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Introduction Ball (2000) stated that 'The strength of nursing profession depends on its ability to take advantage of the best that technology can offer'. Therefore, preparing nurses to face the information challenges of the future requires a solid grounding in information sciences. Simply teaching computer applications in nursing will provide nurses with the skills to critically appraise their information needs and utilization of gathering information in patient care (Romano, 1985; Hannah et al., 1994). Providers of health care as nurses depend on accurate information in order to accommodate future changes at the lowest possible costs. The delivery of community health nursing care is an information intensive industry requiring support systems to collect and analyze data. Nurses recognize from the beginning of their education that, like the basic sciences, information science is a supportive discipline for nursing (Grier, 1999). McGuire (2001) expected that the future of the nursing informatics and telehealth is bright and promising. Innovations in nursing science combined with advances in information and communication technologies will provide community health nurse and planners with tools that will increase their contact with the communities they serve. As the community health-nursing mission is to improve the health of communities and populations so the community nursing professionals focus on (a) preventing, identifying, investigating, and eliminating community health problems and hazards; (b) assuring that the community has access to competent personal health care services; and (c) educating and empowering clients to adapt more healthy behaviors (Landy and Janes, 2001). Community health nursing incorporates six basic elements: (1) promotion of healthful living, (2) prevention of health problems, (3) treatment of disorders, (4) rehabilitation, (5) evaluation, and (6) research. Professional nurses are an integral part of community health practice. Nurse’s roles and activities are varied that it is impossible to describe the “typical” community health nurse, their duties range from examining infants in a well-baby clinic or teaching elderly stroke victims in their homes, to carrying out epidemiologic research or engaging in health policy analysis and decision-making. Community-based nursing refers to both the setting and the practice of the nursing role. Nursing care that occurs in a setting other than acute care; also referred to as community health nursing. Population-and community-focused care

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referred to interventions aimed at health promotion and disease prevention that shape a community’s overall health status. Public health nursing is populationfocused, community-oriented nursing practice and the dominant responsibility is to the care of the larger community. In Egypt, much work remains to be done to make nursing informatics a reality. Through hardware, software and personnel; a multi-facet learning program that utilizes distance learning, interactive cable TV, and the internet to connect learning environments to homes, place of work, and the community at large, and by establishing-updating community nursing resources web sites. The graduate level nursing informatics educational environment must continue to strive to become a forum where educator and student meet in an expanded capacity made possible by an increase in the integration of computer literacy within the nursing informatics curricula. Using innovative teaching mediums such as the virtual classroom, distance and continuing education in nursing informatics can be a reality and should be actively promoted. Nursing Informatics Definitions Informatics is derived from the French term informatique, as an area of nursing specialization; nurses with expertise in informatics are often referred to as nursing informaticians. Graves and Corcoran (1989) and Nagelkerk (1994) defined 'nursing informatics as the use of nursing science, computer science and information science in nursing processes for patient/client care, which provides data, information and knowledge to the individual and the organization in a way as to change and influence society and achieve health for all. The specialty of nursing informatics offers strategies for using information and communications technologies to collect individual-and community-related data, store and retrieve this data for clinical decision making (through the process of converting raw data into nursing information and ultimately into nursing knowledge), and provide in-depth analysis of data for increasing productive service delivery while providing quality nursing care. In addition, Saba and McCormick (1996) explain that nursing informatics is a branch of informatics particularly concerned with nurse's use of computer technology and the management of information that facilities nursing practice and enhances nursing knowledge. Nursing informatics is defined by Simpson (1993) as “the legitimate access to and use of data, information, and knowledge to standardize documentation, improve communication, support the decisionmaking process, develop and disseminate knowledge, enhance the quality,

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effectiveness and efficiency of health care and empower clients to make health care choices which contribute to the advancing of the community health nursing science. Nursing informatics can be accomplished using information structures, information processes, and information technology (McGuire, 2001). American Nurse Association (2001) indicated nursing informatics as a specialty that ♦ Integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. ♦ Facilitates the integration of data, information, and knowledge to support patients, nurses and other providers in their decision-making in all roles and settings. ♦ Accomplishes using the information structures and information technology. The goal of nursing informatics is to “optimize information management and communication through the use of information technology and support nurses as they improve the health of populations, communities, families, and individuals (Bargstadt, 1998). Simpson (1993) added that advances in information technology have created new roles for nurses, and emphasized the need for all nurses to become more knowledgeable about health information concepts and technology that designed to manage and process information. Information science encompasses the analysis of information structure, properties, and organization, information storage and retrieval, information system and database architecture and design, library science, projects’ management, and organizational issues such as change management and business process reengineering. Evolution of Nursing Informatics (American Nurse Association, 2001) •1992 nursing informatics (NI) first recognized as specialty by the American Nurses Association (ANA) • 1994 scope of practice for nursing informatics • 1995 standards of practice for nursing informatics • 2001 revised scope and standards of practice of nursing practice • 5,000 RN’s identify themselves as nurse informaticsit • 500 RN’s board certified as nurse informaticist

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Foundation of Nursing Information The foundation of nursing information based on the concepts of data, information, and knowledge as building blocks of nursing communication. Because information and knowledge are essential for nurses when interpreting data and making decisions, it is important to know the differences between these three concepts. Prather (2000) found that data generated during the delivery of actual patient care are rich in clinical detail. Data are generally associated with each clinical data element and continuous parameters such as test results and significant findings are present. Data sets that reflect real-world patients’ experiences and responses can provide valuable insights for clinical knowledge development. Data are discrete observations that are not interpreted, organized, or structured. Examples of Data are age, blood pressure, weight, number of workload units of services Data mining technology was defined by Berry and Linhoff (1997) as “the semiautomatic exploration and analysis of large quantities of data in order to discover meaningful patterns and rules.” The identification of meaningful patterns in data has always been an integral part of scientific discovery, since patterns are necessary for the construction of scientific hypotheses and causal models (Brossette, 1998). Data mining as a method for data analysis in nursing research can contribute to the discovery of causal factors and demonstrate outcome effectiveness. It is a technology that can turn massive amounts of raw data into useful information that can improve clinical nursing practice. Information is data that has been interpreted, organized, or structured to provide meaning to the data. Examples of Information; ● Prevalence of clients/ health center by this month compared by the last year.

● Percentage distributions of workload of immunization clinic by services and intervention by activity category by nurses by month.

Information is key to effective decision-making and integral to quality nursing practice. Much of what nurses do involves information–from assessing the health care needs of clients, to developing care plans, to communicating client

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information to other health professionals, to analyzing staffing and budget reports. In fact, nurses work in information intensive environment. Advances in information technology (computers and software) over the last 25 years have created significant opportunities for nurses to be aware of current information when making decisions (Canadian Nurses Association, 2001). Knowledge is the synthesis of information to identify relationships that provide further insight to an issue or subject area. Examples of Knowledge ● Referral systems protocols ● Care plans for specific health problem ●Relationship between different nursing interventions and client outcomes.

While the concepts of data, information, and knowledge are different, the concepts as a whole are typically referred to generically as information. All the three concepts are stored in computers and software programs be developed to assist in the interpretation of the data and the development of nursing knowledge. Lyman and Varian (2000) stated that the world’s total annual production of information amounts to approximate Mega Bytes (MB) for each man, woman, child on earth, and that number is expected to double every year for foreseeable future. Ninety-three percent of the information that is currently produced each year is now stored in digital. Increased computing power, decreasing costs, and advances in data capture and storage technologies have resulted in massive data sets in many disciplines, including nursing. Timothy (2001) who is an informatics specialist at Communicable Disease Control says that even though the field is often associated with applications and programs, packages, or tools, it actually encompasses a larger process of what he calls the “data progression pathway.” This pathway represents the process of moving from data to information, information to knowledge, knowledge to decisions, and decisions to outcomes. Knowledge-Based Services Knowledge networks not only allow scholars and scientists to work together more effectively, across distance, but also offer completely new approaches to investigating and analyzing concepts and phenomena. Knowledge Discovery in Databases (KDD) is a process that includes data selection, data

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preprocessing, data transformation, data mining, interpretation, and evaluation (Wright (1998). Knowledge-based systems are recent but will expand with the spread of informatics and telemetric supports. These systems provide expert advice on health-scientific issues. For example; diagnostic support, suggest additional tests or propose a treatment. Such systems often include a combination of literature data (from journals articles and textbooks) and factual data (Thiru et al, 2003). Wright (1998) mentioned that knowledge-based information services consist of systems, resources, and services to: • • • • •

help health care professionals acquire and maintain the knowledge and skills they need to care for clients/patients support clinical and management decision-making (computerized decision support systems should be developed for nurses and decision makers). support performance improvement satisfy research-related needs educate clients/patients and families

Benefits of Informatics Application All health care organizations use information technology in one form or another. Discussion has been for a long time as to what are the direct and indirect benefits of information technology in medical/nursing or health care. The ability to maximize information technology benefits and the associated return on investment is becoming an integral part of the executive management information technology skill set. Thiru, Simon, Sullivan, Brew, and Cooper (2003) added that there are three categories of potential benefits that can be identified in relation to the quantitative, qualitative, and strategic benefits use of computers and electronic data processing in the health care sector. These are; Quantitative benefits. For example the use of electronic data interchange technology to transmit surveillance data in real time or to electronically submit medical claims, which results in time and labor cost savings. •

• Qualitative benefits. These benefits measured only in terms of the impact of technology on the performance of health systems and their efficiency. Accurate data, fast transfer of data, wider accessibility, and linking of data elements are benefits that are not easily quantified.

