Challenges for Nursing

  Computer and telecommunication systems have proven to be effective management tools for health care data and communication of this information to other healthcare professionals and their use will become the way of the future. As the federal government plans for the United States to have electronic health records by 2014, the National League for Nurses (NLN) (2008) has found that the next generation of nurses will not be prepared to work in such a technology-rich environment. Hence, the NLN has made recommendations for the development of programs to help achieve competency in informatics.

 The science of nursing informatics has evolved to aid in the management of nursing data. Kaminiski (2005) suggests that disciplines such as nursing, which are information intensive, require the careful investigation into the use of computers to process nursing information and nurses need to feel comfortable working with computerized data. Nursing leaders, such as the American Nurses Association (ANA) support skilled information management and in 1992, officially established the role of the informatics nurse specialist, offering the first credentialing exam in 1995 (HIMSS Nursing Informatics Awareness Task Force, 2007).

  The HIMSS Nursing Informatics Task Force (2007) reports the revitalization and redefinition of the role of the nurse and nursing practice as an expected outcome of the IT initiatives. As the movement towards evidence-based practice drives the direction of health care, it is perceivable that it will become necessary for nurses to have key information for decision making at the point of care. Langowski (2005) defines point-of-care technology as a computerized patient record that includes all the patient data in one place and is accessible to caregivers at different locations. Langowski (2005) further explains that with this technology, software programs can be designed to assist health care providers in making decisions for individual patients, as data are entered for analysis by the computer software, and recommendations are made so decisions can be made quickly, with minimal errors. The HIMSS Nursing Informatics Awareness Task Force (2007) explains that when evidence-based practice is coded to an appropriate taxonomy system, the computerized nursing documentation will allow nurses to track their care and improve patient outcomes by implementing appropriate interventions for identified problems.

  While electronic health records are designed to provide access to information compiled from various providers, regardless of their physical location or healthcare system, this network will provide access to healthcare information for clinical decision making nationwide. Thede (2008) reports that data stored electronically is increasingly available to identify patterns of health care provided and subsequent outcomes among large groups of people. Often, nursing care data does not go beyond what’s required of the employing institution or accrediting bodies. Thus, Thede (2008) explains that the electronic health record will contain no data about the decisions nurses make and data will not be used in healthcare planning. The nurse’s role in healthcare will remain indiscernible and not considered in healthcare policy.

  Nursing documentation is a dynamic and complex process. As an educator of nursing students, the writer is concerned not only with the present gaps in nursing documentation to the electronic record, but with abilities of nursing students to learn the skill. Because institutions providing clinical experience to students utilize varying charting methods, students cannot become proficient at documentation. Just as Thede (2008) suggests that nurses decide what data is to be included in the electronic record and what terminology is used to record the data, educators must work to establish consistent documentation guidelines for students. This represents only a small challenge compared to the undertaking that the federal government has undertaken with regards to health information technology.

Future Generations

  One can only surmise what future generations will say about what the healthcare industry is doing today. One would hope that future nurses would look back in awe at how nurses documented with paper and pen to present a complete picture of the patient’s condition. Or that they are grateful for the vision of nursing leaders to develop documentation guidelines that not only provides effective communication between health care professionals, a plan of patient care for the patient, an avenue for compensation from health care insurances, analysis of health care, a source for education and research, the legal document of the patient’s medical condition, but also has enabled the discipline of nursing to be instrumental in the development of health care policy.

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