responses to a situation. Examples of decision support systems include
staffing and expert systems. Nurse selects a clinical problem, types this into the
computer with a client’s presenting symptoms, and laboratory data, and then a
print out shows the probability of the client having this problem, what data may
still need to be collected, treatment possibilities, and prognosis. Expert systems
are based on a group of content specialists’ decision-making processes about a
specific clinical problem (Sparks, 1993).

Preparing Nurses for Computerization

As the use of computer technology and information science increases in nursing
practice, education, and administration, so will nurses’ need to be skilled and
knowledgeable in the use of information technology. Principally, computer
competence is a nurse’s ability to effectively use the computer systems available
and adapt his or her use to a variety of settings (Ellis, 2002).

How can nurses prepare themselves for computerization at work, and how
can health care organizations facilitate this transition? This is a critical question
when the majority of nurses in Egypt has had no experience with computers or
feels uncomfortable and intimidated by them. The focus now is on the computer’s
need for input data. If we are serious about designing computers to support nurses
in the care of clients, more effort needs to be made to change how these data are
being collected and accessed. This change should focus on the nurse’s need to
collect and retrieve data as quickly and easily as possible. It also fosters
communication among the members of the healthcare team.

Computer-based courses typically involve simulated cases, slide

presentation, real-time discussions, online chat, and exercises. Streaming
technologies enable the use of video and audio over the Web to create a more
classroom-like, e-learning experience (McPeck, 2001).
Nursing Informatics and its Application to Community Health Nursing 16

Sample Model for Designing Educational Programs for

Computerization among Community Health Nurses

Adaskin, Hughes, McMullan, and McMorris (1994) conducted a study to

identify the essential factors that influenced nurses during the implementation of
the computerization process.

Factors Model for Designing Computer Educational Programs


Change Process
Change Process
Time Frame
Time Frame


Training Software
Training Software

Figure (1) showed the factors for designing computer educational programs
(Adaskin et al., 1994).

This figure shows the support of administration in the center of the wheel
as leadership. Strong leadership, planned changes, effective communication,
special software, established time frames, and a carefully planned training process
can yield success in implementing a nursing information system.

Time Frame, Once a decision is made to purchase and implement a

nursing information system, a detailed time line should be drawn to detail the
steps in the process and identify who is responsible for each activity. The time
line provides the entire organization with a plan of activities and anticipated
events over the specified time period. Providing sufficient resources and time for
training staff is a necessary step for success.
Nursing Informatics and its Application to Community Health Nursing 17

Leadership, and knowledge of the computerized systems from the

administrative and staff development team are essential in preparing nurses for
computerization. A coordinated leadership team can provide resources people on
units as nurses go “on line” to troubleshoot and boost staff confidence and
morale. The support provided at this time is crucial for effectiveness and provides
many opportunities for answers to questions by the nurses of the system. If
resources are constrained in the organization, a schedule placed on each unit
identifying the times that a resource person will be available and listing a
telephone number of a backup who can be called for questions that require
immediate attention (Adaskin et al., 1994).

Software, communication is important when selecting the software that

will be used for the nursing information system. The input of administrators,
educators, and community nursing clinicians can be utilized for develop of a
multipurpose nursing information system. A system that has the capability of
providing the functions that each group needs, as well as one that is relatively
simple to use is essential. The ability to modify or add programs is also important
(McGuire, 2001).

Communication, throughout change process, clear, direct communication

is essential for an orderly transition. Developing a network where staff
development personnel are responsible for assigned community clinic to
communicate about the nursing information system facilitates idea exchanges.
Identifying one nurse from each clinic who is responsible for distributing new
information and is the contact person for the staff development representative
provides an effective communication link. The nursing representative not only
accepts information to distribute to peers but also provides invaluable insights on
problems that need to be solved. Compiling key questions and writing simple
explanations that can be posted on all nursing clinics provide another excellent
mechanism for communicating knowledge. It is also important to visit each
community nursing clinic to observe how effective and proficient the staff are
becoming with the new system (Romano, 1985; Hannah et al., 1994).

Training, using adult education techniques to expose nurses to computers

in a positive learning environment lessens initial computer anxiety and enhances
computer literacy. Educators and administrators can optimize computer learning
for nurses by creating environments conducive to learning and by adhering to
adult learning principles. Education should be flexible and user driven. The use of
written and oral instructions along with pictures, graphs, and charts on an
individual and group basis are needed to assist in meeting all learning needs.
Adaskin et al. (1994) found that providing too much material too fast was
Nursing Informatics and its Application to Community Health Nursing 18

detrimental to nurses’ learning. Pacing the material in two or more sessions

proved to be better than a one-time marathon session. The time between classes
gives nurses an opportunity to process information, practice with structured
feedback at a demonstration site, and then return to the second session with
questions and heightened confidence.