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• Strategic benefits. Data collection and analysis bring immediate benefit to an organization, but in the long term, these data constitute the basis for health research and strategic planning. In addition, Zielstorff (1998) stated that clinical information systems in current health care environment, including long-term care, provide five functions. These five functions include providing the legal record of care, supporting clinical decision-making, capturing costs for financial purposes, accumulating a database for administrative queries assurance/research, and supporting data exchange between systems. Benefits of Nursing Informatics For Community Health Nursing The combination of nursing and information systems management produces several benefits for nurses practicing in the community. These benefits include; management of client-level data, the use of standardized nursing language, provision of care in an efficient and productive manner and the use of information systems for research, health promotion, and illness prevention in the community. These benefits are explored as follow; I. Standardized Nursing Language Concepts that are common across disciplines and across the continuum of health services need to be structured and defined in a standard or common way. This means that not only do nurses need standards for common concepts, but nurses also need standards that are compatible across information systems that can be used by different health professionals, across the continuum of health service delivery, and within and across provinces and territories. The International Organization for Standardization (IOS, 2004) defines standards as; documented agreements containing technical specifications or other precise criteria to be used consistently as rules, guidelines, or definitions of characteristics to ensure that materials, products, process, and services are fit for their purpose. Today, there are many different types of health information standards including technical standards for computer hardware and software, data standards to enable the development of quality and comparable information, and information exchanging standards or protocols to facilitate the sharing of information. Lundy and Janes (2001) mentioned that the development and implementation of computer health information systems or automated health information systems requires some form of structured vocabulary or terminology

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with common definitions for common terms to enable the effective management and processing of data. Over the last decade, there has been significant progress in development of health information concepts and standards. At the international level, the International Council of Nurses (ICN) is leading the development of universal language for defining and describing nursing practice – the International Classification for Nursing Practice (ICNP). ICNP provides nursing with a common framework that facilitates cross mapping of existing nursing vocabularies and classification to enable comparison of nursing data across organizations, health sectors, and countries. The alpha version of ICNP was released in 1996 for review and feedback and significantly revised beta version was released in 1999 and has been translated into more than 20 languages (ICN, 1999). In Canada, Nursing Components Working Group has continued to build on the work started in early 1990s to develop a standardized minimum data set for nursing. There is now a national consensus that critical nursing care data elements include client status, nursing interventions and client outcomes. While nurses have reached a consensus on the kinds of data elements required, they now must begin moving these concepts to implementation by ensuring that they are included within information systems. This involves nurses assessing the health needs of clients and collecting client-specific interventions in a standardized way in order to gain a better understanding of the impact of those interventions on client outcomes (Simon, 2003). II. Classification of Client-level Data International Classification of Diseases and Related Health Problems; Canadian Classification for Health interventions also enhanced the new version of the International statistical Classification of Diseases and Related Health Problems. Nurses provided input to the development of Canadian International Health Intervention plans to maintain both classifications and utility to the field nurses should play a key role in ensuring that changes and enhancements to the classification are relevant to nurses information needs (Canadian Nurses Association, 2000). Classification standard for client-nursing data The classification contains a comprehensive list of nursing diagnostic, therapeutic, support and nursing interventions, allowing for the standard collection of health interventions, regardless of the service provided or service setting (NANDA, American Nurse Association, 2004).

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III. Identification of Client Outcomes With regard to the identification of client outcomes that are relevant to the work that nurses do, the Ontario Nursing and Health Outcomes Project (1997) has done significant work in identifying client outcomes that are sensitive to nursing. The client outcomes that have been identified include; functional status, self-care, symptom control, and client satisfaction with nursing care. Plans include developing pilot projects in acute, long-term and community care (Canadian Nurses Association, 2000). IV. Client Information Management The management of client-level data provides the community health nurse with an accurate assessment of clients and their caregivers’ situation for the purpose of planning, implementing, and evaluating care. Information systems allow for the organization of data collected during an individual’s admission to a community health care facility. This information can be stored for future retrieval, and the aggregation of this information can be analyzed for the benefit of the community (Wright, 1998). V. Efficiency and Time Benefits The use of nursing information systems can provide community health nurse managers and staff with efficiencies in productivity. The collection of client-and caregiver-centered information is often a time-consuming endeavor and uses financial and personnel resources. Savings in time are often demonstrated by the use of computer systems for communicating information over distance, over time, and to multiple users of the data and clinical information can be shared with several users at the same time (Smith, 2000). VI. Privacy, confidentiality and security of health information With rapid advances in information technology, nurses need basic knowledge of concepts relating to privacy, confidentiality, and security of health information, especially if they are involved in the development of health information systems. The United Kingdom (UK) Data Protection Act of 1998 has presented challenges for those engaged in epidemiological research using patient data. However, the precise meaning of this Act, and others that flow from European Human Rights Legislation, is still very much open to interpretation (Tom and Frank, 2004).

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Privacy: It is the right of an individual to determine, when, how and to what extent they will share information about themselves with others (Tom and Frank, 2004). Confidentiality: It refers to the obligations of one person to protect the personal information of another person. The protection of the confidentiality of personal health information has always been a fundamental principle of health care system (Tom and Frank, 2004). In addition, Canadian Nurses Association (1997) added that the code of ethics for registered nurses determined that nurses safe guard the trust of the clients that health information linked with the context of a professional relationship and can be shared outside the health care team only with the client’s permission or as legally needs. Security; it refers to the procedures and technologies that are used to restrict access to, and maintain the integrity of health information. McGuire (2001) stated that the establishment of various standards related to privacy, confidentiality and security have evolved over the years. Finally, in implementing operational guidelines, various procedures and security systems are used; each is based on specific technical standards. McGuire (2001) mentioned that there are too many technical standards related to information systems security to be done, and explains some examples that are relevant to nurses such as: ● Identification (e.g., passwords) and authentication (e.g., digital signature) of users of health information. ● Provision of audit trails or records of access activity relating to health information. ● Protection from unauthorized access (e.g., firewall) to health information. In 1981, the Council of Europe enacted its Convention for the Protection of Individuals with regard to automatic processing of personal data. Data should be: 1. Obtained and processed fairly and lawfully. 2. Stored for specified and legitimate purposes and not used in a way incompatible with those purposes. 3. Adequate, relevant, and not excessive in relation to the purposes for which they are stored. 4. Accurate and, where necessary, kept up to date.

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5. Preserved in a form, which permits identification of the data subjects for no longer than is required for the purpose for which those data are stored. With the atmosphere of uncertainty about data protection, Tom and Frank (2004) stated that there is a threat to informatics research in primary care and it should serve as an extra motivation for community nurses to develop effective ethical processes for managing information that justify the trust of the community. Uncertainty is a challenge, but a positive response to that challenge will bring a stronger system for managing individual data in health researches. Code of ethics and legality for Electronic Health (e-health) were developed by Mediterranean Region Countries through the World health Organization (2004) about the following topics: definitions, confidentiality, honesty, quality, sustainability, privacy, sharing, and accountability of the electronic health (Appendix ◄1► Arabic Version). In the Eastern Mediterranean region, nurses have also laid some important groundwork for cross border cooperation in regulation. There is reported to be a wide variation in regulatory laws, policies and practices governing nursing in this region, and the goals of current activity include one relating to inter-linked or integrated systems for registration and licensing. Standards for nursing education and prototype criteria have been developed, with support from both ICN and WHO. Sample Application Model of Nursing Informatics McCloskey and Bulechek (2002) provide a framework of a theoretical model from which to expand nursing knowledge and conduct research on nursing intervention and outcomes. This application sample consists of the following elements; Administration ● Analysis of reports generated from a spreadsheet software application ● Review of outcomes indicators using a decision-support software application ● Recording of workload and interventions as a by-product of electronic charting (software). Clinical Practice ● Recording of client assessment data in an electronic health record ● Recording of workload and interventions as a by-product of electronic charting (software).

