Nursing informatics competencies required of nurses in Taiwan

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1 international journal of medical informatics 80 (2011) journal homepage: Nursing informatics competencies required of nurses in Taiwan Jieh Chang a, Mollie R. Poynton b,, Carole A. Gassert b, Nancy Staggers b a National Taichung Nursing College, Taiwan b University of Utah College of Nursing, United States article info abstract Article history: Received 10 October 2009 Received in revised form 17 December 2010 Accepted 16 January 2011 Keywords: Informatics Education Nursing Internationality Nursing Purpose: In today s workplace, nurses are highly skilled professionals possessing expertise in both information technology and nursing. Nursing informatics competencies are recognized as an important capability of nurses. No established guidelines existed for nurses in Asia. This study focused on identifying the nursing informatics competencies required of nurses in Taiwan. Methods: A modified Web-based Delphi method was used for two expert groups in nursing, educators and administrators. Experts responded to 323 items on the Nursing Informatics Competencies Questionnaire, modified from the initial work of Staggers, Gassert and Curran to include 45 additional items. Three Web-based Delphi rounds were conducted. Analysis included detailed item analysis. Competencies that met 60% or greater agreement of item importance and appropriate level of nursing practice were included. Results: N = 32 experts agreed to participate in 1, 23 nursing educators and 9 administrators. The participation rates for s 2 and 3 = 68.8%. By 3, 318 of 323 nursing informatics competencies achieved required consensus levels. Of the new competencies, 42 of 45 were validated. A high degree of agreement existed for specific nursing informatics competencies required for nurses in Taiwan (97.8%). Conclusions: This study provides a current master list of nursing informatics competency requirements for nurses at four levels in the U.S. and Taiwan. The results are very similar to the original work of Staggers et al. The results have international relevance because of the global importance of information technology for the nursing profession Elsevier Ireland Ltd. All rights reserved. 1. Introduction Nurses must exploit information technology, especially clinical technology, to function in contemporary health care settings worldwide. Information technology has the potential to facilitate nursing care delivery by increasing time spent in direct patient care [1,2], improving decision making, reducing duplicate work, decreasing error [3,4], and minimizing time spent on documentation [1]. Recent publications identified unintended consequences of applications such as provider order entry [5 8] and the lack of sufficient cognitive support in existing clinical systems [9]. Nevertheless, information technology will increase its penetration into health care settings even with current drawbacks. The fact is that nurses in all specialties and roles must have the knowledge and skills to use information technology [10 12]. Informatics competencies are a global imperative for nurses. Corresponding author at: University of Utah College of Nursing, 10 S 2000 East Salt Lake City, UT , United States. Tel.: address: mollie.poynton@nurs.utah.edu (M.R. Poynton) /$ see front matter 2011 Elsevier Ireland Ltd. All rights reserved. doi: /j.ijmedinf

2 international journal of medical informatics 80 (2011) The identification of specific informatics competencies for nurses has been a topic of keen interest during recent years. Researchers and nurses in professional organizations completed substantial work toward defining nursing informatics competencies [11,13 22]. Researchers in Australia are currently identifying national information technology and information management competencies for nurses [10]. The Technology Informatics Guiding Educational Reform (TIGER) initiative released a list of informatics competencies for practicing nurses in the U.S. in late 2009 [23], adopting the European Computer Driving License. This is a computer literacy certification program offered, for payment, by the Council of the European Professional Informatics Societies [24]. The International Medical Informatics Association (IMIA) developed recommendations for educating health informaticists, including nurse specialists, first in 1999 [25] and provided an updated version in early 2010 [22]. Despite this flurry of work, research to validate the disparate lists of informatics competencies is sparse. More informal consensus is the main method of competency development across groups. To date, the only existing informatics competencies formally validated is that identified by Staggers et al. [20] and the pending research in Australia. In Asia, Yee described Singapore nurses needs in basic and work-related information technology [21], and necessary computer competencies for nurses in Taiwan [16]. Nursing professionals in Taiwan faced rapid changes in information technology and they are adapting to these changes [26]. Jiang and colleagues [16] called for Taiwanese nurse educators and administrators to educate nursing students on computer competencies. No standards or guidelines exist relative to what broader nursing informatics competencies should be, making it difficult to design appropriate nursing curricula or provide competency guidelines to employers in Taiwan. To that end, the purpose of this research was to identify nurse educators and nurse administrators perceptions of informatics competencies required of nurses in Taiwan. 