Nursing staff development personnel should serve as role models with

computerization to show that learning can be interesting. When new technology is
introduced, support staff should be available and visible to help nurses gain
expertise with the equipment. Demonstration of new technology (equipment and
software) should be frequent and visible in places such as the cafeteria. Placing
personal computer on community nursing clinics and supporting staff to use them
encourages computer skill development (Ellis, 2002).

Change Process, change is a regular occurrence in the health care

environment. The computerization of nursing systems is one aspect of the
changes taking place in the information revolution. As a result, nurses have
widely varying attitudes toward computers and change in the workplace. To
transition the nursing team effectively from one system to another, the nurse
informatics must be aware of the factors that encourage and those that impede the

Change process can be exciting, painful, and challenging. Careful planning

and step-by- step approach to selecting software, creating a transition process, and
evaluating the outcome are essential for success. Lewin’s Force field theory
(1995) provides a clear framework for exploring and implementing
computerization. Lewin’s three-phase framework comprises “unfreezing,”
“moving,” and “refreezing.” Unfreezing is a time when nurses identify a need to
implement a computerized nursing system and begins to acquire computer skills.

The first step of Lewin’s process, unfreezing, involves the identification of

the current need or problem. At this stage, there may be feelings of discomfort
apprehension, and upset among the nurses. The nurse informatics facilitates
activities that distinguish the driving forces and restraining forces in this step.
Strategies are developed to strengthen the driving forces and weaken or reduce
the restraining forces. It is during this phase that nurses in the organization begin
to realize that the change is necessary and valuable to the success of the

The second step of the process involves changing or moving to a new level.
It is here that the actual change occurs and the driving forces have equalized or
Nursing Informatics and its Application to Community Health Nursing 19

overcome the restraining forces. The nurse informaticist has gathered the
necessary information to move forward with the proposed change. A detailed plan
is constructed for implementing the change, and the change is executed within the
organization. In the final step of Lewin’s process, refreezing, the change is
stabilized at the new level within the organization. The nurse informatics assist
with maintenance and evaluation as functions stabilize and the change is
incorporated into the system.

Database Mining
Data mining is a powerful tool in the knowledge discovery process that can
now be done with a number of open-source software packages. It is a tool that has
the potential to expand the scope of inquiry by opening up the realms of health
care data available in large databases (Computers Informatics Nursing, 4004). In
addition, data mining as a method for data analysis in nursing research can
contribute to the discovery of causal factors and demonstrate outcome

The database has two main aims as stated by Hippisely-Cox, Stables and
Pringle (2004) the first is to provide very good access to high- quality validated
data for use in ethical research. The second aim is for QRESEARCH such as
surveys that make morbidity statistic available to health community at large.

Examples of Databases (Database Mining)

1. Health Baseline Statistics Data for Egypt ( Appendix ◄2►).
2. Management information systems and applications
(decision support, payroll, personnel, finance, etc.).
3. Epidemiological surveillance database(s).
4. Information technology training programs for nursing and other health care
5. Hospital management systems
(registration, electronic medical records, finance, insurance).
6. Geographic information systems.
7. Computer-based directory of national health care institutions
(hospitals, laboratories, clinics, centers of excellence, etc.).
8. Computer-based directory of health care professionals
(physicians, radiologists, dentists, pharmacists, etc.).
9. Bibliographic, library and documentation database(s).
10.Computer-based network of health care institutions
(hospitals, laboratories, blood banks, etc.).
11.Full-text database(s) for laws, legislation, regulations, etc.
Nursing Informatics and its Application to Community Health Nursing 20

12.Computer-based directory of health and nursing education

(colleges of medicine, dentistry, pharmacy, nursing, etc.).
13.E-health, telemedicine, teleradiology, telepathology services.
14. Current Situation, Progress of Health for All in Egypt (Appendix ◄3►).

Examples of Community Health Informatics Areas

― Management data in health care is ranged from the management of an
activity, such as immunization or an awareness campaign, to the management of a
national program (e.g. disease control). The management of a health care
institution (e.g. a hospital or a laboratory) or the management of an entire national
health service (Richards, 1998).

— Immunization data from public and private providers throughout the

country was used to focus on as prevention resources through determining
geographically where children were at risk of disease due to under immunization.
In Egypt, Sean (1990) said that children’s immunization campaign were promoted
by health center nationwide, the highest rates of infant mortality were in Upper
Egypt, followed by Cairo, Alexandria and other urban areas; the lowest rates were
in lower Egypt.