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Education ● Distance learning/teaching via the internet ● Recording of workload and interventions as a by-product of electronic charting (software) Research ● Evaluation of nurse-sensitive outcomes measures using a standard minimum data set ● Use of knowledge bases via the internet ● Recording of workload and interventions as a by-product of electronic charting (software). Therefore, Nursing Informatics can be viewed through a number of different lenses. The most common ones include the standard areas of nursing: nursing practice, nursing education, nursing research, and nursing administration. Nursing Informatics can also be viewed through the sociological lens of hegemony, empowerment, dialogue, synthesis, and creative expression. Physical Infrastructure/Architecture The infrastructure consists of both the telecommunication media used to actually transmitting information—such as phone lines, fiber-optic cables, satellites, and microwave systems—and the media used as input/output devices— such as telephones, video cameras, monitors, fax machines, and computers—that are needed to send and receive data. One set of media cannot be used without the other in informatics but various combinations of use are essential. Communication systems include small citizens band (CB), high-frequency (HF), very-high-frequency (VHF), and ultra-high-frequency (UHF) radio systems; a public switched telephone network; data and private networks; public broadcasting networks; and satellites—including low and medium earth-orbiting satellites—with variable capabilities and geographic coverage. The core network links telecommunication service providers and international gateway exchanges and provides all the trunk transmission, switching, and other network capabilities. Other communication capabilities such as mobile telecommunication systems, intelligent network products, and integration of overlay networks (such as an integrated services digital network and data networks) are being added (Simpson, 2003). The infrastructure consists of a combination of both land-based and airbased communication networks and systems, each offering various bandwidths— from a single telephone line using copper wire, which is adequate for voice, facsimile, and text-based data transmission, to broadcast television cable and

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satellite networks. Convergence of these technologies makes it possible to combine audio, data, and video communication by means of personal computer access to telecommunication networks that include access to high-speed computers with CD-ROM drives and local-call access to an Internet service provider in order to take advantage of what the Internet, the World Wide Web, and educational CDs have to offer (Salazar-Riera, 2002). The infrastructure required for high-quality information and health service delivery is far from universally available or reliable. It is extremely costly in sparsely populated or distant areas, although ultimately its absence may be more costly. It is needed to prepare communities now to exercise their rights, be informed and have their preferences considered when they need health care. Also the administrators of health services have to consider the financial cost of health care in rural and remote areas, and they must encourage professional excellence by providing continuing education to nurses and other health workers so that they can adequately work with informed consumers and deliver care in accordance with the best available practice guidelines (Canadian Institute for Health Informatics, 1997). Governments must have the will and the fiscal objectives to resource the necessary telecommunication infrastructure for their citizens irrespective of location. In addition, the information and telecommunication technology infrastructure needs to be accommodated with many and varied applications which required for the support of rural and remote communities. The disadvantaged in rural and remote areas can benefit significantly from these technologies. This is feasible only when the technologies can be fully utilized for a variety of purposes. Nursing informatics system needs to develop people who have the necessary computer and information literacy skills to benefit from using technologies. Professional and regulatory bodies also need to devise and implement competencies and standards to ensure adequate preparation of nurses before they embark on “adventurous” practice in nursing informatics and its application in community health nursing (Yasnoff, et al., 2001). Sparks (1993) emphasized the necessity of introducing nursing staff to the three major international electronic networks (Internet, Fidonet, and Bitnet) that will enhance their information access. These electronic highways link academic, research, governmental and commercial organizations. These systems provide access to multiple computer bulletin boards that provide information and networking. Electronic mail provides instantaneous transmittal of messages to

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and from nurses. Also providing library materials on client care units is another issue to encourage the development of computer skills. Nursing journals, such as Computer in Nursing, basic computer books, periodicals, or manuals can provide basic, useful news for nursing staff. Computer Applications in Community Health nursing Computer technology has made it possible not only to explore health care dilemmas, but has opened up the universe as a laboratory for possible answers (Cox, Harsanyi and Dean, 1987). Computer technology gives nurses the tools to develop and implement systems. Informatics addresses such issues, as the impact computerization will have on data collection, analysis, information dissemination, communication, and even on the understanding of public health issues. The use of the internet is an example of how informatics differs from computer science. Internet technology is a powerful tool, but informatics specialists must be employed in deciding how this tool should be used to better meet the goals of public health (Yasnoff, et al., 2001). A prerequisite to the widespread use of powerful new information applications is the pervasive deployment throughout the community health system of modern computers that interconnected through a standards-based network. In recent years, substantial progress has been made toward this goal. Beginning with the Information Network for Public Health Officials (INPHO) and continuing with the Health Alert Network, CDC has made systematic efforts to improve the nation’s public health telecommunications, information, and distance-learning infrastructure by promoting internet connectivity and other information infrastructure for nation and local community health workers (Richard, 1998). Offering basic computer classes that assist nurses to acquire keyboarding and word processing skills, and basic computer terminology provides a base for further expertise. Understanding basic computer terms such as personal computers, word processing, mainframe equipment, software and hardware applications, modems, and databases can become an important foundation on which expertise and skills are built (Todd, 1998). The use of computer application such as e-mail, databases, and spreadsheets can provide community health nurses with tools to increase their productivity and knowledge. E-mails can be used to coordinate communication among health care providers in the community. Databases have been used to collect and organize massive amounts of client-and community related data to be used in research and analysis. Spreadsheets can be used to perform complicated

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mathematical or statistical calculations that support clinical decision making (McPeck, 2001). Decision support and expert systems are beginning to emerge in nursing and are useful to clinicians, educators, and administrators. Decision support systems can prompt and help make clinical decisions by providing typical data and responses to a situation. Examples of decision support systems include staffing and expert systems. Nurse selects a clinical problem, types this into the computer with a client’s presenting symptoms, and laboratory data, and then a print out shows the probability of the client having this problem, what data may still need to be collected, treatment possibilities, and prognosis. Expert systems are based on a group of content specialists’ decision-making processes about a specific clinical problem (Sparks, 1993). Preparing Nurses for Computerization As the use of computer technology and information science increases in nursing practice, education, and administration, so will nurses’ need to be skilled and knowledgeable in the use of information technology. Principally, computer competence is a nurse’s ability to effectively use the computer systems available and adapt his or her use to a variety of settings (Ellis, 2002). How can nurses prepare themselves for computerization at work, and how can health care organizations facilitate this transition? This is a critical question when the majority of nurses in Egypt has had no experience with computers or feels uncomfortable and intimidated by them. The focus now is on the computer’s need for input data. If we are serious about designing computers to support nurses in the care of clients, more effort needs to be made to change how these data are being collected and accessed. This change should focus on the nurse’s need to collect and retrieve data as quickly and easily as possible. It also fosters communication among the members of the healthcare team. Computer-based courses typically involve simulated cases, slide presentation, real-time discussions, online chat, and exercises. Streaming technologies enable the use of video and audio over the Web to create a more classroom-like, e-learning experience (McPeck, 2001).

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Sample Model for Designing Educational Programs for Computerization among Community Health Nurses Adaskin, Hughes, McMullan, and McMorris (1994) conducted a study to identify the essential factors that influenced nurses during the implementation of the computerization process. Factors Model for Designing Computer Educational Programs

Communication Communication

Change Process Change Process

Time Frame Time Frame Leadership Leadership

Training Training

Software Software

Figure (1) showed the factors for designing computer educational programs (Adaskin et al., 1994).

This figure shows the support of administration in the center of the wheel as leadership. Strong leadership, planned changes, effective communication, special software, established time frames, and a carefully planned training process can yield success in implementing a nursing information system. Time Frame, Once a decision is made to purchase and implement a nursing information system, a detailed time line should be drawn to detail the steps in the process and identify who is responsible for each activity. The time line provides the entire organization with a plan of activities and anticipated events over the specified time period. Providing sufficient resources and time for training staff is a necessary step for success.

