current resident or

Non-Profit Org.U.S. Postage Paid

Princeton, MNPermit No. 14

THE BULLETINBrought to you by the Indiana Nurses Foundation (INF) and the Indiana State Nurses Association (ISNA) whose

dues paying members make it possible to advocate for nurses and nursing at the state and federal level.Quarterly publication direct mailed to approximately 2,300 RNs and electronically via email to 65,000+ RNs licensed in Indiana.

Volume 46 • Number 2February, March, April 2020

INSIDECertification Corner

Page 2

CEO Note

Page 3

Policy Primer

Page 4

Pillar Power

Page 7

Welcome New & Reinstated Members

Page 9

Independent Study:Nursing 2.0: Care in the Age of Technology

Page 10

MESSAGE from the PRESIDENTEmily B. Sego

DNP, RN, NEA-BC

Happy New Year from the Indiana State Nurses Association! This is an exciting year for all of us in that 2020 has been designated as “The Year of the Nurse and Midwife” by the World Health Organization in honor of the 200th birthday of Florence Nightingale. Over the next few weeks, the American Nurses Association will be launching its official “The Year of the Nurse” website with activities and ideas that will help us showcase the critical work we do. Stay tuned!

If kicking off 2020 with “The Year of the Nurse” is not enough, we also captured the #1 spot in Gallup’s Annual Most Honest and Ethical Professions Poll for the 18th consecutive year. What better way to start the New Year by celebrating nurses and what we bring to healthcare and the patients we serve.

How do you plan to celebrate “The Year of the Nurse” in 2020? We want to hear from you and your teams! Share your pictures and stories of celebration with @IndianaNurses including hashtags #YON2020 #YearOfTheNurse and #IndianaNurses.

In December, the ANA held its annual leadership summit in Washington, D.C. A few topics addressed were staffing and nurse suicide rates. As far as staffing, many felt that our strategy for supporting new staffing models needs to be reframed. One recommendation was to remove the word “ratios” from any conversations around staffing. Nursing representatives attending from several states felt that the word “ratios” is perceived negatively and can inhibit further dialogue with key stakeholders.

A recent study published by Judy Davidson, DNP, RN and her colleagues at the University of California San Diego showed that suicide among male and female nurses alike, were higher than the general population. In response to this alarming data, the ANA is developing a suicide prevention committee

to address this issue. I am pleased to announce that Brian Arwood, MSN, RN-BC will be the representative for the State of Indiana. Brian is a Certified Psychiatric Nurse at Community Health Network in Kokomo and currently serves as President Elect for the Indiana chapter of the American Psychiatric Nurses Association and is a Director on the ISNA board.

As we move through the New Year, take time to reflect on where our profession has been and what we want it to look like in the future. Personally, I want to see more diversity in nursing, more nurses involved in health policy, and more nurses continuing their education. As a servant nurse leader, it is my responsibility to contribute to the future of nursing which is why I recently made the commitment to go back into teaching and help mentor graduate level nursing students engage in health policy. I will also be working with the American Nurses Credentialing Center to write test questions for the Advanced, Nurse Executive Board Certification. In addition, I took a leap of faith and left a job I loved to follow my passion in nursing to be the VP, Chief Nurse Executive of Ambulatory Care at Community Health Network. During my first week on the job, I was immersed in discussions with colleagues regarding diversity, equity and inclusion in nursing, relationship based care, and increasing the number of certified nurses. What a way to begin 2020! Nurses, this is our year to shine! How will you contribute and leverage “The Year of the Nurse” in 2020 to elevate the nursing profession?

The Bulletin February, March, April 20202

Published by:Arthur L. Davis

Publishing Agency, Inc.

www.indiananurses.org

An official publication of the Indiana Nurses Foundation and the Indiana State Nurses Association, 2915 North High School Road, Indianapolis, IN 46224-2969. Tel: 317/299-4575. Fax: 317/297-3525. E-mail: info@indiananurses.org. Web site: www.indiananurses.org

Materials may not be reproduced without written permission from the Editor. Views stated may not necessarily represent those of the Indiana Nurses Foundation or the Indiana State Nurses Association.

ISNA StaffKatherine Feley, DNP, RN, NE-BC, CPPS, CEO

Blayne Miley, JD, Director of Policy and AdvocacyMarla Holbrook, BS, Office Manager

ISNA Board of DirectorsEmily Sego, President; Beth Townsend, Vice President; Barbara Kelly, Treasurer; Angela Mamat, Secretary; Directors: Shalini Alim, Brian Atwood, Jolynn Kuehr, Susan Waltz and Recent Graduate Director, Andrea Jacobs

ISNA Mission StatementISNA works through its members to promote and influence quality nursing and health care.

ISNA accomplishes its mission through unity, advocacy, professionalism, and leadership.

ISNA is a multi-purpose professional association serving registered nurses since 1903.

ISNA is a constituent member of the American Nurses Association.

Address ChangeThe INF Bulletin obtains its mailing list from the Indiana Board of Nursing. Send your address changes to the Indiana Board of Nursing at Professional Licensing Agency, 402 W. Washington Street, Rm W072, Indianapolis, IN 46204 or call 317-234-2043.

Bulletin Copy Deadline DatesAll ISNA members are encouraged to submit material for publication that is of interest to nurses. The material will be reviewed and may be edited for publication. To submit an article mail to The Bulletin, 2915 North High School Road, Indianapolis, IN. 46224-2969 or E-mail to info@indiananurses.org.

The Bulletin is published quarterly every February, May, August and November. Copy deadline is December 15 for publication in the February/March/April The Bulletin; March 15 for May/June/July publication; June 15 for August/September/October, and September 15 for November/December/January.

If you wish additional information or have questions, please contact ISNA headquarters.

For advertising rates and information, please contact Arthur L. Davis Publishing Agency, Inc., 517 Washington Street, PO Box 216, Cedar Falls, Iowa 50613, (800) 626-4081, sales@aldpub.com. ISNA and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement.

Acceptance of advertising does not imply endorsement or approval by the Indiana Nurses Foundation of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this association disapproves of the product or its use. ISNA and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of ISNA or those of the national or local associations.

THE BULLETINCERTIFICATION CORNERSue Johnson

Betsy Vance, RN, CEN, RN-BC is the Chief Nursing Information Officer at an Indiana health system in Indianapolis. She began her career as a student nurse extern and then a staff nurse in one of the busiest emergency departments in the state of Indiana.  Betsy later transitioned to leadership roles, including emergency department performance improvement/quality assurance coordinator and the emergency department clinical informatics process improvement coordinator. In her current position as chief nursing information officer, Betsy applies her expertise to clinical workflow evaluation and process improvement and then translates clinical workflow needs into technology solutions. She is a board-certified emergency nurse (CEN), received her informatics certification, and has earned her Lean Six Sigma Healthcare Black Belt. 

Here is Betsy’s certification journey in her own words.

What certification(s) do you have? CEN (Board Certification Emergency Nursing from

the Emergency Nursing Association) and RN-BC (Informatics certification from the American Nursing Credentialing Center)

Why did you decide to take the certification exam? Professional development and commitment to these

nursing disciplines and personal growth.

How did you prepare for the exam? What did you study? What resources did you use?

For the CEN – study guides and books; For the Informatics Certification – a formal on-line study lecture series (6 weeks) and study books.

How do you use your certification in your practice? I use concepts from both certification in my practice

however use more of the informatics principles since I am the Chief Nursing Information Officer at my health system. I also use concepts to teach informatics foundations and application to the nursing practice and developing nursing knowledge. Nursing Informatics is a critical piece to health systems to ensure technology whether it is a new software system or devices fits the needs of the clinicians.

How has being certified made you a better nurse and leader?

