Nursing Informatics 2014 227

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doi:10.3233/978-1-61499-415-2-227

Leadership Strategies for Improved

Nursing Synergy between Informatics and
Telehealth
Claudia C. BARTZ1
International Council of Nurses, Geneva, Switzerland

Abstract. The goal of best practice, best possible health care worldwide is shared
by nurses and all involved with eHealth today. The purpose of this paper is to
characterize the similarities and differences between informatics and telehealth
from a nursing perspective, and to advocate for leadership strategies that would
bring the strengths of each group to a more synergistic, collaborative professional
model for the benefit of both groups. After comparing telehealth and informatics
nursing and looking for commonalities, suggestions are made for bridging the gap
between the two groups. Potential strategies include identifying leaders, using
conflict avoidance techniques, and pursuing coaching and mentoring opportunities
across the gap to enhance the professional standing and contributions of both
groups. An added consideration would be to have joint conferences wherein the
strengths, challenges and knowledge repositories of informatics and telehealth
could be mutually appreciated.

Keywords. eHealth, leadership, collaboration

Introduction

eHealth is the use of information and communication technologies (ICT) for health.
Examples include treating patients, conducting research, educating the health
workforce, tracking diseases and monitoring public health [1]. The eHealth construct
includes both informatics and telehealth. Informatics is a broad academic field
encompassing computer science, human-computer interaction, information science,
information technology, algorithms, areas of mathematics (especially mathematical
logic and category theory), and related social sciences [2]. Telehealth can be defined as
the delivery of health-related services and information via telecommunications
technologies [3]. Telehealth encompasses disease prevention, health promotion, care
delivery for cure and palliation, and education.
Nurses are fully engaged in both informatics and telehealth and many nurses have
taken leadership roles in their chosen area of emphasis. While nurses in both areas
ultimately have the same goals, those being health care that is of good quality,
accessible, affordable and with optimal outcomes, the pathways to those goals are quite
different. The purpose of this paper is to characterize the similarities and differences
between informatics and telehealth from a nursing perspective, and to advocate for

1
Claudia C. Bartz. ICN eHealth Programme Coordinator, International Council of Nurses, 3 place Jean-
Marteau, Geneva, Switzerland, CH-1201; E-mail: [email protected].
228 C.C. Bartz / Leadership Strategies for Improved Nursing Synergy

leadership strategies that would bring the strengths of each group to a more synergistic,
collaborative professional model for the benefit of both groups, in order to contribute to
improved health care worldwide. The paper supports the NI2014 goal
(http://www.ni2014.org/AbstractsInformation.html) of advancing nursing informatics
leadership and professional development.

1. Telehealth Nursing

Telehealth nursing leverages information and communication technology (ICT) to

extend the capability of nurses with the aims of improving access and quality, and
managing costs [4]. While the use of technology changes the care delivery medium,
and may necessitate new competencies, the nursing process and scope of practice are
not significantly different in telenursing [5]. Telehealth nursing is practiced in almost
every conceivable field of nursing from neonatal care to palliative care and from aiding
people needing health promotion to caring for those with the most complex needs for
care. This very wide range for practice is both the beauty and the challenge of
telehealth nursing as nurses work toward characterizing it and understanding the social,
economic, political, legal and ethical implications of its practice.
In addition to country-based associations, international organizations such as the
International Council of Nurses (ICN) and the International Society for Telemedicine
and eHealth (ISfTeH) have recognized the importance of telehealth nursing with
designated groups for nursing. The ICN Telenursing Network has more than 250
members representing over 60 countries (http://www.icn.ch/networks/telenursing-
network/). The Network provides a global forum for telenursing in the context of a
federation of national nurses associations. Its goals are to serve as a global resource for
nurses, promote effective networking and linkages, and enable the sharing of
telenursing knowledge and expertise across the globe. The Network meets biennially at
the ICN Conferences and Congresses. The ISfTeH Telenursing Working Group
(http://www.isfteh.org/working_groups/category/telenursing) has 51 members
representing 21 countries. The Working Group provides an interdisciplinary forum in
which nurses can exchange knowledge and experience with other health care providers
who are working with or supporting the use of eHealth applications through biannual,
interdisciplinary meetings and an online journal.
Nurses have always been technology adaptors for their practice, always with the
health needs and care delivery expectations of individuals, groups and communities
foremost. The reality is that people with chronic disease or acute illnesses who live in a
remote area, or who are near to care sites but are economically or socially remote, can
all receive home care, home monitoring and education for self-management from a
nurse using telehealth technologies and strategies. In addition to direct care roles,
telehealth nurses include educators, researchers and nurses in industry, government and
non-governmental organizations.