— Surveillance is another aspect of community health area that could be

dramatically transformed by the application of information systems and
continuously monitored for changes in the incidence or characteristics of
identifiable illnesses or even specific clusters of findings. Although the methods
for conducting public health surveillance may differ considerably by program and
disease, surveillance activities share many common practices. Brossette (1998)
added that National Electronic Disease Surveillance Systems integrate and link
public health surveillance activities through internet-based communications
infrastructure, standards, and policy-level agreements on data access, sharing,
burden reduction, and confidentiality protection. Specific examples of internet use
by the health team were mentioned as follows by Communicable Disease Control

• Nursing/medical training and continuous education

• Health information access
• Patient care and support
• Remote diagnosis and consulting
• Emergency/epidemic support
• Tele-working for the disabled
Nursing Informatics and its Application to Community Health Nursing 21

• Preventative care education and preventive health

• Electronic publishing of full-text of health and biomedical literature.

— Educating the populace about the role of life-style choices and client
behavior in health promotion and prevention of disease and injury are basic
community health functions (Friede, Blum and McDonald,1995).

— The collection and analysis of health-related statistics is an essential

public health activity that relies on the use of general statistical methods. This
bibliography covers health statistics systems, but excludes many publications that
discuss general-purpose tools and techniques for statistical analysis (Yasnoff et al,

― Epidemiological surveillance involves collection of ongoing routine

data to examine the extent of disease, to follow trends and to detect changes in
disease occurrences. The spread of epidemics is one of the classic problems
around which the art and science of computer modeling developed, and computer
modeling of epidemics has an extensive literature.

Epidemiological surveillance is essentially the study of the patterns of

distribution and the trends of diseases and related health care measures, by
geographical area, age group, community, etc., so as to establish priorities and
optimize health care measures through monitoring and evaluation, this requires
the collection and analysis of varied and relatively large amounts of data, from
and about the locations where diseases and related health problems occur and
from where patients present themselves, typically in urban and rural health
centers and hospitals (Communicable Disease Control, 2004).

— Long term care settings such as nursing homes and other health care
institutions have found it difficult to manage the regulatory process and provide
quality health care without computerized clinical information systems (Zielstorff,

— The electronic health record (EHR): Advances in information

technology have accelerated efforts to implement information systems such as the
electronic health record. The electronic health record is a collection of all of an
individual’s interactions with the health care system that will be available
electronically (subject to privacy, confidentiality and security guidelines and
legislation) to health care professionals anywhere in the country (WHO, 2002).
Nursing Informatics and its Application to Community Health Nursing 22

Many health-care institutions are seeking to develop integrated clinical

workstations. These are single entry points into a medical world in which
computational tools only assist with clinical matters(reporting results of tests,
allowing direct entry of orders by clinicians, facilitating access to transcribed
reports, and in some cases supporting telemedicine applications or decision-
support functions), but also with administrative and financial topics (tracking of
patients within the hospital, managing materials and inventory, supporting
personnel functions, managing the payroll, and the like), research (for example,
analyzing the outcomes associated with treatments and procedures, performing
quality assurance, supporting clinical trials, and implementing various treatment
protocols), scholarly information (for example, accessing digital libraries,
supporting bibliographic search, and providing access to drug-information
databases), and even office automation (providing access to spreadsheets, word
processors, and the like (Yasnoff, et al, 2001).

The increasing demand for well-structured and accessible patient data, in

combination with developments in computer science, has sparked great interest in
the development of an electronic patient record. Computers have the potential to
improve legibility, accessibility and structure, but these place heavy demands on
data collection. The computer-based medical record has a number of advantages
over the paper-based record, which make it an essential requirement for health
care (Thacker and Berkelman, 1998).).

— Primary Health Care Informatics: Simon (2003) proposed the

following themes for application of primary health care informatics;
▪ Data quality, exploring the barriers to the coding of structured
information in primary care and how these may be overcomed.
▪ The use of computers in patient-centered consultation. Usually
these are one-to-one encounters between the patient and the
healthcare professional. The challenge is to develop technology that
supports patient-centered counseling.
▪ e-Health initiatives: Telemedicine and telemonitoring of patients in
their own homes has been demonstrated in a wide range of clinical
▪ Knowledge management for primary care. Information overload is
a real phenomenon in clinical practice. Primary care professionals
need to know where to look for information rather than hold it
themselves. There is also a need to prioritize and to accelerate
learning in priority areas, possibly developing an appropriate
knowledge management strategy for primary care.
Nursing Informatics and its Application to Community Health Nursing 23

Cowley, Dawa and Ellis (2003) said that “If primary care is to rise to the
challenge, the primary care team needs to be supported by tools and
methodologies that enable it to reflect on, and improve, the quality of the service
it provides within the context of an already demanding schedule.