I have a sense of confidence in my practice and feel proud of my accomplishments. I also feel that it has prepared me for making strategic decisions involving patient safety and preserving evidenced-based, quality care, standardization as well as improving efficiency and satisfaction of the technology.

What advice would you give to others seeking the same certification?

If you are considering, I would highly recommend. There will never be a good time and just make a commitment to start slow, dedicate time for studying and make a goal to take the exam.  

Thanks, Betsy, for sharing your story with us and for serving as a role model for other nurse leaders!

Do you want to share your certification story with your colleagues? It may encourage them to join you! Please contact me at SueJohn126@comcast.net to share your experiences!

Enter the workforce with confidence, experience and excellent preparationbecause you chose USI.

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Asbury Towers Retirement Community, a non-profit retirement community, located in Greencastle, Indiana, is searching for a Director of Nursing to direct the overall operation of our SNF/

AL Nursing Department. Individual must possess a current, unencumbered, Indiana license as a Registered Nurse and have

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Equal Opportunity Employer

February, March, April 2020 The Bulletin 3

Katherine Feley, DNP, RN

2020. What does this number mean to you? This number was often highlighted throughout my early life in health education classrooms and used as the focus of many school papers to inform us of the national objectives to improve the health of Americans. Back then, 2020 was a futuristic, robot-filled, space traveling time frame I didn’t need to really worry about. As a young girl, I didn’t think about how my actions over time would lead up to this very point. It’s here! It’s actually 2020, just without the robots as I had imagined.

I love the New Year holiday. I am not typically an advocate of resolutions, but this holiday reminds me of the opportunity for renewal and refocus as I reflect on where I’ve been, where I am today, and where I see myself in the future, whether that is within this futurist 2020 or 2030. The year of 2020 will be an energizing year for me. I was blessed with a new daughter, Evelyn, and an opportunity to invest in the nursing profession

through ISNA. I smile at the possibility my daughter may love nursing as much as I do. What will 2030 and 2040 look like for her? How will I share the significance and gratification of being a nurse so that one day she may choose to follow in my footsteps?

2020 is an exciting year for all of us. The American Nurses Association (ANA), along with the World Health Organization, has declared 2020 as the Year of the Nurse and Midwife. A year to elevate our profession, celebrate our victories, and increase the understanding of the value of nursing. This year ANA and ISNA will focus on promoting excellence, infusing leadership, and fostering innovation. I ask that as we dive into 2020 you take time to reflect and plan for your own professional rebirth. Will you be applying for a leadership position, returning to school or completing that certification you’ve been thinking about, or sharing your ideas for new and improved health care delivery? How will you celebrate your accomplishments and the achievements of our colleagues?

Please join me in celebrating the #yearofthenurse (the year of us!) and as you reflect on your journey, you find peace and happiness. 2030 is just around the corner; are you headed in the right direction? Let’s make 2020 our best year yet, after all, it is the start of our future.

CEO NOTE

2020: A Futuristic, Robot-Filled, Space Traveling Time Frame

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The Bulletin February, March, April 20204

Blayne Miley, JD ISNA Director of Policy & Advocacy

bmiley@indiananurses.org

Below you will find summaries of some of the health-related bills that have been introduced in the 2020 Indiana General Assembly session. As we go to press in mid-January, these bills have just been published and the legislature is starting to hold committee hearings. By the time this article reaches you some of the bills will still be alive in the legislative process and others will be dead. At iga.in.gov, you can lookup full details of all the bills; committee schedules, livestreams, and video recordings; and your state legislators and their contact information. We need more nurses to share their expertise with their state legislators, and you can help! Members of ISNA receive weekly updates through our e-newsletter, the ISNAbler, so you can stay current on what is happening at the Statehouse that impacts your profession.

Advanced Practice Registered NursesSB 21 & HB 1207 Requires Pharmacists to Honor Prescriptions Written by APRNs & PAs Licensed in Other States

Require pharmacists to honor prescriptions from duly licensed APRNs in other states.

HB 1326 Community Mental Health CentersOverhauls the regulation of community mental health

centers. For purposes of Indiana Medicaid, grants APRNs working in community mental health centers the same supervisory rights and responsibilities as physicians, including prior authorization.

POLICY PRIMERHB 1392 APRN & PA sign death certificates

Allows APRNs and PAs to sign death certificates and submit death records to the appropriate regulatory entities.

SB 98 CRNA SupervisionAllows CRNAs to work under the direction of

podiatrists. In ambulatory outpatient surgery centers, allows CRNAs to work under the direction of any physician, instead of only those with specialized training in anesthesia. Updates the national certifying body for CRNAs.

Board of NursingHB 1150 Board of Nursing members

Allows recently retired nurses to serve on the Board of Nursing and requires the Board to have two APRN members, one of which must have prescriptive authority. This change would add flexibility to the eligibility requirements to serve on the Board of Nursing. Because serving on the Board is a major time commitment, it can be challenging for PLA to find qualified applicants that are able to maintain Board responsibilities and employment responsibilities. (HB 1150)

HB 1110 Health workforce student loan repaymentCreate an interprofessional health workforce loan

repayment program by imposing a $10 or $20 fee on all applications and renewals of health licenses (the additional fee for nursing licenses is $10). Fifty percent of the money raised would be retained by a health workforce council to provide student loan repayment however they see fit. The council membership is comprised of government agencies and organizational stakeholders, such as the Indiana Hospital Association and the Indiana Rural Health Association. No members of the council represent individual professions. Each health profession board will make recommendations to the council regarding areas of workforce needs. The rest of the money collected would be apportioned to the respective boards based on the percentage of total

licenses each board has. Each board can award student loan repayment grants to providers that have provided essential services in health workforce shortage areas for at least one year before the application, and agree to provide essential services in health workforce shortage areas after receiving the award for a number of years determined by the council. Any money apportioned to a board that is not distributed by the board reverts to the fund for use by the council every two years. (HB 1110)

Public HealthSB 1 & SB 423 & HB 1006 Tobacco and e-cigarette age to 21

Raises the minimum age to purchase or possess tobacco and e-cigarettes to 21. Increases fines to retailers for selling to underage individuals.

SB 193 Prohibit flavored e-liquidsProhibits the sale, manufacture, or distribution of

flavored e-cigarettes.

SB 207 Syringe exchange programsRequires syringe exchange programs to maintain a

voluntary registry of participants. Individuals on the registry have a defense against certain drug crimes. Also removes the requirement of a public health emergency to start a syringe exchange program.

SB 287: Minority health care student scholarshipEstablishes a scholarship for up to $4,000 annually

for minority students pursuing health care careers, including nursing. Requires a commitment to practice in Indiana for at least three years upon licensure.

SB 356 Healthy food grant programEstablishes a healthy food financing program to

provide grants to increase the availability of fresh and nutritious food in underserved communities.

Hospital ProtocolsSB 146 Forensic Medical Exam Requirements

WHY BECOME A MEMBER OF CAPNI? § A constantly updated interactive website (www.capni.enpnetwork.com) § The ability to network electronically with APRNs statewide § Up to date information on APRN issues state wide and nationally § The benefits of group membership in AANP § Regular Region meetings to provide education and networking

opportunities § Job postings on our Career Center § Reduced rates for our conferences § Political advocacy for legislative/regulatory issues

CAPNI is for ALL APRNs in the State of Indiana!

COST OF MEMBERSHIP § $125 annual professional membership

§ $50 annual retiree membership

§ $50 annual student membership

Visit www.capni.enpnetwork.com to become a member or to learn more!

