Factors in the development of clinical informatics competence in early career health sciences professionals in Australia: a qualitative study
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- Gray, K. & Sim, J. Adv in Health Sci Educ (2011) 16: 31. doi:10.1007/s10459-010-9238-3
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This paper reports on a qualitative study investigating how Australian health professionals may be developing and deploying essential clinical informatics capabilities in the first 5 years of their professional practice. It explores the experiences of four professionals in applying what they have learned formally and informally during their university education and during workplace learning and training. This study is based on a broad review of the literature on clinical informatics education and training; its findings support international analyses and suggest that new strategic efforts among stakeholders in the healthcare system are required to make progress in building workforce capacity in this field, in Australia and elsewhere.
KeywordsClinical educationClinical competenceCurriculumHealth informaticsProfessionsWork-based learning
Clinical informatics may include work with health information systems, e-health services, electronic health records, clinical and administrative decision-support systems, telehealth and many other established and emerging uses of information and communications technology in the health professions (Whetton 2005, pp. v–xi). Clinical informatics is an increasingly influential part of the working environment of “clinical staff including doctors, nurses, pathologists, pharmacists and other clinical professionals” (Australian Health Information Council 2003). Hence it is important to individual health sciences professionals and also to the healthcare organisations where they work, that at least basic levels of clinical informatics competence can be assumed in staff throughout the workplace. Further, the definition of clinical informatics competence has national and international significance for evolving professional practice and education standards, and for reform of healthcare system operations and management.
This paper reports on a qualitative study investigating how Australian health professionals may be developing and deploying essential clinical informatics capabilities in the first 5 years of their professional practice. It explores the experiences of four professionals in applying what they have learned formally and informally during their university education and during workplace learning and training. This study is based on a broad review of the literature on clinical informatics education and training and its findings have implications for this field.
Review of the literature
There are substantial questions in the literature about how to improve acceptance and use of information and communication technologies (ICT) in healthcare workplaces. It has been said of the United States, for example, that “the barriers to rapid and widespread development and diffusion of cost effective and practically useful HIT [health information technologies] are exclusively related to human factors” (Sistrom 2005, p. 431); and of the UK, that staff may develop “a strong sense of tension between caregiving and maintenance of the computer as a tool to provide a shared display of the current situation” (Harrop et al. 2006, p. 300).
Educational preparation of the workforce could be a key to improving ICT acceptance and use in healthcare. However, despite growing advocacy of clinical informatics competence and teaching, this is generally poorly identified in entry-level education for clinical health sciences professionals around the world, and very little progress has been made in over a decade. Recent evidence of this, for example in medical education, can be found in Ramasamy and Murphy (2007) and McGowan et al. (2007). Sometimes pre-clinical learners have access to a required or elective unit of study, but rarely is a set of learning objectives addressed across units or years of training.
Many clinical educators acquired their own clinical expertise in low-technology work settings, so they are unfamiliar with the emerging field of clinical informatics and find it difficult to contribute to this aspect of educational reform within their profession. Thus Nagle (2007) says “everything I know about informatics, I didn’t learn at nursing school”, and Buckeridge and Goel (2002) report that academics teaching core aspects of medical degree studies may find informatics difficult to conceptualize as a field of study, they may be equivocal about its inclusion in professional training, and they may assume that students will learn what they need to know about it by osmosis.
Among the few informatics-oriented educators within the health sciences professions, there is much interest in specifying and developing essential clinical health informatics competencies. Examples include allied health (Williamson et al. 2005), dentistry (Schleyer 2003), medicine (Blumenthal et al. 2005), nursing (Smedley 2005) and social work (Parker-Oliver and Demiris 2008). Most of this literature emanates from separate professions. One exception is the American Medical Informatics Association which aims to see large numbers of professionals in the United States healthcare workforce trained in three domains of informatics—clinical/health care, public health and translational bioinformatics (AMIA 2008). Another exception is the Australian College of Health Informatics, which has itemised twenty specific areas in which it recommends that all types of clinical professionals should have at least elementary informatics knowledge and skills (Garde and Hovenga 2006, p. 6).