2. Informatics Nursing

Several often-referenced definitions for nursing informatics have been proposed in the
last three decades, all using a concept-based foundation. Essentially, nursing
informatics is described as a specialty based in nursing science, computer science, and
 C.C. Bartz / Leadership Strategies for Improved Nursing Synergy 229

information science to manage and communicate data, information, and knowledge in

nursing practice [6], [7]. A definition by the International Medical Informatics
Association (IMIA) – Nursing Informatics Special Interest Group (IMIA-NI SIG) states
that nursing informatics science and practice integrates nursing, its information and
knowledge and their management with information and communication technologies to
promote the health of people, families and communities worldwide [8]. A fourth major
concept, wisdom, was suggested as an addition to the definition concept set, depicting
more completely the intellectual and practical processes moving from data to
information to knowledge to wisdom [9].
As a nursing specialty, nurses with an interest in computer and information science
can pursue graduate education in informatics. While generally not direct care providers,
informatics nurses contribute to an important second-layer of health care delivery in
developing health information systems, electronic health records and terminologies for
documentation. Informatics nurses are also educators and researchers, contributing to
nursing expertise and capability and also to the body of knowledge about care delivery
systems that integrate information and communication technologies with health care
quality and positive outcomes as unifying goals. Informatics nurses are also found in
industry, government and non-governmental organizations.
In addition to many country-based nursing informatics organizations or special
interest groups within organizations, the IMIA-NI SIG (http://www.imia-
medinfo.org/new2/node/151) represents nursing internationally. The focus of IMIA-NI
is to foster collaboration among nurses and others who are interested in nursing
informatics to facilitate development in the field. The SIG aims to share knowledge,
experience and ideas with nurses and healthcare providers worldwide about the practice
of nursing informatics and the benefits of enhanced information management. The
IMIA-NI SIG has 28 society (formerly country) representatives and several observer
members and meets annually at related informatics conferences.

3. Commonalities between Informatics and Telehealth Nursing

Informatics nurses and telehealth nurses have common issues on which collaboration
could be useful, both for addressing the issues themselves and for expressing a stronger
voice from nursing across the eHealth community and beyond. For example, the
privacy and security of health-related data is of great concern to most people involved
with telehealth and informatics. Even with data sets from different sources, for
example, from individual patients receiving care at a distance to thousands of electronic
health records held in repositories, the ability to acquire, use and store those data in
such a way as to meet comprehensive ethical and legal standards continues to raise
great concern among clinicians, educators, researchers and managers.
Cross-border licensure stipulations and recognition of accreditations and
certifications represent another common issue for nurses. Telehealth nurses may have
experienced the dilemma of restriction of practice based on licensure sooner than
informatics nurses. For example, the establishment of eICUs, where nurses at a central
location may ‘work’ at ICUs in other states or territories, means that licensure
boundaries must be addressed. However, informatics nurses may become more
concerned about where they are licensed to practice as they become more involved in
health information systems design and acquisition, often for multi-site, multi-state or
international organizations. Also, nurse educators are teaching more international
230 C.C. Bartz / Leadership Strategies for Improved Nursing Synergy

