Nursing Informatics with a Systems Flavor

Judith A. Effken, PhD, RN       jeffken@nursing.arizona.edu

University of Arizona College of Nursing



            At the University of Arizona College of Nursing (http://www.nursing.arizona.edu), we chose to build our informatics program on an already existing Nursing Systems program (http://www.nursing.arizona.edu/systems.htm).  There were several pragmatic reasons for doing so:

·       The nursing systems program prepares nurses for some of the most challenging roles in today's rapidly changing health care environment by helping students develop the conceptual and technical skills needed to assess and analyze clinical situations and health care organizations, conduct program evaluations, and use research findings and technology to help formulate decisions about delivery systems, information management, quality improvement, organizational redesign and outcomes of care.   Clearly, these are skills needed by nursing informatics specialists as well. 

·       The nursing systems program included courses that were immediately applicable for nursing informatics (e.g., data management and a theory of systems management course in which theory of information systems was included as one of three modules).

·       We had a core group of faculty with nationally recognized expertise in nursing systems research, qualitative and quantitative research methodologies, and instrumentation. 

·       Other programs on campus could supplement our core courses.  The Management Information Systems program at the University of Arizona College of Business and Policy is probably the top-rated program of its kind in the country.  In addition, Information Resources and Library Science offers several excellent informatics courses (Human Factors, System Analysis, Knowledge Structures, and Health & Medical Informatics). 

There was also a strong theoretical motivation for developing our program in the context of systems management. To be successful in healthcare informatics requires understanding how the health care system works and how to work successfully within that system.  Systems theories provide an invaluable framework for designing, implementing, and evaluating health care information systems.  Theory provides the nursing informatics specialist with prescriptions, or at least guidelines, that can be used as the basis for design, implementation, evaluation, and research.   Interestingly, at the 1999 AMIA Spring Congress focused on informatics education, several informatics leaders placed "knowledge of how health care systems work" at the top of their list of  “things I didn’t learn in school and had to discover for myself.” 

We view “systems theory” in its broadest sense, that is, as a variety of theories and theoretical frameworks that can be used to guide the practitioner who deals with health care systems.  Many of these theories or theoretical frameworks have evolved from Bertalanffy’s (1986) General System Theory.  Some of the more contemporary theories and frameworks we find useful include those of Peter Senge, Peter Drucker, and Gareth Morgan. 

Systems theories also encompass change management theories and models, from Lewin (1952) and Rogers (1983) to Robbins and Finley (1996).  These theories and models help informatics specialists analyze organizations and apply theoretically motivated strategies to manage change effectively.   Managing change may be the most challenging aspect of informatics projects—and something we don’t always teach students.

Theory gives our program a strong foundation for research or practice.  All Masters’ students take a nursing theory course.  Systems students (including those in informatics) also take the Theory of Systems Management course.  Doctoral students take additional midrange theory and metatheory courses, and, in a seminar, inquire more deeply into the theoretical foundations of their practice.  For example, this semester, a small group of students and faculty are working collaboratively to define what it means to conduct systems (including informatics) research and determine to what degree our current systems research is founded on theory.

Our systems focus gives our informatics program a unique flavor. Because evaluation research is a faculty strength, we have chosen to capitalize on that strength in our program. As a result, in addition to having a strong foundation in core informatics competencies, our students are exceptionally well prepared to evaluate health care systems in general, and information systems in particular.  Not surprisingly, several of our graduates now have positions that involve systems evaluation or outcomes research.

Informatics at the Baccalaureate, Masters, and Doctoral Levels

Baccalaureate Level Informatics

Most students come into the program with some computer skills (word processing and online literature searches, for example).  Other baccalaureate informatics competencies (e.g., use of educational and clinical applications) are incorporated throughout the program.  One informatics elective, Information Technology for Health Professionals, is offered (http://www.courses.nursing.arizona.edu).  In this course, which is taught collaboratively by faculty from the Arizona Health Sciences Center Library and the College of Nursing, students are exposed to ways to find, organize, evaluate, use and create electronic information resources.