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Leadership, and knowledge of the computerized systems from the administrative and staff development team are essential in preparing nurses for computerization. A coordinated leadership team can provide resources people on units as nurses go “on line” to troubleshoot and boost staff confidence and morale. The support provided at this time is crucial for effectiveness and provides many opportunities for answers to questions by the nurses of the system. If resources are constrained in the organization, a schedule placed on each unit identifying the times that a resource person will be available and listing a telephone number of a backup who can be called for questions that require immediate attention (Adaskin et al., 1994). Software, communication is important when selecting the software that will be used for the nursing information system. The input of administrators, educators, and community nursing clinicians can be utilized for develop of a multipurpose nursing information system. A system that has the capability of providing the functions that each group needs, as well as one that is relatively simple to use is essential. The ability to modify or add programs is also important (McGuire, 2001). Communication, throughout change process, clear, direct communication is essential for an orderly transition. Developing a network where staff development personnel are responsible for assigned community clinic to communicate about the nursing information system facilitates idea exchanges. Identifying one nurse from each clinic who is responsible for distributing new information and is the contact person for the staff development representative provides an effective communication link. The nursing representative not only accepts information to distribute to peers but also provides invaluable insights on problems that need to be solved. Compiling key questions and writing simple explanations that can be posted on all nursing clinics provide another excellent mechanism for communicating knowledge. It is also important to visit each community nursing clinic to observe how effective and proficient the staff are becoming with the new system (Romano, 1985; Hannah et al., 1994). Training, using adult education techniques to expose nurses to computers in a positive learning environment lessens initial computer anxiety and enhances computer literacy. Educators and administrators can optimize computer learning for nurses by creating environments conducive to learning and by adhering to adult learning principles. Education should be flexible and user driven. The use of written and oral instructions along with pictures, graphs, and charts on an individual and group basis are needed to assist in meeting all learning needs. Adaskin et al. (1994) found that providing too much material too fast was

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detrimental to nurses’ learning. Pacing the material in two or more sessions proved to be better than a one-time marathon session. The time between classes gives nurses an opportunity to process information, practice with structured feedback at a demonstration site, and then return to the second session with questions and heightened confidence. Nursing staff development personnel should serve as role models with computerization to show that learning can be interesting. When new technology is introduced, support staff should be available and visible to help nurses gain expertise with the equipment. Demonstration of new technology (equipment and software) should be frequent and visible in places such as the cafeteria. Placing personal computer on community nursing clinics and supporting staff to use them encourages computer skill development (Ellis, 2002). Change Process, change is a regular occurrence in the health care environment. The computerization of nursing systems is one aspect of the changes taking place in the information revolution. As a result, nurses have widely varying attitudes toward computers and change in the workplace. To transition the nursing team effectively from one system to another, the nurse informatics must be aware of the factors that encourage and those that impede the change. Change process can be exciting, painful, and challenging. Careful planning and step-by- step approach to selecting software, creating a transition process, and evaluating the outcome are essential for success. Lewin’s Force field theory (1995) provides a clear framework for exploring and implementing computerization. Lewin’s three-phase framework comprises “unfreezing,” “moving,” and “refreezing.” Unfreezing is a time when nurses identify a need to implement a computerized nursing system and begins to acquire computer skills. The first step of Lewin’s process, unfreezing, involves the identification of the current need or problem. At this stage, there may be feelings of discomfort apprehension, and upset among the nurses. The nurse informatics facilitates activities that distinguish the driving forces and restraining forces in this step. Strategies are developed to strengthen the driving forces and weaken or reduce the restraining forces. It is during this phase that nurses in the organization begin to realize that the change is necessary and valuable to the success of the organization. The second step of the process involves changing or moving to a new level. It is here that the actual change occurs and the driving forces have equalized or

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overcome the restraining forces. The nurse informaticist has gathered the necessary information to move forward with the proposed change. A detailed plan is constructed for implementing the change, and the change is executed within the organization. In the final step of Lewin’s process, refreezing, the change is stabilized at the new level within the organization. The nurse informatics assist with maintenance and evaluation as functions stabilize and the change is incorporated into the system. Database Mining Data mining is a powerful tool in the knowledge discovery process that can now be done with a number of open-source software packages. It is a tool that has the potential to expand the scope of inquiry by opening up the realms of health care data available in large databases (Computers Informatics Nursing, 4004). In addition, data mining as a method for data analysis in nursing research can contribute to the discovery of causal factors and demonstrate outcome effectiveness. The database has two main aims as stated by Hippisely-Cox, Stables and Pringle (2004) the first is to provide very good access to high- quality validated data for use in ethical research. The second aim is for QRESEARCH such as surveys that make morbidity statistic available to health community at large. Examples of Databases (Database Mining) 1. Health Baseline Statistics Data for Egypt ( Appendix ◄2►). 2. Management information systems and applications (decision support, payroll, personnel, finance, etc.). 3. Epidemiological surveillance database(s). 4. Information technology training programs for nursing and other health care professionals. 5. Hospital management systems (registration, electronic medical records, finance, insurance). 6. Geographic information systems. 7. Computer-based directory of national health care institutions (hospitals, laboratories, clinics, centers of excellence, etc.). 8. Computer-based directory of health care professionals (physicians, radiologists, dentists, pharmacists, etc.). 9. Bibliographic, library and documentation database(s). 10.Computer-based network of health care institutions (hospitals, laboratories, blood banks, etc.). 11.Full-text database(s) for laws, legislation, regulations, etc.

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12.Computer-based directory of health and nursing education (colleges of medicine, dentistry, pharmacy, nursing, etc.). 13.E-health, telemedicine, teleradiology, telepathology services. 14. Current Situation, Progress of Health for All in Egypt (Appendix ◄3►). Examples of Community Health Informatics Areas Management data in health care is ranged from the management of an activity, such as immunization or an awareness campaign, to the management of a national program (e.g. disease control). The management of a health care institution (e.g. a hospital or a laboratory) or the management of an entire national health service (Richards, 1998). ―

— Immunization data from public and private providers throughout the country was used to focus on as prevention resources through determining geographically where children were at risk of disease due to under immunization. In Egypt, Sean (1990) said that children’s immunization campaign were promoted by health center nationwide, the highest rates of infant mortality were in Upper Egypt, followed by Cairo, Alexandria and other urban areas; the lowest rates were in lower Egypt. — Surveillance is another aspect of community health area that could be dramatically transformed by the application of information systems and continuously monitored for changes in the incidence or characteristics of identifiable illnesses or even specific clusters of findings. Although the methods for conducting public health surveillance may differ considerably by program and disease, surveillance activities share many common practices. Brossette (1998) added that National Electronic Disease Surveillance Systems integrate and link public health surveillance activities through internet-based communications infrastructure, standards, and policy-level agreements on data access, sharing, burden reduction, and confidentiality protection. Specific examples of internet use by the health team were mentioned as follows by Communicable Disease Control (2004): • • • • • •

Nursing/medical training and continuous education Health information access Patient care and support Remote diagnosis and consulting Emergency/epidemic support Tele-working for the disabled

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Preventative care education and preventive health Electronic publishing of full-text of health and biomedical literature.

— Educating the populace about the role of life-style choices and client behavior in health promotion and prevention of disease and injury are basic community health functions (Friede, Blum and McDonald,1995). — The collection and analysis of health-related statistics is an essential public health activity that relies on the use of general statistical methods. This bibliography covers health statistics systems, but excludes many publications that discuss general-purpose tools and techniques for statistical analysis (Yasnoff et al, 2001). ― Epidemiological surveillance involves collection of ongoing routine data to examine the extent of disease, to follow trends and to detect changes in disease occurrences. The spread of epidemics is one of the classic problems around which the art and science of computer modeling developed, and computer modeling of epidemics has an extensive literature. Epidemiological surveillance is essentially the study of the patterns of distribution and the trends of diseases and related health care measures, by geographical area, age group, community, etc., so as to establish priorities and optimize health care measures through monitoring and evaluation, this requires the collection and analysis of varied and relatively large amounts of data, from and about the locations where diseases and related health problems occur and from where patients present themselves, typically in urban and rural health centers and hospitals (Communicable Disease Control, 2004). — Long term care settings such as nursing homes and other health care institutions have found it difficult to manage the regulatory process and provide quality health care without computerized clinical information systems (Zielstorff, 1998). — The electronic health record (EHR): Advances in information technology have accelerated efforts to implement information systems such as the electronic health record. The electronic health record is a collection of all of an individual’s interactions with the health care system that will be available electronically (subject to privacy, confidentiality and security guidelines and legislation) to health care professionals anywhere in the country (WHO, 2002).