Advocacy Day (for members only)

Indiana State Capitol | 200 West Washington Street, Indianapolis, IN 46204 Tuesday, February 11, 2020 at 10:00am - 2:00pm ET

REGISTER AT: capni.enpnetwork.com/nurse-practitioner-events/133978-advocacy-day#!registration

2020 CAPNI Annual APRN ConferenceIndianapolis Marriott North | 3645 River Crossing Parkway, Indianapolis, IN 46240

Thursday, February 20, 2020 at 7:30am - Friday, February 21, 2020 at 5:00pm ET

REGISTER AT: capni.enpnetwork.com/nurse-practitioner-events/133396-2020-

capni-annual-aprn-conference#!registration

February, March, April 2020 The Bulletin 5Requires a sexual assault victim to have a sexual

assault counselor present before and during a forensic medical examination, unless they knowingly and voluntarily waive the right to the counselor.

SB 182 Health providers must identify full name and license type

Requires health providers to wear ID badges specifying their first and last name, and their license type when providing direct patient care. Exceptions for surgical and emergency settings or if the provider’s license type is otherwise prominently displayed in the health care setting. Requires health providers to specify license type in advertising, which includes business cards.

SB 91 & HB 1129 Require Infants to be Screened for Adrenoleukodystrophy (ALD)

Screening must be at the earliest feasible time.

HB 1084 Newborn screening for cytomegalovirusRequires every infant to be screened for

cytomegalovirus at the earliest feasible time.

HB 1259 Firearms at hospitalsAllows a hospital to prohibit the possession of

firearms on any premises owned or operated by the hospital. Provides exceptions for security personnel and unconscious individuals brought to the hospital for emergency services.

School HealthSB 141 School based health clinics

Allows FSSA to apply for a modification of Indiana’s Medicaid program to allow Medicaid reimbursement for school based health clinic services.

SB 142 Medicaid reimbursement for school health referrals

Allows school corporations to seek Medicaid reimbursement for delivered health services, including nursing.

SB 246 School mental health servicesRequires schools to partner with community health

centers or providers for mental health and addiction

services before applying for a grant from the Indiana secured school fund.

SB 275: Concussion protocolRequires the Department of Education to develop and

disseminate a mandatory protocol for schools to use to determine when a student who received a concussion can return to classroom work.

SB 378: Mental health wellness educationRequires school curriculums to include mental health

wellness education. Permits schools to offer mental health screenings to students with the written consent of a parent/guardian.

HB 1011 Meningococcal disease informationRequires the Department of Education to provide

additional information to students on meningococcal disease and its immunizations.

HB 1237 Medicaid reimbursement for school health services

Allows schools to receive Medicaid reimbursement for certain health services provided to students, including nursing services performed by an RN, LPN, or unlicensed assistive personnel operating under delegation from an RN.

Medical Marijuana SB 86 Limited Medical Marijuana

Creates a defense to the criminal charge of possessing marijuana or paraphernalia if the individual has a medical marijuana card from another state or a physician certifies the individual has a terminal illness or untreatable disease and the benefits of marijuana use exceed the risks.

SB 103 Limited Medical MarijuanaCreates a defense to the criminal charge of possessing

marijuana or paraphernalia if a physician certifies the individual has a terminal illness or untreatable disease and the benefits of marijuana use exceed the risks.

HB 1041 Medical cannabisPermits the use of cannabis for people with serious

medical conditions as determined by their physician. Regulates the distribution of medical cannabis.

HB 1163 Medical marijuanaAllows medical marijuana in Indiana. Requires a

physician recommendation for use. Specifies eligible medical conditions for the recommendation.

Health Care Cost & TransparencySB 3 Health care costs

Limits out of network charges for health care services. Requires providers that are out of network but providing services at a facility that is in network to provide a good

Policy Primer continued on page 6

ucnursing.online

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For a complete job description, qualifications, or to apply, please visit http://jobs.ivytech.edu.

Ivy Tech is an accredited, equal opportunity, affirmative action community college.

NURSING FACULTY

The Bulletin February, March, April 20206

faith estimate to patients for the cost of care at least five days before the service is provided.

SB 4 All payer claims databaseCreates an advisory committee to make

recommendations concerning the creation of an Indiana all payer claims database to facilitate the reporting of health care and health quality data that results in transparency and public reporting of safety, quality, cost, and efficiency information at all levels of health care. Specifies committee members including representatives for hospitals, physicians, and pharmacists, but not nurses.

SB 5 Health care pricing disclosureProhibits health care provider contracts from

prohibiting the disclosure of the pricing of health care services.

SB 421 Cost limits for epi-pens & insulinProhibits cost sharing for minors that are prescribed

epi-pens. Limits the amount an insured individual is allowed to be charged for a 30 day supply of insulin to $50.

HB 1004 Out of network billingProhibits a provider from billing a patient for greater

than the in network amount, unless they notify the patient with a good faith estimate.

HB 1005 Health care cost estimatesRequires providers to give patients good faith

estimates of charges for nonemergency health care services upon request. Initial version includes physicians and physician assistants, but not APRNs. Requires facilities to post cost estimates.

HB 1146 Health care cost disclosureRequires health care facilities to provide patients the

cost to the patient of health care services, upon the ordering of the service.

If one or more of these bills strikes your interest, email me (bmiley@indiananurses.org) for a status update, and then contact your state legislators!

Policy Primer continued from page 5

February, March, April 2020 The Bulletin 7

Pillar PowerBeth Townsend, EdD, MSN, RN, EBP-C

What are ISNA “Pillars” and why are they powerful?

A brief explanation of the alignment between the mission, values, and pillars of the ISNA will help to answer that question. Mission and vision statements are designed to explain an organization’s purpose and direction and to guide decision making, problem-solving, and prioritizing in their broadest sense. The ISNA mission statement declares that “it works through its members to promote and influence quality nursing and healthcare,” while the vision proclaims that the “ISNA is the recognized leader for nurses and professional nursing practice in Indiana.”

Core values are more specific and provide clarity on who the organization is today, how it acts, and who it serves. The core values of the ISNA are advocacy, collaboration, facilitation, information, leadership, and education. The “pillars” are the most specific and important part of what makes an organization successful because they drive the strategic plans and values of an organization. Unity, advocacy, professionalism, and leadership are the pillars that support the mission and values of the ISNA. As cornerstones of the ISNA’s work, they are powerful channels to action – they provide direction for operationalizing the mission and values.

Nursing Professionalism and Evidence-based PracticeThe ISNA pillar of Professionalism states that

we aspire to “drive excellence in nursing practice, education, innovation and contribution in nursing research to improve the health of patients, families, and communities.” Standard nine of the ANA’s Professional Practice Standards® specifically emphasizes the need for nurses to engage in evidence-based practice (EBP) and research. According to the Institute of Medicine (IOM, 2003) EBP is one of the core competencies for all healthcare providers. Frontline nurses are especially well-positioned to identify and create innovations that improve patient care quality and safety through EBP. Every nurse has a professional responsibility to contribute to the advancement of practice and nursing knowledge. Engagement in EBP empowers nurses to fulfill that responsibility using a systematic approach to problem-solving and knowledge generation.

If it’s the right thing to do, what’s the problem? Despite the IOM (IOM, 2010) goal that by the year

2020, 90% of all clinical decisions will be evidence-based, the implementation of EBP is not ubiquitous in today’s healthcare environments (Stavor, Zedreck-Gonzalez & Hoffman, 2017). Nurses agree that EBP is useful to improve the quality of care and outcomes for patients, but they have identified several barriers to implementation. Insufficient education on how to develop a research question, search for and evaluate the literature, and apply research to practice was found to discourage the adoption of EBP (Florczak, 2016; Skela-Savic, Havalic-Touzery, & Pesjak, 2017; Stavor et al., 2017). Barriers at the organizational level include workload, lack of administrative support, and

cultural resistance to change (Sanares-Carreon, 2016). Uncertainty about how to translate new knowledge into practice is another factor that discourages the adoption of EBP. Ensuring the successful integration of a practice change requires an understanding of organizational culture, change management, and how to traverse the organizational channels that facilitate the acceptance of innovations. Frontline nurses need the support and guidance of leaders who are proficient in EBP to help them navigate the complexities of institutional bureaucracy.

