Developing nursing informatics curriculum

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					Developing nursing informatics curriculum

Speaker: Ms Imola Jehoda
         Semmelweis University Faculty of Health Sciences Library
         Budapest, Hungary
Author: Ms Imola Jehoda
Background: The nursing informatics is an important part of the health science curriculum on many levels of
nursing programs across the world. Sweeping changes in health care gives urgency to the call to transform
nursing curricula so that new competencies could more closely match practical needs.

Aim: This paper is a report of an integrative review of nursing informatics programs. The purpose is to
describe the findings of the review to understand the current state of informatics integration within basic
nursing curricula.

Data sources: The Ovid CINAHL, Ovid Nursing Database and MEDLINE, EBSCO CINAHL with Fulltext,
EBSCO Health Source: Nursing/Academic Edition and ERIC, PROQUEST Nursing and Allied Health
Sources, PUBMED electronic databases were searched for the period 1991 – 2008 for research based papers
published in English. Manual searching as scrutiny is an additional method.

Findings: Inclusion criteria of the study were defined. The integrative review was conducted and each paper
was explored in relation to: design, purposes, sample, outcome measures and results. Comparisons between
study findings are difficult to make because of variation in methodology, settings and sample characteristics.
There is limited empirical evidence addressing the use of computer technology, skills and competencies.

   1.) The outcomes of the study are important to guide curriculum development in meeting the changing
       health care environmental demands for quality, cost effectiveness and safety.
   2.) Information literacy and computer literacy are critical to the future of nursing.
   3.) Nursing science programs must integrate the contents of complex informatics and competencies into
       their curricula to prepare nurses for future missions.

After the first attempts to make data processing automatic, there was no doubt that healthcare would be among
the important areas of application.
As early as in the second half of the 19th century, Florence Nightingale laid down a fundamental principle of
her activity, namely that the preparation and execution of every decision needs accurate data. (1)
This data collection and processing, in accordance with the development of technology, first happened using
punch cards and later punched tapes. The sudden dynamic development of both the creation of theories
regarding this and the related functional data processing was given rise to by the invetion and installation of
ENIAC (15 February 1946), the predecessor of modern computers. (2) Computers functioning on a large scale,
were only usable and economically operatable under conditions of large-scale production, handling large
amounts of data. In the 1970s another technological invetion, the silicion chip helped the huge cathode ray tube
computers become smaller leading to the spread of computers that could be placed on a desk, which were first
known and used as desktop- later as personal computers.
The new tool (hardware) speeded up and made possible the development of programs and software needed for
the diverse applications and the customizable, service-oriented data management. The first hospital
applications are reported to have happened in the 1970s. (3)
After the appearance of the software applied in diverse areas of healthcare in the 1980s, the end-user
applications were constructed too in almost every field of curing and research. The further development of
these - the appearance of the web-based services - was fostered by the faster and faster expansion of the
information infrastructure. (4)
The work carried out by using tools of information technology and the increasing number of employees gave
rise to the attribute ”information society” characterizing society's level of development due to the high amount
of research examining the spread of tools and programs in society (culture, recreation, new types of
telecommunications channels),
The necessity of treating "Nursing Informatics" (hereinafter NI) as a separate discipline first arose at the
session of American Nursing Association in 1960. (5) The technical literature started to publish contributions
about the topic of "computer applications in nursing" in the 1970s. (6) Numerous research projects were
started, and numerous trade associations and academic associations published their views on the subject,
predominantly in the USA. Reasearch regarding the application was started and the International Medical
Informatics Association held the first conference on NI in 1982. The steady growth of computer applications
made it necessary to train the end-user workforce, i.e. to introduce IT subject at every level of nursing- and
medical science education. Numerous theoretical models were created about how to compile their contents and
curricula, among which the Conceptual Framework of Nursing Informatics published by Graves J. and
Corcoran S. in 1989 was exceptionally prescient. According to it NI is nothing but "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."
In the same year, Grobe S. was one of the first nurse informaticians to write about the importance of
incorporating the competencies into nursing education. (8)
The American Nurses Association, in an issue of "Scope of Practice for Nursing Informatics", was the first to
define and publish their governing principles, which already included the competencies required at all 3 levels
of education. The grouping of these is as follows:
         * Minimum Information Competencies for the Profession (general level)
         * Nurse Informatics Practice (bachelor level)
         * Specialist Practice in Nursing Informatics (12 competencies of master level)
These have since been combined into a single document and have benn updated twice. (Last updated in 2008.)
The implementation of the programs belonging to the courses is possible in various forms, for which
Zytkowski M. mentions some patterns. (10)
The further improved structure of Turley J.'s Nursing Informatics Model (1996) is also based on the organic
unity of the three part disciplines, "These circles (three intersecting sciences) overlap to form Informatics at
their core.", and the planning of NI curricula is still based on them. (11)
One of the important milestones in determining and developing the elemental course competencies is the study
done in Delphi by the three nurse informaticians (Staggers N, Gassert C, Curran C.). Based on that study there
are 22 elemental competencies that need to be acquired, as the integration of knowledges, skills and attitudes in
the performance of varions nursing informatics activities. The four major competencies were ordered beside
them: beginning nurse, experienced nurse, informatics specialist and informatics innovator. They identify 300
competencies for the four levels of qualification. (12)
Besides that, academic research continuosly tried to explore and clarify the contents of NI, which started to
develop dramatically in the '90s. They were trying to do so especially with the contents of Nursing Science,
aiming for standardization. Saba VK. (13) published his systematizing work, based on a national sample of
home health care patients’ records, titled Home Health Care Classification, in which he identified nursing
diagnoses and interventions. (14)
The new definition of NI by the American Nurses Association was published with the results of this work
already included. The definition approached the third area, nursing science complementing the other two areas
of science (computer science and information science) as follows: "It encompasses a nursing theory such as the
nursing process, a nursing model, and a nursing vocabulary such as the Home Health Care Classification
(HHCC)". (15)
One of the most detailed progress reports about the NI specialty is contained in the summarizing work „A
National Informatics Agenda for Nursing Education and Practice”, (16) which, besides clarifying the academic
principles, introduces education models and practical applications and determines the acquisition of
educational contents and practical skills, which are based on surveying the needs, as an aim for the future.
In the last decade of the last century the usage and support of NI and developed IT began to spread even in the
subfields of nursing science, including both the clinical specialties and the patient education. Informatics is

