Francis, I. (Feb, 2017). Nursing Informatics and the Metaparadigms of Nursing. Online Journal of Nursing Informatics (OJNI), 21(1), Available at http://www.himss.org/ojni
Technology has entered every aspect of health care, including interactions between nurses and patients. However, a number of factors influence this interaction. The nurse’s perception of technology is a primary factor in whether or not it will be successfully employed. Yet few ethical frameworks or theoretical models have been developed to help guide nursing practice in the technological environment. Knight and Shea’s (2014) Empowerment Informatics Framework was developed out of an examination of health-enabling technologies within the context of nursing informatics. Still, a broader, more comprehensive model is needed that can be used by clinicians and researchers. Returning to the metaparadigms of nursing provides a starting point for model development. Nursing informaticians are uniquely positioned to develop models and frameworks for the ethical and effective integration of technology and caring science.
The nursing metaparadigm is a conceptual framework that demonstrates the interconnected nature of nursing, person (patient), environment and health. Examination of the impact of technology on the practice of nursing is well served by use of this framework, which has been nursing’s foundation from Florence Nightingale forward. This paper will present three different viewpoints of technology and nursing practice; nurse perceptions and utilization of technology within an inpatient acute care setting, an over-arching examination of the ethicality of the use of technology in the science of caring, and nurse and patient perceptions of utilizing health-enabling technology in an outpatient community setting. The role of the nurse informatician (NI) will be represented at the intersection of nursing, person, health, and environment.
Nursing Perceptions as a Fundamental Priority
Technology can have no impact if nurses do not use it in practice. Similarly, it is not a viable tool for patients if they do not engage with it. When nurses and patients engage in the use of health information technology (HIT), ethical guidelines facilitate the preservation of the patient’s rights and dignity when interacting in the technological environment.
The Impact of Nursing Perceptions on the Use of Technology in Practice
Perhaps the most basic aspect to consider when examining the impact of technology on nursing practice is whether the nurses’ perception of or attitude toward the use of technology in practice is a limiting factor. Piscotty, Kalisch and Gracey-Thomas addressed this question in their 2015 study, which examined the relationship between nursing care reminder use and missed nursing care. Utilizing a descriptive study design (N = 165), data was collected from all 19 nursing units in a large teaching hospital in southeast Michigan. Multiple regression equations were utilized in order to determine whether nurses’ negative perception of technology affected their appropriate use of electronic reminders. The researchers found a statistically significant direct association between missed nursing care and reminder usage, supporting their hypothesis that nurses’ perceptions of the impact of health information technology is an important mediator in the relationship between reminder usage and missed nursing care.
Structure, Process, and Outcomes Model of Healthcare Quality and Nursing Perceptions
Piscotty et al, (2015) used the Structure, Process and Outcomes Model of Healthcare Quality as a conceptual framework for their study. In order to understand the relationships between nursing care, nursing structure and process, and patient outcomes, a systems approach was utilized, as organized by this model. Dependent, independent and mediating variables were conceptually defined, and empirical indicators were developed and operationally defined. This allowed the researchers to quantify behaviors, and isolate factors affecting specific behaviors and their impact on outcomes. The end result was both a visual representation of the concepts placed into the flow of the framework and the statistical analysis that supported the hypothesis.
Integration of this model into research about nurses’ use of technology provided a logical scaffolding for the development of the study design and a way to communicate essential concepts in a diagrammatic manner. The structure (input) studied was electronic nursing care reminders. Processes (throughputs) were nurses’ perceptions of health information technology and frequency of reminders. Outcomes (output) were incidences of missed nursing care (Piscotty et al. 2015). This seemingly simple model enabled these researchers to validate their hypothesis that nurses’ support for the utilization of HIT is critical to its efficacy.
Importance of Theoretical Frameworks in the Application of Technology to Practice
The existence (or lack) of theoretical frameworks that support nurses to conceptualize the application of technology to practice is an emerging concern for nursing informatics. The idea that technology is a panacea to solve the ‘Iron Triangle’ of access, quality and cost is too simplistic. The use of technology must be guided by greater comprehension of its ultimate goal, impact and benefit. Theoretical frameworks can be utilized for this purpose.
