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Instructions for Continuing Nursing Education Contact Hours appear on page 288
Roy L Simpson
h i e f N u r s e E x e c u t i v e s N e e d
o n t e m p o r a r y I n f o r m a t i c s
o m p e t e n c i e s
E X E C U T I V E S U M M R Y
Using the informatics O rganizing
Research Model (Effken, 2003) to
add context to the information
gieaned from ethnographic inter-
views of seven chief nurse execu-
tives (CNEs) currentiy ieading inte-
grated deiivery systems, the author
conciuded nurse executives can no
ionger depend exciusiveiy on
American Organization
of
Nurse
Executives (AONE) competencies
as they ou tsource their responsibiii-
ty for information technoiogy knowi-
edge
to
nurse informaticians, chief
information officers, and physicians.
Aithough AONE sets out a specific
iist of recommended information
technoiogy competencies for sys-
tem C NEs, innovative nursing prac-
tice demands
a
more strategic,
broader ievei of knowiedge.
This broader competency centers
on the reality of CNEs being
charged with creating and imple-
menting
a
patient-centered vision
that drives heaith care organiza-
tions investment in technoiogy.
A new study identifies and vaiidates
the gaps between seiected CNEs
self-identified informatics compe-
tencies and those set out by AONE
(Simpson, 2012).
ROY L. SIMPSON DNP RN DPNAP
FAAN is Vice President, Nursing, Cerner
Corporation, Kansas City, MO.
T
H E S E N T I NE L W OR K O F
C r a v e S
and Corcoran (1989) de-
fines nursing informatics
as
the
combination
of
computer science, information
science
and
nursing science
de-
signed to assist in the manage-
ment
and
processing
of
nursing
data, information
and
knowledge
to support
the
practice
of
nursing
and
the
delivery
of
nursing care
(para. 1). The American Organi-
zation
of
Nurse Executives (AONE,
2011) sets competencies related
to
information technology. These
competencies range from
the use
of email, office productivity soft-
ware, 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 envi-
ronmental factors is setting the
stage
for
a more rapid deployment
of clinical information systems:
• The financial incen tives asso-
ciated with
the
meaningful
use of technology as outlined
in the American Reinvestment
and Recovery Act
of
2009.
• Technology-based innova tions
such
as
cloud computing
and
social media.
• Widespread adoption
of so-
phisticated analytical tools
for
executive decision making.
• The inability of most chief
nurse executives (CNEs)
to ef-
fectively champion nursing's
technology-related needs
in
the physician-led
and
domi-
nated technology evaluation
process.
The unparalleled complexity
of patient care makes nursing
completely dependent
on the
instantaneous availability of infor-
mation
to
fuel
the
iterative nature
of decision making central to
patient care.
In
patient care,
it is
information technology that amas-
ses data and turns
it
into informa-
tion
and,
ultimately,
the
knowl-
edge that advances nursing and
patient care (Simpson, 2012).
Not only are technology evalu-
ations
and
their related decisions
organizationally transformative,
their im pact can be felt for deca des.
The life cycle
of
every technology
investment spans seven distinct
phases, from planning
to
procure-
ment to deployment to management
to support and disposition, only to
cycle back
to
planning. With
an
ever-present obsolescence engag-
ing
at
any step
in
the process creat-
ing change, this ever-cycling life
cycle continues.
In
addition,
the
impact
of
technology's plan ned
obsolescence cannot be overlooked
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when nurse executives make infor-
mation 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 whole-
heartedly 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 re-
placement knowing ohsolescence
can trump at any time the process-
es .
This practica lity differentiates
Simpson's model from Effken's
model.
