Nurses' Informatics Competency Assessment of Health Information System Usage

Abstract

Nurses' informatics competencies are nurses' professional requirements to guarantee the quality of patient care and affect nurses' use of health information systems. The purpose of this survey was to describe nurses' perceptions of their informatics competencies regarding health information system usage. A previously tested web-based questionnaire with multiple-choice questions was sent to nurses whose e-mail address was available through three Finnish Nursing Associations (N = 58 276). A total of 3610 nurses working in Finland responded. Both descriptive and explanatory statistics were used to analyze the data. The three dependent variables “nursing documentation,” “digital environment,” and “ethics and data protection” were formulated from the data. Nurses' overall informatics competency was good. The “ethics and data protection” competency score was higher than that of “nursing documentation” or “digital environment.” Recently graduated nurses and nurses working in outpatient care, virtual hospital, examination, or operation had highest “digital environment” competency score. Health information system experience was associated with “nursing documentation.” Nurses are highly qualified health information systems users. However, the competency requirements generated by rapidly expanding digitalization have challenged nurses. It is important to increase educational programs for nurses of how to use digital devices, and how to support patients to use digital services.

Global^1,2 and national^3,4 digital health strategies seek to implement appropriate digital health technologies for consumers, social and healthcare professionals and providers, and industry. One of the World Health Organization's¹ strategic objectives is to strengthen the governance of digital health at national and international levels, and to support the capabilities and skills needed for countries to promote, innovate, and scale up digital health technologies. Specifically, it is important to promote digital health competencies in education and training for all health professionals and allied workers.¹

The European Union's target is a single digital market for the European Union region, with interoperability through open exchange formats and European Union–wide standardization of health information systems (HISs).⁵ Professionals need to be able to access evidence-based information rapidly and easily, but at the same time all European Union citizens should have basic digital health literacy skills to enhance the solving of health problems.⁶ Finland is one of the forerunners in digitalization, with the “Kanta” (https://www.kanta.fi/en/citizens) national data repository,⁷ and in the implementation of digital healthcare services, such as Virtual Hospital (https://www.helsinki.fi/en/news/healthier-world/real-patients-virtual-hospital) digital care pathways.^8–10 In the Finnish public healthcare system, HIS coverage has been 100% since 2010.¹¹ Digitalization is changing the way nurses work, their workflow, and the way they use knowledge.^12,13 The continuum of data to wisdom and the availability of understandable and integrated services are important components of digital care environments.¹⁴ Additionally, digitalization provides new instruments for nurses to use HIS data by means of decision support systems, and in administrative decisions. One of the nurses' duties is to empower and guide patients to understand their health data and to motivate them to self-care with the help of digital devices in virtual care services.²

Competencies of digital health, defined as “the field of knowledge and practice associated with the development and use of digital technologies to improve health,”^1,15 and informatics competencies have been defined in recent years in several related fields and studies focusing on various health professions. The Healthcare Information and Management Systems Society and Technology Informatics Guiding Education Reform (TIGER 2020) initiative's interprofessional community updated the global informatics definitions in 2020. Within the core of the health informatics field, the concept of nursing informatics is comprehensive, including information management, analytical sciences, data continuum, data infrastructure, processes, and technology. Nursing informatics involves participants from nurses to patients, interprofessional teams and other stakeholders, with the aim of improving efficiency, reducing costs and enhancing the quality of patient care.¹⁶

The definition of nursing informatics competencies has evolved over the years (eg, Refs 17–19). This is as expected, considering that the new technological advances alongside digitalization have also increased competence requirements for health professionals. As digitalization raises social and ethical issues based on dominant technologies,²⁰ elements of ethics, data protection, and security have been included in the core informatics competencies for nurses^17,21,22 and other healthcare professionals.^19,23–25 One of the core competencies is also multiprofessional development work in digital pathways, in which patients are also supposed to participate.^24,25 Moreover, attitudes, beliefs, encouragement, and motivation have been related to the use, knowledge, skills, and competencies of informatics and digitalization.^15,26

