KG

A brief history of nursing informatics

Overview

  • This is a historical overview of nursing informatics in the United States, tracing ideas, standards, and practice from Florence Nightingale’s call for standardized records to the early 21st-century move toward interoperable, computable language and data. It emphasizes the central goal: transform nursing care and health outcomes through informatics via standards, collaboration, and education, while noting ongoing challenges.
  • Core themes:
    • The power of standardized nursing data for care assessment and improvement.
    • The evolution of language standards and computability to enable semantic interoperability.
    • The need for multidisciplinary and cross-institutional collaboration to realize informatics potential.
    • The ethical and practical implications of adopting standards, data sharing, and decision support in clinical practice.

KEY CONCEPTS AND DEFINITIONS

  • Nursing informatics: integration of nursing science, information science, and computer science to manage and process nursing data, information, and knowledge for practice, education, and research. Distinct levels include data, information, and knowledge.
  • Data standards and interoperability: shared, computable language and data definitions that allow data to be exchanged and understood across systems (semantic interoperability).
  • Four uniquely nursing data elements (part of a 16-item minimum data set):
    • nursing diagnoses
    • nursing interventions
    • nursing outcomes
    • intensity of nursing care
  • Terminology and terminology systems mentioned:
    • Omaha System
    • North American Nursing Diagnosis Association (NANDA)
    • Nursing Interventions Classification (NIC)
    • Nursing Outcomes Classification (NOC)
    • International Classification of Nursing Practice (ICNP)
    • Home Health Care Classification (HHCC) → later generalized to Clinical Care Classification (CCC)
    • SNOMED (Systematized Nomenclature of Medicine) and SNOMED CT (international standard)
    • UMLS (Unified Medical Language System)
    • HL7 and LOINC (for broader health information exchange)
  • Key standards/organizations mentioned:
    • ISO Technical Committee 215 (ISO-TC 215) on health informatics terminology and standards
    • IHTSDO (International Health Terminology Standards Development Organisation; now SNOMED International)
    • AHIC (Agency for Health Information Technology Adoption leadership)
    • HITSP (Health Information Technology Standards Panel)
    • CCHIT (Certification Commission for Healthcare Information Technology)
    • NCNIP (National Commission on Nursing Implementation Project) Task Force on Nursing Information Systems
  • Core educational and organizational shifts:
    • TIGER (Technology Informatics Guiding Educational Reform) initiative to forge a vision for informatics-enabled nursing education and practice
    • Alliance for Nursing Informatics (ANI) to unify nursing informatics voices across organizations
    • AMIA NI-WG (Nursing Informatics Working Group) as a professional home within AMIA

TIMELINE AND MAJOR DEVELOPMENTS
THE BEGINNING (Nightingale and Werley foundations)

  • Florence Nightingale (mid-1800s): championed standardized clinical records to assess and improve care; argued that improved statistics could reveal the relative value of operations and treatments and influence hospital practice to save lives.
    • Quote reference: Nightingale’s expectation that better data would illuminate care value and improve patient outcomes.
  • Nightingale’s legacy: planted seeds for three intertwined health sciences: health services research, evidence-based practice, and nursing informatics.
  • About 137 years later, the Institute of Medicine highlighted medical errors as a major safety issue, underscoring Nightingale’s early insight about data-driven improvement.
  • Harriette Werley (late 1950s–1960s): emphasized the need for a minimum standardized nursing data set; as the first designated nurse researcher at Walter Reed Army Research Institute, she anticipated computer-based data use to improve care quality and safety.
  • 1960: American Nurses Association (ANA) appointed a committee to identify research priorities; Werley persuaded the group to focus on nurses’ information use in communication and decision-making.