students in both telehealth, which is integrated with the course offering, and
informatics, which maybe be integrated but may also be a separate informatics course.
Educators therefore have a responsibility to ensure that students have full knowledge of
their own scope of practice and parameters of licensure for their place of work.
Students in a class or a course might represent any number of countries and might seek
knowledge about telehealth, informatics or both as part of the learning process.
The nursing community has for some time emphasized the development of
standards and competencies for various levels and areas or specialties of nursing
practice. The American Nurses Association has published Nursing Informatics Scope
and Standards of Practice [10] which includes some information about telehealth
nursing. A new edition is under preparation at this time, demonstrating the steady
evolution of the informatics specialty and its community of practice. The section of the
book on the scope of nursing informatics practice has sub-sections on the boundaries
and tenets of nursing informatics as well as ethics in nursing practice. These sections
would be very useful in informing joint discussions between informatics nurses and
telehealth nurses about the data security and cross-boundary issues discussed above.
The International Council of Nurses has published International Competencies for
Telenursing [5] and International Professional Standards for Telenursing Programmes
[11]. These documents are also in the process of being updated with the aim of guiding
current practice and anticipating the issues and expectations for future practice. The
telenursing competencies, [5] which address the topics of professional, ethical and legal
practice; care provision and management; and professional development, have
substantive material that could serve to inform the standards of practice and standards
of professional performance for informatics nurses. And, although the telenursing
standards [11] were written for programme development and evaluation, there are
concepts and definitions for terms that could also inform the nursing informatics
standards of practice and standards of professional performance.
Informatics nurses and telehealth nurses attend national and international multi-
disciplinary conferences targeted at their own areas of practice. However, while most
conferences have some content in the ‘other’ practice area, they cannot be considered
joint or even co-located conferences.

4. Leadership for Bridging the Gap between Telehealth and Informatics Nursing

Leadership is a multi-faceted capability. Leaders are fully occupied with ensuring that
others are successful and productive. The leader label is the least of a true leader’s
concern. Leaders establish an environment of trust, open communication and clarity
about the ethical standards, goals and boundaries of the organization. Boundaries might
include resource allocations and decision-making responsibilities. A leader shows
respect, courtesy, tolerance, flexibility and readiness to learn. A leader is humble and
willing to do any job in the organization.
A well-led group, with all members on the learning curve to become good leaders
themselves, will demonstrate the ability to resolve differences and conflicts. As noted
above, informatics nurses and telehealth nurses have differences in their education,
practice and self-concept, with nursing informatics considered a specialty and
telehealth nursing including nurses in any specialty who have added ICT-supported
capacity for care delivery and education. An effort to bring the two groups of nurses
together for the purposes of learning from each other, and using and extending each
 C.C. Bartz / Leadership Strategies for Improved Nursing Synergy 231

other’s body of knowledge, seems to be warranted in the spirit of professional

collaboration and advancing nursing worldwide.
While the two groups of nurses under consideration in this paper are not in conflict
per se, conflict resolution strategies [12], [13] might be considered as a catalyst for
closer collaboration. For example, good communication skills are important in face to
face interactions and, possibly even more important, in electronic communications. In
face to face communication we rely to a great extent on nonverbal cues to help to
ensure that we understand what is being said. With electronic communication, the
essential nonverbal cues such as tone of voice, facial expression and body positioning
are lost to us. We may or may not “hear” the real meaning of what is said
electronically.
Another strategy for group success and avoidance of conflict would be to agree on
a common goal, or goals, and on ground rules for discussion as a foundation for starting
the work. The group should be the right size and include only those participants who
are willing to address the business at hand. This would include willingness to work
outside the group meetings if that is deemed necessary for goal accomplishment. As
sessions (for example, meetings, conference calls) are underway and reach a
conclusion, an important strategy during closure is to ensure that actual or potential
conflicts that may have arisen during the session are addressed and resolved before they
grow into something much worse. It is also important, as the session ends, to review the
essence of the discussions and the decisions that have been taken. Good leaders are
good meeting managers.
Leaders should also demonstrate and encourage coaching or mentoring at all levels
of the organization. In general, coaching might be considered to be specific to the work
environment while mentoring is supposed to be more serendipitous, where a more
experienced person takes on a protégé with less experience and with the dyad not
necessarily being in the same work setting. Nurses have traditionally recognized the
important of coaching and mentoring other nurses in or outside of work settings.
The overall acceptance of the goodness of mentoring presents a great opportunity
for telehealth nurses and informatics nurses who are willing to be mentors or coaches.
This might occur within one’s practice community. Or, telehealth nurses might reach
out to informatics nurses and informatics nurses could reach out to telehealth nurses,
with one being the mentor and one the protégé, depending on knowledge and skill
levels and the purposes or goals of the partnership. This is not to imply that
informatics-telehealth dyads, which could range from novice collaborators to expert
collaborators, might not also benefit from a purposeful partnership.
The potential for infusing each other’s practice area with new knowledge and new
avenues for exploration are without limit. A physician who is an experienced,
successful surgeon took on a coach during his surgeries and described his experiences
[14]. Among his conclusions were the recognition that coaches are your outside ears
and eyes since they are able to break performance down into its parts, and that coaches
let the learner set the direction while getting the learner to think things through. Nurses
can learn from these observations, whether they are in a coach-learner dyad, a mentor-
protégé dyad, or in collaboration with someone at a parallel level.
A last consideration for leaders who seek to bridge the informatics-telehealth gap
would be to think about conferencing jointly. In our own experiences, we may have
found that conference speakers are telling us what we already know about our area of
practice. The eHealth community is so large and complex, it may be worth opening
communication channels as wide as possible. Again, the ultimate goal would be
232 C.C. Bartz / Leadership Strategies for Improved Nursing Synergy

