+1(978)310-4246 credencewriters@gmail.com



In women (P) how does following an acute myocardial infarction (I) compare to men (C) with mortality rates? (O)

Create a 6- to 7-slide PowerPoint presentation in which you do the following: · Identify and briefly describe your chosen clinical issue of interest. · Describe how you developed a PICO(T) question focused on your chosen clinical issue of interest. · Identify the four research databases that you used to conduct your search for the peer-reviewed articles you selected. · Provide APA citations of the four peer-reviewed articles you selected. · Describe the levels of evidence in each of the four peer-reviewed articles you selected, including an explanation of the strengths of using systematic reviews for clinical research. Be specific and provide examples.

the 4 research databases used: ProQuest, CINAHL Plus database, Medline, ERIC


Article 1: Summary/Abstract TITLE: “State-Level Sexism and Women’s Health Care Access in the United States: Differences by Race/Ethnicity, 2014–2019.”

Objectives. To quantify racial/ethnic differences in the relationship between state-level sexism and barriers to health care access among non-Hispanic White, non-Hispanic Black, and Hispanic women in the United States. Methods. We merged a multidimensional state-level sexism index compiled from administrative data with the national Consumer Survey of Health Care Access (2014–2019; n = 10 898) to test associations between exposure to state-level sexism and barriers to access, availability, and affordability of health care.

Article 2 Summary/Abstract TITLE: “Using Qualitative Research Articles to Talk about Gender and Race Inequities in Health Care”

Using peer-reviewed articles, this activity informs students of experiences female-identifying patients encounter in health-care contexts. The activity draws the students’ attention to gendered and racial prejudices and how those could impact patients’ relationship with practitioners.

Article 3 Summary/Abstract TITLE: “Sexism and Health: Advancing Knowledge Through Structural and Intersectional Approaches.

A”n editorial on the relationship between sexism and public health is presented. The author discusses the impact of structural sexism on women’s health and their access to health services, the application of intersectionality to research on sexism and women’s health, and the need for health equity.

Article 4 Summary/Abstract TITLE: ”

Because Women’s Lives Matter, We Need to Eliminate Gender Bias.”

The author reflects on gender bias in a health care setting. Topics covered include the potential effects of gender bias, the highlights of various studies relating to gender bias in critical care, and different strategies designed to mitigate gender bias in health care. Also discussed is the potential contributions of critical care nurses in eliminating gender bias.



two outside resources related to the peer-reviewed articles selected, and fully integrates at least two outside resources and two course-specific resources that fully support the presentation.




