Early in my nursing career, I was able to compare pre-computer-supported nursing practice to nursing practice after the integration of computers in healthcare. I graduated from Church Home and Hospital’s diploma program in 1969, served in the Army Nurse Corps - including a year in Vietnam, and returned to civilian life in 1972. On leaving the Army Nurse Corps, I began trauma nursing at Maryland Institute for Emergency Medical Services System (MIEMSS) - the first shock-trauma unit in the United States - and stayed there until January 1978, earning my BSN during that period. I left MIEMSS for about a year, exploring nursing in other settings. I returned to MIEMSS in September 1979, while beginning work on my Master of Science degree in nursing at the University of Maryland.
While I was away, the MIEMSS director had installed dumb terminals (VT 52s) at each bedside in the trauma unit. (A dumb terminal was state-of-the-art at the time. Dumb means the terminal had no independent functions. It depended on a host computer for all processing.) Work was well underway on developing a patient data management system (PDMS) for capturing data at the atomic level and returning that data to clinicians for decision support. The computers were dual PDP 11 minicomputers, from the Digital Equipment Corporation (DEC), connected together to provide near-simultaneous duplicate databases and 24/7 availability. VAX minicomputers from DEC replaced these PDP minicomputers sometime later, and VT100 dumb terminals replaced the older terminals.
Working the night shift while attending graduate school, I would play around with the functions on these terminals. I saw the potential benefits for nurses of collecting and managing patient data with this technology. I wanted to see more nursing-related data. Through asking about this possibility and showing an interest, I became the computer nurse. The futuristic vision we had was supporting clinical practice through data capture, returning the data to the clinicians in multiple formats, and helping clinicians transform data into information.
The greatest part of my computer/technology related knowledge was self-taught. Formal educational offerings in this area were lacking for nurses, since nursing informatics did not exist as a concept. In the beginning, I knew nothing of programming or hardware. I read everything I could, asked tons of questions, attended early conferences on nursing and computers, and practiced, practiced, practiced. I took a PASCAL programming course and, while successful, learned I was not, at heart, a programmer. My formal focus in the graduate program was staff development education, because a specialty in computers or informatics did not exist. My thesis, however, was a study of nurses’ attitudes towards computers in the clinical setting.
I left MIEMSS and joined a company called Quantitative Medicine, Inc. (QMI), which was a developer of clinical information systems. There, I designed applications, built individualized datasets, managed trouble calls, developed and taught implementation classes, conducted some small-scale evaluation studies, and performed a myriad of other activities.
At this time, I was accepted into the PhD program at the School of Nursing, University Of Maryland, but there was not a specific informatics track at the doctoral level. Each student chose an indirect care or direct care focus and developed his or her own specialty knowledge through course work and independent study. I published articles on databases, clinical information systems, and the nursing implications resulting from the implementation of these systems. As my expertise grew, I made local and national presentations. My research focus was the effectiveness for nurses of patient data management systems.
In 1987, I left QMI to work with another information system vendor. I earned my doctorate in 1989 and joined the American Nurses Association (ANA) as the senior policy fellow for research and databases. My primary focus was supporting the work of the Steering Committee on Databases to Support Clinical Nursing Practice. This committee of ANA members - prominent in all areas of nursing informatics - worked on identifying data sets, nomenclatures, and taxonomies that supported clinical nursing practice. Within this scope of work, I covered the National Library of Medicine’s Unified Medical Language System (UMLS), The Omaha System, North American Nursing Diagnosis Association, Nursing Interventions Classification, Nursing Outcomes Classification, Home Health Care Classification, and SNOMED – among others. I worked with the initial volunteer group promoting the computer-based patient record – the Computer-based Patient Record Institute (CPRI) – to enact the findings of the Institute of Medicine’s report on such records and enabled ANA to be an initial voting member of the CPRI.
In the area of technical informatics standards, I represented ANA (and, it turns out, all of nursing) in many volunteer standards development organizations (SDOs) and organizations that approved such standards. These included Health Level 7, where I co-chaired the patient care special interest group, ASTM’s Committee E31, American National Standards Institute (ANSI) and the Health Information Standards Planning Panel (HISPP). I participated in federal government groups as an informal advisor, working on telehealth standards and informatics technical standards. One of these groups was the Joint Working Group on Telehealth. For most of my time at ANA, I usually was the only nursing representative at these meetings.