1970s: early informatics in nursing and home/community data

  • Early reports of computer applications in nursing appeared in the 1970s:
    • Nursing care planning systems to reduce documentation burden and improve plan quality.
    • Scheduling systems for patient activities in a rehabilitation setting.
  • El Camino Hospital projects: nurses contributed to an integrated system for nursing care planning, documentation, and feedback; standard care plans were designed to be modified for individual patients and foreshadowed evidence-based protocols and pathways.
  • Federal support for nursing informatics in the 1970s:
    • National Center for Health Services Research (NCHSR; precursor to AHRQ) funded projects with nursing care planning and documentation.
    • Department of Defense TRIMIS project and Veterans Health Administration’s early clinical records initiatives.
    • Division of Nursing (DN), HRSA, funded nursing informatics development; grants supported Omaha Visiting Nurse Association work (Omaha System: standardized home care data elements and forms).
  • 1975 onward: grants supported home health data standardization, enabling paper- and computer-based records to meet reporting requirements (e.g., Medicare/Medicaid complex reporting).
  • National leaders and conferences:
    • Virginia Saba (DN) and Goldie Levenson (NLN) promoted computerized management information systems for community health.
    • Early interprofessional efforts to develop and apply informatics for health care (e.g., NIH Clinical Center involvement).
    • Rita Zielstorff (Massachusetts General Hospital) contributed nursing perspectives to grant-funded, computer-based projects, including: paperless order entry, computerized medication administration records with decision support, NP ambulatory records, and multidisciplinary long-term care records.
  • Early nursing informatics research themes:
    • Nursing knowledge representation and decision support; prototypes to derive nursing diagnoses from assessment data.
    • Absence of defined nursing diagnoses in literature early on; later efforts to standardize language and data definitions would take decades.
  • 1973 first meeting of the North American Nursing Diagnosis Association (NANDA) established; initial set of 37 nursing diagnoses identified, guiding future standardization work.
  • Foundation work by Werley and Margaret Grier on data standards and data relevance to nursing practice; convened an invitational conference to identify data types and applications relevant to patient care, management, education, and research.

1980s: growth, data elements, and new terminologies

  • Informatics gains momentum with the personal computer era (1980s): prototyping of nursing informatics applications at smaller scales.
  • 1981: Virginia Saba organized a nursing track at SCAMC (Symposium on Computer Applications in Medical Care).
  • 1981: NIH Clinical Center hosted a national conference on Computer Technology and Nursing; co-sponsored by HRSA Division of Nursing and TRIMIS.
  • 1982: IMIA (International Medical Informatics Association) sponsored the first nursing informatics conference.
  • Nursing informatics education expands: early leaders (e.g., Judith Ronald, Virginia Saba, Diane Skiba) establish informatics courses in nursing schools.
  • Leadership roles and professional recognition grow: Ozbolt becomes the first nurse on the SCAMC board; later involved in AMIA leadership.
  • 1980s data standards and minimum data set efforts surface:
    • The 16 data elements to be collected for studies of costs and effectiveness are defined; four uniquely nursing elements highlighted: nursing diagnosis, nursing intervention, nursing outcome, intensity of nursing care.
    • Operationalization of the elements remains unresolved at this time.
  • Evolving nursing languages and classifications emerge:
    • Omaha System offers practical approaches for recording nursing diagnoses, interventions, and outcomes.
    • NANDA continues to grow with more nursing diagnoses.
    • NIC (Nursing Interventions Classification) developed to describe nursing actions; first edition around 1984; multiple editions thereafter.
  • Professional recognition of nursing informatics:
    • ANA and NLN establish a Council (1984) and a Forum (1985) on Computer Applications in Nursing; promote informatics nationally and internationally, develop educational materials, resolutions, and competencies.
  • Education and program development:
    • 1988: University of Maryland (UMd) opens the first graduate program in nursing informatics; curriculum design under Dean Barbara Heller, with Gassert and Mills contributing to program development.
  • Foundational definitions and research priorities:
    • 1989: Graves and Corcoran publish a seminal paper defining nursing informatics as a discipline combining nursing science, information science, and computer science to manage nursing data, information, and knowledge in support of practice; clarify data, information, and knowledge as successive levels of interpretation and generality.
    • 1989: NIH NCNR (National Center for Nursing Research) convenes an expert panel to identify research priorities in nursing informatics; emphasis on data standards as foundational for applying informatics to practice, decision support, and knowledge creation from practice data.