Volume 49, Number 11, pp 543-548
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
A Systems-Level Method for Developing
Nursing Informatics Solutions
The Role of Executive Leadership
Sammie Mosier, DHA, MA, BSN, NE-BC, CMSRN, BC
Wm. Dan Roberts, PhD, RN, ACNP
Jane Englebright, PhD, RN, CENP, FAAN
Nursing leadership can play an essential role in the development of nursing informatics solutions by virtue of
their broad understanding and oversight of nursing
care. We describe a systems-level method for creating
nursing informatics solutions with clearly defined structure and leadership from nursing executives. Based on
the guiding principles of clear lines of responsibility,
respect for expertise, and commitment to project
aims, this allows nursing executive leadership to organize, set up, and own the development of nursing informatics solutions.
Data about nursing care have become a critical component of operational and patient care decisions.
These data can potentially affect the productivity, efficiency, performance, effectiveness, cost, and value
of nursing care when properly collected and used.
The management and processing of data into knowledge for use in nursing practice have become an important specialty within the last decade.1
Nurse executives are dependent on data for effective decision making. The American Organization of
Nurse Leaders has identified essential competencies
in informatics that are necessary for effective leadership of this technology and data-informed environment.2 In the age of big data, nurse executives are
responsible for creation of the framework that allows
for nurses and other experts to apply their knowledge,
Author Affiliations: Vice President and Assistant Chief Nurse
Executive (Dr Mosier), Vice President of Care Delivery and Performance (Dr Roberts), and Senior Vice President and Chief Nurse
Executive (Dr Englebright), HCA Healthcare, Nashville Tennessee.
The authors declare no conflicts of interest.
Correspondence: Dr Englebright, HCA Healthcare, One Park
Plaza, Nashville, TN 37203 (Jane.Englebright@hcahealthcare.com).
DOI: 10.1097/NNA.0000000000000815
such as through the creation of a data culture, the development of data competencies, and the establishment of data infrastructure.3
Together, nurse executives and nurse informaticists
are forging new solutions to improve nursing processes
and patient care. The challenge is in determining how
best to coordinate the efforts of subject matter experts
from nursing, informatics, and information technology to design, develop, and deploy solutions to very
complex problems. Nursing leadership is well poised
to influence these processes by virtue of their broad
understanding and oversight of nursing care. While
not usually engaged in the development of nursing informatics solutions, we propose that executive leadership is necessary to this process.
Here we discuss our development of a systems-level
method, with clearly defined structure and leadership
from nursing executives, to create nursing informatics
solutions that enhance patient care. This article will
describe the method and provide case examples of
2 successful applications.
This project was conducted within a large network of
hospitals with affiliated facilities across the United States
and United Kingdom. The goal was to develop a method
for aligning leadership, clinical experts, informaticists,
and information technology experts to design, develop,
and deploy nursing informatics solutions.
The chief nurse executive (CNE) developed the
framework to harmonize the work efforts of disparate groups of clinical and informatics experts that
were necessary to design, develop, and deploy nursing
informatics solutions. The framework was based on
3 guiding principles: clear lines of responsibility and
JONA Vol. 49, No. 11 November 2019
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
authority, respect for each type of expertise necessary
to the project, and clear commitment to the aims of
the project.
Figure 1 depicts the structure. Clear lines of responsibility consisted of dedicated leadership for each
component of the process, starting with executive sponsorship and guidance. A steering committee of nursing executives set the vision, objectives, scope, and
guiding principles. The steering committee served as
a resource for the other teams and an arbitrator of
disputes between conflicting priorities. Teams of content experts and end-users were tasked with defining
good practice and ideal workflow to generate technology requirements. Technical experts were charged
with designing the technology solutions that could meet
requirements, support the workflow, present content
optimally, and incorporate decision support when possible. The clinical and technical teams work iteratively
to develop and test aspects of the proposed solution.
Subject matter experts provided critical input on
regulatory requirements, answering questions and
providing audit and review services. Project management resources ensured the appropriate flow of decisions
and work products among the teams in the appropriate
sequence and ensured that any issues were escalated
to the steering committee expeditiously.
Respect for different types of expertise ensured
that each of the above responsible parties was able to
operate fully within their area of expertise. Technical
experts deferred to clinicians on content and workflow.
Clinical experts deferred to informatics experts on the
best way to design input and output and the use of decision support. Regulatory experts deferred to clinical
experts on content and workflow while providing
guidance on regulatory requirements, including evaluation of the final product.
Commitment to the vision and guiding principles
established by the steering committee was a requirement for all colleagues participating in the project. A
clearly articulated set of guiding principles was used
in each work session to guide team members as they
designed, developed, and deployed the new solution.
Final success was measured on how well the solution
adhered to these guiding principles.
This framework was used to develop 2 distinct
nursing informatics solutions within a large hospital
system: Evidence-Based Clinical Documentation (EBCD)