The TIGER core competencies for nursing informatics are a result of a worldwide multimethod study summarizing 24 core competency areas in the five roles of nursing and nursing management in health informatics. According to TIGER recommendations, nursing documentation is an important competency area in clinical nursing and coordination of interprofessional care, as well as in quality management and information technology management in nursing.^21,22 Nursing documentation is related to the use of HISs and standardized terminologies, such as Clinical Care Classification (CCC), International Classification for Nursing Practice (ICNP), NANDA International (NANDA-I), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC).^27,28 Because nursing documentation is one of the largest data sources in HIS data, it is essential that the data quality is excellent. This facilitates the secondary use of data with, for example, artificial intelligence software in digital environments.²⁹

Numerous factors have been proposed to affect nurses' informatics competencies. Kleib and Nagle³⁰ found that especially the quality of informatics training provided by the employer but also age, work setting, educational level, continuing education and training in informatics, previous informatics education, and the use of technology in patient care were associated with nurses' informatics competencies. Khezri and Abdekhoda³¹ also found that nurses' age had an effect on informatics competencies. In addition to the previous factors, self-efficacy, job satisfaction, evidence-based practice and computer skills, HIS experience related to time spent on it, and clinical experience were factors associated with nurses' informatics skills.

Although there have been considerable efforts over the years to define the content of core informatics competencies, less attention has been paid to the evaluation of practical informatics skills and competencies.³² In one Canadian study,³⁰ nurses evaluated their informatics competencies to be adequate. The lowest rated competencies were knowledge and information management, and the highest were information and communication technology use skills. In the Netherlands, one study³³ showed that those nurses who were digitally lagging often had insufficient and ineffective digital education. Learning conditions of digital education including HIS training did not meet the nurses' personal learning needs and styles of the content, form, and pacing of received formal education. In order to avoid nurses' critical attitude toward HISs,³⁴ the learning conditions should be suitable for their competences, job roles, tasks, and working contexts.^34–39 Thus, comprehensive training, workflow redesign, and nurse involvement in the HIS implementing project should be provided. In a multidisciplinary team, a common language for the development of digital services is important,^24,25,40 as are professionals' skills to support patients to choose suitable digital communication devices and software.^41,42

The Finnish national nursing documentation model, which has been integrated into HISs, consists of the nursing process, the structured core nursing data (nursing diagnosis, nursing interventions, nursing outcomes, nursing care intensity and nursing discharge summary), and the standardized terminology, the Finnish Care Classification, originally based on the Clinical Care Classification. The Finnish Care Classification is the only nursing terminology translated and validated to the Finnish nursing culture over 20 years ago and further developed and used in Finnish healthcare organizations.⁴³ The nursing discharge summary, which is electronically available both to patients and to professionals,^43,44 is stored in the patient data repository (“Kanta”) as required by law.⁴⁵ Nationwide cross-sectional surveys on information system services for physicians have been conducted in Finland since 2010 as part of the “Monitoring of Health and Social Care Digitalization” projects of the commissions of the Ministry of Social Affairs and Health.^46–48 For the first time, a similar HIS survey was extended to nurses in 2017. On the basis of nurses' own self-perceptions, they have particularly good information and communication technology competencies and competencies related to structured national headings, whereas competencies regarding patient-related digital work and structured nursing documentation were less well developed. Higher education and longer experience of HIS use impacted the rather good results,^48,49 which were utilized in the development of a national curriculum of nursing education⁴² and in the update of a digital strategy for nurses.⁴

Continuous evaluation is important for the identification of progress and new development areas, and therefore, the survey of nurses was repeated in March 2020, just before the COVID-19 pandemic. Referring to the aims of especially the national strategy³ to develop HISs to support the health and social care domain, professionals, and citizens, the purpose of this cross-sectional survey was to describe nurses' perceptions of their informatics competencies regarding HIS usage in daily patient care.

The following research questions were set:

1. What is the current level of nurses' informatics competencies?

2. What factors are related to nurses' informatics competencies?

METHODS

Data Collection and Setting

The questionnaire of this national cross-sectional survey was based on previous studies^48,49 assessing professionals' opinions of the functionalities, usability, and support for daily practice of information systems and the current state of the art of EHR usage in Finland. A slightly updated version of the questionnaire was piloted by a group of 10 nurses enrolled through the University of Eastern Finland, and who received written testing instructions. Based on the testing, some clarifications were made to the terms, especially those relating to nursing documentation, and by separating multipart claims.