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Many health-care institutions are seeking to develop integrated clinical workstations. These are single entry points into a medical world in which computational tools only assist with clinical matters(reporting results of tests, allowing direct entry of orders by clinicians, facilitating access to transcribed reports, and in some cases supporting telemedicine applications or decisionsupport functions), but also with administrative and financial topics (tracking of patients within the hospital, managing materials and inventory, supporting personnel functions, managing the payroll, and the like), research (for example, analyzing the outcomes associated with treatments and procedures, performing quality assurance, supporting clinical trials, and implementing various treatment protocols), scholarly information (for example, accessing digital libraries, supporting bibliographic search, and providing access to drug-information databases), and even office automation (providing access to spreadsheets, word processors, and the like (Yasnoff, et al, 2001). The increasing demand for well-structured and accessible patient data, in combination with developments in computer science, has sparked great interest in the development of an electronic patient record. Computers have the potential to improve legibility, accessibility and structure, but these place heavy demands on data collection. The computer-based medical record has a number of advantages over the paper-based record, which make it an essential requirement for health care (Thacker and Berkelman, 1998).). — Primary Health Care Informatics: Simon (2003) proposed the following themes for application of primary health care informatics; ▪ Data quality, exploring the barriers to the coding of structured information in primary care and how these may be overcomed. ▪ The use of computers in patient-centered consultation. Usually these are one-to-one encounters between the patient and the healthcare professional. The challenge is to develop technology that supports patient-centered counseling. ▪ e-Health initiatives: Telemedicine and telemonitoring of patients in their own homes has been demonstrated in a wide range of clinical settings. ▪ Knowledge management for primary care. Information overload is a real phenomenon in clinical practice. Primary care professionals need to know where to look for information rather than hold it themselves. There is also a need to prioritize and to accelerate learning in priority areas, possibly developing an appropriate knowledge management strategy for primary care.

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Cowley, Dawa and Ellis (2003) said that “If primary care is to rise to the challenge, the primary care team needs to be supported by tools and methodologies that enable it to reflect on, and improve, the quality of the service it provides within the context of an already demanding schedule. The Need for Community Health Nursing Informatics Community health is a natural arena for the application of advanced information technologies and it is related to community nursing informatics in several respects. Both disciplines seek to use information science and technology to improve client health. There are matters areas of common concern and lessons learned in community nursing often apply to community health informatics. Further, there are applications for which there is no real distinction between community health and community nursing informatics, such as systems for accessing community health data from electronic medical/nursing record system or providing client-specific prevention guidance at the clinical encounter (McGuire, 2001). Health informatics is now a necessity for effective practice in the information age. A deeper level of informatics training is needed by community health leaders and managers to successfully tackle their decision- making and management responsibilities with regard to information systems development projects. Finally, a cadre of community health informaticians with comprehensive training and experience in both public health and informatics is needed to serve in leadership, research, and teaching roles (Howard, 2002). Informatics has been used in the medical field for about 30 years, but the public health community has embraced it only recently, since the early 1990s, Communicable Disease Control (CDC) has been working with other federal health agencies, state and local governments, professional associations, and the health care informatics community to advance its use. Examples of informatics activities include integration (linking together a wide variety of surveillance activities), standardization (developing and using detailed standards for data elements required to support public health surveillance), and information dissemination (using the Internet to dynamically generate and disseminate information). Each of these strategies improves the timeliness, completeness, and accessibility of public health data (Zlot 2001). Community health informatics is defined as the systematic application of information and computer science and technology to community health practice, research, and learning (Friede, Blum and McDonald, 1995 & Yasnoff, et al. 2000). In recent years, a variety of training resources have been developed that

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address one or more aspects of informatics. However, to date these resources have been developed in relative isolation, and no consensus has been heretofore established as to specific informatics competencies that various public health professionals should obtain (Zlot 2001). “I like to think of community health informatics as more than the sum of its parts,” said Zlot (2001) discussing why people often have difficulty understanding what it involves and why it is important. She explained that public health informatics combines various disciplines— public health science, computer science, information technology, cognitive science, education, management, economics, and even political science and anthropology— to ensure that public health data are easy to access, analyze, and communicate, and are used appropriately. Effective community health practice requires timely, accurate, and authoritative information from a wide variety of sources. Not surprisingly, community health professionals have been among, the earliest adaptors of computers and other information technologies, and numerous useful computerized information and surveillance systems have been developed (Richards, 1998). As part of their responsibilities, community health nurses often provide personal health care to clients who would otherwise lack access to care, but it is through population-based interventions that the public health system seeks to have greatest impact on the accessibility of care. Community health activities depend to some extent on the availability of recent accurate and comparable information of community health nursing resources through the internet (Appendix ◄4►). Lundy and Janes (2001) describe the scope of community health informatics which includes the conceptualization, design, development, deployment, refinement, maintenance, and evaluation of communication, surveillance, and information systems relevant to community health. It requires the application of knowledge from numerous disciplines, particularly information science, medical/nursing sciences, computer science, management, organizational theory, psychology, communications, political science, and law. Its practice must also incorporate knowledge from the other fields that contribute to community health e.g., epidemiology, microbiology, toxicology, statistics, etc.

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Principles of Community Nursing Informatics: Grier and McGuire (1999) mentioned that community nursing informatics principles are flowing directly from the scope and nature of community health that distinguishes it from other nursing informatics specialty areas. These principles define, guide, and provide the context for the types of activities and challenges that comprise this new field: 1- The primary focus on community health informatics should be on applications of information science and technology that promote the health of populations and community, as opposed to the health of specific individual patient. In community health, consideration for the community as the client may require “treatment” such as quarantine or disclosure of the disease status of an individual to prevent further spread of illness. It also requires attention to environmental factors that affect the health risk of entire populations rather than specifically identifiable individuals. 2- The second focus on community health nursing informatics should be on applications of information science and technology that prevent disease and injury by altering the conditions or the environment that put populations of individuals at risk. Community health nursing emphasizes the prevention of disease and injury versus intervention after the problem has already occurred. 3- Community health nursing informatics applications should explore the potential for prevention at all vulnerable points in the causal chains leading to disease, injury, or disability. Applications should not be restricted to particular social, behavioral, or environmental contexts. 4- As a last principle of community health, nursing informatics should reflect the governmental context in which community health is practiced. Much of community health operates through government agencies that require direct responsiveness to legislative, regulatory, and policy directives, careful balancing of competing priorities, and open disclosure of all activities.

Major Challenges of Community Health Nursing Informatics

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Although there are numerous ways in which information science and technology can improve community health nursing practice, Thacker and Berkelman, (1998), mentioned that there are three areas that represent grand challenges: I-

Developing coherent, integrated national public health information systems for assessing community problems in a comprehensive manner through the development of integrated nationwide community health data systems. This requires a clear definition of community health data needs and the sources for these data, consensus on data and communications standards – to facilitate data quality, comparability, and exchange – along with policies to support data sharing, mechanisms, and tools for accessing and disseminating data and information in a useful manner. Agreement on standards is particularly challenging because of the diverse needs of the many groups who record and use health information, including providers, clients, administrators, researchers, and public health officials.

II-

Developing closer integration between community health and clinical care for facilitating the improved exchange of information between public health and clinical care. Many of the data in public health information systems still come from forms filled out by hand, which are later computer-coded. Even where reporting is electronic, initial data entry is typically still manual. This results in serious underreporting of many reportable diseases and conditions. Electronic information sharing and data exchange provide the means by which we can better integrate public health and clinical care activities, but a great deal of creativity and hard work are needed to take full advantage of these opportunities.

III-

Addressing pervasive concerns about the impact of information technology on privacy, confidentiality, and security are pervasive and persistent challenges to progress in community health nursing informatics. Information systems are correctly perceived by the public to be a double-edged sword- whatever is done to make integrated, comprehensive information more easily available for worthwhile purposes must of necessity create new opportunities for misuse.