and the Nursing Data Portal (NDP). These informatics solutions were designed to meet the operational
goals of: 1) minimizing nursing documentation into
an evidence-based story of the patient; 2) creating a
more useful and usable patient-centric record that
guides and informs the provision of safe, effective,
and efficient care by the interdisciplinary team; and
3) rendering standardized and normalized data for
the purpose of performance visibility and evaluation
of nursing care of individuals and population at both
the process and outcome levels. Through adherence
to the framework, the resulting informatics solutions
constructed to contribute to the healthcare learning
environment through the continuous generation of
knowledge and feedback to clinical practice.
Figure 1. Structure.
JONA Vol. 49, No. 11 November 2019
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Evidence-Based Clinical Documentation
In the development of EBCD, clear lines of responsibility began with the chief nursing officer (CNO) Council (Figure 2). The CNO Council served as the steering
committee for EBCD, overseeing the progress of the
project teams. This group served as a champion of
the organization’s nursing agenda and provided guidance and input into decisions related to patient care,
including operational issues and prioritization of clinical projects. The CNO Council defined the guiding
principles for the process and product, ensured adherence to the overall vision, and acted as an arbitrator
of conflicting viewpoints.
The Content Team was led by clinical leaders and
included ad hoc committees of clinical experts organized by specialty. Each ad hoc committee focused
on the specific tasks and questions relevant to their
area of expertise. Clinical experts with current patient
care experience were able to define the data flow
needed to support the previously developed ideal
workflows,4 use evidence reviews to develop content,
and identify the desired decision support.
Development of the decision support, creation of
a style guide, and review of existing screen designs
were the responsibility of technical experts. Regulatory subject matter experts addressed questions about
regulatory compliance, billing compliance, and risk
management and performed on-site assessment for
regulatory compliance. Throughout the entire process,
the project management team managed to timeline,
maintained communication, designed implementation and education strategies, and assisted the collaboration between teams to resolve issues.
With the clear lines of responsibility defined and
respect for expertise established, the development of
EBCD progressed in alignment with the vision for this
project. The overall vision for this project was to create a patient-centric record that guides and informs
the provision of safe, effective, and efficient care by
the interdisciplinary team and produces data to valuate care of individual and population of care (Figure 3).
To achieve this vision, guiding principles were developed in regard to design and content.
The guiding principles of EBCD design were established to ensure that the final product enhanced
and supported the process of patient care documentation, such as strict adherence to the style guide for
consistency and alignment with the previously defined
ideal workflows.4 The guiding principles of EBCD
content ensured that documentation entered through
this system would be meaningful to patient care or
necessary for regulatory or billing requirements and
that the resulting documentation would support the
ethical and competent clinician.
Nursing Data Portal
In the development of the NDP, the steering committee consisted of the CNO Council with representation
from CNEs and unit directors, the 2 primary endusers for the product. Responsibility for content was
Figure 2. Evidence-based practice clinical documentation project team.
JONA Vol. 49, No. 11 November 2019
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Figure 3. Flow of information for patient centric record.
designated to corporate clinical leaders and data
owners. Technical responsibility was shared between
the nursing analytics, data science, and information
technology teams. Other defined responsibilities were
assigned to subject matter expert teams, including patient experience, human resources, and financial and
executive leaders. Strong project management processes facilitated the iterative flow of decisions and
tool development (Figure 4).
The focused expertise of these teams was key to
the success of this project. The steering committee identified 4 domains of performance (clinical outcomes,
patient experience, efficiency, and nursing engagement) and provided final approval of the indicators
that would be used in the completed product. Technical experts were the backbone of all the data needs for
the final project. They created the data visualization
plan, transformed data to usable scoring methods,
harmonized time frames from disparate data sources,
and aligned the data to other reports with the same
metrics. The various subject matter experts suggested
common metrics that were to be included in the final
product. These teams also validated all data posttransformation prior to the creation of data visualizations. In essence, the subject matter experts verified
the work of the technical experts before any data were
released for viewing. Project management team members designed the implementation and education strategies for this project and also managed communication
and issue resolution among the teams to meet the project timeline goals.
With the clear lines of responsibility established
and experts assembled for the various project components, the development of the NDP progressed toward
its singular unifying vision: one common platform for
sharing nursing performance data (Figure 5). Through
the careful design of source system screens and data
pathways and requirements, nursing performance
Figure 4. Nursing data portal project team.
JONA Vol. 49, No. 11 November 2019
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Figure 5. Platform to share nursing performance data.
metrics from multiple systems could be concisely
displayed on 1 page for maximum accessibility. The