In spring 2020, the web-based questionnaire was sent to all nurse members, including registered nurses (RNs), midwives, and public health nurses of the Finnish Nursing Association, the National Association of Health and Welfare Professionals (TEHY), and the National Professional Association for the Interests of Experts and Managers in Health Care (TAJA), who had provided an email address (N = 58 276). The term “nurse” here includes the following: (1) RN, post–secondary education; (2) RN, bachelor of healthcare; and (3) RN, master of healthcare and master of nursing science (university degree). In case of misunderstandings regarding the questionnaire, the covering letter of the questionnaire included two contact persons.

All methods of the research were carried out in accordance with the Declaration of Helsinki. Ethical approval for the study was provided by the institutional review board of the Finnish Institute for Health and Welfare (THL/482/6.02.01/2020). The covering letter for the questionnaire included information as follows: filling in the questionnaire was regarded as informed consent. Therefore, the authors consider that written informed consent was obtained from the participants.

Instruments

The data for this study consist of background and multiple-choice questions (Table 1). The background questions included continuous variables, such as age and year of graduation, and nominal scales, including educational level, work sector, daily number of HIS logins, and experience as HIS user. The data were considered as representative as they corresponded to the age and gender distributions of the population.^48,49 The data were checked for any inconsistencies and the structure of the data was examined using descriptive statistics.

Table 1.

Descriptive Statistics of Background Characteristics

	N	Mean	SD	Min	Max
Age	3132	45.68	11.01	22	67
Graduation year	3132	2002.60	11.04	1974	2020

	n	%
Education
RN, post–secondary education	1000	31.9
RN, bachelor of healthcare	1839	58.7
RN, master of healthcare and master of nursing science	293	9.4
Work sector
Inpatient ward	1269	40.5
Outpatient care and virtual hospital	1126	36.0
Emergency room and emergency care	242	7.7
Examination, operation, and labor	263	8.4
Mobile care and home healthcare	232	7.4
Number of daily logins to different HISs
0	3	0.1
1	1164	37.2
2	1036	33.1
3	513	16.4
4	210	6.7
≥5	199	6.4
Experience using HISs
<6 months	566	18.1
6 months-1 year	320	10.2
1 year-3 years	714	22.8
3 years-6 years	400	12.8
>6 years	1132	36.1
Experienced as HIS user
Beginner	89	2.8
Weak	197	6.3
Moderate	714	22.8
Experienced	1263	40.3
Highly experienced	869	27.8

The three dependent variables were calculated from a set of multichoice questions relating to nursing informatics competencies. These questions were worded as “How well do you feel you have mastered the following skills required by information systems?” and included 16 different items (Table 2). These items were rated on a 4-point scale ranging from 1 = weak to 4 = excellent. To group these items, we conducted an exploratory factor analysis. Three factors were discovered and named as “nursing documentation,” “digital environment,” and “ethics and data protection.” The details of the factor analysis can be found in an additional file (see Table Supplemental Digital Content 1, http://links.lww.com/CIN/A258). Based on the results of the exploratory factor analysis, the dependent variables were calculated as the averages of the measurement items. Before computing the variables, Cronbach's α values were calculated to examine the reliability of the dependent variables. The “nursing documentation” consists of eight items (α = .93), the “digital environment” consists of six items (α = .86), and the “ethics and data protection” consists of two items (α = .82). Descriptive statistics (mean and standard deviations) of the dependent variables and items can be found in Table 2.

Table 2.