foundational to all areas of nursing practice, and the healthcare environment is particularly demanding on nurse
On the recommendation of Staggers N. (17), the academic foundations of NI were expanded, and the standards
regarding the curriculum and accreditation were put into the new edition of ”Scope and Standards of Nursing
Informatics Practice”. (18)
The outstanding achievement of the 2000s, supporting the NI specialty, was the development of the TIGER
Initiative: Addressing Information Technology Competencies in Curriculum and Workforce (TIGER =
Technology Informatics Guiding Educational Reform). The summit was attended by the four largest
professional associations:
         - the American Nurses Association (later AACN) representing the nurse practicioners
         - the National League for Nursing and American Association of Colleges of Nursing representing
            nurses in education
         - The American Organization of Nurse Executives representing administrative nurses
         - and in consideration of the importance of the topic, the American Nurses Association Dean's meeting
           joined too.
The four largest associations represent more than 2 million nurses and at the summit they were joined by 45
smaller specialized professional associations.
The accepted initiatives declare that the informatics is a professional key competency in the 21st century.
Because of that, the required informatics competencies have to be built into the Nursing Curriculum at every
level of education and the usage of the necessary IT tools have to be taught in order to establish these
competencies. (29,53,54)
The other notable NI statement was made by the National League for Nursing (NLN), titled: ”Preparing the
Next Generation of Nurses for Practice in a Technology-Rich Environment: An Informatics Agenda.” It calls
on educators to advocate that all nursing graduates have up-to-date skills in computer literacy, information
literacy, and informatics. The new position statement requires faculty and curricular initiatives development in
information technology. The goal of the federal government was as follows: most Americans should have an
electronic healthcare record by 2014. (20)
Even in these days, numerous forecasts are created regarding the future of NI. The topic is dealt with in the
fullest detail by the Nursing and Informatics for the 21st Century. (21)
The authors still accept and carry on the concept of NI, but they define the contents of the concept in a wider
range. (Not just NI, but Nursing and Informatics) This is also revealed by an interview made with one of the
authors, Delaney CW. (22)
”… informatics includes the core that combines information science and computer science; this core is coupled
with a discipline [for example nursing]. It is important that all disciplines have their discipline – specific
informatics, whether it is pharmacy, medicine, nursing or public health. Taken together, there’s also a common
health informatics core that we all share.” … ”The (nursing) educational need right now is for every nursing
graduate, from curricula from all nursing programs, to graduate with computer and informatics competencies.
They are then prepared for practice, teaching and research in this world that is so strongly defined by
technology and informatics.”
We conclude that NI plays an essential role in the future directions of healthcare, and in the relationship
between nurses and information technology.


This paper is a report of an integrative review of nursing informatics programs. The purpose is to describe the
findings of the review to understand the current state of informatics skills – computer literacy and information
literacy – integration of nursing science curricula at all levels.

An integrative review method was used to identify the literature published to determine the state of knowledge
and development of nursing informatics, particularly to imply health- and nursing informatics research,
theoretical matters and implementation in nursing science.

Inclusion / exclusion criterias
The papers reviewed
   • were published between 1991 and 2008
   • evaluated or assessed skills of nursing informatics
   • examined nursing informatics educational programs in the context of nurse education
   • included nursing informatics curriculum development programs
   • had empirical evidence: implementation of the nursing informatics competencies in the practice
   • included a sample of nurses from all levels and types of nursing education
   • could be implemented in any country
   • had full texts accessible
   Papers were excluded if they were
   • not available in english
   • conference or congresse matters, published in proceedings
   • dissertations
   • books, book chapters.