1990s: Internet, standardization, and competency development

  • Technological advances of the 1990s reshape the field:
    • The Internet enables remote communication and collaboration; Web applications facilitate data exchange across diverse platforms.
    • Laptops and PDAs bring technology to the bedside and home care; knowledge resources (e.g., MEDLINE) reach point-of-care contexts.
  • National initiatives and consensus-building:
    • Kellogg Foundation–funded National Commission on Nursing Implementation Project (NCNIP), in collaboration with ANA and NLN, sponsors an invitational working conference that defines essential characteristics for professional nursing information systems to guide practice, education, and research.
    • AMIA is founded in 1990 through the merger of three informatics associations; the nurses who had been participating in SCAMC activities form the Nursing Informatics Working Group (NI-WG) within AMIA, with Ozbolt as its first chair. This becomes a model for other AMIA working groups.
  • Professional scope and standards mature:
    • 1994: ANA publishes the first versions of the Scope of Nursing Informatics Practice and the Standards of Nursing Informatics Practice; later updated (most recently in 2008).
    • 1995: American Nurses Credentialing Center (ANCC) establishes basic certification in nursing informatics as a recognized specialty.
    • 1996: Turley advances a model outlining research areas in nursing informatics, expanding on Graves and Corcoran’s definition.
  • Education and research expansion:
    • New graduate programs established at University of Utah, University of Colorado, Duke, and other institutions.
    • Nancy Staggers earns the first PhD in Nursing Informatics at the University of Maryland and develops a program of nurse–computer interaction research.
    • Linda Woolery (later Goodwin) uses data mining and machine learning to predict preterm birth—an early application of informatics to clinical prediction models.
  • Patient/family education and consumer health informatics emerge:
    • Patricia Brennan advocates computer-based education and support for patients and caregivers at home; demonstrates benefits of computer-based interactions among patients, families, and nurses.
  • Terminology and language challenges persist:
    • Continued proliferation of nursing languages; the ANA’s CNPII anticipates a Unified Nursing Language System but language silos persist across settings.
    • Susan Grobe analyzes home health records and develops Nursing Interventions Lexicon/Taxonomy; HHCC evolves toward broader applicability as a generalizable language (ultimately CCC).
  • Terminology developments advancing toward computability and interoperability:
    • HHCC identified nursing diagnoses and interventions predictive of resource use; ensembles like NANDA, NIC, and NOC expand to broader contexts.
    • Omaha System adopted by many home care and community agencies.
    • ICNP (International Classification of Nursing Practice) initiated to create a global nursing terminology framework; ICN coordinates this effort.
    • SNOMED collaboration and SNOMED integration explored for nursing concepts; CAP (Collaboration with CAP) experiments to incorporate nursing data into broader nomenclature.
    • SNOMED and SNOMED CT become central reference terminologies; UMLS links nursing terms to broader biomedical terminology. SNOMED CT licensing and international stewardship evolve over the decade.
  • Challenges with data standardization remain substantial at century’s end:
    • Many organizations adopt nonstandard, vendor-specific terms for ease of implementation, hindering data retrieval, quality improvement, and research.
    • Researchers and informaticians work toward computable, semantically interoperable nursing terminology and mapping strategies across different systems and languages.
  • 1999–2000: Nursing Terminology Summit Conferences (global collaboration):
    • Facilitated discussions among developers of nursing terminology standards from multiple regions to address issues and move toward formal reference terminology models for nursing.
    • Result: groundwork for ISO adoption (New Work Item proposal) and global collaboration to standardize nursing language.