Whichever set of competencies is chosen for clinical informatics learning and teaching, curriculum needs to be ambitious about moving beyond the idea of “competence” in a basic-training, button-pushing, procedural sense—as exemplified by the Essential IT Skills program of the UK National Health Service, for “anyone who uses a health or care information system in their workplace, whatever their role” (NHS 2008). This ambition is still unmet in the many other workforce sectors besides healthcare, with Eisenberg (2008, p. 39, citing Drucker 1992) arguing the need for business organisations to teach staff “to apply computer skills to real situations and needs […] to identify information problems and be able to locate, use, synthesise, and evaluate information in relation to those problems.”
Competency is the (individual) ability to make deliberate choices from a repertoire of behaviours for handling situations and tasks in specific contexts of professional practice, by using and integrating knowledge, skills, judgement, attitudes and personal values, in accordance with professional role and responsibilities. Competency is to be inferred from task behaviour, outcomes and the justification of choices that have been made, as well as from reflection on performance and performance effects.
It is increasingly important that those who educate and employ clinical professionals share research into many aspects of clinical informatics education and training, in order to understand “where we are now […] in order to clarify what practical steps are needed to move forward into the future” (Iliffe 2005, p. 122). One foundation for improving clinical informatics education, training and continuing professional development is an understanding of whether and how entry-level professionals acquire clinical informatics competencies and learn to work with technology at present, an area where there are numerous anecdotes but, there is little empirical evidence (Gray and Sim 2007).
Justification of methods
Research in this area needs to be underpinned by a sound understanding of the nature of workplace learning. As Egan and Jaye (2009, p. 107) note, clinical learning is about “not only clinical skills but also how to be health professionals”. Eraut (2007) explains how workplace learning by professionals is strongly influenced by factors that include the allocation, structuring, challenge and value of the work, as well as the encounters, relationships, feedback and support involved in the learning experience. Currie et al. report on case studies in healthcare settings where management “assumptions that IT is a tool that aids collection, interpretation and use of information” raise staff “issues around professional roles and who can conduct such activities effectively” (2007, p. 410). Research in this area falls into the category of “dynamical and phenomenological questions challenging medical care and health care organizations” (Sturmberg and Martin 2009, p. 545).
Accordingly, this study used a phenomenological research design to investigate the phenomenon of clinical informatics competence by capturing the essentials of the experiences that early career health professionals had with developing and applying the key informatics knowledge and skills recommended for Australian clinical practitioners. It aimed to provide a succinct description of what it meant for such professionals to be competent to work with clinical informatics, and to gauge the distance between the recommendations for informatics knowledge, skills and attitudes and the realities of current entry-level clinical practice.
Participants for this study were recruited among healthcare practitioners who had graduated in the past 5 years from a range of entry-level professional degrees (including dentistry, dietetics, medicine, midwifery, nursing, occupational therapy, paramedics, pharmacy, physiotherapy, psychology, social work and radiography). They must have held a paid professional role for at least 6 months during the previous year, in any of a range of clinical settings such as hospitals, clinics, agencies and private practices.
Invitations to participate were distributed widely to professional associations, at a major conference and through the researchers’ professional networks over a 6 month period. Of nine prospective participants thus identified, a convenience sample of five who met participation criteria well were interviewed in depth; four were then selected for professional, workplace and demographic diversity and analysed for this pilot study (Table 1).
Case studies of clinical informatics learning experiences of four health sciences professionals
Master by coursework
Master by coursework
Government agency in a rural regional centre
Major teaching hospital in a metropolitan centre
Major teaching hospital as well as other institution in a metropolitan centre
Private practice as well as hospital inpatient facilities in a metropolitan centre
What experiences have you had with this ICT in your work and what was that like for you?
What education, training or continuing professional development have you had about this ICT and what was that like?
What other ways might you have heard about this ICT (such as in the media or by word of mouth)?