Search methods
Literature searches were conducted November to December 2008 and January to 24 March 2009.
Eight electronic databases were searched:
    • OVID Nursing Database
    • EBSCO CINAHL with Full Text
    • EBSCO Health Source: Nursing/Academic Edition
    • PROQUEST Nursing and Allied Health Sources
    • PUBMED

The search started with the permutation of ”Health Sciences Education or Nursing Education” AND ”Nursing
Informatics”. MeSH headings and other specific database headings, relevant keywords, free text terms were
combined as appropriate to focus the search on the specific topics. These searches led to a variety of papers
focusing on several fields of nursing education.
To avoid excluding relevant articles, the general subject terms were explored without limit, and specific subject
terms were added: <curriculum>, <competencies>, <program development>, <program evaluation>,
<information literacy>.
Citation tracking and scrutiny of reference lists were also undertaken in the search for additional papers. A
manual search was further conducted to locate other relevant works.
The same inclusion criteria were used for searching: papers to be included if they were ones published between
1991 and 2008 in English and links were provided to the full text. The full texts were to be available for
electronic retrieval and there were a few full texts with manual search – published more than 10-15 years ago.

Search outcome
Databases                                                       Hits
   • OVID MEDLINE                                                46
   • OVID CINAHL                                                 76
   • OVID Nursing Database                                       65
   • EBSCO CINAHL with Full Text                                 76
   • EBSCO ERIC                                                   7
   • EBSCO Health Source: Nursing/Academic Edition                5
   • PROQUEST Nursing and Allied Health Sources                  14
   • PUBMED                                                     616

Titles were cross-checked for duplicates and relevance to the focus of the review.
Figure 1. Search Procedure Flow Chart

                        Full references retrieved from
                                eight databases

                                                                    Refused by title

                            Full abstracts screened

                                                                  Refused by abstract

                             Full papers obtained

                                                                   Refused full paper

                          Full literature included in
                                   the review

                       Reviewed theoretical literature        Reviewed research literature
                                  n=77                                  n=39


In the review, I evaluated 116 academic publications published between 1991 and 2008. The primary criterion
of the separation and grouping was based on whether the publications were based on research or just described
and popularized theories. As a result of this, I found 39 research based publications, out of which 11 elaborate
several synthetized topics. 9 out of them are connected to two topics and 2 are connected to three topics.
There were 77 publications digesting the theoretical basics. Several topics are touched upon by 12 of them, of
which 9 are connected to two, and 3 are connected to three topics, touching on the implementation of the
results too. One of the reasons for this is that usually, after reviewing the NI programs, most of the authors
immediately reveal the possibility or even the necessity of the development of the curriculum.
The presentation of the results - in accordance with the selection criteria - goes by the synthetized topics,
separating the research based and the theory based publications, but featuring them from all perspectives
(several times) if their subject or method calls for it.

Synthetized themes

I. Reviewed literature discussing the evaluation fields of Nursing Informatics (NI)

I / A. Research based literature

Number of       First Author       Focus                                Data collection methods
references      alphabetical
23              Bakken S et al.    NI research agenda: 2008 – 18.       Interdisciplinary research
121             Carty B et         Findings from a national study of   Research survey
                al.(1998)          nursing education
24              Charters KG        NI: outcomes, quality improvement Comparison of sources national
                (2003)                                                 datas
25              Craig A et al.     Impact of an information literacy   Combined qualitative and
                (2007)             programme                           quantitative techniques in pre- and
                                                                       post test
26              Desjardins KS et   Effect on an informatics for        Measurement of informatics
                al. (2005)         Evidence -based Practice            competencies by three research
                                   Curriculum                          questions
109             Edwards PA.        Evaluation of learning and program Pilot study: Questionnaires,
                (2005)             effectiveness.                      interviews, standardized scales
27              Eley R et al.      National Survey of Australian       Self-administered postal survey
                (2008)             Nurses: information and computer
                                   technology education
105             Gaumer GL et al.   Use of information technology by    Survey: statistical analysis of nurse
                (2007)             advanced practice nurses            practitioner program
28              Guenther JT.       NI : mapping the literature         Five core journals references were
                (2006)                                                 analyzed for 1996 - 1998
29              Hart MD. (2008)    Informatics competency and          Systematic literature review: total of
                                   development: within the US          17 citations were selected
                                   nursing population workforce
102             Hwang HG et al.    The measurement of initial nursing Questionnaire
                (2008)             NI literacy for clinical nurses
30              Jiang WW et al.    Computer competencies for the       Delphi technique
                (2004)             nursing profession
31              Ku YL et al.       Efficacy of integrating information Comparative study, based on Likert
                (2007)             literacy education                  Scale
32              Lin JS et al.      An exploration of NI competency     Cross sectional research study: based
                (2007)             and satisfaction related to network online questionnaire
33              Maag MM.           A National Study: Nursing           Questionnaires, Technology Attitude
                (2006)             Students’ Attitudes Toward          Scale
34              McDowell DE et     Computer literacy in baccalaurate   Self-reported questionnaires
                al. (2007)         nursing students during the last 8  evaluation study
35              McNeil BJ et al.   A US Survey: Nursing information Based three online research
                (2003)             technology knowledge, skills        questionnaire 266 of 672 programs
                                                                       completed the survey.
36              McNeil BJ et al.   US National Survey: NI knowledge Online survey of deans/directors of
                (2005)             and competencies in nursing         266 baccalaureate and higher
                                   education programs                  nursing programs
37              McNeil BJ et al.   Computer literacy study             The survey is based 37 discrete
                (2006)                                                 quantitative questions
38              Ragneskog H et     Competence in NI in Sweden          Competence questionnaires,
                al. (2006)                                             separated by students vs. nursing
39              Saranto K et al. NI in nursing education: a                Specially designed questionnaire
                (1998)           challenge to nurse teachers               with three open–ended questions
40              Tarrant M et al. Curricular approach to improve the        Evaluation studies based pre- and
                (2008)           information literacy and academic         post test
                                 writing skills
41              Thompson BW et National Survey: informatics in the         Self – reported questionnaires
                al. (2008)       nursing curriculum
42              Wallace MC et    Evaluation: Teaching information          Comparison: Pre- and post-
                al. (2000)       literacy skills                           programme questionnaires
43              Wharrad H et al. Health informatics skills in nurse        Evaluation based questionnaire
                (2002)           education
44              Wharrad H et al. Putting post-registration nursing         Questionnaire from use of web site
                (2005)           students on-line                          and discussion forum