Education and the Implementation of EBPBecause an in-depth discussion of EBP is beyond

the scope of this article, an abbreviated example is presented to provide a general overview of the EBP implementation process. It is not unusual to begin by partnering with an EBP-savvy academician to assist with the design and delivery of staff education and the EBP implementation plan. Create a team of EBP champions whose enthusiasm will inspire others and encourage their acceptance of EBP. The champions will receive EBP education, enabling them to function as the unit “expert resources.” It has also been suggested that advanced practice nurses function as mentors due to their clinical knowledge, and familiarity with organizational culture and change management (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). Next, select an EBP model to guide the implementation plan. Numerous models have been designed to provide direction, one of which is the Johns Hopkins Nursing Evidence-based Practice Model (Dang & Dearholt, 2018) a framework that is frequently utilized because it is straightforward, comprehensive, and substantive. Follow the Hopkins seven-step EBP implementation plan:

1. Identify a clinical practice or organizational change

2. Create a PICO question that guides the change project

3. Search for evidence4. Appraise, evaluate and synthesize the evidence5. Integrate the evidence into decision-making for

the EBP change6. Create and implement an evaluation plan7. Create a dissemination and sustainability plan for

the EBP change

Proficiency in each of these components is essential to the planning, implementation, and evaluation of EBP.

What can the ISNA do? A Call to ActionAs members of the ISNA, we have a responsibility to

champion and promote EBP as a systematic approach to support and inform problem-solving and decision making that increases patient safety, improves the quality of care and empowers nurses to build new knowledge through research. Those of us who work in areas where EBP is not the norm can begin by assessing the current state of EBP. It is essential to cultivate a spirit of inquiry and heighten awareness: ask about perceived barriers, identify champions of EBP, identify organizational and departmental catalysts (is there a shared governance council who might initiate the change to EBP? What is the level of understanding of EBP? Are the nurses receptive to joining an EBP implementation planning team?)

The ISNA Professionalism pillar statement obliges us to lead the drive to excellence in all areas of nursing practice. The ANA has recently announced its intent to elevate and celebrate the contributions of nurses as the world recognizes 2020 as the “Year of the Nurse.” What better way to celebrate nurses than by promoting EBP and publicizing the practice improvements? Let’s embrace the opportunity to undertake a powerful course of action that will advance the professionalism of nurses and significantly impact the quality of healthcare in the state of Indiana.

ReferencesAmerican Nurses’ Association (n.d.) ANA Standards of

Excellence. Retrieved from https://www.nursingworld.org/ana/about-ana/standards/

Dang, D., & Dearholt (2019). Johns Hopkins nursing evidence-based practice: Model and guidelines (3rd ed.). Indianapolis, IN: Sigma Theta Tau International.

Florczak, K. (2016). Evidence-based practice: What’s new is old. Nursing Science Quarterly, 29(2), 108-112.

Institute of Medicine (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.

Institute of Medicine (2010). The future of nursing: Leading change, advancing health. Washington DC: National Academies Press.

Melnyk, B., & Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan, L. (2012). The state of evidence-based practice in U.S. nurses: Critical implications for nurse leaders and educators. Journal of Nursing Administration, 42(9), 410-417.

Sanares-Carreon, D. (2016). From caterpillars to butterflies: Engaging nurse leaders in evidence-based practice reform. Nursing Administration Quarterly, 40(2), 174-181.

Skela-Savic, B., Hvalic-Touzery, S., & Pesjak, K. (2017). Professional values and competencies as explanatory factors for the use of evidence-based practice in nursing. Journal of Advanced Nursing, 73(8), 1910-1923.

Stavor, D., Zedreck-Gonzalez, J., & Hoffman, R. (2017). Improving the use of evidence-based practice and research utilization through the identification of barriers to implementation in a critical access hospital. Journal of Nursing Administration 47(1), 56-61.

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The Bulletin February, March, April 20208

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Saint Mary’s College, a Catholic liberal art’s College for women, invites applications for the position of Director, Department of Nursing Science and The Marjorie A. Neuhoff Chair in Nursing in the

Division of Nursing Science, Social Work, and Gerontology.

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February, March, April 2020 The Bulletin 9

ISNA WELCOMES our NEW and REINSTATED MEMBERSNona Alyea GreenfieldCathryn Baack IndianapolisKevin Baer BloomingtonFabian Bahena BloomingtonVictoria Bailey WhitestownAlena Barrett LebanonLorpu Benjamin IndianapolisTina Blowers DecaturKristy Bridgewater ScottsburgPaula Brinkley ChandlerJennifer Burchett IndianapolisVanessa Burton IndianapolisSherry Chalfant SpringportAmanda Chavez La PorteMelodie Cline KokomoMelissa Compton GreenwoodRicci Cornell LafayetteMorgan Craig FloraLynn Crist IndianapolisSandra Curtin OtterbeinBradley Davis PortageCarmen Davis IndianapolisKim Deckard EllettsvilleBrooke Doherty CharlestownHeather Dorsey IndianapolisTosha Draper FishersTheresa Eaton PlainfieldMichele Escobedo BrownsburgGina Fencl Saint JohnAshley Ford CovingtonArlenda Foree MerrillvilleGeorge Fotopoulos HighlandRamonna Fratena LafayettePatricia Ginda West LafayetteCarrie Goforth CharlestownJessica Gorka FishersJill Graupman MonticelloRoshanda Grayson-Thomas PortageTaiyler Griffin South BendBrandon Grindle Terre HauteCaleb Grise IndianapolisEmily Hallberg WestfieldKelly Hampton GreenvilleBarbara Hannah AlexandriaLolita Harmon MerrillvilleMandy Harper BloomingtonWendi Harrell PlymouthSherry Hash ZionsvilleJennifer Hattabaugh GreentownSusanne Heinzman IndianapolisKelly Herbert ScherervilleElizabeth Hernandez Crown PointLizelle Hill JasperLisa Hite FloraStephanie Holdcroft West Baden SpringsAshley Holmes Fort Wayne

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The Bulletin February, March, April 202010

When describing nurses, words like caring, knowledgeable, trustworthy and hardworking may come to mind. Technology and data expertise probably don’t – but they should. Nurses routinely use technology in the form of equipment to perform their daily functions in the workplace. They also regularly find and create data by charting and looking for information about their patients. Both of these functions require knowledge and skill to carry out, yet nurses may fail to realize – and give themselves credit for – their expertise in this work.

Technology can be defined as “the practical application of knowledge, especially in a particular area; a manner of accomplishing a task especially using technical processes, methods, or knowledge” (Merriam-Webster, n.d.) This very much describes the work nurses do, whether in using technical equipment or creating/documenting, finding, and/or sharing information related to the care of our patients. The expanding effect of technology on our profession is inevitable. Case in point: The National Academy of Medicine created a committee to address technology roles in nursing, including sponsoring a series of

INDEPENDENT STUDYNursing 2.0: Care in the Age of Technology

Learner Outcome: Learners will have an increased knowledge related to the implications of technology in nursing practice.

Disclosures1.0 Contact Hour will be awarded with

successful completion.

Criteria for Successful Completion: Read the entire study and complete the evaluation. Submit fee of $20 and the evaluation to Indiana State Nurses Association, 2915 N. High School Road, Indianapolis, IN 46224, to receive CNE certificate of completeness.

Expiration: 11/30/2021

This study was written by Bobbi Spring, MS, RN, ANP-BC, CCRN, CEN

There is no conflict of interest among anyone with the ability to control content of this activity.