Another challenge facing nurses’ educators is to develop nurses’ abilities to handle a wide range of information technologies. Computer equipment that permeates all aspects of care, computerized information systems, electronic

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motoring devices, and microprocessor implants are essential for nurses to be encountered (Hannah, Ball, & Edwards, 1994; Saba & McCormick, 1995). Informatics Competencies for Community Health Professionals The competencies and knowledge needed by community health nursing information include an understanding of the respective roles and domains of information technology and public health team members and also to the ability to develop and use an information technology architecture are needed through working knowledge of information system development, networking, and database design; familiarity with data standards; a clear understanding of privacy and confidentiality issues, as well as security technologies; and skills in information technology planning and procurement, information technology leadership, managing change, communication, and systems evaluation research. The term” competency” has been defined as; complex combination of knowledge, skills and abilities that are critical to the effective and efficient function of the organization. Alternatively, combination of observable and measurable skills, knowledge, performance, behaviors, and personal attributes that contribute to enhanced employee performance and organizational success (American Nurses Association, 1995). Nursing Informatics Competency The definition of nursing competency is the integration of knowledge, skills, and attitudes in the performance of various nursing informatics activities within prescribed levels of nursing practice (Staggers & Gassert, 2000).

Table (1) Nursing Informatics Competency among Nurses as presented by Staggers & Gassert (2000). competency levels of practicing Nurses Beginning Nurse • Has fundamental information management and computer technology skills. • Uses existing information systems and available information to manage practice.

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Experienced Nurse • Has proficiency in a domain of interest (e.g., public health, education, administration). • Highly skilled in using information management and computer technology skills to support his/her major area of practice. • Sees relationships among data elements and makes judgments based on trends and patterns within these data. • Uses current information systems but collaborates with the informatics nurse specials to suggest improvement to systems.

Informatics Nurse Specialist • An RN with advanced preparation possessing additional knowledge and skills specific to information management and computer technology. • Focuses on information needs for the practice of nursing, which includes education, administration, research, and clinical practice. • Uses the tools of critical thinking, process skills, data management skills (including, acquiring, preserving, retrieving, aggregating, analyzing, and transmitting data), systems development life cycle, and computer skills.

Informatics Innovator • Educationally prepared to conduct informatics research and generate informatics theory. • Has a vision of what is possible and a keen sense of timing to make things happen. • Leads the advancement of informatics practice and research. • Functions with an ongoing healthy skepticism of existing data management practices and is creative in developing solutions. • Possesses a sophisticated level of understanding and skills in information management and computer technology • Understands the interdependence of systems, discipline, and outcomes, and can finesses situations to o maximize outcomes.

American Nurse Association (2001) added another distribution for nurses according to competency informatics characteristics as follows: I. New Clinician • Computer literacy • Information literacy • Web literacy • Identify, collect, record relevant data • Analyze and interpret nursing information • Use application designed for nursing practice • Protect privacy of health information. II. Experienced Clinician • Identifies relationships among data elements • Uses current solutions, and makes suggestions for improvements. • Manages data, information and knowledge • Participates as a content expert

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• Promotes integrity of and access to information • Active involvement in improving information management and communication • Acts as an advocate for incorporating innovations. III. Nurse Informaticist Competencies • Collaborates with informatics community to optimize nursing information management. • Functions in interdisciplinary environment. • Synthesizes data, information, and knowledge to clarify informatics issues or problems. • Analyze multiple approaches/solutions to informatics issues or problems. • Develops informatics solutions • manages the implementation process • Evaluates and adjusts solutions • Contributes to the body of informatics knowledge. Nursing Informatics Areas of Competency (Howard, 2002): ■ Ethics ■ Research/quality measurement and improvement ■ Financing, organization of health care. ■ Development of professional role and patient provider relationship/leadership ■ Health promotion and disease prevention/competencies relevant to primary health care. Nursing Informatics Roles There are needs to utilize more systematic and informed approaches to the application of information science and technology in order to take full advantage of its potential to enhance and facilitate community health activities (Lasker, Humphreys, and Braithwaite, 1995). These are embodied in the nurses’ informatics roles; • Project Management • Consultant • Educator • Researcher • Development supporter • Decision support/outcomes management • Advocacy/policy development. Roles of nurse regarding his/her position within nursing team;

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1. Front Line staff: nurses who carry out the bulk of day-to-day tasks

(e.g., nurses, counselors, investigators, lab technicians, health educators, and other clinicians). Responsibilities may include basic data collection and analysis, fieldwork, program planning, outreach activities, programmatic support, and other organizational tasks. 2. Senior level staff (Senior Level Technical Staff): nurses with a specialized staff function but not serving as managers (e.g., epidemiologists, biostatisticians, health planners, health policy analysis). They have increased technical knowledge of principles in areas such as epidemiology, program planning, and evaluation, data collection, budget development, grant writing, etc., and may be responsible for coordination and/or oversight of pieces of projects or programs. 3. Supervisory and management staff: nurses for major programs or functions of an organization, with staff who report to them. Increased skills can be expected in program development, program implementation, program evaluation, community relations, writing, public speaking, managing timelines and work plans, presenting arguments and recommendations on policy issues. Nursing Informatics Competencies Self-Assessment; there is a website that was created to offer registered nurses an online tool for self assessment in general Nursing Informatics competencies. Various competency taxonomies have been reviewed and integrated in the process. The intention of this work is to give the nurse a preliminary analysis of current expertise and learning needs in the realm of informatics in nursing. The results of this assessment do not represent testing or examinations offered by any informatics-related organization or particular school. This is purely a professional development exercise in self-assessment for assisting nurse in creating a personal learning plan for further education and practice (www.nursing informatics competency, self-assessment.com). Electronic learning(Distance Learning) For Nursing Education Informatics Goals for nursing education as stated by Simpson (1998) are to educate nursing students and practicing nurses in core informatics contents, to prepare nurses with specialized skills in informatics, to enhance nursing practice and to education through informatics, to prepare nursing faculty in informatics, and increase collaborative efforts in nursing informatics The impact of the internet on nursing education has been profound. Lindeman (2000) believes this is an era of rapid change for nursing education.

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Considering the current era of distance learning, education can be accessed primarily through internet using asynchronous communication, electronic mail, newsgroups, and conferencing (Carliton, 1999). Maddux (2001) notes that college students of any discipline are now enticed by marketing that offers online “bachelor’s, master’s, or doctoral degrees in nursing sciences in 12 months without mandatory attendance in structured classroom settings”. Undergraduate and graduate degrees in nursing can be obtained via the internet through the Web sites of colleges and universities. Peterson, Hennig, Dow and Sole (2001) pointed out different internet teaching methods for nursing education as; (a) using handheld computers, (b) using the Internet for clinical instruction, (c) facilitating synchronous and asynchronous online discussions, (d) assessing health needs on another continent via the Internet, (e) designing Internet Journal discussions, (f) identifying Internet surveys research opportunities for students, (g) teaching pathophysiology through online discussion boards, and (h) using e-mail to develop nursing scholarship. Simpson (2003) said that “Welcome to Virtual Education for Practical Experience”, and defined Virtual Reality (VR) that it employs computers and various multimedia peripherals to produce a simulated (i.e., virtual) environment that users perceive as comparable to real-world objects and events. Conventional desktop computers, multimedia, and distance learning systems deliver nonimmersive VR, allowing students or nurses to log on to distance learning and continuing education courses from the convenience of their homes, the college computer lab, their officers, or an inpatient settings. There are several software nursing education programs which affiliated to different health institutions and universities on the internet and through the distance and e-education learning. Magnus and Derkach, 1994 & Todd, 1998 were proposed nursing informatics education model for graduate nursing informatics students (Appendix ◄5►). Globalization and Nursing Informatics Comptencies Shaw (2002) stated that the concept of globalization goes beyond that related primarily to economic and trade developments that cross national borders. Globalization defined as the flow of information, goods, capital and people across political and economic boundaries. The General Agreement on Trade and Services (GATS) Signed in 1994, this far-reaching agreement is administered by World Trading Organization (WTO). It defines four different models for