vision of the NDP was achieved through adherence
to the guiding principle of easily understood data
and visualizations.
Through the creation of a systems-level framework
that clearly defined responsibility, roles, and vision,
we successfully designed and implemented 2 largescale nursing informatics solutions. These informatics
solutions were different from each other—1 clinically
focused and 1 focused on leadership—but were built
upon the same systems-level framework. In this method,
there was a clearly defined role and responsibility for
nursing executive leadership from the beginning of
the project to the end.
Multiple contemporaneous articles have demonstrated the supportive role of nursing leadership and
informatics.5,6 Specific leadership roles, such as chief
nursing informatics officers and nursing informatics
executives, have emerged as central to the support of
transformation and the use of appropriate technology
solutions in clinical practice.7,8 Outside these specific
roles, there is a need for nurse leaders, including CNEs,
to have knowledge about informatics and its role in
patient care.9 Nurse leaders should be allowed opportunities to both gain these competencies and apply
their knowledge to decision making regarding informatics system and nursing care.9-11
Our systems-level method demonstrates the role
of specific leadership in guiding the ideation, design,
development, data mapping and visualization, and
application of the products developed during the informatics and technology life cycle. Each of these
components is integral to the functionality, adoption,
and use of the final solution. Nursing executive leadership must not only develop a clear structure, timeline, and goals for the entire process but also provide
valuable insight into product development. This leadership contributed to the effectiveness of these solutions as part of the continuous feedback loop within
a learning healthcare environment. The knowledge and
understanding of clinical practice gained through these
solutions can be applied to subsequent applications
and efforts to refine and innovate within nursing care.
Furthermore, our method maximizes the expertise of those most knowledgeable about individual
components. The clarity of roles ensured that critical
input was provided by the appropriate team members. For instance, technical experts and informatics
professionals focused on the best way to design input
and output and the use of decision support while clinicians were responsible for content and workflow.
An added benefit of this method is improved adoption of the resulting solutions. Leadership engagement is
a key component of implementation processes.12-14 In
our method, leadership are engaged early and often in
the design process, ensuring that the solutions also met
the needs of leaders. Leadership engagement allowed
for local needs and workflow considerations to be incorporated into the design, improving end-user uptake.
In summary, we have developed a systems-level
method that allows nursing executive leadership to
organize, set up, and own processes related to the development nursing informatics solutions. Our organization has used this structure for several projects with
positive results. Use and adaptation of the strategies
of this method may offer a way for nursing leadership
to guide and influence future solutions.
1. Murphy J. Nursing informatics: the intersection of nursing, computer, and information sciences. Nurs Econ. 2010;28(3):204-207.
2. American Organization of Nurse Executives. AONE Nurse
Executive Competencies. Chicago, IL: AONE; 2015. https://
www.aonl.org/sites/default/files/aone/nurse-executivecompetencies.pdf. Accessed July 25, 2019.
3. Englebright J, Caspers B. The role of the chief nurse executive in
the big data revolution. Nurse Lead. 2016;14(4):280-284.
JONA Vol. 49, No. 11 November 2019
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
4. Mosier S, Englebright J. The first step toward reducing documentation: defining ideal workflows. Comput Inform Nurs.
5. Remus S. The big data revolution: opportunities for chief nurse
executives. Nurs Leadersh. 2016;28(4):18-28.
6. Liebe JD, Hüsers J, Hübner U. Investigating the roots of successful IT adoption processes—an empirical study exploring the
shared awareness-knowledge of directors of nursing and chief information officers. BMC Med Inform Decis Mak. 2016;16:10.
7. Institute of Medicine. The Future of Nursing: Leading Change,
Advancing Health. Washington, DC: The National Academies
Press; 2010.
8. Hussey PA, Kennedy MA. Instantiating informatics in nursing
practice for integrated patient centred holistic models of care:
a discussion paper. J Adv Nurs. 2016;72(5):1030-1041.
9. Simpson RL. Chief nurse executives need contemporary informatics competencies. Nurs Econ. 2013;31(6):277-287; quiz 2887.
10. Healthcare Information and Management Systems Society
(HIMSS). Transforming Nursing Practice Through Technology
and Informatics: A Position Statement. Chicago, IL: HIMSS;
2011. https://www.himss.org/position-statement-transformingnursing-through-technology-and-informatics. Accessed July 25,
Oakes M, Frisch N, Potter P, Borycki E. Readiness of nurse executives and leaders to advocate for health information systems
supporting nursing. Stud Health Technol Inform. 2015;208:
Sandström B, Borglin G, Nilsson R, Willman A. Promoting the
implementation of evidence-based practice: a literature review
focusing on the role of nursing leadership. Worldviews Evid
Based Nurs. 2011;8(4):212-223.
Aarons GA, Sommerfeld DH. Leadership, innovation climate,
and attitudes toward evidence-based practice during a statewide implementation. J Am Acad Child Adolesc Psychiatry.
Gifford WA, Davies B, Edwards N, Graham ID. Leadership
strategies to influence the use of clinical practice guidelines.
Nurs Leadersh. 2006;19:72-88.
The Journal of Nursing Administration
Instructions for Authors
Instructions for Authors can be found online at the address
below. To ensure that your manuscript is in compliance
with new submission procedures, you should read this
document carefully before manuscript preparation. All
manuscripts must be submitted electronically through this
Please visit http://JONA.EdMgr.com.