The Graduate Program in Informatics

Masters’ Program.   Students enter the program with a broad mix of experience.  Most have had extensive clinical experience and some have informatics backgrounds.  In the future, we anticipate that we will be admitting a limited number of students directly from the baccalaureate program who are second degree students or as part of our AD to MS program.  Because we are not a clinically focused informatics program, we assume that our students are competent in the clinical arena before they enter the program.   Because case management students are finding that informatics knowledge is essential for their practice, we recently approved a dual case-management/systems program that will allow them to have the best of both worlds.  We expect that as the role of nurse practitioner takes on more case management characteristics, we will be asked to provide core informatics content for that group as well. 

Providing core informatics competencies. Graduate students take four required courses and two electives in informatics (http://www.courses.nursing.arizona.edu):

·       Theory of Health Care Systems includes three modules: theory of organizational systems, theory of information systems, and project management.  In three related papers, students first analyze a health care system and the information system in that organization, then propose a change project and a plan to manage the change.  

·       Introduction to Healthcare Informatics provides students with a broad overview of nursing informatics, including history of health care computing, and anatomy and physiology of computers and information systems.  In this survey course, students explore the current status of computer applications for healthcare administration, practice, education and research.   Site visits let students see and critique the newest and most creative applications in Southern Arizona.  For example, we routinely tour the Human Body Simulator used by the College of Medicine to teach anesthesia students, as well as for a research environment. We also routinely visit the Arizona Telemedicine Program (http://www.ahsc.arizona.edu/atp/), which is at the cutting edge of that technology.   We have also been fortunate to have practitioners come to talk to students about applications, as well as issues and their approaches to solutions.  In their final project, students identify an information problem, then use Gassert’s (1996) model to analyze the problem, develop an intervention--including hardware and software components, describe their change management model, and conduct a cost-benefit analysis.  Ethical, ergonomic, and organizational aspects of the project are also analyzed.  Because of the quality of these projects, several have been implemented in agencies.   

·       Data Management teaches students to access and analyze large national healthcare data sets. Students learn to use EXCEL spread sheets for managing and analyzing flat databases and ACCESS for creating and managing relational databases. As their final project, students conduct a data-mining or theory-driven analysis of a data set that they select.   For some students, this initial analysis has generated hypotheses that they went on to test in their theses. 

·       Nursing Informatics Application is an internship in which students undertake a precepted informatics project.  Seminar time is used to discuss the role of the informatics nurse, as well as to share challenges and discoveries from the internship.  We combine our systems manager and informatics students in the same seminars since issues are often common to both groups.  Some of the internships students have undertaken include: 

·       pre and post implementation evaluation of a nursing documentation program,

·       analysis of how data from inpatient and outpatient clinics can be merged into a common database, and

·       evaluating the transferability of a cardiac screening program currently utilized in emergency departments to a preoperative screening clinic.  

As our program grows, we are looking forward to having a cadre of masters or doctorally prepared informatics nurses in Arizona who can precept our future students. 

The remaining two courses are electives, selected on the basis of the student’s interest.  We are fortunate to have excellent collaborating faculty in other departments who welcome our students and provide them with additional breadth and depth of informatics knowledge.

Depending on their interests, it is possible for students to build a very focused or very diverse portfolio during their time in the program.  Course projects are easily integrated into a portfolio, as are papers that result from student-faculty research.  All students take at least two research courses and an advanced practice role development course.  All students do a thesis. The thesis offers students an additional opportunity for immersion into a particular aspect of informatics research and over time will certainly contribute to the knowledge base of nursing informatics.  Projects such as designing or evaluating an information system easily meet the thesis requirements.

Post Masters’ Certificate.  Our Post Masters’ Certificate in informatics, which includes the six basic informatics courses, is quite popular.  Students have come into that program from diverse backgrounds.  Some are nurse practitioners or case managers who see the need for additional informatics skills—or want to make a change in their career trajectory. Others are employed in informatics roles, but want to add a more theoretically based knowledge component to their practice. 