What effects do you think this ICT is having or might have on the way you work as a professional [specialisation]?
At the end of the interview, the participant was asked to make closing reflections about how significant CIC was to her/his work as a clinical professional. The interviews lasted between 45 and 90 minutes.
Interview data were transcribed and analysed by both researchers, first working separately and then together. The first cycle of analysis produced one simple account (i.e. which topics were of any interest to participants) and two more complex accounts (i.e. an account of what they thought about this kind of clinical informatics competence and an account of how they encountered this kind of competence). The next cycle used empirical transcendental phenomenological analysis techniques (as described in Creswell et al. 2007, p. 254) on the latter two accounts, to distil participants’ experiences into significant statements and formulate sub-themes, in relation to conceptions of working with ICTs and experiences of learning to work with ICTs.
Analysis of data
Awareness of clinical informatics topics among early career health sciences professionals
Awareness of clinical informatics topics among four early career health science professionals
Clinical informatics topics
1. Artificial intelligence
3. Biomedical modeling
4. Biomedical signal processing
6. Coding & classification
7. Decision support systems
8. Electronic patient records
10. Health information systems architecture
11. Information management
12. Integrated e-health/health information systems
13. Knowledge management
14. Mathematical models
15. Measurement technologies
16. Mobile wireless devices
17. Online training systems
18. Organ imaging
20. Simulated 3D interactions
22. Web-based information & communication services
Although these findings are from a small sample, the use of the probe increased the opportunities for recognition and discussion of a wide range of experiences with learning to use ICTs. The fact that experiences with so few technologies were elicited in this study suggests that healthcare systems currently cannot rely on either formal or informal learning to give early career professionals a broad grasp of the key informatics knowledge and skills recommended for Australian clinical practitioners.
These findings appear to confirm commentators’ views that improving the clinical informatics capability of the workforce needs deliberate intervention; it cannot be left to general knowledge or generational change. Further these findings appear to indicate that most of the Australian recommended competencies are far removed from realities of day-to-day clinical work of these four professionals, suggesting that it is not feasible for them to develop these competencies through on-the-job education. The lack of overlap in different professionals’ interest in topics other than electronic patient records or coding and classification further suggests that efforts to provide interprofessional education about most of the Australian recommended competencies will need to proceed from very first principles.
Conceptions of working with ICTs among early career health sciences professionals
The physiotherapist estimated that ICT use comprised 25% of daily work, in the form of email and electronic documents.
The psychologist estimated that ICT use comprised 50% of daily work, in the form of email, computerised clinical histories and web-based reference information.
The medical scientist estimated that ICT use comprised 80% of daily work, in the form of email and hospital databases.
The radiographer estimated that ICT use comprised 100% of daily work, in the form of email and imaging systems—“That’s us. That’s what we do.”