I / B. Theoretical based literature

Number of         First Author alphabetical (date)          Focus
45                Fetter MS. (2008)                         Enchancing Baccalaureate Nursing Information
                                                            Technology Outcomes : overview of NI
46                Heimar FM. (2005)                         NI: Current issues around the world
119               Hovenga EJ. (2000)                        The article represents the health information
                                                            education in 20 countries of five continents
47                Nagelkerk J et al. (1998)                 NI: overview of the essential factors for
                                                            development of educational programs
106               Orness LL et al. (2007)                   BSN curriculum evaluation of NI content
6                 Ozbolt JG et al. (2008)                   NI: brief history and advance in the USA
48                Saba VK. (2001)                           NI: overview and discussion of development
49                Saranto K et al. (2004)                   Literature review: information literacy
50                Simpson RL. (2007)                        NI: the economics of education – costs of
                                                            informatics-trained nurses
51                Skiba DJ. (2004)                          Redesigning nursing curricula for Evidence Based
52                Skiba DJ. (2004)                          Informatics competencies for beginning nurses
53                The TIGER = Technology Informatics        National Nursing Leadership Organizations USA
                  Guiding Education Reform Initiative       Recommendations
54                Weawer CA et al. (2006)                   ANI Connection: TIGER Initiative
55                Willmer M. (2005)                         Promoting practical clinical management learning:
                                                            use of ICT skills
10                Zytkowski M. (2003)                       NI: Contemporary Nursing Practice

The number of publications connected to the first synthetized topic is 41, out of which 26 are research based
and 15 are theory based.
5 of the 26 research based publications are extensive national surveys (27,33,35,36,41) and their geographic
distribution is as follows: 4 are from the USA and 1 is from Australia. One of the studies presents the tasks of
NI, and the vision of its accelerated development in the future, based on the evaluation of the foregoing results.
The other publications evaluate the individual fields of NI using the various research and sampling methods
listed in the synthesis. The distribution of the publications related to the specialties evaluated is as follows:
-       Information Literacy (25,40,42)
-       Informatics and Computer Literacy, Computer Competencies (29,30,34,37,43,44)
-       Examination of the place and situation of NI in the system of Nursing Education (24,28,32,38,39).

The 15 theory based, descriptive publications provide the synthesis of technical literature regarding to the past,
present and future of NI.(6,47,48) Most of them trace the course of development of the discipline until now,
presenting the opportunities of develompent in the future and an insight into NI education all over the world.
Several authors (53,54) deal with reviewing and popularizing the TIGER Initiative and the application of
competencies recorded in it in both education and practice. The new methods (Evidence-Based Practice)
appearing with the development of nursing science suggests the necessity of redesigning the curriculum.
(45,51,52) The information literacy, one of the subfields of NI, is reviewed and evaluated in the form of
literature review (49). Several studies emphasize that it is important to learn using advanced IT tools in clinical
practice within the confines of the NI subject. (45,47,48,55)

II. Reviewed literature discussing exposition of Nursing Informatics (NI) educational programs in the
    context of nurse education
II /A. Research based literature

Number of       First Author        Focus                              Data collection methods
references      alphabetical
128             Arnold JM.          NI: educational needs              Survey: 497 respondens, 23 content
                (1996)                                                 areas, 3 subsamples; nurse educators,
                                                                       nurse managers and informatics nurses
100             Berkow S et al.     Nursing competencies in the        National Survey: from new graduate
                (2008)              safe and effective nursing         nurses deemed essential competencies
56              Bird D et al.       The role of library and            Discussion and evaluation of an
                (1998)              information services in            experience for curriculum planning by
                                    curriculum planning                questionnaire
57              Chastain AR.        Information technology             Comparison and analysis by Staggers
                (2002)              integration into the curriculum    questionnaire
26               Desjardins KS      Effect on an informatics for       Comparison the types of computer skill
                et al. (2005)       Evidence-based Practice            competencies by competency scale and
                                    Curriculum                         scores
58              Jacobs SK et al.    A Curriculum integrated            Survey and evaluation of information
                (2003)              approach: Information literacy     literacy competencies by pre- and post
114             Rosenfeld P et      Pilot project: develop the         Comparison and evaluation by pre-and
                al. (2002)          information literacy skills of     post tests
                                    staff nurses
59              Saranto K et al.    Developing the information        Three-round Delphi postal survey
                (1997)              technology syllabus
60              Shorten A et al.    Developing information literacy Comparison and evaluation by pre-and
                (2001)                                                postprogramme questionnaires
40              Tarrant M et al.    Curricular approach to improve Comparison of pre-, post-, and final
                (2008)              the information literacy and      information literacy scores by
                                    academic writing skills           demographic indicators
41              Thompson BW         National Survey: Informatics in Curriculum integration methods: if the
                et al. (2008)       the nursing curriculum            informatics is integrated and if the
                                                                      content is integrated (tables)
61              Yee CC. (2002)      Identifying information           Evaluation study: Rossett’s needs
                                    technology competencies           analysis model by interview
44              Wharrad HJ et       Putting post-registration nursing Discussion optimal use of on-line
                al. (2005)          students on-line                  resources by Salmon’s 5 stage model