The Need for Community Health Nursing Informatics

Community health is a natural arena for the application of advanced
information technologies and it is related to community nursing informatics in
several respects. Both disciplines seek to use information science and technology
to improve client health. There are matters areas of common concern and lessons
learned in community nursing often apply to community health informatics.
Further, there are applications for which there is no real distinction between
community health and community nursing informatics, such as systems for
accessing community health data from electronic medical/nursing record system
or providing client-specific prevention guidance at the clinical encounter
(McGuire, 2001).

Health informatics is now a necessity for effective practice in the

information age. A deeper level of informatics training is needed by community
health leaders and managers to successfully tackle their decision- making and
management responsibilities with regard to information systems development
projects. Finally, a cadre of community health informaticians with comprehensive
training and experience in both public health and informatics is needed to serve in
leadership, research, and teaching roles (Howard, 2002).

Informatics has been used in the medical field for about 30 years, but the
public health community has embraced it only recently, since the early 1990s,
Communicable Disease Control (CDC) has been working with other federal
health agencies, state and local governments, professional associations, and the
health care informatics community to advance its use. Examples of informatics
activities include integration (linking together a wide variety of surveillance
activities), standardization (developing and using detailed standards for data
elements required to support public health surveillance), and information
dissemination (using the Internet to dynamically generate and disseminate
information). Each of these strategies improves the timeliness, completeness, and
accessibility of public health data (Zlot 2001).

Community health informatics is defined as the systematic application of

information and computer science and technology to community health practice,
research, and learning (Friede, Blum and McDonald, 1995 & Yasnoff, et al.
2000). In recent years, a variety of training resources have been developed that
Nursing Informatics and its Application to Community Health Nursing 24

address one or more aspects of informatics. However, to date these resources

have been developed in relative isolation, and no consensus has been heretofore
established as to specific informatics competencies that various public health
professionals should obtain (Zlot 2001).

“I like to think of community health informatics as more than the sum of its
parts,” said Zlot (2001) discussing why people often have difficulty
understanding what it involves and why it is important. She explained that public
health informatics combines various disciplines— public health science,
computer science, information technology, cognitive science, education,
management, economics, and even political science and anthropology— to ensure
that public health data are easy to access, analyze, and communicate, and are used

Effective community health practice requires timely, accurate, and

authoritative information from a wide variety of sources. Not surprisingly,
community health professionals have been among, the earliest adaptors of
computers and other information technologies, and numerous useful
computerized information and surveillance systems have been developed
(Richards, 1998).

As part of their responsibilities, community health nurses often provide

personal health care to clients who would otherwise lack access to care, but it is
through population-based interventions that the public health system seeks to
have greatest impact on the accessibility of care. Community health activities
depend to some extent on the availability of recent accurate and comparable
information of community health nursing resources through the internet
(Appendix ◄4►).

Lundy and Janes (2001) describe the scope of community health

informatics which includes the conceptualization, design, development,
deployment, refinement, maintenance, and evaluation of communication,
surveillance, and information systems relevant to community health. It requires
the application of knowledge from numerous disciplines, particularly information
science, medical/nursing sciences, computer science, management, organizational
theory, psychology, communications, political science, and law. Its practice must
also incorporate knowledge from the other fields that contribute to community
health e.g., epidemiology, microbiology, toxicology, statistics, etc.
Nursing Informatics and its Application to Community Health Nursing 25

Principles of Community Nursing Informatics:

Grier and McGuire (1999) mentioned that community nursing informatics
principles are flowing directly from the scope and nature of community health
that distinguishes it from other nursing informatics specialty areas. These
principles define, guide, and provide the context for the types of activities and
challenges that comprise this new field:

1- The primary focus on community health informatics should be on

applications of information science and technology that promote the health
of populations and community, as opposed to the health of specific
individual patient. In community health, consideration for the community
as the client may require “treatment” such as quarantine or disclosure of the
disease status of an individual to prevent further spread of illness. It also
requires attention to environmental factors that affect the health risk of
entire populations rather than specifically identifiable individuals.

2- The second focus on community health nursing informatics should be on

applications of information science and technology that prevent disease and
injury by altering the conditions or the environment that put populations of
individuals at risk. Community health nursing emphasizes the prevention of
disease and injury versus intervention after the problem has already

3- Community health nursing informatics applications should explore the

potential for prevention at all vulnerable points in the causal chains leading
to disease, injury, or disability. Applications should not be restricted to
particular social, behavioral, or environmental contexts.