While the life cycle looks sim-
ple enough, its overlay with con-
tent, outcomes, nursing informat-
ics intervention, and client factors
makes for a complexity not seen in
other health care executive deci-
sion making. These decisions form
inside a context that includes cul-
tural, economic, social, and phys-
ical requirements. Adding an out-
come orientation to the decision
allows cost, quality, safety, and
satisfaction layers to the discus-
sion. The influence brought to
hear by nursing informatics layers
the decision again as content
structure and information flow
considerations impact the tech-
nology under consideration. Fi-
nally, the client factor overlays the
decision with considerations per-
tinent to client or discipline be-
haviors and characteristics. This
decision-making process mirrors
the one descrihed in the Infor-
matics Research Organizing Mo-
del (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 opti-
mized for nursing. CNEs' respon-
sibility to evaluate, select, and
deploy these advanced technolo-
gies mandates either a nursing-
centric deep knowledge of tech-
nology personally or access to that
knowledge via a direct reporting
structure. For CNEs without per-
sonal knowledge of technology
considerations, access to an indi-
vidual with the knowledge and
the criticality of that kno wledge to
advance the practice of nursing
underscores the need for a direct-
reporting 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 technolo-
gies and clinical information sys-
tems personally. Only that level of
knowledge can advance the re-
quirements 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 infor-
mation systems: process mapping,
or discovering how the actual
steps of nursing practice unfold
during patien t care: and workflow
design, the mechanical arrange-
ment of information, forms, and
triggers to capture and document
nursing practice. However mech-
anical the process of creating and
deploying workflows, they cannot
he created hy engineers and tech-
nologists who lack the hands-on
experience of delivering patient
care at the bedside. Vendor-resi-
dent engineers lack the
site-specif-
ic 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 uni-
versal in application goal, what it
is not is nursing site specific,
requiring some modifications if
intended to achieve outcomes of
efficiencies for software accept-
ance hy end users.
In this study, the lack of stan-
dardization of nursing processes,
procedures, and operations greatly
complicated CNFs' health infor-
mation technology (HIT)-related
decision making, especially in
patient care operations with a
high degree of automation. This
increasingly complex patient care
environment complicates a
specif-
ic and central HIT-related respon-
sihility that falls to the CNF: the
design and implementation of
overarching nursing workflows.
While som e aspects of patient care
remain resistant to standardiza-
tion, 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 knowledg e that only CNFs and
nurse informaticists can provide
as seen in the Informatics Re-
search Organizing Model by
Fffken. The critica lity of these tw o
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 urpose
The purpose of this study was
to identify and validate the gaps
existing between selected CNFs'
self-ascrihed lived experience in-
formation technology competen-
cies and those laid out by AONF.
Technology competencies are not
just a part of CNFs' responsibili-
ties;
this understanding and its
related skills are critical to CNFs'
institutional and organizational
leadership. While a thorough un-
derstanding of technology's im-
pact on patient care remains the
responsihility of nurse informati-
cians,
CNFs will need to possess a
broad, working knowledge of T 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 technologi-
cal innovations. Given the critical
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nature of nursing input f o the pur-
chase, design, and ufilization of sys-
tems, baseline information abouf
needed nurse executive competen-
cies could inform educators and
professional organizations about
th e needs for nurse executive edu-
cation in the IT and nursing infor-
matics arena (Cerner, 2010). CNEs
may need more sophisticated
tecimology-relafed competencies
and expertise if they are to harness
the power of computing to demon-
strate the quality and financial-
related 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 ap-
proved 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 CNE
ft-om
an IDS
using HIT from Cerner C orporation
was included in the research.
A Confidentiality Agreement,
which was signed by each inform-
ant prior to the interview, stipulat-
ed the coded data would not be
released to anyone and the identi-
ty of the informants would not be
revealed.
To protect the inform ants' pri-
vacy, th e MP3 files of each inter-
view were associated with an
alpha-numeric code. This code
traveled with the digital file when
it was sent to a professional serv-
ice for transcription.
To better understand CNEs'
roles in the lived experience of
this complex decision making, the
invesfigator condu cted ethnograph-
ic interviews of seven CNE mem-
bers of the HMA. Membership in
fhe academy reflects fhe CNEs'
affiliation with the country's lead-
ing health systems and corpora-
tions. According to HMA (2012),
membership includes executives
from approxim ately 90 health sys-
tems 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 net-
works with a total of 8 645 beds
located in seven states with an
aggregate employee population of
53,735.
Health M anagement Academy
members gain their industry-rec-
ognized 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 executive-
level 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 mem ber IDSs functioned as
a network of health care institu-
tions, practices, and organizations
to provide or arrange to provide a
coordinated continuum of servic-
es 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 man-
aged care (Washington State Hos-
pital Association, 2012).