2. Background 2.1. Nursing informatics competencies Research related to informatics competencies began soon after computers became available to nurses in the 1980s. By 1988, nurses in the International Medical Informatics Association and the National League for Nursing developed the first informatics competencies, and other studies soon followed [27,28]. Unfortunately, the early lists of competencies [29,30] were not adopted into nursing curricula [20]. Moreover, these identified competencies described entry-level competencies such as computer skills for nurses, and not the more sophisticated informatics skills needed by experienced nurses and especially, informatics nurse specialists (INS). Renewed interest in informatics competencies for nurses began in the early 2000s. Staggers et al. [18 20] defined and validated informatics competencies for nurses at four levels of practice: beginning, experienced, INS and informatics innovator. Subsequently, authors identified informatics competencies for nurse practitioners [14], expanded beginning nurse competencies to include the knowledge and skills for evidenced-based practice [15], identified a need for computer literacy as well as information literacy for undergraduate nursing students, and identified self-reported informatics content taught in undergraduate programs in the U.S. [31]. Authors outlined informatics competencies needed for nursing practice to improve patient safety and expand nursing practice [13,32,33] as well as knowledge and skills in organizational and human behavior such as project management [34]. Consensus efforts to define new nursing and general informatics competencies are underway. Nurses in the Technology Informatics Guiding Educational Reform (TIGER) initiative in the U.S. reviewed past competency work and adopted the European Computer Driving License certification for nurses basic computer skills [23,24]. This certification is offered internationally for pay by the Council for European Informatics Societies. This organization also offers certification for various information technology professionals [24]. Australian nurses reported on a national effort to create information technology and information management competencies for nurses [10]. Development methods were described at a conference in June 2009 [10]; however, the results are not yet available. Hart [17] completed a systematic review of existing informatics competencies in 2008, recommending that administrators shift from competencies creation to implementing existing competencies in work settings [20]. In 2009, nursing graduates at one U.S. institution reported moderate information technology skills with their priority educational need identified as exposure to the latest informatics systems [35]. Most recently, IMIA released a set of educational guidelines for informatics professionals in early In summary, the work on competencies is flourishing. It expanded from a beginning focus on education to initial practice requirements including competencies for safe nursing practice; however, the majority of work centers on the educational arena. Informatics competency determinations in work settings lag behind curriculum development [17,20]. Although competencies lists are developed by IMIA, and organizations in the U.S. and Australia, no current, consolidated, research-based list of competencies exists across informatics organizations or authors Nursing informatics in Taiwan There is extensive use of clinical information systems in Taiwan. Most medical centers and large hospitals have installed improved information technology equipment and designed hospital information systems to provide highquality health services. Available functions include nursing assessment, nursing diagnosis, nursing care plan, patient classification, and nursing care activities associated with finance, management, coordination, and multidisciplinary tasks [36]. A lack of research about nursing informatics competencies in clinical and education settings exists for nurses in Taiwan. Only one study identifying needed competencies exists for nurses in Taiwan and that work concentrated on domains of computer competencies across educational programs [16]. A master list of informatics competencies for nurses in Taiwan is needed. To that end, the current study built on a previous study by Staggers et al. [20] and identified

3 334 international journal of medical informatics 80 (2011) Fig. 1 Information Management Framework. From Staggers et al. [20]. Reprinted by permission. nursing informatics competencies required by nurses in their practice Conceptual Framework for the Study The concepts in this information management framework [20] were synthesized from diverse sources of nursing and information systems literature with informatics competencies as the key concept of the framework. Informatics competencies along with human information processing skills comprise the overall construct of information management competencies. Three components of informatics competencies (computer skills, informatics knowledge, and informatics skills) are interdependent and of equal importance. The highlighted elements are the focus in this study (see Fig. 1). 