Descriptive Statistics of the Dependent Variables and Their Items

	N	Mean	SD
Nursing documentation (α = .93)	3124	2.78	0.63
Documentation of patient care according to the nursing process	3029	2.98	0.70
Documentation of nursing diagnosis (FiCND)	1716	2.53	0.85
Documentation of the aims of the planned care	2594	2.73	0.77
Documentation of planned nursing interventions (FiCNI)	1598	2.55	0.86
Documentation of nursing interventions (FiCNI)	1629	2.63	0.85
Documentation of the assessment of patient outcomes (FiCNO)	1527	2.43	0.86
Documentation of patient care intensity	2074	2.68	0.82
Documentation of nursing discharge summary	2441	2.68	0.82
Working in digital environment (α = .86)	3122	2.58	0.65
Basic IT skills	3089	3.15	0.75
Use of clinical guidelines and other research skills at work	2846	2.61	0.81
Supporting the patient to take advantage of the potential of electronic self-assessment and self-care	2484	2.34	0.83
Supporting the patient to choose the most appropriate service	2458	2.36	0.81
Work in the digital healthcare environment	2675	2.52	0.86
The development of eHealth services in multiprofessional collaboration with the patient and other stakeholders	1934	2.12	0.87
Ethics and data protection (α = .82)	3089	3.06	0.68
Compliance with data protection and data security principles in daily work	3069	3.07	0.74
Application of the ethical rules in eHealth services	2994	3.06	0.72

Abbreviations: FiCND, Finnish Classification of Nursing Diagnosis; FiCNI, Finnish Classification of Nursing Interventions; FiCNO, Finnish Classification of Nursing Outcomes; IT, information technology.

Statistical Analysis

To examine the associations of nurses' background on informatics competencies, we ran three multiple linear regression analyses. At a time, each of the informatics competency factors was used as a dependent variable, but otherwise, the analyses were identical. During these analyses, we also examined possible multicollinearity problems with the variance inflation factor. The majority of the variance inflation factor was between 1 and 3, indicating no serious multicollinearity. The number of observations varies between models due to the listwise deletion, which deletes a case from the analysis if any of the variables used in the analysis lacks some data. Results of these analyses are presented in Table 3. Statistical analyses were carried out with Stata/IC version 15.1 for Windows (StataCorp LLC, College Station, TX, USA).

Table 3.

Association of Background Variables With Three Informatics Competencies (Linear Regression)

	Nursing Documentation	Digital Environment	Ethics and Data Protection
	β	β	β
Age	−0.121a	−0.110a	−0.087b
Graduation year	0.075c	0.215a	0.139a
Education (ref. RN, post–secondary education)
RN, bachelor of healthcare	0.029	0.035	0.011
RN, master of healthcare and master of nursing science	0.059a	0.131a	0.072a
Work sector (ref. inpatient ward)
Outpatient care and virtual hospital	−0.032	0.098a	0.022
Emergency room and emergency care	−0.002	0.045b	0.018
Examination, operation, and labor	−0.028	0.076a	0.034
Mobile care and home healthcare	−0.050b	0.012	−0.014
Number of daily logins to different HISs	n.s.	n.s.	n.s.
Experience using a particular HIS daily (ref. <6 months)
6 months-1 year	0.050b	−0.009	0.014
1 year-3 years	0.053c	−0.028	0.037
3 years-6 years	0.043c	−0.011	0.010
>6 years	0.044	−0.072b	0.037
Experienced as HIS user (ref. beginner)
Entry level specialist	0.098a	0.047	0.087b
Intermediate	0.303a	0.133b	0.196a
Advanced	0.559a	0.336a	0.341a
Expert	0.736a	0.541a	0.492a
Observations	3124	3122	3089
Adjusted R2	0.222	0.232	0.120

Standardized β coefficients; n.s. = not significant.

^aP < .001.

^bP < .01.

^cP < .05.

RESULTS

Background Variables

Altogether, 3610 (6.2% of the recipients of invitation email and 36% of all recipients who opened the email) nurses responded to the questionnaire. Most of the respondents (92.7%) were female, with a bachelor of healthcare degree. The mean age of all respondents was 46, and they worked mainly in the inpatient ward (40.5%) or in outpatient care/virtual hospital (36%). Generally, the respondent needed to login to one (37.2%) or two (33.1%) different HISs during his/her shift. Slightly over one-third of the respondents had used the specific HIS for over 6 years, and nearly 70% evaluated themselves as advanced or expert HIS users (Table 1).