An ethnographic approach to
CNE interviewing used iterative
questioning based on the tacit
information and inferences glean-
ed ftom the early interviews to
inform fhe later conversations,
making the cumulative findings
richer and more insightful than
knowledge gained from consis-
tently asking a standard set of
questions to all CNE informants
(Spradley, 1979).
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As each interview was con-
ducted, the author reviewed the
data collected ftom that interview
independent of the previously
gathered information. Once that
stand-alone analysis w as com-
plete, information gleaned from
each interview was compared to
the data stemming ftom previous
informant interviews. Common
and disparate themes were cap-
tured for analysis as well.
Research Reveals Common
Disparate Themes
This research set out to an-
swer a single pivotal question:
What is the state of CNEs' HIT-
related decision making compared
to the competencies outlined in
AGNE's recommended informa-
tion technology competencies?
A key part of analyzing the
data ftom informant interviews
centered on identifying cultural
themes, which defined any princi-
ple 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, key-
words were identified and trend-
ed, 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
th e research might refer to a com-
puter phy sician, wh ile inform-
ants speaking in later interviews
might refer to the same type of
individual as a chief med ical in-
form ation officer. If the term
evolved in informant sessions, the
term computer nurse was re-
placed with nurse informa tician
in later interviews.
Terminology related to nurses
represented a single area of evolu-
tion but other subject areas were
likely to shin as well. Eor exam-
ple,
early interviews probing
nurse executives' data use yielded
comments relative to data analy-
sis. As the interview process pro-
gressed, mentions of fhe term
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data analysis dwin dled w ith
more informant comments focus-
ing on the use of statistical data
mining and dashboa rds, 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 con-
sumed the left one-third of the
area with the remaining two-
thirds forming a second column.
Handwritten notes taken during
the interviews filled the second
colunm, leaving the left-hand col-
um n o pen 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 pre-
vious interview's ke}rwords and
themes were used to enrich subse-
quent 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 pin-
pointed keywords and emerging
themes, which were capttired on
sticky notes. The use of reposi-
tionable notes proved to be a key
element of the analysis process as
the review continued over several
days. KeyTvords and trends natu-
rally led to trends and patterns of
comments.
To conclude the analysis, an
exercise that pinpointed evidence
of each AOI^-recommended in-
formation technology was conduct-
ed. This analysis showed the CNEs
demonstrated competencies in
each required area with one excep-
tion. As a group, the CNEs did not
dem onstrate an aw areness of socie-
tal and technological trends, issues,
and new developments as they
relate to nu rsing (AONE, 2011).
The Data
Using keywords and exem-
plars to expand on CNEs' themes
gave context to the data. Themes
and associated keywords are sum-
marized in Tables 1 and 2. Themes
aligned with the keywords and
exemplar quotes from the seven
interviews are identified in Table 2.
nalysis
Interview data Dvixing an alysis
of the CNE interviews, five domi-
nant and often interwoven themes
emerged: technology knowledge,
collaboration, HIT selection, execu-
five leadership, and standardization.
Each of these themes represented
overarching areas of concern for the
CNEs, who demonstrated compe-
tency in each of the AONE-recom-
mended IT competencies with one
exception. That exception centered
on the CNEs' lack of awareness
about societal and technology
trends, issues, and new develop-
ments as they related to nursing.
Technology knowledge CNEs'
lived experience, as expressed
through a series of seven ethno-
graphic interviews, validated the
opinion voiced in the literature
that nurse executives lack the
foundational knowledge of tech-
nology needed to understand,
appreciate, and leverage rapidly
advancing technically based capa-
bilities (Ball et al., 2010). The in-
terviews indicated CNEs have
chosen to bypass amassing deep
technology knowledge, instead
relying on emotional intelligence
and dependencies on nurse infor-
maticians and chief information
officers (CIOs), to exert nursing's
influence into HIT decision mak-
ing. CNEs' lived experience a-
ligned with the trend for nurse
leaders to look to nurse informati-
cians and clinical nurse special-
ists (CNSs) to provide the deep
technology knowledge they lack
(Westra & Delaney, 2008). State-
ments such as, I depend on my
nurs e informatician to give me th e
information flagged this depe nd-
ence.
CNEs said they depended on
HIT vendors for their technology
education, which gave pause to
understanding the various trade-
offs 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 tech-
nology knowledge renders them
unable to champion the collec-
tion, analysis, and trending of
nursing data in a chief medical
officer (CMO)-dominated HIT dis-
cussion.