4- As a last principle of community health, nursing informatics should reflect

the governmental context in which community health is practiced. Much of
community health operates through government agencies that require direct
responsiveness to legislative, regulatory, and policy directives, careful
balancing of competing priorities, and open disclosure of all activities.

Major Challenges of Community Health

Nursing Informatics
Nursing Informatics and its Application to Community Health Nursing 26

Although there are numerous ways in which information science and

technology can improve community health nursing practice, Thacker and
Berkelman, (1998), mentioned that there are three areas that represent grand

I- Developing coherent, integrated national public health information

systems for assessing community problems in a comprehensive manner
through the development of integrated nationwide community health
data systems. This requires a clear definition of community health data
needs and the sources for these data, consensus on data and
communications standards – to facilitate data quality, comparability,
and exchange – along with policies to support data sharing,
mechanisms, and tools for accessing and disseminating data and
information in a useful manner. Agreement on standards is particularly
challenging because of the diverse needs of the many groups who
record and use health information, including providers, clients,
administrators, researchers, and public health officials.

II- Developing closer integration between community health and clinical

care for facilitating the improved exchange of information between
public health and clinical care. Many of the data in public health
information systems still come from forms filled out by hand, which are
later computer-coded. Even where reporting is electronic, initial data
entry is typically still manual. This results in serious underreporting of
many reportable diseases and conditions. Electronic information sharing
and data exchange provide the means by which we can better integrate
public health and clinical care activities, but a great deal of creativity
and hard work are needed to take full advantage of these opportunities.

III- Addressing pervasive concerns about the impact of information

technology on privacy, confidentiality, and security are pervasive and
persistent challenges to progress in community health nursing
informatics. Information systems are correctly perceived by the public
to be a double-edged sword- whatever is done to make integrated,
comprehensive information more easily available for worthwhile
purposes must of necessity create new opportunities for misuse.

Another challenge facing nurses’ educators is to develop nurses’ abilities to

handle a wide range of information technologies. Computer equipment that
permeates all aspects of care, computerized information systems, electronic
Nursing Informatics and its Application to Community Health Nursing 27

motoring devices, and microprocessor implants are essential for nurses to be

encountered (Hannah, Ball, & Edwards, 1994; Saba & McCormick, 1995).

Informatics Competencies for Community Health Professionals

The competencies and knowledge needed by community health nursing
information include an understanding of the respective roles and domains of
information technology and public health team members and also to the ability to
develop and use an information technology architecture are needed through
working knowledge of information system development, networking, and
database design; familiarity with data standards; a clear understanding of privacy
and confidentiality issues, as well as security technologies; and skills in
information technology planning and procurement, information technology
leadership, managing change, communication, and systems evaluation research.

The term” competency” has been defined as; complex combination of

knowledge, skills and abilities that are critical to the effective and efficient
function of the organization. Alternatively, combination of observable and
measurable skills, knowledge, performance, behaviors, and personal attributes
that contribute to enhanced employee performance and organizational success
(American Nurses Association, 1995).

Nursing Informatics Competency

The definition of nursing competency is the integration of knowledge,
skills, and attitudes in the performance of various nursing informatics activities
within prescribed levels of nursing practice (Staggers & Gassert, 2000).

Table (1) Nursing Informatics Competency among Nurses as presented by

Staggers & Gassert (2000).

competency levels of practicing Nurses

Beginning Nurse
• Has fundamental information management and computer technology skills.
• Uses existing information systems and available information to manage practice.
Nursing Informatics and its Application to Community Health Nursing 28

Experienced Nurse
• Has proficiency in a domain of interest (e.g., public health, education, administration).
• Highly skilled in using information management and computer technology skills to support his/her
major area of practice.
• Sees relationships among data elements and makes judgments based on trends and patterns within
these data.
• Uses current information systems but collaborates with the informatics nurse specials to suggest
improvement to systems.
Informatics Nurse Specialist
• An RN with advanced preparation possessing additional knowledge and skills specific to
information management and computer technology.
• Focuses on information needs for the practice of nursing, which includes education, administration,
research, and clinical practice.
• Uses the tools of critical thinking, process skills, data management skills (including, acquiring,
preserving, retrieving, aggregating, analyzing, and transmitting data), systems development life cycle,
and computer skills.
Informatics Innovator
• Educationally prepared to conduct informatics research and generate informatics theory.
• Has a vision of what is possible and a keen sense of timing to make things happen.
• Leads the advancement of informatics practice and research.
• Functions with an ongoing healthy skepticism of existing data management practices and is creative
in developing solutions.
• Possesses a sophisticated level of understanding and skills in information management and computer
• Understands the interdependence of systems, discipline, and outcomes, and can finesses situations to o
maximize outcomes.

