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A Boston IT Party--International Re(-E)volutions in Nursing Informatics.

Do we need a revolution in the theory and practice of nursing informatics, or can the discipline evolve slowly to address the emerging possible future(s) and changing issues that face us, and that will affect the practice of healthcare, and of nursing? The word 'revolution' is variously defined; it may be a radical, sudden and pervasive change in an aspect of society and the social structure, or of a discipline, or a thorough replacement of an established system. It can also be a return to a point relatively the same. An evolutionary change is a gradual process in which something changes into a different and usually more complex or better form. Whichever approach we adopt, we need to try to 'future-proof' our thinking and our practice, to improve health and nursing, rather than returning to past approaches or practices that may no longer be of use to us.

With the aid of an understanding of our history and development, nurses and nurse informaticians can be better equipped to consider what they need to do to define the future nature and direction of our disciplines, and consider whether we need a revolution or an evolution in nursing and nursing informatics. The purpose of this article is to stimulate nurses and nurse informaticians to consider this historical development, in particular through the way in which definitions of nursing informatics have changed, but retained certain consistencies. From an understanding of our past development, and with immersion in the realities of the present, we can consider what possible futures we may face, and what factors will determine the future development of nursing and healthcare. As the Spanish philosopher Miguel de Unamuno said, "My aim is to agitate and disturb people. I'm not selling bread, I'm selling yeast" (Wikipedia, 2010); which can be roughly translated into saying that I am asking people to think for themselves, and reach their own answers, rather than my necessarily providing them with ready answers to the issues.

The historical overview of definitions of nursing informatics should be of particular value to younger nurses, and those new to the field, who may not have been as immersed in our history over the past 30 years. While the focus is on nursing informatics, we must always take into account the fact that we do not work in isolation, but that many outside influences exist, which we may not be able to control, and which will have inevitable impacts on the future of health and healthcare, and of our own disciplines.

Nursing has long been concerned with the collection and use of information to support nursing care. Florence Nightingale, considered by many to have been the first nurse informatician (Betts & Wright, 2003), was concerned with the collection and analysis of data. Nightingale is also renowned as an early statistician, and developed graphical representations of data (her coxcomb to illustrate causes of mortality among British forces fighting in the Crimean War) (Betts & Wright, 2006). While the technologies used to collect, analyse and manipulate the data to provide meaningful information may have changed significantly over the years, the basic concerns remain unchanged. The following, written 150 years by Florence Nightingale, suggests that we may not have made a great deal of progress as we would like to believe in resolving some of the underlying issues. She said that:
 "In attempting to arrive at the truth, I have applied everywhere for
 information but in scarcely an instance have I been able to obtain
 hospital records fit for any purpose of comparison. If they could be
 obtained, they would enable us to decide many other questions besides
 the one alluded to. They would show subscribers how their money was
 being spent, what amount of good was really being done with it or
 whether the money was not doing mischief rather than good."
 (Nightingale, 1863)

Nursing has, it seems, long been concerned with information and records, and using them to support and improve care. The underlying purpose of nursing informatics has been similar; it has not been just about using the technology, although sometimes nursing informatics has been criticised for an apparent focus on the technologies at the expense of their appropriate use. Nightingale's words point to the absence in her time of 'fit for purpose' information and records, and to the need show good use of healthcare funds. Despite the advances made, we seem still to be concerned with many of the same basic issues, in particular the need for information to demonstrate that the huge sums of money that go into healthcare, and healthcare technologies, in all countries of the world are improving patient care. We can extrapolate from her concerns, and suggest that, if she were with us today, she might point out the need to appropriately analyse the data we collect to provide meaningful information, use that information to generate knowledge to improve health and healthcare, and that IT systems do not necessarily result in better data quality and use of information.