Conceptions of working with ICTs among four early career health science professionals
What it is like to work with particular ICTs
Re electronic patient records: “it’s not logical … it’s more about knowing the rules … nothing is quite related” (p. 10)
Re telehealth: “slightly disastrous …for clients who are quite isolated it’s beneficial but… talking to a computer, a TV screen about rather personal issues is quite for me at times concerning” (p. 5); “glorified…perceived as… an easy fix, like quite a simple process” (p. 7)
Re health information systems: “Sometimes the system goes down and then well, I can’t do my job. I mean I could, I can, but … I become I suppose quite reliant on it” (p. 17)
Re electronic patient records and web-based information and communication: “Most of the … stuff was just in communicating results and requests… it’s not difficult in terms of put in the patient’s name and it spits out all the information that’s needed” (p. 6); “we all just get on the computer and look it up. We don’t actually talk … it makes work … progress at a reasonable speed” (pp. 12–13)
Re artificial intelligence: “The more complicated machines…it’s telling you that the parameters you have set won’t allow you to scan in a particular way… Don’t do this, don’t do that, change this, you need to change that.” (p. 4)
Re information and knowledge management: “Give out information to everyone willy nilly, it’d cause anarchy… make people go haywire …doesn’t necessarily improve the departmental communication… aids in confusing everyone” (p. 13)
Re electronic patient records: “a bit confusing… it [would be] helpful because time is limited” (pp. 14–15)
Re biomedical signal processing: “complicated … I had a few troubles” (p. 9)
Re health information systems: “each [workplace] it’s different … it just takes a little bit of time to get used to all these different technologies.” (p. 6); “you have to go about how the [workplace management] thinks about the technologies” (p. 15)
ICTs in current professional identity
“Everything we know about our clientele is presented with … a clinical history and it’s all presented via the computer …, so it’s very much information technology based.” (p. 3)
“ICT doesn’t work for every client, as I say, clients were distressed and in duress you know, quite impersonal and I don’t know how that’s supposed to be helping someone” (p. 7)
“I think everyone has their own kind of individual way of [using the system], it just comes down to like your own idiosyncrasies” (p. 9)
“If you didn’t have that sort of ICT behind you, you are just a robot in doing it, whereas at least the ICT brings in your thought process, as into implications of what you’ve found” (p. 15)
“[ICT] probably helps you in decision-making but it also helps you in then maybe passing that information onto someone else who can act on it, like doctors or clinicians …, because we just do the tests and that sort of thing but if you’re coming up with the same sort of information each time, then maybe that can be passed on” (p. 16)
“In a larger…hospital, you have usually a PACS system (picture archiving and communication system) … we have to be competent in getting communication, whatever it might be” (p. 2)
“[Informatics] that’s a tricky one for us… it’s the basis of the [professional] system” (p. 3)
“Often in our profession we don’t know what’s going on in the background on our multi-million dollar machines” (p. 3)
“Clinical information is basically the details from the patient that I get … and which has to be basically retained by me and the patient. That’s the basic fundamental of the health professions. Confidentiality” (p. 5)
“Whether I use computers, whether I use technologies or not, it’s for my convenience but my identity wouldn’t change in front of my patients basically” (p. 15)
“[ICT] is important in terms of between different health professionals in the field and it’s important in terms of communicating with colleagues around but …not actually with the patient.” (p. 18)
ICTs and future professional identity
“Sometimes clients are threatened by, you know, obviously it’s their information…We see stuff from psychiatrists, psychologists, social workers, a whole gamut of people, so I see [electronic records] just pretty much staying the same or getting less” (pp. 13–14)
“A lot more [ICTs] would be damaging … we’re even seeing now, we’re starting to think about, robots doing a lot of the stuff that we do” (p. 13)
Re technology probe list: “complicated … there’s so many different things … there’s a lot” (p. 5)
“It’s quite scary for us … the machine being able to do its own thing when it fancies… that’s something we have to avoid” (p. 5)
Re technology probe list: “it’s actually quite shocking… seems very limited for radiographers… we don’t really know about the rest that is available to us” (p. 19)
“I think [ICTs] will get more and more complex with advancement… if I continue to use this technology and I’m aware of it I’ll be fine but if I’m not it would be a lot more difficult for me” (p. 15)
Technology to extend professional communication attracted mixed views—“we could be passing on more useful information” (medical scientist) and “it’s a reasonable way to keep up with other professionals” (physiotherapist); but “too much information flowing around the workplace would be anarchic” (radiographer). Technology to mediate work with clients was problematic—causing them concern and distress (psychologist); risking the confidential, interpersonal relationship (physiotherapist). On balance, only one participant related ICT use to professional competence in positive terms—“the ICT brings in your thought process, as into implications of what you’ve found” (medical scientist), but this participant also had a technologically simplistic conception of working with patients—“put in the patient’s name and it spits out all the information that’s needed”.
The less than enthusiastic attitude to ICT use in healthcare in the findings from this pilot study is quite remarkable, considering the general acceptance of ICTs in personal, social and economic life in Australia. These findings suggest that clinical informatics education needs to start by addressing learners’ concerns about professional disempowerment and broadening their views about professional advancement. The findings further underscore the need and also the challenge to find constructive common ground in interprofessional approaches to clinical informatics education, otherwise a mixed group of learners might be inclined to mutually reinforce the theme that making increased use of ICTs reduces the satisfaction and status of professional work.