3. Methods This study was approved by the Institutional Review Board of the University of Utah Sample Purposeful sampling and snowball sampling were employed to identify expert nurse educators and administrators from 39 nursing schools and 15 medical centers/hospitals in Taiwan. Experts were chosen for their expertise in nursing, not the specialty area of nursing informatics, because Taiwan has few nursing informatics specialists. Potential experts meeting selection criteria were identified in databases of Taiwan s Ministry of Education and Department of Health, and invited to participate. They were also asked to suggest other potential experts for participation. Three criteria were employed in selection: (a) job position, (b) educational requirements, and (c) work experience in nursing. Informed consent was obtained from each participant electronically Instrumentation The Delphi instrument used in this study, the Nursing Informatics Competencies Questionnaire (NICQ), was developed from two sources: (a) the nursing informatics competencies for four levels of nursing identified by Staggers et al. [20] and (b) 45 added-item competencies derived from an updated literature review that achieved a 75% or greater agreement of item importance in an expert panel. The original questionnaire developed by Staggers, Gassert and Curran included 281 competencies. After a review of the literature from 1998 to 2004, 56 potential additional competencies were identified. These competencies were assigned to one of three major classifications: (a) computer skills 14 items, (b) informatics knowledge 26 items, (c) informatics skills 16 items into four levels of nursing practice. In addition, two new subcategories of informatics knowledge (evidence-based and information literacy) were added. All candidate items were evaluated for relevance by a convenience sample of five nursing informatics experts. Of the 56 added items competencies, 45 achieved a 75% or greater agreement of item importance. One item was deleted due to duplication. In addition, six items were moved from Level 2 to Level 1 with 75% agreement. Table 1 presents the changed and added items. The new questionnaire, the Nursing Informatics Competencies Questionnaire (NICQ), consisted of 323 competencies, including a rating scale and three domains groups: (a) computer skills, (b) informatics knowledge, and (c) informatics skills in four levels of nursing practice (beginning nurse, the experienced nurse, informatics specialist, and informatics innovator) Delphi procedure A three-round Delphi study was conducted to collect and refine group opinion on nursing informatics competencies in Taiwan using the NICQ. The three rounds were conducted in sequence, and s 2 and 3 questionnaires were based on results of the previous round. A Web-based survey system was used to collect data. General procedures. Each expert was sent the following by (a) a URL for instructions and (b) a URL for accessing the demographic questionnaire and the Nursing Informatics Competencies Questionnaire. For each questionnaire, experts were asked to indicate: (a) the important of the competency using a 4-point Likert-type scale and (b) whether the item

4 international journal of medical informatics 80 (2011) Table 1 New and changed items, revised from Staggers, Gassert, Curran questionnaire (Nursing Informatics Competencies Questionnaire). a Level 1 (Beginning Nurse) Uses decision support systems, expert systems and other aids for clinical decision making and care planning Uses an application to enter patient data (e.g., vital signs, demographic and physiological data) a Uses spreadsheet application, such as Microsoft Excel Uses basic computer terminology, especially for help-line support Uses existing external peripheral devices (e.g., CD-ROMs, DVD, zip drives) a Uses a variety of search tools Recognizes when information is needed and communicates that need Understands the procedure of scholarly information Understands the importance of organized collection of information Understands the essentials of information sources such as a variable form, different characteristics, and various physical formats Understands and applies essential information-seeking concepts and practices Recognizes need for continual learning informatics skills, applications, and knowledge Applies the principles of data integrity, professional ethics and legal requirements for patient confidentiality and data security Maintains privacy and confidentiality in clinical log management Analyzes patient information needs, accesses technology resources to meet needs and evaluates effectiveness Evaluates health information on the Internet using a structure critique format Level 2 (Experienced Nurse) Uses administrative applications for budget (cost-effectiveness, cost-benefit, and cost utility) a Uses administrative applications for quality assurance data Uses telecommunications to support care delivery, empowers the consumer, transforms education, and enhances decision making Understands how to manage the development of a patient-friendly Web site Uses applications to aggregate and analyzes data for forecasting, accreditation, clinician value, nurse-sensitive outcomes, EBP, and quality improvement Uses applications to format and present data and information Identifies pertinent literature resources and incorporates into practice and professional development Understands the principles of data display to facilitate analysis Is knowledgeable regarding optimal search strategies to locate clinically sound and useful studies from information resources Critically analyzes data, information, and knowledge for use in site specific evidence-based practice Identifies, evaluates and applies the most relevant information Synthesizes best evidence Develops and presents evidenced-based case presentations Synthesizes data from more than one source and applies