2000s: international standards, policy, and infrastructure for interoperability

  • International and ISO standardization:
    • 2000: Nursing Terminology Summit participants collaborate with IMIA and ICN; propose to ISO-TC 215 to develop reference terminology models for nursing.
    • 2003: ISO adopts the proposed nursing terminology models; this marks a significant step toward global standardization of nursing language.
    • By 2008 (10th Summit): shift from model development to revision and implementation of standards; progress toward mapping interface terminologies to SNOMED CT concepts, enabling cross-terminology computability.
  • SNOMED CT and UMLS integration initiatives:
    • 2004: National Library of Medicine licenses SNOMED CT for use by US healthcare organizations; SNOMED is integrated with UMLS for broader interoperability.
    • 2004–2007: SNOMED licensing and broader adoption progress; SNOMED becomes central to international terminologies through IHTSDO (now SNOMED International).
  • U.S. policy and national infrastructure imperatives:
    • Institute of Medicine reports (To Err is Human, Crossing the Quality Chasm) catalyze awareness and urgency for informatics as a key technology to improve health care quality and safety.
    • 2004: President George W. Bush issues an Executive Order establishing a national push for electronic health records (EHRs) by 2014 and creates the Office of the National Coordinator for Health Information Technology (ONC).
    • Leavitt (then Secretary of HHS) establishes the AHIC (American Health Information Community) to expedite national health information infrastructure development.
    • HITSP and ANSI collaborate to identify and recommend standards for federal adoption to ensure interoperability; CCHIT emerges as a private certifier for health IT products.
  • Nursing’s leadership in standards and interoperability:
    • 2004–2008: Nurses actively participate in HITSP, CCHIT, SNOMED, HL7, LOINC, and related standards groups; the first nursing language recommended for broad adoption is the Clinical Care Classification (CCC).
    • Judith Warren becomes the first nurse appointed to the National Committee on Vital and Health Statistics (NCVHS), reflecting rising nurse leadership in national data policy.
  • Education, workforce, and competency development:
    • TIGER initiative evolves beyond foundational vision to ongoing collaborative teams addressing education, informatics competencies, and practice change; ANI supports and coordinates these efforts.
    • Distinction between informatics competencies for all nurses and specialized roles (informatics nurse practitioners and innovators) is established, reflecting maturation of the field.
  • Notable individuals and milestones:
    • Judith G. Ozbolt (nurse informaticist) contributes to NI-WG leadership, research, and curricular development.
    • Judy Staggers and colleagues advance nurse–computer interaction research and the evolving definition of nursing informatics.
    • Nancy Staggers (and collaborators) contribute to nurse–computer interaction and competencies across practice levels; this work informs education and accreditation standards (e.g., Scope and Standards of Nursing Informatics Practice).
    • Patricia Brennan’s consumer-health informatics work advances personal health records and home health informatics research.
    • Angela McBride and Marion Ball articulate a national informatics vision and help catalyze TIGER and ANI activities.

EMERGING DEVELOPMENTS AND CONTINUING CHALLENGES

  • A wide-reaching shift in expectations and capabilities (early 2000s onward):
    • Nursing informatics is recognized as essential to modern health care rather than a niche specialty.
    • The Alliance for Nursing Informatics (ANI) consolidates voices from about 25 member organizations, representing roughly 3,000 nurses, to advocate for policy and standards.
    • TIGER and ANI emphasize education reform, standardization, and practice transformation through informatics.
  • Ongoing challenges identified:
    • Persistent need for education about the value of standardized language and data for administrators and clinicians; demand that vendors implement systems using standardized language with robust analytics, feedback, decision support, and research capabilities.
    • Clinicians and terminology experts must collaborate to create computable, semantically interoperable language for domains not yet well covered by existing standards.
    • Integration of nursing records with broader health records to enhance communication and data retrieval for clinical decision-making and quality improvement.
  • Research and domain expansion:
    • Informatics extends beyond traditional clinical care toward genetics/genomics and public health; discovery methods are used to detect health risks and inform preventive strategies.
    • Informatics supports translating knowledge into practice while acknowledging the need for organizational and behavioral changes across individuals, organizations, and systems.
  • Notable contemporary researchers and directions:
    • Patricia Brennan’s consumer-oriented informatics initiatives and personal health records.
    • Eun-Shim Nahm and colleagues study usability and efficacy of home- and patient-facing health informatics tools for older adults and caregivers.
    • Cornelia Ruland and colleagues develop decision support for patient-preference-based care planning and shared decision making; later work on patient safety and risk communication.
    • Nancy Staggers’ ongoing research into nurse–computer interactions and usability; continued development of informatics competencies and evolving definitions of nursing informatics.
  • Implications for education and practice:
    • Future nurses must not only learn technical skills but also develop wisdom in using data, information, knowledge, and technology to transform nursing practice and health systems.
    • Curricula, teaching methods, and accreditation standards adapt to reflect these expanded competencies and the broader role of informatics in nursing.
  • Philosophical and ethical considerations:
    • The shift toward standardized records entails questions of privacy, data governance, and the responsible use of data for improvement while safeguarding patient rights.
    • Collaboration across disciplines is essential to ensure that data, tools, and workflows support safe, effective, ethical care and positive health outcomes.