Is it possible the CNEs share
an overarching lack of ownership
and urgency around the acquisi-
tion 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 dash-
board for management - not a
strategic decision-support tool for
their own use.
Collaboration HTT-related col-
laboration specific to system eval-
uation and selection posed a
series of challenges for the CNEs.
Collectively, they ex pressed a pre-
vailing scenario in which their
opinions are not heard and they
are unable to counter physician
viewpoints in CMO-driven deci-
sion making about HIT.
Leadership CNEs pointed out
that when health care organiza-
tions em ploy CIOs from indu stries
outside the health care environ-
ment, a particular challenge aris-
es. 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 oper-
ational efficiency.
HIT selection Collaboration
again entered into th e CNEs' inter-
views when they spoke about
implementing and utilizing the
selected HIT systems. The logis-
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Table 2. (continued)
Themes and Associated Keywords from CN Es interviews
Theme Keywords Exemplar Quotes
Health
information
technology
selection
Driving
improvement
Collaboration
Working with the
board ot directors
Standardization
Technology
leadership
Technoiogy
priorities
Executive
decision making
Technology
innovation
Executive
leadership
Keys to success
Standardization
Implementation,
rollout, evaluation
Inquisitive
Data analysis,
governance,
physician-
dominated, strategic
plan, CIO, strategic
plan, change
initiatives
Rollout
Baseline
Development,
learning,
teaching,
informatics
Triage, shared
priorities, continuum
of care, risk
stratification
Governance,
lobbying,
emotional
intelligence
Engineering
Integrity, executive
secession, informal
dialogue, visibility
Relationships
Leading, informatics
infrastructure
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.
As a chief quality officer,
1
w as very inquisitive about how to get da ta out of the
system and use it to drive improvement.
...chief patient safety officer who has become very involved in analyzing the w ork
that's going on and how it might contribute to errors. He m easures adverse events
related to anything in the electronic health record.
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.
It really took standing up to the board me mbe rs...and saying, 'It's [the system] not
ready We w ill have potential patient safety issues if we roll this out.'
Part of the dilemma has been in a m ulti-hospital system [is around] who is really
making the [rollout] decision.
'They [multiple hospitals in the IDS] all want something different.. .The standards
and processes have to be the same.
We've had two m ajor 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 [pre-
development] conversations...
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 do n't have an identified discharge date, we're not planning to get you
to the next point of disposition...
1
would want to make sure that [the CNE candidate] had a very high score in terms
of em otional intelligence. [That w ould
be]...
critical in a place like this.
I'd like to go back to engineering school because
1
think it's a gap in my knowledge
as a nurse executive...
My nurse informatician and
1
have mutual integrity.
1
completely trust that what the
people are reporting to me is accurate.
[CNEs] may have the knowledge and be superb...but where they fail is in creating
relationships that are effective...whether it's [with] finan ce...o r...IT...o r the person in
charge of facilities.
Much of the work that I've been involved in [is] leading...around standardization of
practice and elimination of variation. [We are] pushing toward role clarity and
[seeing] how that gets expressed through the use of technology
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Tabie 2. (continued)
Themes and Associated Keywords from CN Es Interviews
Theme Keywords Exemplar Quotes
Return on
investment (ROI)
Communications
Metrics
Cost of ownership,
achieving ROI
Alignment, social
media, listening,
needs
Drowning, process
focus,
outcome
focus
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.
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 commu nicafe] more effectively wifh our em ployees.
We're now segmenting and tailoring our message, so that some of our
communication [about nursing and technology] can be global.
...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 outcom es and pushing that down to the unit level.
Gap nalysis
A gap analysis of the CNEs'
HIT-related competencies and
AONE's recommended IT compe-
tencies were conduc ted. The major-
ity of CNEs self-described their
technology competencies as ali-
gned with the AONE-recommend-
ed 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 deci-
sion making. Table 3 shows the
CNEs' aligrmient w ith AO NE's rec-
ommended information technolo-
gy comp etencies.