The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91)

Future of Nursing 2030 Town Hall meetings. The key items focused on were advancing health care equity in the digital age, technology to inform practice and advance equity, and nurses’ well-being and its impact on patients and caregivers (Troseth, 2019).

Technology infuses our practice. It is not just the equipment or systems in our workplace but how nurses use devices and the care provided as a result of technology use. We can consider this as three levels. The first level is the devices, systems and products, including information and communication technology (ICT), we use in our work. The second level is the actual use of this technology. This use can be as simple as pushing a button to turn on a device, such as an electronic thermometer or as complex as monitoring an intra-aortic balloon pump (IABP) machine. At the third level technology is the service or purpose that is provided by the use of the devices and systems. An example of this could be a decrease in medication errors by using a bar-coded medication administration (BCMA) system. (Korhonen, Nordman & Eriksson, 2015). Technology, for the purposes of this overview article, will focus on both the equipment and the information/documentation systems used regularly by nurses.

Nurses’ use of technical equipmentArtificial Intelligence (AI)

Some technology is so commonly and easily used by nurses, such as automated blood pressure machines or basic cardiac monitors, that one may forget the complexity of these devices. In these instances, as with most use of technologic devices, the critical skill is not in actually using the device but rather in interpreting the information gained from it. Other devices, such as smart infusion devices, are even more complex and incorporate the use of artificial intelligence (AI). Many nurses, as well as the public in general, may not be aware this, in part due to the quality and efficient functioning of the AI being used. In fact, “when AI is good, you won’t know you are using it” (Goodwin as cited in EchoNous, 2018, para. 2).

So, what then, is AI? AI was first developed as a way for machines to mimic functions of human intelligence and cognition, including the ability to think, perceive, learn, make decisions and problem solve. AI has evolved far beyond its initial conception, computing with increased power and speed in collecting and processing data, which, along with enhanced connectivity, can increase productivity. (National Institution for Transforming India (NITI) Aayog, 2018). At one time novel and groundbreaking, these technologies are now common in healthcare and used on a daily basis. These advances, including the electronic health record (EHR), mobile health (mHealth) utilizing smartphones, telehealth and

sensors for remote patient monitoring and simulation to name a few, can add value to nursing care delivery in the form of more efficient workflow, improved outcomes, cost containment and increased patient and nurse satisfaction. (Carroll, 2018).

We encounter the use of AI on a daily basis, at home, work or businesses. Those of us who use voice activated assistive devices in our homes, such as Siri® or Alexa®, are using a form of AI. Internet programs that track our preferences in online shopping or watching shows online use AI. Smartphone-assisted devices use AI. These are just a few examples of how commonly AI is integrated into our personal lives. In the clinical setting, AI is regularly used in the programming for equipment such as infusion pumps or BCMA systems. These intelligent systems are based on programmed algorithms, which are “sequential instructions that ensure particular task completion. They are a set of well-constructed rules given to an AI program to help it learn on its own. When many algorithms are put together and layered in applications, they become the backbone of AI” (Polson & Scott, as cited in Carroll, 2019, para. 2). These algorithms attempt to predict the next step of use, such as confirming an infusion rate is correct or warning that it exceeds pre-programmed limits, and store this data to improve future performance. But these algorithms should never replace our own nursing judgment and can be overridden as necessary. “While AI stands to be a tool that can help increase efficiency, help clinicians make more informed decisions for their patients, and hopefully is fun to use, there is widespread recognition that a move towards more AI integration in nursing will always be a machine + man formula….the clinician will always have the last word” (EchoNous, 2018, para. 6). As the American Nurses Association’s (ANA) Dr. Bonnie Clipper stresses that, “nurses will learn to incorporate AI into our practice but it will not replace the human factor. Only they can provide hands-on patient care” (EchoNous, 2018, para. 3).

RoboticsRobotics, “the technology dealing with the design,

construction, and operation of robots in automation” (Merriam-Webster, n.d.), extends the use of AI support even further into our work. Healthcare use of robotics ranges from simplistic robots used for transport of materials (with programming similar to that of robot vacuum cleaners, such as Roomba®, used in our homes) to precise robotic surgery. “Driven by the shortage in qualified nurses and the high percentage of aging populations, the past decade has witnessed a significant growth in the use of robots in nursing, especially in countries like Japan.” (Maalouf, Sidaoui, Elhajj & Asmar, 2018, p. 590). “Socially intelligent mobile robots have long been posited as one response to a chronic nursing shortage in the U.S. According to the Bureau of Labor Statistics, demand for nurses in the U.S. is set to grow from 2.7 million in 2014 to 3.2 million in 2024, an increase of 16 percent. Much of the growth will be driven by aging baby boomers who need additional care” (Nichols, 2019, para 3). One such type of robots, named Moxie, are now being trialed at Texas Health Dallas, The University of Texas Medical Branch (UTMB Health) and Houston Methodist Hospital. Moxie’s role is to “support clinical staff by augmenting logistical tasks that limit valuable patient care time….creating a more efficient and thoughtful environment allowing for better patient care.” (Thomaz, 2018, para. 6). While this is a recent and newsworthy development in the US, Japan is a decade ahead, and “robots with names like Paro, Pepper, and Dinsow have been successfully integrated into the healthcare ecosystem, albeit for relatively limited tasks.” (Nichols, 2018)

Maalouf, Sidaoui, Elhajj and Asmar (2018) classified robotic use into two types: assistive (used for physical care, including service and monitoring tasks) or social assistive (focused on the cognitive and emotional well-being of patients in need of companionship). Examples of these are robots being used to interact with patients in extended-care facilities and monitor for dementia as well as perform physical functions such as lifting patients, helping them to stand and get out of bathtubs (Glauser, 2017). These robotic functions can help decrease the workload of nurses but will never replace our critical

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February, March, April 2020 The Bulletin 11reasoning. Robots will still need to be overseen and evaluated for safe use by a nurse with clinical expertise.

Nurses’ use of information technologyElectronic Medical Record (EMR)

Information technology involves data creation, collection, evaluation and storage. Nurses are more familiar with this technology in the form of the electronic medical record (EMR) or the electronic health record (EHR) systems. These systems, which also to use AI to varying degrees, are another area of technological advancement that has had a major impact on nursing, in particular, the documentation of nursing care. Charting has historically been with paper and pen, often in narrative format. While the Internet came into existence in the 1960s, it wasn’t until the advent of the World Wide Web and growth surge in the early 1990s (Computer Hope, 2019) that computers became practical to use in the workplace. Even then, computers were not used regularly for nursing documentation, with paper charts still being the prevalent record of a patient’s history. Medical records and charts in paper form are not without problems, including transfer of information from one place to another, whether floor to another floor or from one organization to another. They are also susceptible to damage, loss or theft. Some healthcare systems, seeing the potential for electronic records, became early adopters of the use of EMRs, which are digital versions of a patient’s chart intended for use within an organization. With this adoption came concerns of patient privacy and data breaches, among others.

Health Information Technology for Economic and Clinical Health Act (HITECH)In 2009 the Health Information Technology for Economic and Clinical Health

Act (HITECH Act) was signed into law as part of the American Recovery and Reinvestment Act of 2009 (ARRA). This legislation provided more rigorous enforcement of HIPAA (Health Insurance Portability and Accountability Act of 1996) and required notification of breaches as well as allowing patients access to their electronic records (USF Health, n.d.).

HIPAA also served to accelerate the use of electronic health records (EHRs) by healthcare organizations as HITECH proposed the meaningful use of inter-operable electronic health records throughout the United States health care delivery system as a critical national goal by 2017. This transition occurred in three stages and required EHR technology to be used in a meaningful way, also known as Meaningful Use.