Nurses' Informatics Competencies and Associated Factors

The respondents evaluated their overall informatics competencies as good (mean, 2.8). Especially competencies related to ethics and data protection were evaluated as very good. By contrast, the mean of the competency relating to digital environment, the development of eHealth services in multiprofessional collaboration with the patient and other stakeholders, was the lowest (2.12) (Table 2).

The association of background variables with the three informatics competencies can be seen in Table 3. Age had a negative association with all informatics competencies, especially with “nursing documentation” and “digital environment”. Nurses who had been using a particular HIS for more than 6 months were slightly more confident on their nursing documentation skills.

Nurses' experience of using a HIS was positively associated with all informatics competencies. Regarding the work sector, nurses working in the inpatient ward and mobile care reported the least competence in “digital environment”. The nurse's graduation year also had a strong positive association with the competencies “digital environment” and “ethics and data protection.” Compared with nurses with post–secondary education and with bachelor of healthcare, nurses with a master of healthcare were more competent in all three informatics competencies, especially working in digital environment. The number of daily logins to different HISs was not associated with in any of the three competencies.

DISCUSSION

The purpose of this survey was to describe nurses' perceptions of their informatics competencies regarding HIS usage in daily patient care. Competencies were measured through three factors: “nursing documentation,” “digital environment,” and “ethics and data protection.” Of the three competence areas examined, competence was clearly rated highest in “ethics and data protection” and lowest in “digital environment.” This refers to relevant content of the nursing curriculum relating to data protection and data security principles and ethical rules in daily patient care when using digital services.⁴² According to this result, nurses have very good competencies in ethical issues, which is important because digitalization is changing the patient-nurse relationship from a face-to-face to a remote connection. Thus, it requires nurses to identify remotely the patient's needs for care, to teach and guide the patient according to his/her needs, and to assess patient outcomes. The patient's dignity, integrity, independence, and confidentiality and protection of patient data should also be preserved in digital care processes.^1,2,4,15,21

Nursing documentation including terminologies is one of the leading areas of expertise in nursing informatics.^21,22 Internationally, several standardized terminologies have been developed, validated, translated, and used for nursing documentation.^27,28 As our study revealed a slightly low total competency score of nursing documentation, it needs to be acknowledged carefully. In Finland, nursing documentation skills and competencies are included in the nursing curricula at the Universities of Applied Sciences, in keeping with the aims of higher education in Europe.⁴² However, the national nursing documentation model including the Finnish Care Classification terminology is not utilized in all healthcare organizations,⁴³ which might contribute to the results. Nevertheless, when nursing notes are documented by using standardized terminology, nursing discharge summaries are also accurate, unified, and understandable. Thus, the terminology-based documentation better guarantees the continuity of patient care between primary and specialized care⁴⁴ and supports patient self-care.⁴⁵

This study also found that the competencies of the important phases of the nursing process, nursing diagnoses, interventions, and outcomes were at a low level. Concerns must be raised, since structured and high-quality nursing data are a basis for utilizing big data in nursing and quality management,^13,21,28 affecting the reliability of results produced by artificial intelligence software, such as problem-solving software programs, to provide support to nurses and help them make more informed decisions in patient care.²⁹

Inadequate training, lacking connections with daily work processes, has been presented to associate with the lack of digital skills.³³ According to nurses, the best way to learn is learning by doing.⁴⁴ Unfortunately, in this study, every competency factor category is probably affected by the fact that, despite the continuing training requirements of healthcare organizations,³⁵ the continuing training of nurses' use of HISs is not organized systematically among them.^33,38,39 Thus, parallel to teaching how to use the HIS, there is a need to teach terminology use, as well as how to integrate the latest information models into information systems and clinical nursing practices and work processes. Knowledge of standardized terminologies and their benefits increases willingness to use and implement the national documentation model.