improved health across the globe. The next gap to bridge would then be to bring
consumers and citizens more fully into the health care communities’ deliberations and
learning opportunities.

5. Conclusion

Telehealth nurses and informatics nurses have a great deal to learn from each other
about the technology explosion underlying today’s health care environment worldwide
and the immense potential for advancing the accessibility, care delivery quality, care
outcomes, and data for knowledge development. Perhaps the greatest wisdom would be
for nurses in these fields to work collaboratively to advance professional nursing and to
ensure that nursing is and continues to be a strong voice in the world of eHealth.

References

[1] World Health Organization. Definition of eHealth. [Internet]. 2013 [cited 2013 Sept 18]. Available
from: http://www.who.int/topics/ehealth/en/
[2] Wikipedia. Informatics. [Internet]. 2013 [updated 2013 Jul 28; cited 2013 Sept 24]. Available from:
http://en.wikipedia.org/wiki/Informatics
[3] Wikipedia. Telehealth. [Internet]. 2013 [updated 2013 Aug 27; cited 2013 Sept 24]. Available from:
http://en.wikipedia.org/wiki/Telehealth
[4] C. Bartz. Telehealth nursing: knowledge generation and practice application. In: Jordanova M. Lievens
F, editors. Med-e-Tel 2011. Proceedings of the International eHealth, Telemedicine and Health ICT
Forum for Educational, Networking and Business; 2011 April 6-8; Luxembourg. Belgium: ISfTeH;
2011. P. 251-254.
[5] L. Schlachta-Fairchild. International Competencies for Telenursing. Geneva: International Council of
Nurses, 2007.
[6] N. Staggers, CB. Thompson. The evolution of definitions for nursing informatics: a critical analysis and
revised definition. J Amer Med Inf Assn 2002; 33(1): 75-81.
[7] J. Graves, S. Corcoran. The study of nursing informatics. Image 1989; 21(4): 227-230.
[8] IMIA News. IMIA-NI definition of nursing informatics updated. [Internet]. 2009 [cited 2013 Sept 24].
Available from: http://imianews.wordpress.com/2009/08/24/imia-ni-definition-of-nursing-informatics-
updated/
[9] S. Englebardt, R. Nelson. Health care informatics: An interdisciplinary approach. St Louis: Mosby-
Year Book, Inc; 2002.
[10] American Nurses Association. Nursing informatics: Scope and standards of practice. Silver Spring:
Nursebooks.org; 2008.
[11] K.M. Hunter, International Professional Standards for Telenursing Programmes. Geneva: International
Council of Nurses; 2001.
[12] A. Northam, Conflict in the workplace: part 1. Am J Nurse 109 (2009), 70-73.
[13] A. Northam, Conflict in the workplace: part 2. Am J Nurse 109 (2009), 65-67.
[14] A. Gawande, Top athletes and singers have coaches.. Should you? .The New Yorker [Internet].
(2011 Oct 3). [cited 2013 Sep 18]. The New Yorker. Available from:
http://www.newyorker.com/reporting/2011/10/03/111003fa_fact_gawande