Nursing Informatics and

Leadership, an Essential
Competency for a
Global Priority:
eHealth
Pamela Hussey, PhD, MSc, MEd, RN, RCN, Elizabeth Adams, MSc, HDip (Stats), Dip
(Phy & Chem), Dip (Counselling), Dip (Mgt), BNS (Hons), Cert (ODN) RGN, FFNMRCSI,
and Franklin A. Shaffer, EdD, RN, FAAN

C ontemporary healthcare delivery is at an

intersection. On one hand, policymakers
and researchers strongly advocate self-care manage-
ment programs, patient empowerment, and promo-
tion of community-based services. Conversely,
hospital centrism and hyper-specialization contin-
ue to prevail. Reporting in 2008, the World
Health Organisation (WHO) argued the case that
the medical model invariably fails to deliver
affordable, accessible, and equitable health for
citizens.1 This failure can be linked with strong
commercial undertones and medical models
that, from the patient’s view, often results in a
fragmentation of care. Since this report was pub-
lished by WHO in 2008, the need to address the
fragmentation of care unfortunately persists. More
recent resources by WHO include an eHealth Toolkit
that provides strategic guidance to leaders in relation
to an eHealth vision for all.2

T he implications on failing to address care fragmentation

culminates in the persistence of poor care co-ordina-
tion, and in some cases, limited access to critical informa-
Nursing leaders, both independently and collectively with
the multidisciplinary team, are therefore required to deliber-
ate on how fragmentation of care can be addressed to
tion at the point of care delivery. This potentially impacts advance care co-ordination and present pragmatic solutions at
negatively upon clinical decision making and the optimiza- a local, regional, and national policy level.6,7 In some
tion of patient outcomes.3 As a consequence, uptake and use instances, nursing leaders are developing expert reports on
of technology for integrated care co-ordination are increas- the responsibility of the profession on core nursing interven-
ingly reported upon as a core requirement to tackle frag- tions in healthcare delivery.6 Areas in which nursing engage-
mentation of care.4,5 ment is proving effective include discharge planning and