II / B. Theoretical based literature

Number of           First Author              Focus
references          alphabetical (date)
62                  Barnard A et al. (2005)   Developing Information Literacy Skills
63                  Booth RG et al. (2006)    Educating the eHealth Professional Nurse
115                 Carty B et al. (2001)     The development of a graduate program in nursing informatics
64                  Curran C. (2003)          Informatics competencies for nurse practitioners
98                  Curran C. (2008)          Informatics content and competencies
99                  Gassert CA. (2008)        Master list of informatics competencies for nurses
65                  GoossenWTF et al.         Changes in NI education: Seven years experience
135                 GoossenWT et al.          NI education for masters level nursing practice
66                  Ivory C. (2008)           Informatics competencies for Perinatal Nurses
67                  Kelly M. (2006)           Program design for Nurse Informaticians
116                 Marini SD. (2000)         Planning, developing, integrating and evaluating NI programs
103                 Mays CH et al. (2008)     Suggestions for maintaning information technology competency
122                 McGonigle D et al.        Definition the new discipline and propose for new courses
68                  Morgan PD et al.          Use of Information Literacy Skills: Interdisciplinary Perspectives
113                 Nagle LM et al. (2004)    The fondings of a national study from current state of informatics
                                              integration within basic nursing curricula.
123                 Noll ML et al. (1993)     Integrating nursing informatics into a faculty nurses
69                  Sackett K et al. (2005) Incorporating Healthcare Informatics in Nursing Education
111                 Pelletier D et al. (2004) The article describes the teaching of Information Management
70                  Pravikoff DS. (2006)      A culture of Evidence Based Practice and Information Literacy
130                 Saba VK et al. (1997)     Full integration of NI education at all levels at academic
                                              institutions and in practice
71                  Sherwood G et al.         Quality and safety curricula in nursing education
72                  Simpson RL. (1994)        NI core competencies
110                 Smedley A. (2005)         Use and integration of ICT technology skills into nursing program
112                 Smith K et al. (2004)     NI competencies development, Healthcare informatics
                                              certifications and ethical standards
73                  Staggers N et al.         Informatics competencies for Nurses at Four Levels of Practice
129                 Travis LL. (1997)         The integrated curriculum is effective in familiarising students
                                              with informatics
74                  Travis LL et al. (1998) An Innovative NI Curriculum
127                 Vanderbeek J et al.       Bringing NI into the undergraduate nursing education programs
75                  Verhey MP. (1994)         Information Literacy an Undergraduate Nursing Curriculum
76                  Wallace MC et al.         Information Literacy: a curriculum integrated approach

The number of publications examining the place and structure of NI in the system of nursing education is 43.
13 of them are research based, whereas 30 are theory based. In comparison with the previous synthetised topic,
we conclude that the number of research based studies is much lower, i.e. the processing method is rather
theoretical, and the approach is descriptive. The reason for this is that the NI program reviews, the curriculum
descriptions and the presentation of their connection to the system of nursing education rather allows an
interpretative, theoretical approach to the topic.

4 of the research based publications are identical to the ones introduced in the first topic, because their authors,
with a complex approach to the topic, extend the evaluation to reviewing the NI programs and examining the
acceptance of their contents. (26,40,41,44) This complexity especially applies to the study of National Survey:
Informatics in the Nursing Curriculum (41). As its early premise, we can mention the study made by Arnold
JM. (128) arguing for the need for professional nurses in NI education.
From the further studies, 3 engage in the new methods of approaching the education of Information Literacy
and the itegration of library information services into the curriculum. (56,58,60)
The necessity of learning about the competencies related to Information Technology and integrating them into
the curriculum is evidenced by the studies of several authors. (44,57,59,61,100)
From the theory based publications, the Informatics competencies for nurses at four levels of practice from
Staggers N et al.(73) and Curran C.'s extensive analitical works got into the technical literature as widely
accepted principles and guidelines. These authors, complementing each other, demonstrated the necessary NI
competencies starting from training through the entire professional career.
Prior to them, there were already some attempts at mapping separate set of NI competencies and integrating
them into the system of Nursing Education. (65,72,74,122,123,130)
McGonigle D et al.'s (122) study written in 1991 was a pioneer that defined the new discipline and suggested
starting the new courses. In 1993, Noll M et al. (123) already presents the integration of the new subject and in
1994 Simpson presents that of the NI key competencies into faculty courses.
In 1997, Saba VK et al.'s (130) guidelines set forth and urged the full integration of NI for medical
professionals learning, practicing and working at all levels of higher education, and analyzed his experience of
the efficiency of the courses integrated into the system of Nursing Education in the development of the
students' IT skills. Their usefulness was also confirmed in the publications of Travis LL.(74,129).
The continous changing of the set of competencies according to the develompent of informatics as a
precondition of the development of the NI curriculum is the subject of the analytical studies of Curran C.(98)
and Gassert CA. Pelletier (111), Sherwood (71) and Smedley (110) demonstrate the diverse geographic
potentials of further development.
Besides the extensive recommendations for competencies and education programs in relation to all areas of
education and work, there were numerous other studies that elaborated curricula from a number of areas of
education or work. (63,66, 67,69,113,114,115,127,135) These inform us of the development of the general
curriculum of Information Literacy (68,75,76), the curriculum related to Evidence Based Practice and the
development of the Competency of Information Technoligy.