Meaningful use required the EHR to meet the five following criteria:1. Improving quality, safety, efficiency, and reducing health disparities2. Engage patients and families in their health3. Improve care coordination4. Improve population and public health5. Ensure adequate privacy and security protection for personal health

information(Centers for Disease Control and Prevention, 2019, para. 2).

Electronic Health Record (EHR)Healthcare organizations and private providers were required to create EHR

systems in order to receive funding from the Centers for Medicare & Medicaid Services (CMS). This financial incentive, as well as the advantages of going to a paperless system, were major pushes toward incorporating EHRs into use in healthcare organizations, as well as private providers. EHRs differ from EMRs in that their function has advanced beyond the patient’s record only being shared within an organization, to allowing this information to be easily (and safely) shared among providers, other departments, and other organizations. This is important as it allows a patient’s information to “travel with them” so to speak, as well as to provide critical data that can inform clinical decisions and improve coordination of care between all the patient’s providers. Imagine the time savings, not to mention patient satisfaction, of simply updating any new patient information in the EHR each visit, rather than recording all diagnoses, medications, etc. from the beginning, which was often the case with traditional recording keeping, or even use of an EMR, when a patient went to new provider, hospital or specialist.

Clinical Decision Support (CDS)This usefulness of the EHR also goes well beyond documentation. Most, if not

all, EHR systems are enhanced with clinical decision support (CDS) functionality, which is an evidenced based tool to provide clinicians with information to enhance their decision making. CDS is also used to provide alerts during order entry. These alerts can be tailored to differentiate between life-threatening concerns (such as severe allergic reactions or significant contraindications to medications or treatments) and those with minor consequences. As the use of AI evolves, advanced CDS guidance can become even more patient specific, with inclusion of such information as genetic, familial and past medical history data. CDS has the potential to reduce errors in diagnosis and treatment. (Sensmeier, 2017).

Evidenced Based Practice (EBP)One exciting benefit of HIT is that most systems, especially those that are

programmed with clinical decision support (CDS) technology, are linked to library sources. This means information on current best evidenced-based practices (EBP) is at the nurse’s fingertips in the work place. This is advantageous as “Nurses’ information needs are substantial, with one study reporting 1,820 clinical decisions made during 180 hours of observation” (Yoder et al., 2014, p.27). Unfortunately, despite this wealth of resources and the need for such, staff nurses do not see themselves as active consumers of research, relying instead on unit-based educators or clinical nurse specialists to find, read, analyze, and synthesize the evidence for them. Other barriers noted by nurses, despite their awareness of the value of research are lack of time, lack of resources, and lack of knowledge. Expecting bedside nurses to add the activities of EBP research to their already busy workload is unrealistic unless they are compensated for the time and have the support of an EBP expert coach (Yoder et al. 2014). Melnyk et al. (2018) found that a large number of nurses in the US do not feel that they are meeting the EBP competencies. Nurse leaders, managers, and educators have a responsibility to create a culture that supports EBP and research utilization. (Yoder et al. 2014). With this vast information access, nurses, and ultimately our patients, would benefit from the resources provided by HIT.

Independent Study continued on page 12

The Bulletin February, March, April 202012

Technology-Induced ErrorsBy 2017, the conversion to EHRs should have been

completed by most, if not all, healthcare providers and organizations in order to comply with HITECH mandates. This transition has not been without its challenges, which can be reflected in nursing’s adaptation to the surge of information created by the EHR and the demands of learning of how to use it. Nurses are expected to be the largest users of electronic medical records (EMRs), although measuring the impact of this implementation on the quality of nursing care has not been well examined (Jedwab, Chalmers, Dobroffa & Redley, 2019). However, the use of health information technology (HIT), which includes EHRs, computerized physician order entry, and CDS systems, has been associated with a decrease in medical errors. Unfortunately, with increasing use of HIT, there are now technology-induced errors, which is a newer category of errors, not seen until the use of informational technology. These errors most often occur during the interaction between healthcare providers and HIT during clinical use. It is important to address this category of errors, ideally before they can potentially occur. This requires a multi-faceted approach, including the creation of organizations specifically focused on reducing technology-induced errors and developing new ways to detect such errors before systems are released. For nurses, the most relevant strategies include reporting such errors after they occur and involvement in the development of regulations and policies to reduce such errors. (Borycki, 2013).

Informatics NursingSo how can we address these concerns? Enter the

Informatics Nurse.“Nursing informatics is the specialty that integrates

nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice. It supports nurses, consumers, patients, the interprofessional healthcare team, and other stakeholders in their decision-making in all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes, and information technology” (ANA as cited in HIMSS, n.d. para. 1).

While this specialty was recognized by the ANA in the early 1990s with the publication of the first edition of the Scope and Standards of Nursing Informatics Practice, preparation for this role has not been well addressed by nursing education; many schools not having Informatics degrees or even Informatics overview courses. Since the HITECH act this is changing rapidly, with an increasing demand for INs by healthcare organizations. Another factor driving demand for nursing informatics analysts is that there is an increasing focus on controlling health care costs,

Independent Study continued from page 11 which effective nursing informatics can help to rein in. It is estimated by the American Medical Informatics Association that as many as 70,000 nursing informatics specialists/analysts may be needed in the next five years (NurseJournal, n.d.).

Clinical Documentation Improvement NursingAnother developing role for nurses, with the use

of EMRs/EHRs is that of the Clinical Documentation Improvement (CDI) nurses, who work with providers and clinicians as members of the clinical team to help make the record complete.

Looking at documentation and using their nursing background, CDI nurses anticipate the diagnoses of patients who are being treated, assist healthcare providers in choosing the right words to describe the diagnoses to meet CMS-friendly terminology for diagnosis and billing codes, as well as work with other disciplines such as nursing and dietary, whose documentation supports the healthcare providers’ diagnoses. This is important as nurses traditionally have not played much of a role in hospital or provider billing, at the most making sure supplies used are charged to the correct patient. This is now handled more effectively with the use of the patient’s EHR. However, most nursing care is still subsumed in the room charge. With the EHR’s ability to capture discrete, searchable documentation (through use of checklist charting) the trend is to change the billing culture, including moving from pay for performance to measuring patient outcomes and tracking “never” events. CDI nurses can educate other nurses in the use of EHR documentation for charge capture, billing, and coding. (Braselton, Knuckles & Lyons, 2017).

Generational ConcernsOlder Learner Mythology

As mentioned earlier, transition to use of digital technology has not been without its challenges. One of those challenges is nurses themselves and their experiences with, and attitudes toward, technology. It has been said that you cannot teach an old dog a new trick. This has been proven to be a fallacy. In fact, research demonstrates that an old dog can learn new tricks, but it will likely take longer than it does for a young dog. Once learned however, the old dog will remember these new things long-term (Coren, 2016). This also applies to human elders, “however, adults over 65 may need more training than their younger counterparts given they have had less experience with technology” (Mitzner et al., 2008, p.2047). Older learners also showed interest in receiving additional training, particularly for specific tasks, with preferences for self-training using text materials, such as a manual (Mitzner et al., 2008).

Despite this, there appears to be a widely held belief that younger nurses are expert technology users and older nurses (Baby Boomers) cannot adapt. This is inaccurate and an important misconception to be aware of, as the average age of a working nurse is 51, and roughly 50% of the workforce is over 50, of which

14% of those are 65 or older (Smiley et al., 2018). Following this adage assumes that half of current working nurses cannot meet the technical demands of their roles. It also assumes that younger users, having grown up with technology and computers, are information-savvy digital natives with the ability to multitask, when in fact, they do not exist (Kirschner & DeBruyckere, 2017).