52 Nurse Leader October 2015

e-prescribing.7-9 In order to build on existing therapeutic workflow for service co-ordination. Critical factors influenc-
relationships with patients, nurses must consider revisiting ing new roles and the associated alignment with informatics
existing practices and creating new initiatives for advancing competencies for eHealth action plans are now considered
the eHealth patient-centered agenda. The approach offered in from the perspective of the eHealth patient.
this paper advocates the growth of nursing informatics com- Often described as a consumer of healthcare, the eHealth
petencies as one method that can be used to support nursing patient requires collaborative efforts with the health team to
leadership globally to address the challenges ahead. Nursing acknowledge the individual’s voice in decision making.
informatics competencies at a foundation level include an Healthcare practitioners, therefore, will be required to partici-
ability to source and retrieve best available evidence use of pate in innovative dialogues with the patient in order to assist
information and communication technology (ICT) effective- the consumer to achieve an optimum state of health and
ly and responsibly, and understand the core concepts for well-being. Overarching objectives for the eHealth patient is
documentation of patient-centered care in an electronic to remain in his or her respective community environment,
health record. maintain optimal independence, and choose self-care strate-
gies that address individual health complexities. Essentially,
BACKGROUND healthcare professionals become a part of a multidisciplinary
Global trends are driving the need to address fragmentation of team who provide a supporting environment and offer neces-
care and the promotion of integrated care co-ordination. sary information for consumers to make critical decisions on
Predictive models on health and social care requirements for treatment programs.5
the next quarter of a century report a staggering shift in popu- Other crucial elements of the management of eHealth
lation age, multimorbidity, and complexity of need. Between patients are the support available to the patient from their
2000 and 2050, the proportion of persons over age 60 is esti- family and the environmental supports available to the family
mated to double from approximately 11% to 22%, and the to address patient need. Emerging stakeholders, such as carers
number of individuals age 80 and over will quadruple to 395 and supplemental care delivery agencies, are increasingly
million by 2050.10 From a policy perspective, cost containment targeted for additional funding through redefined governance
is critical; the balance between acute care and chronic condi- structures. The primary goal is, therefore, to control symptom
tions management needs to be redirected toward self-care management by using and supporting self-managed care
management programs that can operate across and between processes. In advancing self-management skills development,
health and social care service providers. The rising burden on the potential impact that nursing practitioners can offer users
healthcare service delivery grounded on existing and predicted , in association with service reform in both Ireland and the
global trends requires prioritizing of two core population United States, ultimately emphasizes enhanced patient out-
groups in particular: the elderly and those with multimorbidity comes.17,18 Nursing practitioners, as one of the largest stake-
of noncommunicable diseases.11 For example, it is estimated holder groups in service delivery, are regarded as instrumental
that 80% of cardiovascular disease–related premature deaths in expanding the use of ICT with users, their families, and as
could be avoided if primary causative factors (smoking, dyslipi- part of the healthcare team for enhanced service co-ordina-
demia, hypertension, diabetes, and obesity) were reduced tion and integrated care provision. So, for nursing leaders,
through adoption of a healthier diet, exercising, and smoking although the eHealth patient may not seem like an obvious
habit cessation.12 In the European Union, initiatives, such as starting place to link with future leadership agendas, there is
the ENS4Care program, emphasize prevention, thus actively much evidence to suggest that existing nursing expertise
engaging with the development of guidelines on eHealth, needs to be translated early at the design stage of planning
nursing, and social care.13 This is primarily due to the fact that eHealth initiatives. Informatics competencies can therefore be
97% of health budgets are currently spent on treatment, considered a critical commodity to advance the nursing voice
whereas only 3% are invested in prevention.7,13 Targeted initia- to support the eHealth patient.
tives that redistribute proportions of national health policy
budgets for prevention and patient-centered assessment offer Nursing Theory Models and eHealth
opportunities to address gaps in service provision. Such When taking the time to reflect upon key principles which
approaches are increasingly evident in literature.14-16 underpin the progression of the eHealth patient, we find
there is also a strong correlation with established nursing
THE eHEALTH PATIENT theory and models. Nursing models are described as abstract
The process of eHealth demands a paradigm shift in how theories that use general measures and present a reference
healthcare practitioners view and engage with health and framework for advancement of nursing. Nursing theories can
social care delivery. eHealth is defined as the use of ICT for be described as assisting in the development and validation of
health, and in the broadest sense, can be described as initia- models of nursing for practice.19 The application of some of
tives that improve the flow of information, through electronic the existing nursing models to new care delivery models in
means, to support the delivery of health services and the eHealth is therefore a useful activity to explore. For example,
management of health systems.10 seminal work by Corbin and Strauss20 published in 1991
From the perspective of nursing leadership, one needs to presented empirical work supporting a theory for a trajectory
comprehend the potential impact eHealth offers to improve model for chronic disease management. In this theory, the

