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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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hief Nurse Executives Need ontemporary Informatics ompetencies

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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

continued on next page

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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-

NURSING ECONOMIC$/November-December 2013A/ol. 31/No. 6


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SERIES

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

NURSING ECON OMIC /November-December 2013/Vol. 31/No. 6


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N

hief Nurse Executives Need ontemporary Informatics ompe tencies

SERIES

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


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-

NURSiNG ECONOiVIICS/November December 2013/Vol. 31/No. 6


11/13

hief Nurse Executives Need ontemporary Informatics ompe tencies

N

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


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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