While Millennials (ages 16-34) are competent in using technology for social networking, surfing the web, or taking selfies, spending an average of 35 hours per week on digital media, it was found that 58% have low skills in solving complex problems with technology at work and/or home. International comparison of millennials’ performance on proficiency in key information-processing skills, such as literacy, numeracy and problem-solving use of technology testing ranked the United States last out of 19 participating countries. This is not much better than Generation X and later Baby Boomers (ages 35-64) with 70 percent having low tech skills (Change the Equation, 2015).

So, where did this misconception come from? Prensky (2001a, 2001 b) coined the term “digital natives” who have grown up using digital technology (such computers, video games, digital music players, video cams, cell phones) all their lives (think of toddlers being given access to their parents’ smart phone to play on). He also referred to those who began using technology later in life as “digital immigrants” who could never fully adapt or be as fluent in using technology as those born with using it (similar to learning a new language later in life). He proposed that the brain is malleable and use of technology changes the way the brain works.

That this actually occurs has been called into debate by others researching technology and adult learning (Bennett, Maton & Kervin, 2008). Prensky later revisited his earlier work, noting that it may not be relevant; instead making the case for digital wisdom, described as “wisdom arising from the use of digital technologies to access cognitive power beyond our innate capacity and to wisdom in the prudent use of technology to enhance our capabilities” (Prensky, 2009, para. 2). Nevertheless, these concerns persist, much like the faulty data used to support anti-vaccination propaganda. The reality is that a nurse who has grown up with digital technology may adapt to using an EHR much sooner than the nurse who has spent most of their career charting with paper and pen. The paper-and-pen using nurse may take longer to learn how to navigate the system and may require more practice, but once the basic skills are learned, they can be proficient in digital technology. Think of the use of digital technology as a skill similar to starting an IV. Some nurses grasp this skill quickly and become quite good at it, some nurses need more practice and time to become proficient, and other nurses who have only a few opportunities to practice may never develop the skill. Learning to use technology, in whatever form, is still learning a skill. This is where nursing management can address

February, March, April 2020 The Bulletin 13the different learning preferences of their nurses and support them in becoming expert in the use of the EHR, including more practice time as needed. Based on their surveys, the American Association of Retired Persons (AARP) (2007) found that there was need for managers to have training about aging and the value of the older worker to the organization. Managers also needed to learn how to engage older workers and provide them with adequate job training and opportunities; this training should be designed to consider the learning limitations and preferred formats of older adults (AARP, 2007).

Interestingly enough, these older nurses, “Baby-boomer registered nurses (RNs), the largest segment of the RN workforce from 1981 to 2012, are now retiring. This would have led to nurse shortages but for the surprising embrace of the profession by millennials–who are entering the nurse workforce at nearly double the rate of the boomers. Still, the boomers’ retirement will reduce growth in the size of the RN workforce to 1.3 percent per year for the period 2015-30.” (Auerbach, Buerhaus & Staiger, 2017, para. 1). And generationally, between the Boomers and the Millennials are the Generation Xers, making up the rest of the nursing workforce.

Generational Learning PreferencesHampton, Pearce and Moser (2017) identified that

each generation has its own distinct characteristics, values, and attitudes based on generational experiences that shape learning preference. Baby Boomers enjoy personal interaction with instructors/trainers, like reinforcement for their efforts, and learn best when they can apply personal experience to their educational activities. (Hampton et al., 2017). Not having grown up with computers and technology, Baby Boomers have little experience to relate to when learning these new skills, hence some of their difficulty with digital content. Hampton et al. (2017) also noted that Generation X learners prefer to receive their educational content in a straightforward manner that allows them to learn at their own pace and on a need to know basis, learning only what will benefit them. These GenXer nurses (and, in part, the Boomers as well) do better with structured environments where they know what is expected of them, in detail. Millennials, on the other hand grew up during a time of instant communication and prefer tasks that provide immediate engagement and real-time fast processing of information, learning immediately from their mistakes rather than waiting for results. Therefore simulation learning works well because Millennials are, in general, more social (having grown up with encouragement to participate in variety of extracurricular activities, including sports) and also do well with group work and collaborative learning, as compared to more isolated learning context that is preferred by the Baby Boomers and GenXers (Hampton, et al., 2017).

Managerial SupportThere is a possibility that the more tech savvy

(and perhaps younger) nurses may feel frustrated by working with nurses who are less adept with technology. Despite this, it may be to nursing manager’s advantage to pair nurses of different generations and technical skills together during trainings or transitions in using new equipment, computer systems, etc. in that they can benefit from each other’s strengths. (Bell, 2013). It should also be mentioned again, that not all younger nurses are technologically proficient, and that all learning should be adapted to generational (if not individual) learning needs and preferences whenever possible in order to foster technological competency. Considering the fast pace of technological advancement in healthcare, nurses, regardless of age, need support to develop and continuously improve their technical skills.

Although it is beyond the scope of this paper, these learning preferences and concerns could apply to both nursing students and patients and their families. The traditional lecture/assessment format of education may not be preferred or as engaging to younger students. In the same vein, handouts and oral review of discharge instructions may not serve our younger patients as well as it does with patients who more comfortable with traditional patient education. These topics warrant further investigation.

System BarriersBesides competence (or lack of), the other major

technological frustrations impacting nurses are functional system barriers.

Nurses, as the largest occupational group of HIT users, expect that it must work well with multitasking and caring for multiple patients in a complex, fast-

paced health care environment. Nurses generally feel that the EHR and BCMA influences quality of care through error reduction and improved patient safety. However, interruptions in planning or providing care due to operational failures, such as software issues (screen abruptly shutting off or freezing), power loss, difficulties logging on due to forgotten password, multiple scanning attempts with BCMA, and difficulty with scanning a particular medication, are frustrating. Documenting in EHRs may also be more time consuming as well reduce time at the bedside for direct patient care. (Zadvinskisa, Chipps & Yen, 2014).

A poorly designed EHR can make nurses work that much harder, which is why nursing needs to be involved in choosing EHR systems, selection of technology enhanced equipment and requesting software that is adapted to our needs. Goodman and Miller (2006) contend that “a computer program should be used in clinical practice only after appropriate evaluation of its efficacy and the documentation that it performs its intended task at an acceptable cost in time and money” (p.1434). If we don’t participate in choosing EHR systems these choices will be made for us and not always to our benefit. “Nursing as a profession needs to anticipate the impact of technology on care to move beyond a reactive approach to technological advances. An anticipatory position is necessary for the nursing profession to exert intention, agency and influence over how technology does, can and should influence fundamental care provision. The capacity to anticipate change requires awareness of current technological developments and thoughtful exploration of how these developments impact nursing fundamentals.” (Archibald & Barnard, 2017, p. 2474).

Ethical ConsiderationsWith these advances in technology and the vast

amount of information generated by EHRs alone, we would be forfeit if we did not consider the associated ethical implications. Sensmeier (2017) notes that “Healthcare is one of the most data-rich industries, driven by digital health, image capture, and widespread EHR adoption. Between EHRs, digitized diagnostics, and wearable medical devices, the average person will leave a trail of more than one million gigabytes of health-related data in their lifetime. According to Harvard Business Review, 30% of the world’s electronic data storage is occupied by healthcare information. At the same time, it takes 17 years to translate science into practice, and electronic healthcare data double every 24 months.” (p. 16).

With these technological advances, and the staggering amount of data continually being generated, comes the power to greatly affect the care and health outcomes of our patients. But with great power comes great responsibility (Lee, 1962). Just because

we have the technological ability to advance so rapidly, does it mean we should, at least not without thoughtful examination of potential consequences? Wadhwa (2014) notes that a major problem is that the human mind itself can’t keep pace with the advances that computers are enabling, and we haven’t come to grips with what is ethical, let alone with what the laws should be, in relation to technologies. Ideally, technological innovation should require ethics integration from early development. However, as Tavani (2013) discusses, when technology is created the makers can’t always envision all possible applications, especially years later. Applying ethical restrictions may not be relevant and may even restrict future work. He also notes that applying an ethical framework after the fact, doesn’t always work either as harm may have occurred in the meantime. To address this concern, Tavani (2013) suggests adopting the views of Moor and Weckert, in that “ethics is something that needs to be done continually as a technology develops and as its potential social consequences become better understood.” (p. 403).