Doctoral Program.  As we developed the Masters’ informatics content, it became clear that we could also extend that content to be part of our Doctoral programs in Systems management.  Now students can take informatics as a major or minor.  We currently have one student in each program. 

Resources and additional learning experiences.  In 1999, we christened our new computer classroom, which has made teaching hands-on applications much easier for students and faculty alike.  The classroom is equipped with 20 networked computers and an instructor workstation with projector capabilities.  In addition, we have a data lab for student and faculty research, and excellent library facilities, which are increasingly online.   Doctoral students provide statistical consultation in the data lab.  Our technical support staff helps teach classes on database and web page design, hardware and network management, in addition to managing the various computer networks at the College. 

Several of our students also have research assistantships at the College in which they are working on research or evaluation projects that allow them to develop their research and database management skills.   Information management skills are so much in demand that as our students finish a course, particularly the database management course, they are finding new positions. 

Student Reactions to the Program

Our students have turned out to be our strongest proponents.  To help readers understand our program through the eyes of our students, I invited current students and recent graduates to talk about what the program meant to them.  Here is a sample of their responses: 


What do Students say about the Informatics Option?

            "The informatics classes have opened my eyes to the future of nursing.  Through these classes I have learned to take a different look at data so it would have more meaning to the nursing profession." 

            "I liked interacting with students from other disciplines. . . . we tend to be rather insular and hearing the issues of others re: data management was helpful." 

            "The practical, hands-on approach is very helpful.  Having to create an Access database was better for me than just learning about the use of various database tools for handling data."

            "When I first enrolled in the database class, I had only an interest in computers with very little experience or knowledge.  This class was not only eye opening regarding the specialty of informatics, but also regarding whether I thought I wanted to go to graduate school again.  Initially, I intended to prepare for a role as an informatics specialist but now a research career related to informatics is most appealing."

"This informatics program has moved me from being a nurse with superficial computer skills to a hybrid of nursing professional able to implement modern technology in the fast- paced world of Healthcare.  I am now able to interface with the technicians in a language that combines nursing needs with computer implementation.  I am still trying to understand what will make nurses, not only more comfortable, but more motivated to learn." 

            "I would never in a million years have gone after a large data base from the government for my thesis had I not gotten "comfortable" with the data management techniques acquired (excel and access), not to mention feeling like I could learn a new software (STATA) without dying.  The outcome was a successful study on the risks of Low Birth Weight in the military population. Because I had acquired the skills and had the backing from faculty, I was able to jump head first into a much more complicated and data rich source."

            "I initially wanted to learn informatics as an addition to the systems focus that I had.  I now have been challenged by the world of systems in nursing that uses computer technology.  My thesis has taken me down the road of how nurses learn using computers.  Talk about a change!!"

            "I became a nurse known for expertise in quality patient care, who could also use computers for extracting and understanding data, and for learning the state of the art in the delivery of patient care.  This led to the Project Manager of Corporate Medical Services recruiting me for my current position as Clinical Analyst." 

            "Because I have the data management background, I am unique and have increased my 'value' to the Air Force.  I can mix the clinical piece with the technology piece - something that is often in scarce supply."

Into the Future

Because Arizona is a large state and Tucson is located near the southern border, we need to provide more distance education options.  A T-3 network exists between the three Arizona universities through the Arizona Telemedicine program (http://www.ahsc.arizona.edu/atp/), which also has education as part of their mission.  Their network also extends to a number of the smaller communities and Indian reservations in the state.  This gives us the potential for using video to transmit courses to multiple sites.  Because we frequently get inquiries about our program from nurses in other parts of the country who can't easily make a move to the Southwest, we are also preparing to offer some of our courses fully or partly online.


            As the need for usable health care information continues to increase, the demand for students with informatics competencies can be expected to grow, both in health care organizations and in industry.  Because of our systems framework, our students are particularly well prepared to analyze and evaluate health care systems and to acquire, analyze, and manage databases.  As a result, their opportunities for employment extend beyond these more traditional informatics roles to include quality improvement, outcomes research, and organizational redesign.