American Nurse Association (2001) added another distribution for nurses

according to competency informatics characteristics as follows:

I. New Clinician
• Computer literacy
• Information literacy
• Web literacy
• Identify, collect, record relevant data
• Analyze and interpret nursing information
• Use application designed for nursing practice
• Protect privacy of health information.

II. Experienced Clinician

• Identifies relationships among data elements
• Uses current solutions, and makes suggestions for improvements.
• Manages data, information and knowledge
• Participates as a content expert
Nursing Informatics and its Application to Community Health Nursing 29

• Promotes integrity of and access to information

• Active involvement in improving information management and
• Acts as an advocate for incorporating innovations.

III. Nurse Informaticist Competencies

• Collaborates with informatics community to optimize nursing
information management.
• Functions in interdisciplinary environment.
• Synthesizes data, information, and knowledge to clarify informatics
issues or problems.
• Analyze multiple approaches/solutions to informatics issues or
• Develops informatics solutions
• manages the implementation process
• Evaluates and adjusts solutions
• Contributes to the body of informatics knowledge.

Nursing Informatics Areas of Competency (Howard, 2002):

■ Ethics
■ Research/quality measurement and improvement
■ Financing, organization of health care.
■ Development of professional role and patient provider relationship/leadership
■ Health promotion and disease prevention/competencies relevant to primary
health care.

Nursing Informatics Roles

There are needs to utilize more systematic and informed approaches to the
application of information science and technology in order to take full advantage
of its potential to enhance and facilitate community health activities (Lasker,
Humphreys, and Braithwaite, 1995). These are embodied in the nurses’
informatics roles;
• Project Management
• Consultant
• Educator
• Researcher
• Development supporter
• Decision support/outcomes management
• Advocacy/policy development.

Roles of nurse regarding his/her position within nursing team;

Nursing Informatics and its Application to Community Health Nursing 30

1. Front Line staff: nurses who carry out the bulk of day-to-day tasks
(e.g., nurses, counselors, investigators, lab technicians, health
educators, and other clinicians). Responsibilities may include basic
data collection and analysis, fieldwork, program planning, outreach
activities, programmatic support, and other organizational tasks.
2. Senior level staff (Senior Level Technical Staff): nurses with a
specialized staff function but not serving as managers (e.g.,
epidemiologists, biostatisticians, health planners, health policy
analysis). They have increased technical knowledge of principles in
areas such as epidemiology, program planning, and evaluation, data
collection, budget development, grant writing, etc., and may be
responsible for coordination and/or oversight of pieces of projects or
3. Supervisory and management staff: nurses for major programs or
functions of an organization, with staff who report to them. Increased
skills can be expected in program development, program
implementation, program evaluation, community relations, writing,
public speaking, managing timelines and work plans, presenting
arguments and recommendations on policy issues.

Nursing Informatics Competencies Self-Assessment; there is a website that

was created to offer registered nurses an online tool for self assessment in general
Nursing Informatics competencies. Various competency taxonomies have been
reviewed and integrated in the process. The intention of this work is to give the
nurse a preliminary analysis of current expertise and learning needs in the realm
of informatics in nursing. The results of this assessment do not represent testing
or examinations offered by any informatics-related organization or particular
school. This is purely a professional development exercise in self-assessment for
assisting nurse in creating a personal learning plan for further education and
practice (www.nursing informatics competency,

Electronic learning(Distance Learning)

For Nursing Education
Informatics Goals for nursing education as stated by Simpson (1998) are to
educate nursing students and practicing nurses in core informatics contents, to
prepare nurses with specialized skills in informatics, to enhance nursing practice
and to education through informatics, to prepare nursing faculty in informatics,
and increase collaborative efforts in nursing informatics

The impact of the internet on nursing education has been profound.

Lindeman (2000) believes this is an era of rapid change for nursing education.
Nursing Informatics and its Application to Community Health Nursing 31

Considering the current era of distance learning, education can be accessed

primarily through internet using asynchronous communication, electronic mail,
newsgroups, and conferencing (Carliton, 1999).

Maddux (2001) notes that college students of any discipline are now
enticed by marketing that offers online “bachelor’s, master’s, or doctoral degrees
in nursing sciences in 12 months without mandatory attendance in structured
classroom settings”. Undergraduate and graduate degrees in nursing can be
obtained via the internet through the Web sites of colleges and universities.