III. Reviewed literature discussing NI curriculum development

III /A. Research based literature

Number of     First Author       Focus                          Data collection methods
references    alphabetical
56            Bird DR.           The role of library and        Analysis of the contribution of LIS professionals
              (1998)             information services (LIS)     to the curriculum: modular curriculum
                                 in curriculum planning         development, survey of the needs of
                                                                educationalists and promote study packages
57            Chastain AR.       Information technology         Curriculum development by analysis of
              (2002)             integration into the           qualitative findings: comparison of information
                                 curriculum                     technology use students, faculty members and
58            Jacobs SK et       A curriculum integrated        Proposal a new model for integrating information
              al. (2003)         approach: Information          literacy into the master’s nursing program
                                 literacy competencies and
                                 Evidence-Based Practice
59            Saranto K et       Developing the                 Recommendations for teaching information
              al. (1997)         information technology         technology in nurse education by three-round
                                 syllabus in nursing            Delphi survey
60             Shorten A et       Developing information          Comparison: in level of confidence before and
               al. (2001)         literacy: skills to evidence-   after the new curriculum-integrated information-
                                  based nursing                   literacy programme
40             Tarrant M et       Curricular approach to          On the basis of evaluation and analysis of
               al. (2008)         improve the information         information literacy and academic writing skills
                                  literacy and academic           competencies is an urgent need to develop
                                  writing skills                  information literacy standards and basic
                                                                  competencies for practising nurses
61             Yee CC.            Identifying information         By using Rossett’s needs analysis model is
               (2002)             technology competencies         realization: the work-related Information
                                  needed                          Technology systems must be included in the
43             Wharrad H et       Health informatics skills in    Universitas 21 project: integration of health
               al. (2002)         nurse education                 informatics into the curriculum: interprofessional
                                                                  and shared learning between the participating
44             Wharrad H et       Putting post-registration       Results suggest: all students would need to
               al. (2005)         nursing students on-line        develop both skills and confidence in utilising
                                                                  computer technology and on-line learning

III / B. Theoretical based literature

Number of          First Author            Focus
references         alphabetical (date)
125                Axford R et al. (1994) Knowledge development and dissemination in NI
62                 Barnard A et al. (2005) Integrating information literacy into nursing curricula and nursing
77                 Barton AJ. (2005)       Information competencies in a community practice
117                Betts H et al. (2000)   The projects demonstrate the increasing in teaching information
                                           management and technology
63                 Booth RG. (2006)        Recommendation: redesign of nursing curricula in relation to NI
98                 Curran CR. (2008)       Informatics content and competencies
78                 Feeg VD. (2004)         Nursing Curriculum Reform Campaign
99                 Gassert CA. (2008)      Nurses preparation to use new information technologies
118                Hebert M. (2000)        Summarizes key points – development of NI competencies - of a
                                           National (Canadian) NI Projects
79                 Hinegardner PG et al.   NI programs at the University of Maryland
126                Kooker BM et al.        NI educating for tomorrow’s challenge
134                Nagelkerk J et al.      NI: New model is presented that identifies six essential factors
69                 Sackett K et al. (2005) Application of healthcare informatics into the strategic planning
                                           process in nursing education
71                 Sherwood G et al.       Quality and safety competency (6 quality and safety competencies
                   (2007)                  are defined) development in nursing education
104                Sockolow P et al.       Use of project management skills in NI project
74                 Travis LL et al. (1998) The basic components of the innovative NI curriculum: course
                                           descriptions and evaluation
11                 Turley JP. (1996)       New model for the development of NI based curriculum
75                 Verhey MP. (1999)       Development and evaluation of the information literacy curriculum
76                 Wallace MC et al.       Models and programmes for information literacy education:

                   (1999)                     description of the curriculum-integrated programme
80                 Westmoreland et al.        Health system nurse specialist curriculum

The number of publications regarding this (III.) topic is 29. Their distribution is as follows: 9 research based
and 20 theory based publications. The close connection with the previous (II/A.) topic analyzed is shown by
the fact that 8 of the 9 research based publications are connected to it, while only 1 is connected to the first
(I/A.) topic. The complex approach of the 8 research based publications is shown by the fact that their authors -
applying each other's achievments - also make their own suggestions on developing the NI curriculum. The
study (43) also having some bearings on the first topic (I/A.), after reviewing and evaluating the health
informatics skills in nurse education, also makes a suggestion to develop the curriculum along this line.