Regarding the EHR, Lee (2017) maintains that there need to be “ethical reflections about the use of EHR data for research and quality improvement….issues of privacy and informed consent for subsequent use of data. Additional ethical aspects are important in the conversation, including data validity, patient obligation to participate in the learning health system, and ethics integration into training for all personnel who interact with personal health data.”(p. 382).

Ethical issues are important to health informatics. An initial ensemble of guiding principles, or ethical criteria, has emerged to orient decision making:

1. Specially trained humans remain, so far, best able to provide health care for other humans. Hence, computer software should not be allowed to overrule a human decision.

2. Practitioners who use informatics tools should be clinically qualified and adequately trained in using the software products.

3. The tools themselves should be carefully evaluated and validated.

4. Health informatics tools and applications should be evaluated not only in terms of performance, including efficacy, but also in terms of their influences on institutions, institutional cultures, and workplace social forces.

5. Ethical obligations should extend to system developers, maintainers, and supervisors as well as to clinician users.

6. Education programs and security measures should be considered essential for protecting confidentiality and privacy while improving appropriate access to personal patient information.

Independent Study continued on page 14

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7. Adequate oversight should be maintained to optimize ethical use of electronic patient information for scientific and institutional research. (Goodman & Miller, 2006, p. 384)

Health care providers, including nurses, use of transparency regarding these ethical concerns and following the suggested guidelines will likely enhance the patient’s trust that their privacy and information are valued and safe. The nursing code of ethics remains applicable, even more so in light of these advances. With the advancement of smart machines and AI technologies, many decisions are made for us based on the machine’s programming. At this point in time, nurses still have final say in whether to follow the recommendations provided by the equipment we are using, or override the decision based on our clinical evaluation of the patient. We are the responsible party.

The rapid advances and increased use of AI governed robots also has led to the development of roboethics, an “area of study concerned with what rules should be created for robots to ensure their ethical behavior and how to design ethical robots. The purpose of roboethics is ensuring that machines with artificial intelligence (AI) behave in ways that prioritize human safety above their assigned tasks and their own safety and that are also in accordance with accepted precepts of human morality.” (Rouse, 2016, para. 1).

Science-fiction author Isaac Asimov is often given credit for being the first person to use the term robotics in a short story composed in the 1940s. In the story, Asimov suggested three principles to guide the behavior of robots and smart machines. Asimov’s Three Laws of Robotics, as they are called, have survived to the present:

1. Robots must never harm human beings or, through inaction, allow a human being to come to harm.

2. Robots must follow instructions from humans without violating rule 1.3. Robots must protect themselves without violating the other rules. (Rouse,

2007, para. 1)

Now this fiction has become reality and of sufficient concern that British Standards Institution (BSI) has published standards, known as BS 8611:2016 to address the ethical use of robots and robotic devices. Building on Asimov’s principles, the “BS8611 suggests that “Robots should not be designed solely or primarily to kill or harm humans; humans, not robots, are the responsible agents; it should be possible to find out who is responsible for any robot and its behavior.” Stipulations include the principle that their design must not allow for cultural, sexual or status discrimination. The document questions whether robots should be designed to foster emotional bonds in users and cautions of the possibility of rogue machines that change their own code.”(Rouse, 2016, para. 4).

Independent Study continued from page 13 Applications to PracticeWhile there are concerns by some in the nursing discipline about technology

taking over our jobs, nurses should accept technology for its potential benefit, rather than avoiding technological advances or fearing for the future of our profession (Erikson & Salzmann-Erikson, 2016; Fleming 2009). Technology can be a boon to nursing practice, with the potential to decrease our workload, increase safety and improve outcomes, however it cannot be stressed enough that it is our practice. Traditionally, nurses have not consistently been involved in decisions that affect our practice, including the inclusion of technology without critical examination of how it impacts care. We need to be proactive in addressing how to integrate the use of robotics and other advanced technologies into the many domains of nursing, rather than reacting after it has been done for us, and to us, by others. (Archibald & Barnard, 2017). Nurses need to have a voice in the EHR systems we use and providing input on how to make our equipment more nurse friendly. For example, in discussing BCMA systems specifically, Boonen, Vosman and Niemeijerit (2015) posit that nurses’ knowledge, often not used for guidance, must play a critical role in the development, implementation and use of medication administration technology as this knowledge ensures the safety and optimal use of BCMA.

The Technology Informatics Guiding Education Reform (TIGER) Initiative is an interprofessional grassroots initiative focused on education reform, fostering community development and global workforce development. TIGER aims to enable practicing nurses and nursing students to fully engage in the unfolding digital era of health care. (HIMSS, n.d. para. 1) “Through its agenda and action plans, TIGER is working to ensure that all nurses are educated in using informatics and thereby empowered to deliver safer, higher-quality patient care.

The challenge is clear: To support IT-enabled nursing practice in the future, nursing education must be redesigned to keep up with the rapidly changing technology environment.” (TIGER, 2007, p.3). TIGER (2007) recommends that nurses become involved in national IT agendas, including Congressional testimony, engage in national standards of health record creation and continuation, contribute to standards that address how patient information is communicated with other health care disciplines, develop nursing informatics curriculum, and to further research into how innovative technologies impact nurses and the quality and safety of patient care (TIGER, 2007). There are many ways we can become involved in addressing the rapidly developing technologic advances, and we must. The future of our profession depends on it.

ConclusionAs demonstrated throughout this paper, technology (in the form of equipment,

devices, and documentation) is essential to nursing practice. However does it also inform nursing care? Do we spend our time nursing the devices rather than the patients? We need to be aware of rapidly advancing trends in healthcare technology, as they have a direct impact on our profession. Rather than fear or ignore them, we should (cautiously and ethically) use them for our benefit and the benefit of our patients. Here is summary of some “pearls” of wisdom regarding technology use by nurses:

• Be cautious about over-reliance on tech – nurse review and critical thinking are required.

• With technology, practice makes perfect, just like any other skill, such as IV insertion.

• Don’t be afraid to play around with it. Check out what pushing a button or key will do (unless it’s the Code Blue button – don’t press that).

• Control + Z (or undo icon) is your best friend.• Deleted items are not always lost.• Always SAVE your work. Saving frequently as you work is better.• Technology is created by humans. Humans aren’t perfect. Ergo, technology

may not always work perfectly.• If your vital signs are abnormal, look at your patient to see if clinical

signs match and check manually (BP by use of blood pressure cuff and stethoscope, feeling for pulse, etc.)

• Find your EBP champion and utilize them. The same goes for your EHR “super-users” or Informatics nurse.

• Have a back-up plan for when the system goes down (and it will). This is where those nurses with experience in paper and pen charting will be invaluable.

• All nurses can learn to use technology and information systems (although it may be at different rates).

Lastly, try to have a sense of humor when technology seems to defeat you (and there will be times it will appear to be out to get you). Isaac Asimov, the prolific and renowned science fiction writer has some brilliant quotes that may help. Regarding computers: “I do not fear computers. I fear the lack of them,” and “Part of the inhumanity of the computer is that, once it is competently programmed and working smoothly, it is completely honest.” (Good Reads, n.d.)

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Thomasz, A. (2018, September 18). Meet Moxi: Our Socially Intelligent Robot Supporting Healthcare Teams. Retrieved from https://medium.com/@diligentrobotics/meet-moxi-our-socially-intelligent-robot-supporting-healthcare-teams-7fc0c144c4e9

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