Experiences of learning to work with ICTs among early career health science professionals
Experiences of learning to work with ICTs among four early career health science professionals
Developing ICT knowledge, skills and attitudes through formal study
“Obviously everything now is via computer and technology, it’s spreadsheets and whatever, but I just don’t think I was fully aware when I was going through uni and my placements as to how much I would rely on the technology to do my job” (p. 16)
“In terms of undergraduate, there wasn’t really any … more sort of the science and what happens as opposed to what happens in a workplace and how that interacts. In my Honours, I did a lot more because I actually was in the research labs … because I was in a workplace.” (p. 7)
“In terms of uni setting, I didn’t think it prepared you, doesn’t prepare you at all for this sort of work environment” (p. 14)
“You are taught that … at university…how the system actually works but you don’t have any hands-on training…. theoretical behind it at university and then hands-on training [on the job].. it takes a little while to all make sense… so it would be good if they did come hand-in-hand” (p. 10)
“What we were taught in terms of information technology just didn’t relate to the wider hospital database system, information systems” (p. 14)
“What you use at a university is not similar to what we actually use in the practice” (p. 13)
“Formal study is much less exposed to the reality, the practicality of the workplaces…doesn’t actually let [students] experience the real world, how it’s like. They should be having more placement …in real hospitals …and actually dealing with these technologies” (p. 17)
Developing ICT knowledge, skills and attitudes through informal learning
Re telehealth: “Basically just got shown how to operate it. Other than that, none.” (p. 6)
Re electronic patient records: ‘“In my degree no, on the job yes”; “Quite good training when I first started in my position … one on one training and then had like a huge workbook to work through as well … there probably are quicker ways and, you know, different ways of navigating, which I know there are but I just don’t do it” (p. 9)
“I get to a particular point and I say ‘I need help. I can’t do it anymore’” … [someone]would actually show me what they were doing so that next time I was able to do it myself… it was good…if I had written down more information then I wouldn’t have had to keep bugging people with questions afterwards but I think that’s better than ‘today we’re going to learn this’ because you do it as you’re up to that stage and ready to take on the next step whereas if you have to ‘every week we’re going to do this section’ you’re often overwhelmed with more information than you actually need” (pp. 10–11)
“So whichever institution you go to, you’d have to learn a new interface to do it, but ultimately it’s the same process… They’ll see one, do one, teach one… That’s the approach that’s taken on the job …. You’ve always got someone around to support you even if you don’t know… A clinical tutor will create user manuals … but whether or not they’re used is something else… sometimes it’s like ‘What do I do now? Quickly.’ You just ‘Do this and do that’ [show and tell] which is the biggest problem for us because bad habits tend to flow through the entire department” (pp. 8–9)
“When I first went to this institution where they use computer technology… one of my supervisors trained me…one to one…she taught me everything… and then the staff who were on helped me if I had any troubles” (p. 13)
“There’s so many technologies and so much advancement nowadays happening so quickly that if I’m learning about something now … after 1 year’s time …[it] would have changed.” (p. 17)
Finding opportunities for further learning related to ICTs
Re online training: “Probably… every 2–3 months …impersonal but beneficial…sometimes by myself, sometimes with others, we’ll do the quiz together or talk about some things which sometimes can be a bit airy, like we’re not quite sure …I think it will get more sophisticated… obviously time-saving… but… it’s impersonal” (pp. 15–16)
“I guess, in terms of the bioinformatics and that sort of thing, that sort of stuff would come up in, like, general articles you were reading… so I might come across it that way. But I do have friends also that are in research settings and so often, you know, we have a bit of a chat. They might say they’re using whatever so it may come across that way as well.” (p. 12)
“For us, any information sharing process is always going to be a social process as well… lunch, catch up with these people that you went to university with and attend a lecture and learn something about Topic A” (p. 18)
“There should be somebody to supervise, just to train someone in the workplace itself, to train all these staff about new technology that they’ve got and how it could actually impact on the worker, how could it actually help and benefit.” (p. 18)
Participants’ uniform perception was that what they learned during their pre-qualification university study was inadequate to equip them for their subsequent encounters with ICTs in work environments. Three participants felt that they did some ICT learning at university, as part of learning about science (medical scientist), theory (radiographer) or unrelated technology (physiotherapist). However, even factoring in compulsory work placements during their formal study, they felt largely unprepared when they entered the professional workforce.