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supplying services. A Foreign Service provider can choose the model best suited to its needs and interests. These four models were discussed and presented as: 1Cross border, where for example a university in one country provide education services to citizens of another country; 2Commercial presence, where for example a U.S. health organization operates a hospital in another country; 3Consumption abroad, for example citizens of one country purchase health services in another country; and 4Movement of natural persons, for example nurse migration to other countries to provide nursing services. For nursing, Shaw (2002) mentioned that all of these models have implications for the provision and quality of nursing services. However, it is the fourth model, movement of natural persons, subsequent work has to be done in relation to areas as technical standards, licensing, education and qualifications. Some specific implications for nursing, increasing global trade, trade agreement, the increasing flexibility and movement of the workforce nationally and internationally, and policy changes in the broad field of regulation, all contribute to the growing complexity in the field of professional regulation. In many countries, this has become a loosely integrated system based primarily, but not exclusively, on credentialing practice. The most common forms of credentialing considered being: ♦ Accreditation of educational institutions – this is usually a voluntary credentialing process signifying quality and identifying areas for improvement; ♦ Licensure through law of the individual profession – this conveys authority to practice. Its primary purpose is protection of the public; ♦ Specialty certification – this represents advanced knowledge and skill, and relates more to recognition of the provider than to protection of the consumer; ♦ Accreditation of service delivery organization – this ranges from application of broad international standards, to specific programs such as hospital accreditation. At an international level, ICN is working on the following credentialing activities: • Establishing standards for international distance learning nursing education, telenursing, international health and nursing consultation, and education programs with international health or nursing components;

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• Developing international mechanisms (including partnerships) for accreditation of programs with international components and certification of nurses and other health professionals as international consultants; and • Establishing international competencies for general nursing applicable to multi-country licensure. Nursing and other health professionals, need to consider the following points in relation to the globalization of health professional regulation (ICN, 2004); ─ Specialty and advanced nursing practice. Nursing has paid little attention to cross border recognition of this. Many programs are still in early stages of development. ─ Sustaining cross-border regulation in the context of more permissive trade agreements. ─ Using the experience of the European Union. The cross-border regulatory experience in nursing within the EU should be reviewed for its potential contribution to shared approaches to regulation. ─ The tension between internationalizing regulation and ensuring appropriate regulation at a country level. ─ Telehealth and telenursing. Nursing should be alert to any developments in regulation or standards related to telenursing services, and other areas where nursing services may cross national borders. National-level regulators could review such developments for their potential use in, or linkage, to their own systems.

Summary Nursing Informatics can be viewed through a number of different lenses. The most common ones include the standard areas of nursing: nursing practice, nursing education, nursing research, and nursing administration. Nursing Informatics can also be viewed through the sociological lens of empowerment, dialogue, synthesis, and creative expression. Nursing informatics and its application to community health nursing as a selected topic to be presented was difficult to cover all its aspects in this paper. The future of nursing informatics and electronic health in Egypt is bright and promising. Innovation in nursing science combined with advances in information

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and communication technologies should provide community health nurses with tools that increasing contact with the communities they serve could be also through community health nursing web-sites resources. Community nurses roles regarding informatics are; “Life-long learner" role, nurses should be able to demonstrate knowledge of information resources and tools available to support life-long learning. "Clinician" role, nurses should be able to use appropriate and available information technology in order to acquire and analyze patient information, leading to proper clinical decisionmaking”. Educator/communicator" role, nurses need effective education/communication skills in the context of relating to peers, patients/clients and the public at large. "Manager" role nurses should be able to collect and analyze information about service clients, the work done and the system functions. "Researcher" role, nurses should be involved in nursing researches; this role includes knowledge of literature sources and how to access them, the use of computers in data collection and analysis and how to disseminate their results. In Egypt, much work remains to be done to make nursing informatics a reality. Through hardware, software and personnel; a multi-facet learning program that utilizes distance learning, interactive cable TV, and the internet to connect learning environments to homes, place of work, and the community at large, and by establishing-updating community nursing resources web sites. The graduate level nursing informatics educational environment must continue to strive to become a forum where educator and student meet in an expanded capacity made possible by an increase in the integration of computer literacy within the nursing informatics curricula. Using innovative teaching mediums such as the virtual classroom, distance and continuing education in nursing informatics can be a reality and should be actively promoted. Nursing should be alert to any developments in regulation or standards related to telenursing services, and other areas where nursing services may cross national to international borders. National-level regulators could review such developments for their potential use in, or linkage, to their own systems.

Recommendations Based on this state-of art article of the “Nursing Informatics and Its Application to Community Health Nursing” the following are recommendations concerning this area of nursing informatics:

Nursing Informatics and its Application to Community Health Nursing

─ The focus is now on the computer’s need for input data. Designing and developing computers software programs are urgent needed to support nurses in the care of clients, more effort needs to be made to change how clients data are being collected and accessed. This change should focus on the nurse’s need to collect and retrieve data as quickly and easily as possible. ─ Nurses must ensure that the proposed change should be viewed as a challenge rather than a threat. Adjusting to change may be difficult and demanding. Therefore, a well-formulated strategy will encourage adaptation to change rather than resistance. ─ Establish National Nursing Informatics Workgroup, to provide leadership and guidance in setting a national informatics agenda for nursing education and practice for the Egyptian Nursing Informatics Curricula. ─ Develop evaluation methods that; ◘ Assure valid and reliable results in studying the effects of complex information systems on community nursing practice. ◘ Measure the contribution of information systems to nurses’ clinical decision-making. ◘ Measure, if possible, the contribution of information systems to client outcomes. ◘ Provide measurable, dependable predicators of nurse’s optimal use of automated information systems. ─ Curricula are needed for developing competencies of nursing informatics at a basic level for the entire nursing staff, an intermediate level for community nursing managers and leaders, and an advanced level for community nursing informatics specialists and researchers. ─ Nursing needs a common language to communicate what nurses do, within both the professional and the larger health care community, which includes clients and families, other healthcare providers, and those who direct healthcare policy and reimbursement. Availability of widely accepted empirically-based nursing diagnosis, interventions and outcomes facilitate the development of nursing and healthcare information systems that are useful for teaching nurses/students the steps of the nursing process and clinical decision making.

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─ Integrating informatics into the graduate community health nursing curricula. Candidates, as well as nurses, must keep abreast of the latest technological developments in patient care, education, and research. Faced with an information exposition, nurse faculty is challenged by the need to educate nursing professionals who are prepared to use technology. Curriculum development, evaluation, and modification are detailed in relation to student learning needs, faculty preparation, and equipment and consultation requirements. ─ The Electronic Health Records should reflects the nursing potentiality to enhance nurses’ decision-making regarding the delivery of care by supplying access to health information about clients, allowing data-entry, and offering electronic access. ─Nursing informatics should be a central feature of the nursing undergraduate and graduate curricula rests on the intimate relationship of information management to the essential roles such as project Manager, consultant, educator, researcher, development supporter and decision maker. For each one of these roles the nursing informatics learning need could be stated into learning objectives. References American Nurses Association. Standards of practice for nursingInformatics, Washangton, DC: American Nurses Publishing 1995:19. http://www.american nurses association.com, accessed June 2004. Ball, I. (2000). Information Industry and Nursing profession, Computer Information Nursing, No.6: 23-24. Bargstadt, G. (1998). Use of nursing information systems in the community settings, In S. Moorhead & C. Delaney (Eds.), Information systems innovation for nursing (pp.213-226). Thousand Oaks, CA: Sage Publications. Berry MJA, Linhoff G,(1997). Data Mining Techniques for Marketing, Sales and Customer, New York: Wiley. Brossette SE. Data Mining and Epidemiologic Surveillance [dissertation]. Birmingham, Ala: University of Alabama at birmingham; 1998, Dissertation Abstr Int 3 (59): 544. Candian Institute for Health Informatics. (1997). Working Group 3: Privacy, confidentiality, Data Integrity, and Security of the Partenership for Health informatics/Telmatics. Ottawa.