Key Findings
The CNEs pointed out two
ways they are marginalized in the
evaluation and selection of clini-
cal information systems. First, the
CNEs found their review respons i-
bilities limited to the functional
level; that is, looking at the sys-
tems' features, rather than their
ability to advance nursing prac-
tice. Second, the CNEs explained
that a CMO-led physician contin-
gent guided IT decision making.
relegating CNEs to a specifier/
recom men der role. CNEs found
themselves limited in their ability
to advocate effectively for tech nol-
ogy needed to support nursing
practice during the evaluation and
selection of clinical information
systems. As a result, there is no
one at the executive decision-
making table to advocate for the
needs of patient care during all-
important 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 tech-
nology 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 car-
diac CNS would also be responsi-
ble 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 th e salvation of
CNSs' future as well because it
clearly differentiates their practice
ftom that of the nu rse practitioner.
No one will know the machine-
specific domain knowledge better
than the CNS who is focused and
mastered in the d om ain specific to
that patient condition.
Impact of Social Media
Although the CNEs demon-
strated knowledge of technology-
fueled innovation in nursing prac-
tice, two substantial gaps exist
between the CNEs' knowledge and
AONE's stated competency. The
first gap pertains to CNEs' aware-
ness of societal and technological
trends, issues, and new develop-
ments as they relate to nursing, a
stated AONE competency. The
second disconnect occurs bet-
ween CNEs' knowledge and the
AONE competency requiring pro-
ficient awareness of legal and eth-
ical issues related to client data,
information, and confidentiality.
Nurses' use of social media lies at
the intersection of both thes e 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 interdisci-
plinary team, etc. (Black, Light,
Paradise Black, & Thomps on,
2013). It is troubling that this per-
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Table 3.
CNEs
Alignment w ith AONE s Recom mended Technology Competencies
Competency | CNE CN E 2 CN E 3 CN E 4 CNE 5 CNE 6
Demonstrate basic competency in em ail, common word processing,
spreadsheet and Internet programs.
Recognize the relevance of nursing data for improving practice.
Recognize the limitations of computer applications.
Use teiecomm unications d evices.
Utilize hospital database m anagement, 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 m anagement 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 aw areness of legal and ethical issues related
to client data, information, and confidentiality.
Read a nd interpret benchm arking, financial, and occupancy data.
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
CNE 7
X
X
X
X
X
X
X
X
X
X
X
X
X
vasive communication violates
The Health Insurance Portability
and Accountability Act regula-
tions (U.S. Department of Health
and Human Services, 1996) and
happens in the majority of facili-
ties,
even where CNEs have
ban ned social med ia. Recently,
researchers from the University of
Florida examined 15 days worth
of anonymo us network utilization
records for 68 workstations locat-
ed in the emergency department
(ED) of an academic medical cen-
ter, 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 Face-
book, visiting the social network-
ing site 9 369 times, and spen ding
12 minutes per hour on the site.
The amount of time spent on
Facebook, while significant, was
overshadowed by a second re-
search finding: the time spent on
Facebook actually increased as
patient volume in the ED rose. As
a result, the researchers recom-
mended 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 confi-
dentiality of vitally important
health information. Policies that
eliminate or restrict the use of
social media in their facilities m ust
be equitable for compliance. Of
course, this creates another set of
dynamics which must be
addressed . Plus it speaks to the def-
inition and knowledge of cloud
compu ting wh ich 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
wou ld have equitably know n infor-
mation was uploaded ftom devices
and security breached.
This research concluded that
while the CNEs applied the major-
ity of AONE-recommended inf^or-
mation technology competencies
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to their executive decision making,
most did not demonstrate an
awareness of societal and techno-
logical trends, issues, and new
developments as they relate to
nursing. Considering the CNEs
cited technology knowledge, or
more precisely, a lack of technolo-
gy know ledge, 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 competen-
cies offered CNEs a point from
which to begin amassing baseline
technology knowledge. For exam-
ple, the competencies, such as
being able to use email, word pro-
cessing, spreadsheet and Internet-
based programs, demonstrate only
baseline knowledge. Baseline com-
petencies do not indicate the level
of knowledge and technical so-
phistication the CNEs needed to
evaluate, select, deploy, and uti-
lize evidence-based HIT' in system
CNE roles of IDSs.
The AGNE baseline compe-
tencies do not address key aspects
of executive decision making rela-
tive to HIT, such as science-based
workflow, evidence-based archi-
tecture, and utility corporations.