www.nurseleader.com Nurse Leader 53

authors identify the patient, the environment, and behavioral patient-centered care.29 The American Organization of Nurse
change as essential concepts to consider when defining Executives identifies information management and technolo-
patient-centered care plans for chronic illness management.20 gy as one of the key competencies to shape the future of
This trajectory model defined by nursing researchers presents healthcare through innovative and expert nursing leader-
a solid framework from which to not only build care plans ship.30 In countries such as Sweden, nursing leaders have
and test new theories, but also consider eHealth initiatives established informatics strategies for future integrated models
when shaping future models of care. eHealth is primarily of eHealth. Such strategies by nurse leaders are well aligned
concerned with using ICT to access information. That is, one with WHO national eHealth actions plans.2,6 For example,
of its benefits is to source the right health information to the taking time to ensure that essential resources and benefits are
right person at the right place and time in a secure, electronic identified for future deployment and evaluation, realizing a
form to optimize the quality and efficiency of healthcare shared national vision, and targeting specific projects in
delivery, research, education, and knowledge (WHO toolkit).2 which eHealth can provide enhanced service efficiencies.
It primarily involves using ICT in three distinct areas: elec- Nursing leaders as part of the multidisciplinary team will
tronic health records, telehealth mobile health, and the use of contribute to defining the building blocks and the most
e-learning initiatives by healthcare professionals for continued effective and practical approach in varying contexts to make
education. In order to create electronic health records that this vision a reality. Examples at a European Union (EU)
support integrated care, interoperability, and standardization is level, include the European Foundation Nursing Association,
required.21 Using resources such as the trajectory model as a who in an EU-funded program entitled ENS4Care, are
springboard in the application of electronic healthcare record defining clinical guidelines based on best practice evidence
design provides a common frame of reference to build data across EU member states. Recent deliverables from this pro-
platforms and create standardized health data records. gram in relation to advanced nursing roles describe eHealth
Standardized eHealth information that is of high quality, as The use of ICT in services and processes, combined with
reliable, and affordable can then be agreed upon to create new skills, to improve the health and well-being of all citizens
electronic health records, pathways, and care plans using an and efficiently to deliver person-centered, coordinated health
integrated and more holistic care approach that strongly and social care to those with complex needs.
aligns to philosophy of care used in nursing theory genera- The ENS4Care Study7 identifies key characteristics of
tion over many years and that is clearly demonstrated in the eHealth as shown in Box 1.
existing literature base.17,20,22-25 Consequently, the profession
can use this knowledge to play a significant role in defining Box 1. ENS4Care Characteristics of eHealth Services7
core requirements and shaping data-requirement gathering
processes for future eHealth services delivery and reporting 1. Use of an ICT component that can support the
mechanisms for safety and quality of care. delivery of care
Locating nurses as thought leaders and change agents in
instigating programs for the adoption, integration, and use of 2. Involvement of nurses and/or social workers
eHealth services, therefore, is based on sound logic. Existing 3. Potential for cost effectiveness
and potential roles, on the focus, position, titles, and activities
of more advanced nurse informaticians have been identified 4. Capacity for patient empowerment
by Nagle.26 In her research on nursing roles in informatics, 5. Proven usability, usefulness, and user-friendliness
she identifies 12 specific roles with numerous associated posi-
tions and activities. Examples described include roles relating 6. Consideration and respect for patient centeredness,
to change leadership such as chief information officer, whose privacy, and safety
associated activities include strategic planning and activities in
design planning, or roles relating to change management with
associated project management roles relating to operational
management and service efficiencies.26,31 ENS4CARE WP4 ADVANCED ROLES
eHealth deployment costs are acknowledged as substantial. It is clear from the evidence at national and international
Appropriate design implementation strategies are needed to levels that key priorities for nursing leaders on a global scale
optimize cost effectiveness.27 Assimilating existing nursing are therefore to determine the strategic context for short-,
knowledge on chronicity with eHealth solutions will result in medium-, and long-term objectives by developing a strong
more practical applications for health and social care provi- vision for next-generation models and theories of eHealth
sion. Broadly speaking, there are two core roles in informat- services and care provision. This priority is reflected well in
ics: the informatics specialist and the clinician who must use the International Medical Informatics Association Special
health information technology. Therefore, one could argue Interest Group definition of nursing informatics, which states
that every nurse has a role in informatics.26,28 that nursing informatics is a science and practice that inte-
Prioritizing informatics competencies within strategic grates nursing, its information and knowledge and their man-
nursing leadership roles can progress the best available fit for agement with ICT to promote the health of people, families,
effective uptake and use of technology-enabled solutions for and communities world-wide.31 Practical approaches on