Peterson, Hennig, Dow and Sole (2001) pointed out different internet
teaching methods for nursing education as; (a) using handheld computers, (b)
using the Internet for clinical instruction, (c) facilitating synchronous and
asynchronous online discussions, (d) assessing health needs on another continent
via the Internet, (e) designing Internet Journal discussions, (f) identifying Internet
surveys research opportunities for students, (g) teaching pathophysiology through
online discussion boards, and (h) using e-mail to develop nursing scholarship.

Simpson (2003) said that “Welcome to Virtual Education for Practical

Experience”, and defined Virtual Reality (VR) that it employs computers and
various multimedia peripherals to produce a simulated (i.e., virtual) environment
that users perceive as comparable to real-world objects and events. Conventional
desktop computers, multimedia, and distance learning systems deliver non-
immersive VR, allowing students or nurses to log on to distance learning and
continuing education courses from the convenience of their homes, the college
computer lab, their officers, or an inpatient settings.

There are several software nursing education programs which affiliated to

different health institutions and universities on the internet and through the
distance and e-education learning. Magnus and Derkach, 1994 & Todd, 1998
were proposed nursing informatics education model for graduate nursing
informatics students (Appendix ◄5►).

Globalization and Nursing Informatics Comptencies

Shaw (2002) stated that the concept of globalization goes beyond that
related primarily to economic and trade developments that cross national borders.
Globalization defined as the flow of information, goods, capital and people across
political and economic boundaries. The General Agreement on Trade and
Services (GATS) Signed in 1994, this far-reaching agreement is administered by
World Trading Organization (WTO). It defines four different models for
Nursing Informatics and its Application to Community Health Nursing 32

supplying services. A Foreign Service provider can choose the model best suited
to its needs and interests. These four models were discussed and presented as:
1- Cross border, where for example a university in one country
provide education services to citizens of another country;
2- Commercial presence, where for example a U.S. health
organization operates a hospital in another country;
3- Consumption abroad, for example citizens of one country
purchase health services in another country; and
4- Movement of natural persons, for example nurse migration to
other countries to provide nursing services.

For nursing, Shaw (2002) mentioned that all of these models have
implications for the provision and quality of nursing services. However, it is the
fourth model, movement of natural persons, subsequent work has to be done in
relation to areas as technical standards, licensing, education and qualifications.

Some specific implications for nursing, increasing global trade, trade

agreement, the increasing flexibility and movement of the workforce nationally
and internationally, and policy changes in the broad field of regulation, all
contribute to the growing complexity in the field of professional regulation. In
many countries, this has become a loosely integrated system based primarily, but
not exclusively, on credentialing practice. The most common forms of
credentialing considered being:
♦ Accreditation of educational institutions – this is usually a
voluntary credentialing process signifying quality and identifying
areas for improvement;
♦ Licensure through law of the individual profession – this conveys
authority to practice. Its primary purpose is protection of the public;
♦ Specialty certification – this represents advanced knowledge and
skill, and relates more to recognition of the provider than to
protection of the consumer;
♦ Accreditation of service delivery organization – this ranges from
application of broad international standards, to specific programs
such as hospital accreditation.

At an international level, ICN is working on the following credentialing activities:

• Establishing standards for international distance learning nursing
education, telenursing, international health and nursing consultation,
and education programs with international health or nursing
Nursing Informatics and its Application to Community Health Nursing 33

• Developing international mechanisms (including partnerships) for

accreditation of programs with international components and
certification of nurses and other health professionals as international
consultants; and

• Establishing international competencies for general nursing

applicable to multi-country licensure.

Nursing and other health professionals, need to consider the following points in
relation to the globalization of health professional regulation (ICN, 2004);
─ Specialty and advanced nursing practice. Nursing has paid little
attention to cross border recognition of this. Many programs are still
in early stages of development.

─ Sustaining cross-border regulation in the context of more

permissive trade agreements.

─ Using the experience of the European Union. The cross-border

regulatory experience in nursing within the EU should be reviewed
for its potential contribution to shared approaches to regulation.

─ The tension between internationalizing regulation and ensuring

appropriate regulation at a country level.

─ Telehealth and telenursing. Nursing should be alert to any

developments in regulation or standards related to telenursing
services, and other areas where nursing services may cross national
borders. National-level regulators could review such developments
for their potential use in, or linkage, to their own systems.

Nursing Informatics can be viewed through a number of different lenses.
The most common ones include the standard areas of nursing: nursing practice,
nursing education, nursing research, and nursing administration. Nursing
Informatics can also be viewed through the sociological lens of empowerment,
dialogue, synthesis, and creative expression.