The way participants learned about ICTs on the job was one-to-one with another staff member, and mostly through unstructured, just-in-time, just-enough learning (a workbook and a workplace manual were available in two cases). They held positive views about this—they felt that they learned what they needed to know. But their accounts also illustrated shortcomings with the informality of this approach, both in terms of efficiency—going back to people over and over with questions (medical scientist); needing to recur every time one changes workplaces or the workplace system changes (physiotherapist)—and effectiveness—failing to establish doing work in the best known way (psychologist); permitting quick fixes and bad habits (radiographer).
Each participant put forward a different mode of study in which they could see themselves possibly doing further learning in this aspect of professional practice—online learning, independent reading, attending lectures and a dedicated work-based training program. Each expressed the importance of having a social dimension to such learning. None conveyed a sense of advancing in their professions through such learning, rather they described very casual approaches to learning—a bit airy, a bit of a chat, a catch-up, being in touch. None of the participants had any knowledge or experience of further learning or training opportunities related to practice registration or employment progression in their profession, or of significance for their personal professional development, either in clinical informatics broadly or in specific sub-topics.
The absence, in the findings of this pilot study, of anything recognisable by these four early career professionals as coherent clinical informatics education, whether in their entry-level study, work-based training or continuing education prospects, accords with the situation internationally as set out in the literature reviewed earlier in the paper. Individual professionals within their professional and workplace cultures are not receiving strong messages about the nature, scope or importance of clinical informatics. Furthermore the way they learn the patchwork of elements that they do learn does not make optimal use of the learning and training capacity in healthcare organizations, and it does not lead them to regard themselves as building a type of professional expertise for critical advantage in their careers.
Much of the literature on clinical informatics education has focused on statements of ideal competencies and the design of specific educational programs. This study sought to illuminate clinical informatics competence from another aspect, namely how it is experienced among those for whom it is advocated. The use of a phenomenological methodology revealed a much more limited sense of clinical informatics competence among practitioners than that found in the detail of competency statements targeted to them.
This study found a substantial gulf between the key informatics knowledge and skills recommended for Australian clinical practitioners and the conceptions that diverse early career health professionals held about their clinical ICT learning and development needs. It found that they held attitudes that diminished their receptiveness to such learning and development, arising from the technologically unsophisticated professional identity they had formed to date and their uncertainty about the potential of unfamiliar technologies to hold sway over their professional practice in the future. It found that they had a pragmatic sense of needing to learn the basics to be able to function in the workplaces in which they found themselves, but that they had no sense of expecting or wanting to take professional responsibility for shaping or leading the implementation of ICTs to improve healthcare.
This pilot study found no evidence of a professional standard of development of clinical informatics competence in early career health sciences professionals, and it found some ad hoc learning that could be counterproductive in the longer term. These findings confirm that the phenomenon of clinical informatics competence is problematic in healthcare. Larger qualitative studies are required to confirm this pattern on a larger scale in the healthcare system, and longitudinal studies will be important to capture workplace changes and related workforce education initiatives, especially in view of the recent sharp rise in interest in e-health. If such a pattern is confirmed, healthcare education providers, professional organizations and employer groups will need to collaborate on an integrated high-profile strategy in order for our healthcare system to have a knowledgeable and skilled professional workforce with progressive and complementary attitudes to working with information and communication technologies.