During my tenure at ANA, I wrote the document that led to ANA establishing nursing informatics as a nursing specialty (1992). I chose the task force members to work on the scope of practice for nursing informatics, coordinated the work, and edited and directed the publishing of the Scope of Practice for Nursing Informatics (1994). Another task force followed, leading to the book, Nursing Informatics Standards of Practice, published in 1995. The members of both task forces worked very hard, giving up weekends to work collaboratively on a very new territory for all of us. The American Nurses Credentialing Center used these publications, as well as many others, to develop the first nursing informatics certification examination.
I believe that some of my most important work took place in the national technical standards area. Here, in many committees and task forces, I was the only registered nurse for many years. My responsibility, as I saw it, was to make sure that all documents that addressed informatics in healthcare had to use inclusionary language. For example, ‘physicians’, as a term, would not be separately named, as in ‘physicians and healthcare professionals’. I pushed for and achieved adoption of terms, such as healthcare informatics, that were more general in nature. Reminding standards developers that the acute-care hospital was not the only place to use informatics was another goal – one I was not as successful in achieving. Overall, I believe I changed how non-healthcare informatics professionals viewed healthcare and nursing practice. Likening my endeavors to the action of ‘water on stone’, I just kept pushing, politely and firmly, backed up by my knowledge, experience, and the literature. I am proud of this achievement. It was hard work, but I met many wonderful people who supported me and who listened to me.
I left the ANA in 1998 to hold the first endowed chair in nursing informatics at the University Of South Florida School Of Nursing in Tampa, FL. In 1999, I began an independent practice in informatics, engaged in consulting, teaching, and other activities. One project that helped me later on was creation of a tutorial to help informatics nurses prepare for the ANCC certification examination. Using the test content outline (TCO) and all of the recommended readings, I developed a set of slides and notes for both in-person and webinar presentations. I acquired a very detailed knowledge of that outline and the content underlying it.
Beginning in January of 2007, I consulted for Walden University on the design and development of the graduate nursing informatics curriculum for the school of nursing. In June of that year, Walden University appointed me as the specialization coordinator for nursing informatics in the School of Nursing. In this role, I continued the development of the informatics specialty courses, managed the regular updating of those courses, taught the courses, managed a group of faculty members, and performed other typical faculty activities.
In 2010, I was hired by Chamberlain College of Nursing (Chamberlain) to develop the graduate-level NI track. It was my responsibility to plan the entire set of courses in the track. To guide this development, I drew again on the most-current version of the ANCC test content outline for the NI certification examination. The work I had done earlier on the tutorial was a wealth of notes and other resources. Early in the design process, Chamberlain committed to preparing the NI specialty students for the ANCC certification through the organization of the content and requiring a minimum of 200 hours of faculty-supervised practice. Following the initial planning time, the development of each course in the track was a collaboration of me, Toni Hebda, and Dee McGonigle, who joined Chamberlain as full-time faculty in 2011. We have been collaborating on research, publications, presentations, and course improvements ever since.
From computer nurse to informatics innovator, I have had the great joy to be involved from the early days of this exciting, innovative, ever-changing nursing specialty. As a pioneer in this field, I have helped shape the formation and evolution of nursing informatics. Through NI, I have contributed positively to nurses, the nursing profession, and patients – our reason for being.
Dr. Hunter is the Dean for the Master of Science in Nursing (MSN) indirect-care tracks at Chamberlain College of Nursing. She has been the subject-matter expert for development of the nursing-informatics-specialization courses in the master’s program. Dr. Hunter began her nursing education with a diploma in nursing and subsequently earned a BSN, MS, and PhD. Her clinical practice was mostly in trauma and critical care nursing. For the past 35 years, Dr. Hunter has specialized in nursing informatics, providing leadership at local, national, and international levels in many dimensions of this specialty. Her research interests focus on the impact of electronic health records and clinical information systems on nursing practice and caring, the unexpected consequences of health informatics, and measuring informatics competencies. She has published and presented nationally and internationally.