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Canadian Nurses Association(2001): Privacy of personal health information.www.nursing/ canadian nurse association.com. Communicable Diseases Control website (2004). www.CDC.com Council of Europe (1981).Convention for the protection of individual regard to Automatic Processing of Personal Data, Chapter II, Article 5. Cowley, C., Dawa, L., and Ellis, B. (2003). Health Informatics and modernization: bringing the gap, British computer Society. In Informatics in Primary Care (2003) 11: 207-14. Cox, H. C., Harsanyi B., & Dean, L C. (1987). Computer and nursing: Application to practice, education, and research. Norwalk, CT: Appleton & Lange. In Nursing Education Perspectives, July/August 2002 Vol. 23 No. 1. El-Henawy, A., Current situation, progress and prospects of health for all in Egypt, Eastern Mediterranean Health Journal, Vol. 6, No. 4, July 2000, 816-821 Emory Unicersity Rollins School of Public Health. The MSPH program in public health Infor Egypt (http://www.emro.who.int/ - file://A:\WHO Egypt.htm) Friede, A., Blum, H. L., and McDonald M. “Public Health Informatics: How Information Age Technology Can Strengthen Public Health,” Annual Review of Public Health 16 (1995); 23925. Graves,J.,& Corcoran, S. (1989). The study of nursing informatics. Image: The Journal of Nursing Scholarship, 21, 227-231 Grier,M., & McGuire,S.(1999). Nursing Informatics: A meands for change. In J. Lancaster (Ed). Nursing issues in leading and managing. St. Louis, Mosby, pp. 533-553. Hippisely-Cox, J., Stables, D., and Pringle M. (2004). QRESEARCH: a new general practice database for research, British Computer Society.In Informatics in Primary Care 2004:12-49-50 Howard, E. P. (2002). Evaluation of Clinical Learning in a Managed Care Environment, Nursing Forum, Volume37, No.1. http://www.nurseecominc.com/html/forum.html. Accessed in August 2004. International Councel of Nurses (ICN): http://ICN.ch/. Accessed in July 2004 International Organization for Standarization (ISO): http://iso.ch/. Accessed in July 2004 Journal of Biosocial Sciences (2001) 33: 161-172 Lewin, K. (1951). Field theory in social sciences: selected theoritical papers. New York:Harper & Row.

Nursing Informatics and its Application to Community Health Nursing

38

Lewin K. Field Theory in Social Science: Selected Theoritical Papers. Westport, CT: Greenwood Press; 1975. Lasker, R.D., FHumphreys,B.L., and Braithwaite,(1995). W.R.,Making a powerful Connection: The Health of the Public and the National Information Infrastructure, Washington, DC: Public Health Data Policy Coordinating Committee, U.S. Public Health check. Lindeman, C. A. The future of nursing education. J. Nurs Educ. (2000); 39:5-12. Lundy, K.S., and Janes, S. (2001) . Community Health Nursing Caring for the Public’s Health, Jones Bartlett Publishers, Boston, USA. Lyman P, and Varian, H.R., (2000).How http://www.sims.berkely.edu/how-much-info

much

information?

Available

at:

Magnus, M., Co, Jr., M., & Cerkach, C. (1994). A first-level graduate studies experience in nursing informatics. Computers in Nursing, 12(4), 189-192. McCloskey.J.C. and Bulechek, G.M.(2002). Nursing Intervention classification, Lippincott Williams & Wilkins Inc. in CIN, web:http://www.us.elsevierhealth.com Muddux, C. D. Computers, statistics, and culture of university mathematics education. Comput Sch. 2001; 17:9-15 McGuire, R. C.,(2001). Nursing Informatics In Community Health Nursing Practice, Chapter 14. In Lundy K.S. & Janes , Community Health Nursing Caring for the Public’s Health (PP 308320). Boston: Jones Bartlett Publication. McPeck, P., “Education Evaluation,” Nurseweek (July 7, 2001). Available online at www.nurseweek.com/news/features/01-07/evalution.html Nagelkerk, J. (1994). Nursing Informatics: Mastering technology Graduating Nurse, 29-30. National Electronic Disease survelleillance System Working Group. National Electronic Disease survelleillance System (NEDSS): a standards-based approach to connect public health and clinical medicine. J Public Health management Practice 2001 Nov; 7(6): 43-50. O’Carroll PW, Yasnoff WA, Ward E, Ripp L, Martin E. Public Health Informatics and Information Systems. New York: Springer-Verlag New York, Inc. (in press, available Nov2002). Peterson, J. Z., Hennig, L. M., Dow, K.M., and Sole, M.I. Designing and facilitating class discussion in an Internet class. Nurse Educ. 2001; 26:28-32. Population Estimates (Egypt, 2001) File://A:\NATIONS Population Estimates.htm

Nursing Informatics and its Application to Community Health Nursing

39

Prather J. (2000). Exploratory Data Analysis to Detect Preterm Risk Factors [dissertation]. Duraham, NC: Department of Biomedical Engineering, Duke University; Abstr Int 62:952. Salazar-Riera, N., Piloting an Information literacy program for staff Nurses: Lessons Learned, Computer Informatics Nursing Journal, 2002, Vol.20. N.6: 236-241. Schwartz, Dan.”Core competencies: what every informatics expert should know”available at http://www.cbmi.upmc.educ/personnel/ds/cdc/tsld006.htm,(accessed 18 April 2001). Sean, S. (1990). Children Immunization Campaign Promoted by health centers nationwide, Egypt, Health and Welfare, UNICEF,Library of Congress, available in online http:www.library of congress.com, accessed July 2004. Shaw,S. (2002). International Trade and Nursing Profession, In the Seventh International Conference on “The Impact of Globalization on Development and Health Care Service in Islamic Countries” Kuwait, March 2002. Simon, D. L., (2003). Introduction to the Primary Care Informatics Working Group of the European Federation for Medical Informatics, British Computer Society, In Informatics in Primary Care (2003) 11: 175-6. Website; http:// www. efmi.org.com Simpson R. L., (1993) Nursing Informatics core competencies, Nursing Management, Vol. 25, No.1, pp. 18-20. Simpson R. L., (1998). The Technologic Imperative: A new Agenda for Nursing Education and Practice, Part 2, Nursing Manage. 29(10):22-25, http://www.nursingmanagement.com Simpson R. L., (2003). Welcome to the Virtual Classroom, How technology is Transforming Nursing Education in the 21st Century, Nurs Admin Q, Vol. 27, No.1, pp.83-86 Smith J.(2000). Health Management information systems: a handbook for decesion-makers, Buckingham, United Kingdom, Open University Press. Staggers, N.,& Gassert, C. (2000). Competencies for nursing informatics. In B. Carty (Ed). Nursing Informatics: Education for practice (pp.17-34). New York: Springer. Richards, J. (1998). “Informatics Training in School and Graduate Programs of Public Health.” MPH Thesis, University of Texas-Houston Health Science Center. Timothy J. Carney, National Center for Chronic Disease Prevention and Health Promotion Volume 14 • Number 2 • Spring/Summer 2001. Thacker,S.B. and Berkelman, R. L.(1998). “Public health Surveillance in the United States,” Epidemiology Review 10: 164-190. Thiru, K., Simon D. L., Sullivan, F., Brew, S., and Cooper A. (2003). Three steps to data quality, British Computer Society, In Informatics in Primary Care (2003) 11: 95-102.

Nursing Informatics and its Application to Community Health Nursing

40

Todd, N. (1998). Using e-mail in an undergraduate nursing course to increase critical thinking skills. Computers in Nursing, 16(2), 115-118. Tom, L., and Frank, M.S. (2004). Confidentiality, clinical governance and research in community, British Computer Society. In Informatics in Primary Care 2004; 12: 1-2 World Health Organization (1997). Health informatics and telematics. Regional Office for the Eastern Mediterranean, Alexandria, Egypt. World Health Organization (2002). Electronic Health Ethics. Regional Office for the Eastern Mediterranean, Egypt, website www.wto.com World Health Organization (2001). Emergency and Humanitarians Action Baseline Statistics for Egypt, Egypt, Available at: www.who.countries.egypt.com World Trading Organization, 1994, website www.wto.com Wright P. (1998). Knowledge development in databases: tools and techniques. Assoc. Computer Machinery (ACM) Crossroads Stud Mag [serial online]. Networks and Distributed System; 1998-5.2. Available at: http://www.acm.org/crossroads/xrds5-2/kdd.html.Accessed July 2003. “What is medical informatics?”http://dmi-ww.mc.duke.edu/dukemi/essent/whatis.html, (accessed 19 April 2001). University of Washington 2002. The Biomedical and Health informatics Graduate Program at the University of Washington. http://www.informatics.washington.edu/html Yasnoff WA, Overhage JM, Humphreys BL, LaVenture M, Goodman KW, Gatewood L, Ross Da, Reid J, Hammond WE, Dwyer D, Huff SM, Gotham I, Kukafka R, Loonsk JW, Wagner MM. (2001). A National Agenda for Public Health Informatics. J Public Health Management Practice 2001; 7(6): 1-21. Zeilstorff R.D. (1998, September30). Characteristics of s good nursing nomenclature from and information perspective. Online Journal of Issues in Nursing Retrieved, from http//www.nursing world.org/ojin/tpc7_4.htm. Zlot, A. National Center for Chronic Disease Prevention and Health Promotion Volume 14 • Number 2 • Spring/Summer 2001.