Evolving definitions of nursing informatics

While the term medical informatics is generally accepted to have been developed in the mid 1960's, the first published use of the term 'nursing informatics' was at the 1980 Medinfo conference held in Tokyo, Japan by Maureen Scholes and Barry Barber, who defined it as "... the application of computer technology to all fields of nursing--nursing services, nurse education, and nursing research." (p.73) (Scholes & Barber, 1980; Thede & Sewell, 2009)

Perhaps the most famous, and still the most widely used and cited definition, is that developed over 20 years ago by Graves and Corcoran (1989, p.227), who defined nursing informatics as a "combination of computer science, information science, and nursing science designed to assist in the management and processing of nursing data, information, and knowledge to support the practice of nursing and the delivery of nursing care." Many other similar definitions and models have been offered over the years, including Turley's model (Turley, 1996), which combined computer science, information and cognitive science with an overall envelope of nursing science. More recently, Simpson (2006, p.5) described nursing informatics as "using technology, research, and professional experience to manage nursing data, information, and knowledge to improve practice and deliver better health care." Good overviews of the many definitions, and their evolution, are provided in Thede & Sewell (2009), Kaminski (2007), Staggers & Thompson (2002) and Guenther (2006).

The world body for nursing informatics, the Nursing Informatics Special Interest Group of the International Medical Informatics Association ( updated its definition at its annual meeting at the NI2009 nursing informatics congress in Helsinki, Finland. Their definition sees that "Nursing informatics science and practice integrates nursing, its information and knowledge and their management with information and communication technologies to promote the health of people, families and communities world wide" (IMIA-NI 2010; Saranto & Casey, 2009). From the IMIA-NI definition, we can identify a range of areas and issues that nursing informatics needs to address: the practice and theory of nursing, information management and knowledge management, the appropriate use of information and communication technologies, and the effects on the health of people, families and communities, through the influence of local, national and global factors.

In closing this historical overview, before moving on to the current context of nursing informatics internationally, it is worth briefly mentioning how the visibility of nursing informatics has risen in the wider field of health and biomedical informatics. Marin & Marques (2005) reviewed the growth of the number of nursing informatics papers. This can be taken as a form of proxy for the nature and levels of activity of nursing informatics. In the first Medinfo conference, held in Stockholm, Sweden in 1974, five of the 177 papers can retrospectively be described as nursing informatics, while in the Geneva, Switzerland Medinfo conference of 1992, 20 of the 259 oral presentations were in nursing informatics. By Medinfo98 in Seoul, Korea, nursing informatics had become closely integrated into the overall programme, a trend that has continued since with Medinfo conferences.

The first international nursing informatics conference was held in London, UK in September 1992, with the theme 'The Impact of Computers on Nursing' (Scholes, Bryant & Barber, 1983), and has been followed every three years by NI Congresses held under the auspices of IMIA-NI. An overview of the content of these events up to 2000 (Scholes, Tallberg & Pluyter-Wenting, 2000) is a useful proxy to show, from the published proceedings of these events, how the nature of nursing informatics has evolved since the early 1980s. Among the common themes that have persisted in the conference literature that the discipline of nursing informatics has explored are information systems, technology and communication systems, education and training, and research, statistics, modelling.

Looking Towards the Future

As we consider the future of nursing, of nursing informatics, and of the nature of health and the delivery of healthcare, both in individuals countries and globally, we can see that a range of issues and developments-societal, scientific, technological, and health and disease-related--will potentially have an influence. While not everyone may have the luxury of time to give detailed consideration to what might seem esoteric philosophical musings, the assertion by the British statesman and philosopher, Edmund Burke, that "those who don't know history are destined to repeat it", coupled with the motto of the Institute for Alternative Futures (, that "the challenge is not only to anticipate the future, but to create it", bring together the key themes of this article.