to practice Acknowledges that the research process in nonlinear and iterative and requires flexibility Acts as an advocate of system users including patient and colleagues Helps patients and clinicians utilize online systems Integrates technology into clinical practice by teaching patients about online databases, e.g., PubMed Assesses the accuracy (quality, accountability, reliability and validity) of health information on the Internet a Participates in quality management initiatives related to patient and nursing data in practice Converts information needs into answerable questions Uses data and statistical analyses to describe and evaluate practice Uses the clinical log to evaluate one s own practice against EBP standards Incorporates structured language into practice Utilizes appropriate structured languages in the clinical log, e.g., ICD coding, nursing terminology, etc. Generates/requests a custom report from existing database. Analyzes the data and applies the finding appropriately Demonstrates knowledge and clinical decision making processes within site specific practice Evaluates the appropriateness of the monitoring systems for the type of data needed Converts data into information and the knowledge Level 3 (Informatics Specialist) (No new or changed items) Level 4 (Informatics Innovator) Analyzes information to generate new knowledge a Italicized text indicates change to existing item. was placed within the correct level of nursing practice. If they disagreed with the level, experts gave the correct placement. Finally, each questionnaire included an open-ended question asking the nurse educators and administrators to briefly describe any additional nursing informatics competencies that should be considered for inclusion. Experts were asked to complete questionnaires within 2 weeks. Follow-up messages were sent to experts who did not finish the questionnaires within 2 weeks. 1. The criteria used to establish consensus on items in s 1 3 was 60% or greater agreement. 2. The 2 questionnaire included only competencies that did not achieve consensus in 1. In addition, the following information from 1 was provided: (a) the frequencies and percentages for items below agreement and (b) the individual expert s responses for each competency.

5 336 international journal of medical informatics 80 (2011) Table 2 Item agreement for items not achieving consensus, s 1 3. Category Agreement of item importance Agreement of appropriate level Level 1: Beginning Nurses 10. Uses decision support systems, 50% 54% 50% 54% 41% 50% expert systems and other aids for clinical decision making and care planning 20. Uses basic computer terminology, 57% 94% 94% 90% especially for help-line support 24. Uses existing external peripheral 52% 81% 81% 82% devices (e.g., CD-ROMs, DVD, zip drives) 29. Uses a variety of search tools 57% 73% 73% 86% 32. Understands the procedure of 51% 45% 45% 64% scholarly information 34. Understands the essentials of 47% 38% 59% 38% 73% 68% information sources such as a variable form, different characteristics, and various physical formats 48. Explains the use of networks for 47% 62% 41% 62% 86% 73% electronic communication (e.g., Internet) 49. Identifies the basic components of 47% 59% 64% 59% 77% 81% the current computer system (e.g., features of a PC, workstation) Added item: Searches medical dictionary, 91% 91% pharmacy information and health information via Internet a Added item: Presents data analysis and 62% 62% statistical capability a Level 2: Experienced Nurses 99. Markets self, system, or application 41% 70% 70% 55% to others 101. Performs basic trouble-shooting in 55% 55% 55% 71% applications Level 3: Informatics Specialists 180. Serves as a liaison among agency departments and vendors 52% 79% 57% 79% 82% 81% a Added-item competency. Added-item competencies submitted in 1 were also included. Each expert was asked to reassess his or her ratings based on the whole group s response. 3. The final questionnaire included only competencies that did not achieve consensus in 2. Frequencies and percentages below the agreement level and experts responses for each competency were again provided and experts were asked to reassess their ratings based on the whole group s response. 4. Results 4.1. Demographics Of the 91 potential experts willing to participate, 32 (35.2%) qualified experts agreed to participate and completed 1. The sample consisted of 23 nursing educators and 9 nursing administrators, from a variety of institutions within Taiwan. Nursing educators. The nursing educators were all female with the majority (65.2%) between 41 and 50 years of age. The modal educational level was a master s degree. The nursing educators areas of expertise included 11 medical surgical (47.8%), 2 maternal child (8.7%), 2 administration/management area (8.7%), 2 mental health, and 5 community health (8.7%). Other expertise consisted of gerontology, nursing professional issues, hospice care, intensive care, nursing education, and long-term care (39.1%). The nursing educators reported a mean 18.7 years of experience in nursing, ranging from 10 to 30 years. The mean length of time nursing educators had been in their current nursing educational experience was 14.3 years with a range of 1 24 years. As for type of nursing school, a majority (73.9%) were vocational schools, with most of the schools (69.6%) being private schools. Ten nursing educators were teaching in junior colleges (43.5%), 6 in colleges (26.1%), and 7 were in universities (30.4%). Nursing educators reported 30.3 h of computer use every week. All used information systems in their institutions. Nursing administrators. Most of the nursing administrators were female (88.9%). Four were 41 50, 3 were 31 40, and 2 were years old. Eight of the 9 held a master s degree. Areas of expertise among nursing administrators included 5 surgical (55.6%), 4 medical (44.4%), 4 administration/management (44.4%), 1 maternal child (11.1%), 1 oncology (11.1%), and