Finland is one of the leading countries in the digitalization of healthcare.¹¹ However, the results of this study showed that nurses may not have sufficient competency to manage in a rapidly changing digital environment. New digital platforms have generated requirements for nurses to learn digital skills while, at the same time, nurses also need to teach patients how to choose and use the most suitable digital services.¹³ For example, mobile devices are already widely used for checking or recording patient data.¹¹

In this study, the competence “digital environment” appeared to be positively associated with a more recent graduation year, which indicates the more relevant current curricula of the Universities of Applied Sciences,⁴² which include digital skills and competencies.^24,25 For example, one learning objective in the nursing curriculum is that the nursing student can demonstrate competence in using digital services as a part of holistic patient care.^4,40,42 According to our findings, compared with the inpatient ward, the “digital environment” competence was slightly better in outpatient care and in the virtual hospital, examination, operation, and labor areas and in the emergency room and emergency care. However, at the same time, the results show that the nurses' competencies to develop eHealth services in multiprofessional collaboration with the patient and other stakeholders need supportive actions.^24,25 All these refer to Finnish national initiatives, such as the HealthVillage.fi digital care services developed by the Virtual Hospital 2.0 project,^7,9,10 the use of “Kanta,” the national data repository, and the national guidance of information management in social welfare and healthcare. The “Kanta” services provide its own view and functions for the citizen and the other for healthcare professionals ensuring access to the patient data in situations where service is received from different actors and in different places.⁴⁸

Only a minority of the respondents evaluated themselves as beginners or entry-level specialist HIS users, which is a slightly better result than 3 years ago.^48,49 Furthermore, nurses' practical and subjective experience of HISs was associated with all three competence areas: nursing documentation, digital environment, and ethics and data protection. Because the mean age of the respondents was 46 years, this might refer to a longer working career and to the wide implementation and use of HISs both in public and private healthcare. It refers also to social services where the use of HISs is increasing and to the continuous development of digital health infrastructure over several years in Finnish healthcare services.¹¹

Conservative interpretation of the results indicates that it takes about 6 months to learn a new system. This fact needs to be considered when introducing and implementing new systems and services for healthcare professionals.⁷ Nurses' motivation plays a vital role in eHealth performance and maintenance. Evidence-based methods, such as action planning and participatory approach, should be promoted. Furthermore, plans for user-centered changes in the work environment, motivation, encouragement, and social support have been introduced to strengthen the use and success of HIS implementation and informatics competencies.^15,26

Study Limitations

Study limitations of consideration include the fact that the data were collected in the spring of 2020, simultaneously with the onset of the COVID-19 epidemic that challenged Finland's healthcare system. Due to this situation, only one reminder was sent, resulting in a final sample size of 3610. The sample is sufficient to describe the RNs' situation in Finland, but because Finnish healthcare has already made much of the transition to HISs, the transferability of the results to other countries' situations should be treated with caution. The sample included slightly more women and respondents older than 40 years. However, most of them were RNs with a bachelor of healthcare degree and HIS end-user groups. Because the choice of words used in statements is always subject to interpretation, one limitation of the study is that there are possibilities of low reliability and validity of the information competencies measurement. Because in a cross-sectional study design interpretations are associations, not causal inferences, in many surveys, the data include self-reported measures and not an external assessment of experiences or competencies. However, self-assessment is a central part of learning new skills.

CONCLUSIONS

Nurses are highly qualified HIS users. Their self-evaluation shows very good competencies in ethics and data protection. However, the competency requirements that the rapidly expanding digitalization has generated have challenged social and healthcare professionals. Nurses need more competencies to take part in multiprofessional development work. Younger, recently graduated nurses, generation Z, are more competent to use digital services. Thus, it is of high importance to increase different training programs for working nurses and for senior nurses with no or too little education and training in the use of digital devices and software programs. Both nurses and their employers are responsible for continuing education in nursing informatics skills and competencies. This goal is in line with national and international strategies.

Nurses are knowledge workers 24/7. Unified, standardized, terminology-based nursing documentation has been shown to produce high-quality patient data, which also affects patient safety. Therefore, nursing directors are encouraged in their decision making to implement nursing terminology in those healthcare organizations that have not yet done so. Further multimethod studies are needed of the informatics competencies of nurses and nursing directors and the needs and effectiveness of informatics education relating to nursing documentation, digital environment, ethics and data protection in different age groups and clinical settings of healthcare professionals.