Technology and Ethics – a Missing Framework
The ethical use of technology within the context of caring is an important point of study for nursing informatics. Korhonen, Nordman and Eriksson (2015) framed this discussion utilizing a caring science approach, with a spotlight on ethics, human good, and the absolute nature of patient dignity. The authors accessed Medline and CINAHL databases, constructing an advanced search that limited results to five-star sources, written in English in the years 2000-2013 to examine the concept of technology and the meaning of ethics within that concept in the nursing literature.
Using an integrative approach, the authors explored technology as a concept, the ethics of technology, and existing models for ethical use of technology in nursing and medicine. Technology was differentiated into three sub-concepts; technology as a process, a service, and a device or product. Ethics was less evident in caring and nursing literature, and was described as evaluation of risks, benefits, or unsolved problems. Finding technology’s ethical connection with fundamental aspects of caring science was difficult: the authors concluded that current models promoting safe and ethical care are insufficient, and research into methods and processes as well as additional legislation must be undertaken in order to ethically integrate technology and caring science (Korhonen, Eriksson, & Nordman, 2015).
No over-arching model or framework for ethical use of technology in nursing practice was identified by this study. The need for a framework or conceptual model which addresses all three dimensions or facets of the ethical use of technology in nursing was identified as an important goal for ongoing research, and warranted a call for legislation and resources (Korhonen et al., 2015).
Role of Health-Enabling Technology and the Empowerment Informatics Framework
Equally important is the ability of the nurse to integrate the use of health-enabling technology into the patient’s care plan. Knight and Shea (2014) examined the key relationships between patient behaviors, patient characteristics and patient-defined goals, and the role of health-enabling technology (HET) in supporting these relationships within the context of nursing informatics. Citing rising costs associated with chronic illness and patient preferences for aging in place, this study prioritized outpatient rather than acute care. Combining existing nursing theory on how patients self-manage with existing informatics theory on nurses’ use of technology, the authors presented their Empowerment Informatics Framework (EIF) for guiding the integration of the two, to promote ethical use of patient-empowering technology by practicing nurses (Knight & Shea, 2014).
Employing a concordance model (as opposed to compliance), the EIF focuses on empowering the patient to learn to live with a chronic condition by incorporating relevant knowledge, practical skill and personal experience/preferences. Using information and communication technologies, nurses collaborate with patients to promote achievement of their own concept of health rather than on specific targets externally set and enforced. Promoting the nursing values of patient advocacy, quality of life, freedom of choice, dignity and support of patient values, the EIF provides a basis for research and practice (Knight & Shea, 2014).
Empowerment Informatics Framework and the Informatics Research Organizing Model
Knight and Shea (2014) made use of Effken’s (2003) Informatics Research Organizing Model (IROM) in developing their Empowerment Informatics Framework (EIF). The IROM is comprised of two component models. One is represented by an inner sphere with a unidirectional, circular flow of the elements (phases): plan, analyze, design, implement and maintain. In the other, outer circles have a bi-directional flow between the elements of context, outcomes, nursing informatics intervention and client. The outer circles encompass the original Informatics Research Organizing model. The inner sphere is a model of the systems development life cycle, with evaluation between each phase (Effken, 2003). This model guided the researchers in their development of a community-based framework, into which they infused the nursing metaparadigms of person, nursing, patient and environment.
The Empowerment Informatics Framework centers on the empowered patient within an environment inclusive of community and nursing. Defining patients’ unique characteristics and context as ‘health force’, the EIF demonstrates relationships between nurses in collaboration with patients using health-enabling technologies (HET). Self-management, health force, and patient-defined goals are the heart of the model, represented by three interconnected ovals with bi-directional arrows. They are encompassed within the sphere of the empowered patient. Nursing interacts with the empowered patient using HET (informatics) which communicates with and supports self-management and health force. The sphere of the nurse overlaps with the sphere of the patient in the areas of shared understanding and mutual goals (Knight & Shea, 2014).
The EIF framework supports both quantitative and qualitative research. It adds a new dimension with the inclusion of self-management interventional goals as a measureable outcome of interest. Including subjective patient-defined health outcomes along with systems-level objective outcome measurements provides a new way of looking at and delivering patient-centered care. This fresh perspective supports informatics nurses to advocate for a patient-focused approach in the application of theory and evidence to patient self-management (Knight & Shea, 2014).