Many of the factors that will influence health and nursing in the future, and in particular the use of information and communications technologies, and hence the role of the nurse informatician, are factors that we can see already in existence, or know are emerging or likely to develop. As the novelist William Gibson, originator of the term 'cyberspace' has noted, 'the future is here. It's just not evenly distributed'. Many nurse informaticians have provided explorations of the future, in attempts to explore the possible development of nursing and of informatics (e.g. McCormick, 2005; McCormick et al, 2007). One of the most detailed explorations took place during the NI2006 Post Congress Conference, where over 30 nursing informatics experts from around the world spent three days possible future developments. The resulting publication of the proceedings, 'Nursing informatics 2020: towards defining our own future' (Murray, Erdley, Park & Kim, 2007) provides an exploration of several areas, including the possible evolving role of the nurse as the nature of health and care change, and as new technologies become increasingly embedded in healthcare and people's everyday lives. Among the issues identified, that the participants felt that nursing informatics needed to address were changing healthcare models, the changing role of the nurse as a knowledge professional, the rise of patient/citizen informatics and of citizens as drivers of the nature of care and interaction, and the influence of genomics. McCormick et al (2007) also took the view that the future of nursing informatics will be impacted by the genomic revolution. At the same time, it was deemed vital that nurses keep an ethical stance.

What will influence health in the future? Many individuals and groups have explored the issues, and the United Kingdom's Ministry of Defence's 'Strategic Trends' (DCDC, 2007) look into a possible future is typical of many. They suggested that factors that would influence health included that by 2010, 50% of the world's population would live in cities and urban areas; the effects of global warming and climate change would impact health directly and many other factors such as food availability; there would be increasing global inequalities, with continuation of absolute poverty for many people; continuing population growth, and increasing competition for scarce resources, such as water; the continuing impact of communicable diseases in many countries; the effects of conflict and global or local crises in displacing large numbers of people; and the increasing pervasiveness of information and communications technologies, with resultant impact of information access.

Many other factors will affect nursing in the future, and the nature of how nursing informatics develops. Among these are the need to manage the potential information overload we will face, consideration of whether new social networking and Web 2.0, 3.0, etc. tools will help us, the rise of mobile tools and health-related applications (mHealth) that will facilitate even more instant access to information resources, in particular in countries where such access has previously been limited. In many countries, the increasing role of empowered citizens, demanding greater control over many aspects of their healthcare, will influence the future development not only of nursing, but of the nature of health and the inter-relationship of health professionals with their patients and families (Saranto, Brennan & Casey, 2009).

It is likely, for a variety of factors, not least the varying amounts of money that different countries can and do spend on healthcare, that different combinations of new technologies can offer possibilities for differing solutions in different countries to the similar problems that we know many are likely to face. However, through the exchange of information and experiences among and between nurses--facilitated by international groups such as IMIA-NI and ANIA-CARING--we can celebrate nursing's commonalities, while at the same time considering its necessary evolution and adaptation to new challenges.

Do we need a revolution, or a re-evolution, or perhaps a little of both to enable the discipline, and individual nurse informaticians to consider possible futures and determine how best to anticipate, and prepare for, the variety of changes that will affect the ways in which we all live and work? Nursing informatics has a solid base and history on which to build. We should not ignore, or throw out, that history, and what we have built so far, but we do need to recognise that it cannot stay the same forever, but must adapt and change. Some of what we do now may no longer be relevant in the future; the skill will be to decide what to keep, what to change, and what we need to do or learn afresh. Perhaps, in addition to evolving from where we are now, we may need a revolution in thinking and attitudes to enable nurses/informaticians to deal with evolving change. Education will be a key means to supporting nurses in coping with change, and continuing education and professional development will be vital to providing the development of skills to deal with new knowledge, new forms of knowledge, and simply the vast amount of information to which we will have access.

Note: This article summarises some of the main content and points from my keynote presentation given at the recent ANIA-CARING conference in Boston, MA on April 23, 2010. The views expressed are personal and should not necessarily be taken to be any official IMIA position on any issues.


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Dr Peter J Murray

Executive Director, International Medical Informatics Association (IMIA)
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Author:Murray, Peter J.
Publication:CARING Newsletter
Date:Jun 22, 2010
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