6 international journal of medical informatics 80 (2011) Table 3 Group differences in agreement: educators vs. administrators. Competency Item importance Appropriate level 1 N =32 2 N = 22 3 N = 22 1 N =32 2 N =22 3 N =22 Uses an application to document patient.06 * 1.00 care Demonstrates basic technology skills.07 * 1.00 (e.g., turn computer off and on, load paper, change toner, remove paper jams, print documents) Describes patients rights as they pertain.06 *.38 to computerized information management Uses decision support systems, expert * systems and other aids for clinical decision making and care planning Is able to navigate Windows (e.g., * manipulate files using file manager, determine active printer, access installed applications, create and delete directories) Recognizes that one does not have to be a * computer programmer to make effective use of the computer in nursing Assesses the accuracy (quality, ** accountability, reliability and validity) of health information on the Internet Determines the limitations, reliability of * computerized patient monitoring systems Determines priorities for new * requirements within budget constraints Uses a variety of search tools * p <.1. p < community health (11.1%). Other expertise consisted of anesthesia and intensive care (33.3%). The nursing administrators reported an average of 17.9 years of experience in nursing, ranging form a low of 9.6 years, claimed by 1 expert, to a high of 35 years. The average length of time nursing administrators had been in their current nursing administrational experience was 13 years with a minimum of 1 year and a maximum of 20 years; a majority (55.7%) worked in private medical centers. The nursing administrators reported an average of 35.1 h of computer use every week. All reported that they used an information system in their institution. Twenty-two (68.8%) of the initial participants completed s 2 and results In this round, 312 competencies (96.6%) achieved a 60% or greater agreement of item importance. Many items (n = 164) resulted in % agreement in the first round. Eleven competencies achieved less than 60% agreement of item importance. Of these 11 competencies, 6 competencies achieved 60% or greater agreement on appropriate level of nursing practice (uses basic computer terminology, especially for help-line support; uses existing external peripheral devices [e.g., CD-ROMs, DVD, zip drives]; uses a variety of search tools; explains the use of networks for electronic communication [e.g., Internet]; markets self, system or application to others; and serves as a liaison among agency departments and vendors). Another five competencies did not achieve 60% or greater agreement of appropriate level of nursing practice ( uses decision support systems, expert systems and other aids for clinical decision making and care planning; understands the procedure of scholarly information; understands the essentials of information sources such as a variable form, different characteristics, and various physical formats; identifies the basic components of the current computer system [e.g., features of a PC, workstation]; and performs basic trouble-shooting in applications ). by round agreement on items not achieving the 60% criteria for consensus is detailed in Table 2. Two additional competencies were suggested by one participant ( searches medical dictionary, pharmacy information and health information via Internet and presents data analysis and statistical capability ). These two competencies were added to the 2 questionnaire results Twenty-two nursing experts completed this round, a response rate of 68.8% (22 of 32). The 2 questionnaire was 13 items: 11 items that nursing experts previously rated but did not achieve consensus, along with two additional items

7 338 international journal of medical informatics 80 (2011) suggested in 1. For item importance, 6 original competencies moved from less than 60% agreement to greater than 60% agreement for both importance and level of practice, increasing the consensus percentage (318) from 96.6% to 98.5%. One of the six competencies that achieved consensus, Markets self, system, or application to others, achieved consensus of item non-importance (68%), and was removed from the 3 questionnaire. The two newly introduced competencies in 2 also achieved consensus for item importance and level of practice results All 2 participants completed 3. In 3, only one competency moved to greater than 60% agreement of item importance and appropriate level of nursing practice, increasing the consensus percentage (318) from 97.5% to 97.8%. The competency, identifies the basic components of the current computer system (e.g., features of a PC, workstation), achieved agreement for both item importance and appropriate level of practice. After three rounds of Delphi questionnaires, four competencies were at less than 60% agreement about item importance (Table 2). In these four competencies, three competencies achieved 60% or greater agreement on appropriate level of nursing practice ( understands the essentials of information sources such as a variable form, different characteristics, and various physical formats ; explains the use of networks for electronic communication [e.g., Internet] ; and serves as a liaison among agency departments and vendors ). Another competency did not achieve 60% or greater agreement on appropriate level of nursing practice, uses decision support systems, expert systems and other aids for clinical decision making and care planning Group differences: educators versus administrators A series of Fischer s exact tests described group differences in agreement on item performance and level between educators and administrators. Statistically significant group differences in agreement were found in s 1 and 2 for several items, though overall agreement usually met or exceed the 60% criterion. These are summarized in Table Discussion At the end of three Web-based Delphi rounds, 318 of the original 323 nursing informatics competencies achieved consensus for both item importance and appropriate level of nursing practice. The level of consensus for these items (97.8%) is very high indicating that respondents agreed about the importance and level of informatics competencies required of Taiwanese nurses. The validated competencies comprise a master list of nursing informatics competencies that can be used to design and develop nursing informatics courses and training programs. Based on the similarity of our results to those of Staggers et al. [20] in their original U.S. study, nursing informatics competencies required of nursing professionals in Taiwan are similar to those required of U.S. nursing professionals. Therefore, this revised and updated list of competencies can be internationally accepted for use. In this study, 42 new competencies were validated, adding to the master list of competencies identified by Staggers et al. [20]. These additional competencies reflect technological changes and newer technologies need in nursing. Both this study and the Staggers et al. study indicate a majority of competencies are for the nursing informatics specialist indicating that it continues to be important to develop educational programs that prepare nursing informatics specialists. Currently, there are no master s or PhD programs in nursing informatics in Taiwan. The results also indicate few significant differences between nursing educators and administrators in their perception of nursing informatics competencies required of nurses in Taiwan. The myriad efforts on developing nursing informatics competencies are beginning slowly to converge. The TIGER initiative in the U.S. adopted the European Computer Driver s License as basic competencies for all nurses, creating consensus for nurses in these nations for basic nurse preparation in informatics. The current research updates and confirms the majority of earlier informatics competencies across four levels of nurses in both Taiwan and the U.S. Other authors expanded the original Staggers et al. informatics competencies to specific groups, e.g., for nurse practitioners [17] and student nurses [41]. Hart in 2008 called for an end to developing unique lists of competencies and suggested redirecting energy into implementing existing informatics competencies into settings [17]. While we agree that the time for action is now; informatics competencies will continue to evolve and require rethinking to be current and pertinent. Nursing informatics competencies are critically necessary in health care delivery systems [37 39]. Several studies have connoted the impact information technology has had on the nursing profession and nursing education [31,40 42]. In the U.S., informatics is becoming an integral part of nursing curricula at both the baccalaureate and graduate level [43,44] as nursing educators work to meet the requirements of the health care delivery systems in which nurses provide care. In Taiwan, nursing informatics is a new nursing domain with only beginning integration into nursing program models [45,46]. This study and previous work clearly indicate that there are specific nursing informatics competencies required of nurses that apply internationally, and should be used to guide nursing educational programming. The challenge of integrating informatics education to achieve competencies into existing nursing education programs is upon us. Author contributions Dr. Jieh Chang served as principal investigator of the study. She was supervised by Drs. Carole Gassert and Mollie Poynton. Dr. Poynton also wrote portions of the current article, and prepared it for submission. Dr. Staggers led and conducted the original competencies research upon which this study was based, and wrote portions of the current article.

8 international journal of medical informatics 80 (2011) Summary points Previously known about this topic Research-validated nursing informatics competencies were originally established by Staggers et al. [20]. Consensus work on the topic is in progress in the U.S. and Australia. No informatics competencies were available in Asia, specifically in Taiwan to guide nursing education. This study Created the Nursing Informatics Competencies Questionnaire by updating the 2002 Staggers, Gassert, and Curran questionnaire with 45 new competencies. Found that 318 of 323 questionnaire items achieved consensus for item relevance and appropriate level of nursing practice. Found that 42 of the 45 new items achieved consensus. Provides an international, master list of current informatics competencies for nursing. Conflict of interest statement The authors have not conflicts of interest to disclose. Appendix A. 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