KEY PEOPLE, ORGANIZATIONS, AND TERMINOLOGIES TO KNOW

  • Pioneers and influencers:
    • Florence Nightingale (foundational vision for data-driven care)
    • Harriet Werley (nursing minimum data set; early informatics leadership)
    • Judy Ozbolt and Judy Saba (pioneering roles in nursing informatics, leadership in SCAMC/AMIA, education, and terminology work)
  • Terminology and data standards leaders:
    • Omaha System; NANDA; NIC; NOC; ICNP; HHCC/CCC; SNOMED/SNOMED CT; UMLS; HL7; LOINC
  • Standards bodies and initiatives:
    • ISO-TC 215; IHTSDO (SNOMED International); AHIC; HITSP; CCHIT; NCVHS
  • Organizations advancing the field:
    • AMIA (Nursing Informatics Working Group), ANA (Scope and Standards of Nursing Informatics Practice), NLN, NIH/NCNIP, ANCC, ANCC certification, SCAMC, TIGER, ANI, ICN
  • Key publications and models:
    • Graves and Corcoran definition of nursing informatics; Turley’s model of nursing informatics research; Staggers and colleagues on nurse–computer interaction and competencies; Brennan’s consumer informatics work; Saba’s CCC and HHCC work; Ozbolt’s Terminology Summit contributions

IMPLICATIONS FOR EXAM PREP: WHAT TO REMEMBER

  • The historical arc shows why standardized nursing language and data are foundational to modern nursing informatics and why computability and semantic interoperability matter for care quality and cost control.
  • Expect questions about major data standards and classifications (e.g., NANDA, NIC, NOC; Omaha System; ICNP; SNOMED CT; UMLS) and how they interact with electronic health records and decision support.
  • Be able to discuss the role of policy and national initiatives in accelerating implementation (e.g., Bush 2004 EHR mandate, ONC, AHIC, HITSP, CCHIT).
  • Understand the evolution from ad hoc, paper-based data toward computable, interoperable terminologies mapped to international standards (ISO, SNOMED CT, SNOMED International).
  • Recognize the importance of education, professional competencies, and interorganizational collaboration (ANI, TIGER, NI-WG) in sustaining informatics growth and practice transformation.

RELEVANCE TO FOUNDATIONAL PRINCIPLES AND REAL-WORLD APPLICATIONS

  • Standards enable scalable, comparable data across settings, enabling quality improvement, cost containment, and evidence-based practice.
  • Interdisciplinary collaboration is essential for moving from data collection to knowledge generation and practical decision support at the point of care.
  • The field’s trajectory—from Nightingale’s data-driven suspicion of hospital practices to contemporary national policy and interoperable standards—illustrates the central idea that information infrastructure is inseparable from safe, effective health care.

NOTE FOR FURTHER STUDY

  • Review the major terminologies and their roles (NANDA, NIC, NOC, Omaha System, HHCC/CCC, ICNP) and how they map to international standards (SNOMED CT, SNOMED, UMLS, ISO 18104:2003).
  • Understand the sequence of policy initiatives that pushed toward interoperability (Bush 2004 EO, AHIC, HITSP, CCHIT).
  • Remember the key decades and their defining developments: Beginnings (Nightingale/Werley), 1970s (early systems, Omaha), 1980s (minimum data set, language development), 1990s (Internet/competencies), 2000s (global standards, policy acceleration).
  • Be prepared to discuss ethical implications of data standardization, including privacy, governance, and the balance between data utility and patient rights.

References to foundational works and figures are available in the original article’s references and can be consulted for deeper detail on specific items (e.g., Graves & Corcoran 1989; Zielstorff & colleagues on CCC/HHCC; Staggers & Gassert competency work).