Nursing informatics and its application to community health nursing as a

selected topic to be presented was difficult to cover all its aspects in this paper.
The future of nursing informatics and electronic health in Egypt is bright and
promising. Innovation in nursing science combined with advances in information
Nursing Informatics and its Application to Community Health Nursing 34

and communication technologies should provide community health nurses with

tools that increasing contact with the communities they serve could be also
through community health nursing web-sites resources.

Community nurses roles regarding informatics are; “Life-long learner"

role, nurses should be able to demonstrate knowledge of information resources
and tools available to support life-long learning. "Clinician" role, nurses should
be able to use appropriate and available information technology in order to
acquire and analyze patient information, leading to proper clinical decision-

Educator/communicator" role, nurses need effective

education/communication skills in the context of relating to peers, patients/clients
and the public at large. "Manager" role nurses should be able to collect and
analyze information about service clients, the work done and the system
functions. "Researcher" role, nurses should be involved in nursing researches; this
role includes knowledge of literature sources and how to access them, the use of
computers in data collection and analysis and how to disseminate their results.

In Egypt, much work remains to be done to make nursing informatics a

reality. Through hardware, software and personnel; a multi-facet learning
program that utilizes distance learning, interactive cable TV, and the internet to
connect learning environments to homes, place of work, and the community at
large, and by establishing-updating community nursing resources web sites. The
graduate level nursing informatics educational environment must continue to
strive to become a forum where educator and student meet in an expanded
capacity made possible by an increase in the integration of computer literacy
within the nursing informatics curricula. Using innovative teaching mediums such
as the virtual classroom, distance and continuing education in nursing informatics
can be a reality and should be actively promoted.

Nursing should be alert to any developments in regulation or standards

related to telenursing services, and other areas where nursing services may cross
national to international borders. National-level regulators could review such
developments for their potential use in, or linkage, to their own systems.

Based on this state-of art article of the “Nursing Informatics and Its
Application to Community Health Nursing” the following are
recommendations concerning this area of nursing informatics:
Nursing Informatics and its Application to Community Health Nursing 35

─ The focus is now on the computer’s need for input data. Designing and
developing computers software programs are urgent needed to support
nurses in the care of clients, more effort needs to be made to change how
clients data are being collected and accessed. This change should focus on
the nurse’s need to collect and retrieve data as quickly and easily as

─ Nurses must ensure that the proposed change should be viewed as a

challenge rather than a threat. Adjusting to change may be difficult and
demanding. Therefore, a well-formulated strategy will encourage
adaptation to change rather than resistance.

─ Establish National Nursing Informatics Workgroup, to provide

leadership and guidance in setting a national informatics agenda for
nursing education and practice for the Egyptian Nursing Informatics

─ Develop evaluation methods that;

◘ Assure valid and reliable results in studying the effects of complex
information systems on community nursing practice.
◘ Measure the contribution of information systems to nurses’ clinical
◘ Measure, if possible, the contribution of information systems to client
◘ Provide measurable, dependable predicators of nurse’s optimal use of
automated information systems.

─ Curricula are needed for developing competencies of nursing informatics

at a basic level for the entire nursing staff, an intermediate level for
community nursing managers and leaders, and an advanced level for
community nursing informatics specialists and researchers.

─ Nursing needs a common language to communicate what nurses do,

within both the professional and the larger health care community, which
includes clients and families, other healthcare providers, and those who
direct healthcare policy and reimbursement. Availability of widely accepted
empirically-based nursing diagnosis, interventions and outcomes facilitate
the development of nursing and healthcare information systems that are
useful for teaching nurses/students the steps of the nursing process and
clinical decision making.
Nursing Informatics and its Application to Community Health Nursing 36

─ Integrating informatics into the graduate community health nursing

curricula. Candidates, as well as nurses, must keep abreast of the latest
technological developments in patient care, education, and research. Faced
with an information exposition, nurse faculty is challenged by the need to
educate nursing professionals who are prepared to use technology.
Curriculum development, evaluation, and modification are detailed in
relation to student learning needs, faculty preparation, and equipment and
consultation requirements.

─ The Electronic Health Records should reflects the nursing potentiality to

enhance nurses’ decision-making regarding the delivery of care by supplying
access to health information about clients, allowing data-entry, and offering
electronic access.

─Nursing informatics should be a central feature of the nursing undergraduate

and graduate curricula rests on the intimate relationship of information
management to the essential roles such as project Manager, consultant,
educator, researcher, development supporter and decision maker. For each one
of these roles the nursing informatics learning need could be stated into learning

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