The Role of the Nurse Informatician and the Metaparadigms of Nursing
Nurses specializing in informatics have numerous roles available to them. The ANA scope and standards specify that nurse informaticians (NI) provide a perspective that showcases nursing values and beliefs. The three overarching standards of NI practice are: incorporation of theories, concepts and principles from appropriate sciences into informatics practice; the integration of ergonomics and human-computer interaction (HCI) into the informatics care plan; and the systematic determination of the social, legal and ethical impact of an informatics solution within nursing and health care (McGonigle & Mastrian, 2015). As the NI must first act from a nursing perspective, the writer offers the model in Figure 1 as the sketch or beginnings of a framework for NI practice.
Figure 1: Proposed Framework for NI practice
This rudimentary model places the NI at the intersection of the metaparadigms of person, nursing, environment and health. Each of the NI roles permits the incorporation of these elements into practice. NI roles include those of project manager, consultant, educator, researcher, product developer, decision support/outcomes manager, advocate/policy developer, clinical analyst/system specialist and entrepreneur (McGonigle & Mastrian, 2015). Without reflecting first upon the practice of nursing, the essential element of caring is at risk.
Nursing Informaticians and Varied Practice Settings
Piscotty et al. (2015) embodied the role of informatics researchers in their study of nursing perceptions and utilization of health information technology. Employing transdisciplinary systems theory, they were able to quantify the impact of nursing attitudes toward technology. Recommending that organizations target specific system design or workflow changes to enhance nurses’ acceptance of HIT, they considered ergonomics and HCI. Concluding that positive patient outcomes call for the design of systems with the nurse end-user in mind, they suggest the need for the additional role of NI as system specialist (Piscotty et al., 2015).
Knight and Shea (2014) similarly fulfill the role of NI researchers. By suggesting a new framework for practice and calling for additional research utilizing their model as a framework, they merge into the role of NI as educator. Their approach and model most closely aligned with the metaparadigms of nursing, and highlighted caring as essential to the practice of nursing informatics. By calling for the utilization of a patient-centered model, they alter our conception of technology as a tool to monitor and achieve compliance, to the view where technology is an empowering agent to be used in concordance with the patient.
Concluding that no strong model exists to guide the ethical use of technology in practice, Korhonen et al. (2015) call upon the roles of the NI as researcher, educator, and advocate/policy developer to bring forth such a model. Insisting that nursing is fundamentally a caring science, they challenged nurse informaticians to create a model which embodies the metaparadigms of nursing.
Nursing informatics is an expanding field with multiple practice settings. In any given setting, effective utilization of technology by nurses benefits from nursing informatics interventions. Although much has been written about the impact of technology in health care, a model for its ethical use in nursing practice is lacking.
Returning to the metaparadigms of person, nursing, health and environment places nurse informaticians at the intersection of nursing, health as perceived by the patient, the technological environment, and the person/patient as an empowered participant in self-care. Practicing from this center within the context of nursing as a caring science, nurse informaticians ensure that core nursing values are not diminished or compromised by technology. Nursing informaticians can contribute significantly to the creation of frameworks and models to guide nurses in the ethical and appropriate use of technology, facilitating an understanding and appreciation for its use as a benefit to both patients and clinicians within a patient-centered care milieu.
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Piscotty, R., Kalisch, B., & Gracey-Thomas, A. (2015) Impact of healthcare information technology on nursing practice. Journal of Nursing Scholarship, 47(4), 287-293. doi: 10.1111/jnu.12138
I am currently completing a Master’s of Nursing Science (MSN) degree in the specialty area of Informatics. My curriculum has been 100% online until this point, however in January, 2017 I will begin a three-month internship with Guy Hembroff at Michigan Technological University. I anticipate learning a great deal from my internship, and being able to bring my experience and clinical frame of reference to ongoing projects.
I have been employed in the health care field since the early 1980’s. I started as a specimen clerk, worked my way up into a position as medical secretary, medical biller, medical practice manager, physician recruiter, and finally had the opportunity to return to school to earn a BSN and become a Registered Nurse. I have seen the industry grow and change since then. This experience, I believe, is invaluable. It gives me the ability to understand how technology, policy, and demographic factors interact in the volatile and quickly changing world of healthcare.
I am passionate about health policy, politics, and health equity. I write my own blog, which has been met with some success. It can be found at https://nursing3p.wordpress.com/ . I truly want to make a difference in bringing health care to all, and believe that by continuing to advocate for rural patients and providers, I can do so. I appreciate your review of my credentials, and hope that I might be able to serve in any appropriate capacity.