From the 20 theory based publications, 9 are also connected to the studies of the previous topic (II/B.), while
the other 11 introduce the following main areas of curriculum development:
       - NI maturing into a discipline, the description of the first programs and forms of education in 1994
       - the forming and the principles of development of the core curriculum of NI by Axford R et al.(125),
           and the further levels of curriculum development within the confines of the new models by Turley
           JP (11) in 1996 and Nagelkerk J et al. (134) in 1998
       - the elaboration and review of the NI competency in Canada too, in the extensive study titled
           National Education Strategy to Develop NI Competencies (118),
       - furthermore as the new tool of competency and curriculum development - linked to the individual
           nursing science subfields - the potential of the project potential is discussed by several authors

IV. Reviewed literature discussing: Implementation of the NI competencies in the practice
IV / A. Research based literature

Number of       First Author      Focus                                       Data collection methods
references      alphabetical
81              Connors HR et al. Academic- business partnership: the         Pilot project: IT integrated
                (2002)            SEEDS (Simulated E-hEalth Delivery          curriculum evaluation by
                                  System) project                             questionnaire
82              Honey M et al.    Improving library services: case study      Quantitative evaluation by
                (2006)                                                        questionnaire, qualitative
                                                                              evaluation by interviews
83              Informa                Nurses computer use                    Comparative survey from Internet
                Healthcare (2008)                                             use for health information
84              Orness LL et al.       Implication of computer                Research questionnaire for the all
                (2007)                 competencies for nursing education     courses in a BSN program
132             Saranto K et al.       The nursing students want to learn     Survey by questionnaire
                (1997)                 more from information technology

IV / B. Theoretical based literature

Number of        First Author alphabetical (date)                       Focus
85               Abrahamsen C. (2003)                                   Informatics challenge: patient safety
63               Booth RG. (2006)                                        See also II / B. 63.
124              Cassey MZ et al. (1994)                                New trends influencing NI
86               Cheek J et al. (1998)                                  Resources for nurses as lifelong
98               Curran CR. (2008)                                      Handheld Devices
87               Delaney C. (2001)                                      New frontiers in NI
88               Dragon N. (2008)                                        Electronic health strategy: is this the
                                                                         end of paper based records
99               Gassert CA. (2008)                                      Health care information technologies
107              Gassert CA et al. (2007)                                Discussion the implementation
                                                                         strategies used
89               HIMSS (Healthcare Information and Management            Specific roles, enchancing nursing
                 Systems Society) Nursing Informatics Awareness          practice
                 Task Force (2007)
90               Jenkins ML et al. (2006)                                National Health Information
                                                                         Infrastructure, implications
131              Lewis D et al. (1997)                                   The place of strategic planning in NI
101              McGowan JJ. (2008)                                      Commentary: Information technology
108              Monsen KA et al. (2006)                                 Implementation of a sound data quality
                                                                         infrastructure for nursing
91               Nagle LM. (2007)                                        Infoway: Canada-wide health
120              Nesler MS et al. (1998)                                 Results in a distance-based master’s
                                                                         degree and certificate program in NI
133              Ribbons RM. (1998)                                      Use of computers as cognitive tools in
                                                                         nurse education
92               Simpson RL. (2005)                                      New information technology for
                                                                         nursing profession
93               Skiba DJ. (2007)                                        Faculty 2.0: Faculty Development
94               Skiba DJ. (2008)                                        New Tools and Opportunities in the
                                                                         nursing practice
95               Skiba DJ et al. (2008)                                  Transformation of the new information
                                                                         technologies into nursing education
96               Smith Glasgow ME et al. (2005)                          Benefits and costs of NI projects
97               Sweeney M et al. (2008)                                 Successfull online continuing education

In this topic analyzed there are altogether 28 publications. 5 of them are research based and 23 are theory
Each of the 5 research based studies - irrespective of the previously discussed topics and independently of one
another - engages in the practical implementation of competencies. The earliest (1997) is Saranto K et al.'s
(132) opinion poll based study, which confirms that nursing students need a more detailed familiarization with
the information technologies within the confines of NI education.
Further research introduces the SEEDS developer project (81), the expansion of library services and the
increase of its standards in a case study (82), the nurse computer use (83) and the integration of computer skills
into the Nursing Education curricula.
From the 23 theory based publications, 3 discuss their subjects in a complex manner (63,98,99), because all
three are devoted to the place and role of the NI curriculum as well as the possibilities of curriculum
development in the Nursing Education system. After this they demonstrate the methods of implementing these
factors, even directly touching upon the Handheld Devices if needed (98).
The questions and possibilities of practical utilization arose already in the early years of the introduction of NI
as an independent discipline. Several studies were devoted to the effects of the new trends brought about by the
computerization of NI between 1994 and 2000 (124). Following that the utilization of the tools of NI arose in
strategic planning (131), research on the methodology of lifelong learning (86), the development of the mobile
learning systems (120) as well as the analysis of the effects of their cognitive functions (133).
Later studies on the elaboration of the general theory of implementation grew in numbers. Besides unfolding
the new frontiers (87) it is also important to integrate the new information technologies (92). This subject was
handled with high priority by Jenkins ML et al. (90) in 2006, who reviewed and analyzed the National Health
Information Infrastructure and the necessity of its integration into nursing practice. In the 2000s, with the
appearance of the more and more numerous and advanced applications, the technical literature of
implementing and integrating these novelties into NI has also grown.
The implementation strategies and the possibilities of their utilization is reviewed by Gassert CA et al. (107)
Skiba DJ. (93,94,95) analyzes the utilization of the tools Faculty 2.0 on the model of Web 2.0 extensively and
with a great breadth of view, introducing to the practicioning technicians the new pool of tools of
communication and the possibilities of application. Eventually he demonstrates the necessity to include them in
the nursing curricula and also mentions some methods of that.
In the other publications the authors introduce the following special fields and possibilities of application:
            - patient safety (85)
            - sound data implications (108)
            - HIMSS (Healthcare Information Management and Systems Society) Statement (89)
            - introduction of new electronic patient records (end of paper based medical record era, 88)
            - demonstration of the Infoway Canada project (91)
            - and succesfull on-line education programs (97).
The cost-volume-profit analysis of the implementation of the NI projects above (96) summarizes and proves
the necessity and importance of their inclusion. The most important is to raise the standards of professional
work, which would be beneficial not only for technicians but, besides them, the much larger number of
consumers of medical services, making the social benefits invaluable.