The complexity of modem nursing
care requires a much deeper imder-
standing of technology capabilities
and options if
NEs
are to a ctively
participate and lead or influence
executive-level decisions related
to the evaluation, selection,
deploymen t, 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 fre-
quency or appropriateness of
CNEs' decisions to delegate deci-
sion making, responsibility, and/o r
accountability to the integrated de-
livery systems' IT organization.
Each of the CNEs participating
in the research demonstrated com-
petency in and applied the majori-
ty of
the
AGNE capabilities to tJieir
IT-related decision making. How-
ever, those competencies corre-
sponded to older, more established
types of technology, such as email,
office productivity software, and
business analysis tools. The gaps in
CNEs' technology-related knowl-
edge, as identified via ethnograph-
ic interviews, pertained to the
AGNE competencies requiring: (a)
an awareness of societal and tech-
nological trends, issues, and new
developments as they relate to
nursing; and (b) proficient aware-
ness of the legal and ethical issues
related to client data, information,
and confidentiality. It is im perative
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 uti-
lization of HIT across the co ntinu -
um of patient care settings. Emo-
tional intelligence ranks high on
the scale for skills used today in
the life cycle of HIT, but that will
not suffice for knowledge in abili-
ty 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 sam e issues th at affect
HIT-related decision making in
IDSs have relevance in for-profit
institutions, smaller health care
facilities, and stand-alone hospi-
tals.
Additionally, follow-up re-
search could examine the role
structured committees of corpo-
rate-based CNEs play in technolo-
gy education and life cycle. This
could be the differentiating com-
petency from operational site-spe-
cific CNEs and clarifying the role
of the corporate CNE of IDSs.
Additionally, studies centering on
CNEs' contribution to the automa-
tion of key nursing processes, such
as the development of nursing sci-
ence-based workflows, would be
useful. Another pressing need re-
volves 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 man-
aging 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 be-
comes a core com petency for CNEs
in organ izations of all sizes. As the
CNE role expands to take on more
organizational and financial res-
ponsibility for patient outcomes,
HIT becomes a key clinical and
operational enabler of quality pa-
tient 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 per-
spective as well. Eocusing on how
CNEs leverage HIT to meet their
organizations' business goals should
be a research imperative.
onclusions
Despite the fact that few tradi-
tional graduate programs in nurs-
ing and business teach these fun-
damental 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 infor-
mation systems. Specifically, CNEs
must view these advanced tech-
nologies from a strategic and oper-
ational perspective that ñne-tunes
the systems' architectural design,
workflow, and processes for de-
ployment in the patient care envi-
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N E s s it a t t h e e x e c u t i v e t a b l e d u r in g t e c h n o l o g y
e v a l u a t io n s a n d r o u t i n e l y f i n d t h e m s e l v e s i l l
p r e p a r e d t o d e b a t e w i t h t h e i r p h y s i c ia n c o u n t e r p a r t s
t h e f u n c t io n s o f t h e c l in i c a l in f o r m a t io n s y s t e m s
ronm ent. Add itionally, 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 second-
ary position behind the require-
ments delineated and champion-
ed by physicians.
This research asked a single,
pivotal question: What is the
state of CNEs' HIT-related deci-
sion making comp ared to the com-
petencies outlined in AONE's rec-
ommended information technolo-
gy com petencies? The answer to
that question was two-fold. CNEs
demonstrated competency in and
applied the majority of the AONE
competencies to their decision-
making process related to the eval-
uation, selection, deployment,
and utilization of HIT. However,
the majority of the CNEs did not
demonstrate a competency specif
ic to AONE's call to dem onstrate
an awareness of societal and tech-
nological trends, issues and new
developments as they relate to
nursin g (AONE, 2011 , p. 10).
In recognition of the critical
need for CNEs at hospitals of all
sizes to acquire and maintain cur-
rent knowledge of HIT, it is time
for the profession to enlist the
help of academic leaders and reg-
ulators in the effort to build a
learning infrastructure capable of
building a wide and deep HIT
comp etency for CNEs in Am erica.
Credentialing organizations
and accreditation agencies, such
as AONE Certification Center,
National League for Nursing
Accrediting Commission, Ameri-
can 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 lev-
els 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, marginaliz-
ing the profession. $
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