54 Nurse Leader October 2015

advancing eHealth include determining high-level resource DISCUSSION
requirements as outlined in the WHO eHealth Action Plan.2
One of these resources promotes nurses across all sectors of Why eHealth Needs Nursing Informatics Examples From
health service delivery with informatics competencies. In the Practice and Policy
following section, we summarize some of the existing com- The nursing informatics role is critical in many aspects of
petencies in informatics as outlined by global networks in eHealth service delivery. Defining concepts and frameworks
nursing informatics. from existing models of nursing care delivery, and designing
interfaces and access to emerging technologies for the testing,
Informatics Competencies a Priority for Nursing evaluation, and management of eHealth services to ensure
Engagement in eHealth that they are fit for purpose demonstrate some of the activi-
The development and scope on defining global and national ties that have been discussed in this paper. Existing policy
nursing informatics competencies is at an advanced stage aspirations on quick eHealth solutions fashioning an ideal
internationally. The TIGER Initiative,32 created in 2004, world need to be recognized for what they are: false dawns. It
established a global nurse led initiative relating to is highly unlikely that rapid implementation chains can
Technology Informatics Guiding Educational Reform. address existing barriers and circumvent problems in short to
Revisiting core values in nursing care delivery, TIGER’s immediate term. There is little doubt that the process for
core objective is to educate the nursing workforce on adop- defining requirements and delivery of eHealth services will
tion and use of technology in healthcare,32 thereby con- take time.37 Recent media reports from the United States on
tributing and supporting initiatives globally that can eHealth programs suggest that they are failing to deliver
advance nursing involvement in creating a new paradigm of anticipated benefits thus far.38-41 Reports suggest that organi-
eHealth service delivery. In 2008, the American Nurses zational culture is a critical factor that requires much respect
Association published standards of practice for the informat- in transformation and healthcare delivery, particularly in
ics nurse specialist.33 Integration of formal nursing infor- regard to patient safety. It is important that nursing leaders
matics competencies in undergraduate and post-graduate take stock of existing core values inherent in the profession
nursing education is integrated in most countries world- such as advocacy and ensure that they are safely migrated into
wide. For example, the 2015 European strategic direction next-generation models of eHealth services. In the United
for strengthening nursing and midwifery toward Health Kingdom, reports advise that the evolving sociopolitical and
2020 goals identifies scaling up and transforming education sociotechnical factors are key issues for careful considera-
to ensure qualified and competent nurses are available to tion.42 Strategies grounded in pragmatism, efficiently ana-
meet changing population needs, with health technology as lyzed and carefully critiqued with wide stakeholder
a priority.34 Health 2020 is the European policy framework engagement are widely recommended in the evidence base.
for health and well-being, adopted by 53 member states, Such approaches ensure that the context of healthcare service
which supports an integrated whole-of-government and delivery can be comprehensively defined for the proposed
whole-of-society approach targeting the determinants of intervention processes to be well understood and the patient
health. Health 2020 presents the social and economic outcomes can be both optimized and evaluated for anticipat-
imperative for action, demonstrating that health and well- ed benefits.43,44
being are important states and essential for economic and Ideally situated to offer experience of care flow mecha-
social development.35 nisms and expertise on holistic care models, nursing leaders
In Canada, the Canadian Association for Schools of and the teams that they manage can provide realistic, achiev-
Nursing created an online resource on entry-to-practice able project plans at local, national, and regional levels. As the
guidelines for nursing graduates.36 Professional journals largest stakeholder group in care delivery, nurses possess good
relating to nursing informatics are also available, such as insight into critical requirements needed to ensure complexi-
CIN Computers in Nursing and Online Journal of Nursing ty-of-need requirements are met and when they are not
Informatics. Although informatics publications are not limited being met.45 Feasible approaches toward health and social
to these journals, they do offer nurses an opportunity to care reform, specifically on eHealth initiatives such as devel-
publish their experiences and learnings from practice, edu- opment of electronic health records, requires clinical input to
cation, and research.26 contextualize subtle and hidden informal practices. For
Common threads that appear in most competencies example, informal communications on discharge planning
include the ability to: and education with the patient on medication management
• Identify and use relevant concepts and terminology to fall along the realm of nursing care.45,46 Examples from
support the delivery of nursing practice within the elec- Canada on the deployment of C-Hobic, a discharge dataset
tronic health record in which nursing engagement has been optimized across
• Use ICT in accordance with professional and regulatory design and delivery processes for collection of patient-cen-
standards tered outcomes offers much needed evidence on cost-effec-
• Support the delivery of evidence-informed care of the tive and efficient service deployment.9
person, including how to access and evaluate appropriate From the perspective of vision, nursing leaders in consid-
resources, and the ethical and legal aspects of using ICT ering competencies must be cognizant of the opportunities

www.nurseleader.com Nurse Leader 55

that electronic data present to the profession. Theoretical present nursing leaders with opportunities to contribute to
frameworks provide building blocks to test new theories and future eHealth and social care delivery. Early examples in
provide evidence to enable more effective and efficient health areas such as discharge management9 and nurse e-prescrib-
and social care delivery mechanisms. They also provide data ing49 are two initiatives that are demonstrating the nursing
to illustrate the nursing contribution in eHealth service pro- contribution well. More examples will surely follow. Initially
vision. Tactically, this approach can facilitate core require- promoted by Hippocrates, the return to holistic, patient-
ments to maintain existing funding and secure future funding centered care, shifting from illness to wellness models, is based
requirements to optimize skill mix and safe patient care.47 on sound logic. What is now required is for health service
Recent evidence suggests that a skilled nursing workforce providers to recognize the significant contribution that nurs-
can directly impact on mortality rates in the acute care sec- ing as a profession can offer for advancing the eHealth agen-
tors. Targeted policy initiatives, such as the advanced nursing da. Transformation of healthcare services is an emotionally
role established in many countries, present nurses with new charged process. Future eHealth programs of care require
career opportunities. Initial findings from new roles illustrate strong nursing leadership to optimize patient safety. NL
cost efficiencies, including positive effects on patient safety,
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