The intent of this review is to draw public attention in the author's country to the importance of the tuition of
The major areas of NI:– computer literacy, information literacy, nursing and health sciences implications –
already constitute separate parts of the Nursing Education curriculum, but an integrative minded, competency
based education is just emerging within the confines of the curriculum reform of Hungarian higher education.
The author wishes to contribute to the successful realization of this by aiming to summarize and analyze the
publications of the international technical literature, which had significant effects on and achievements in the
evolution and development of the NI curriculum
The year 1991 was chosen as the starting date of the review. Although Graves and Corcoran (136) had created
the complex definition of NI already in 1989, it got internationally accepted as a separate discipline only after
its application in databases, which marked the acceptance of the use of the concept. NI as it was entered into
the MEDLINE databases as a separate subject-heading at this time. Before that the subject-headings
<information management>, <medical information>, <nursing as a profession>, <nursing information
systems> were used, which did not cover the inner contents of the entity in its full complexity. The acceptance
of the technical terminology and its integration into academic communication is evidenced by the fact that
since 2005 using it in MeSH in the forms of <nursing informatics> or <informatics, nursing> has been
Although the entire review attempts to reveal the process of the development of NI in detail, summarizing its
stages we can pinpoint the following significant phases of development:
     • 1989 – the creation of the conceptual and operational definition of NI (136)
     • 1991 – proposal to start new - NI - courses (122)
     • 1993 – proposal to integrate the NI courses into the courses of the Nursing Education faculty (123)
     • 1994 – the composition of the first key competencies for the development of NI curricula (72)
            - the description of the first NI program (79), which was given at the faculty of the University of
            - proposal to install the NI at several levels of education (126, 127)
     • 1996 – the surveying of informatic needs of professional nurses, and urging their IT training (128)
     • 1997 – proposal to include the entire NI education into the system of Nursing Education at every level
        of higher education, even postgradually for those who were already in employment Saba VK (130)
     • 2001 – Staggers et al. (73) elaborate the entire set of competencies for the 4 levels of Nursing
        Education in their studies, joined by Curran's studies (98,64) as a supplement
     • from the beginning of the 21th century

          -   national studies, surveys, initiatives and proposals of professional associations have continuosly
              been created and published in the USA to modernize the NI education and make it extensive
          - the Information Literacy curriculum and competencies of NI curriculum are being developed
              continuosly (56,58,60,62,68,70,75,76)
          - the curriculum and competencies of Computer Literacy subfield are also being developed
          - the contents and competencies of Healthcare Information Literacy are being developed
          - from Web 2.0 to Faculty 2.0, the example of implementing and adapting modern IT tools to the
              NI curriculum leads to the future (Skiba DJ, 93)
      •   2008 – the study of Bakken S et al. (23) delineates the diversity of the prospective changes
          embedded into the image of the future of NI research. He selects three of them when dealing with
          the development trends of three areas - Genomic Health Care, Shifting Research Paradigms, Social
          (Web 2.0) Technologies - in detail. In the part titled Key Components of a Nursing Informatics
          Research Agenda for 2008-18 – making a comparison with the seven prioritized fields of NI
          research between 1992 and 1996 - he examines their current and predictable future situations.
          ”These influences are illustrated using the significant issue of healthcare associated infections
          From the major conclusions, we should emphasize the extension of the interdisciplinarity of the
          research, including the utilization of genomical and environmental data. The redesigning of nursing
          practice, the development of the theory of NI and the development of the patient's and caregiver's
          knowledge-based cooperation are necessary in the field of Nursing Science. They all have to be
          complemented by the application of the new technologies and the inclusion of innovative evaluation
          methods, which also takes the organic connection of human-computer interface factors into

Reviewing the major stages of the development of NI we can conclude that NI in fact is a:
      • continuosly developing discipline,
      • whose development is closely related to the current state of development of ICT
      • and the social impregnation of the ICT tools, i.e. the extensive integration of the social web
         technologies into the sphere of scientific and technical applications
      • for this NI is critical to the future of nursing,
      • nursing science programs must integrate the contents of complex informatics and competencies into
         their curricula to prepare nurses for future missions.


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