JONA Vol. 49, No. 11 November 2019
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Because Women’s Lives Matter,
We Need to Eliminate Gender Bias
he Institute of Medicine’s landmark
publication Unequal Treatment1 describes
gender bias as unequal access or treatment that is not justified on the basis of an
underlying health condition. In a health care
setting, bias against women may be manifested
when women are diagnosed, counseled, treated,
or otherwise managed not just differently, but
to a lesser degree of adherence to established
standards of care than men with comparable
health status. Potential effects of this bias include
worse health outcomes for women, marked by
higher complication, morbidity, and mortality
rates.2 This expression of prejudice is believed
to be implicit, operating at an unconscious
level on the basis of situational cues.3 When a
nearly invisible impediment to equitable quality
health care can potentially undermine roughly
half of the world’s population, it should warrant our attention. In the United States, our
309 million residents comprise 50.8% or 156.5
million females4 who may receive substandard
health care.
My personal interest in the topic was piqued
after returning home from my granddaughter’s
funeral following an automobile crash and reading study findings that female trauma victims
with life-threatening injuries comparable to males
were less often triaged by emergency medical
service personnel to trauma facilities and less
often transferred by nontrauma physicians to
trauma centers.5 Because both initial transport6
and secondary transfer to a trauma center7
©2017 American Association of Critical-Care Nurses
Vol 37, No. 2, APRIL 2017
correlate with more favorable clinical outcomes,
whereas initial triage to a nontrauma facility is
associated with a 30% higher mortality rate,8 the
potentially lethal implications of both of those
findings hit home immediately and personally.
I found it hard to reconcile that a practice
arena heavily accustomed to following protocols and procedures based on valid research
delivered a lower standard of care to women.
In pursuit of answers and facts, I examined the
literature surrounding this issue, hoping to locate
evidence that my concern was unfounded. What
I found was that this detriment to women’s health
does not exist as a rare, isolated occurrence limited to third world countries, but has flourished
as a pervasive, largely unrecognized phenomenon in the United States and throughout the
world.9 I shared my findings in a 2012 editorial
titled “Is there gender bias in critical care?”10
In the 5 years since that report, research
continues to describe and affirm the nature,
extent, and effects of gender bias with some
awakening of awareness to its existence and
potential for harm. The Table provides a sampling of the literature findings related to gender bias, with an emphasis on studies relevant
to critical care. Please refer to it to become
acquainted with or to refresh your own recognition of this problem and, I hope, to ignite
your interest in contributing to its eradication.
To support you in this effort, we can consider
some of the approaches suggested for reducing or managing gender bias and then highlight a possibly promising breakthrough
discovered serendipitously.
Practice Area
Sampling of reports related to gender bias against women in health care
Behavioral Health Using written vignettes of homicides that differed only in sex of perpetrator, forensic psychiatrists and students
diagnosed the defendant as legally insane significantly more often when perpetrator was a woman.11
World Health Organization12 and US13 research found most behavioral disorders (depression, anxiety) are diagnosed twice as often in women.
Men receive more intensive treatments than women for common conditions.14
Diabetes Mellitus 85% of men vs 55% of women receive oral antihyperglycemics.15
Despite the UK NICE guideline 2713,16 (mandates “urgent referral to an oncologist” for painless macroscopic
hematuria), 27% of women vs 10% of men had multiple consults before referral. Bladder cancer 5-year survival rate is 57% for men, 44% for women.17,18 Female gender is independent risk factor for delayed referral
and diagnosis of bladder and renal cancer.19
TKA referral in patients with comparable osteoarthritis severity: physicians deny sex influences referral, but
referral rate for men is 3 times that for women. Using identical standardized patients, 42% of physicians
recommended TKA for the male, but not the female. Odds of primary care physicians recommending TKA
for men was twice that for women; for orthopedic physicians, odds for men was 22 times that for women.20
Patients with osteoarthritis needing hip replacement, women less likely than men to receive 4 of 5 care stages:
consult with general practitioner, specialist referral, orthopedic consult, wait listed.21 Women have more disability before referral.22
Women have lower probability of referral to waiting list for kidney transplantation and longer delay between
dialysis and waiting list compared to men.23-25
Women had significantly lower liver transplantation rates than men from 1997 to 2007 and greater deficit to
men since.26
Women had pain years longer than men before referral to pain clinic, where women are prescribed minor
tranquilizers, sedatives, or antidepressants vs analgesics and opioids for men.27
After abdominal surgery, physicians prescribed less pain medication for women compared to men; nurses
gave less pain medication to women.28
After CABG, men received narcotics, women given sedatives.29
First report on gender attributes of pain: physicians minimized women’s pain by attributing it to emotional causes.30
80 physicians (44 men) and 113 nurses (103 women) more likely to treat male patients with opioids than
females. Disparity greater for nurses than physicians.31
Despite ACC/AHA PAD guidelines, at discharge, women are significantly less likely than men to be prescribed
Arterial Disease
3 recommended therapies: statins, aspirin, and β-blockers.32,33
Women are offered surgical revascularization less often (36.4%) than men (53.8%) and are offered CEA less
often at all ages.34 When CEA is offered to women, it is often on a very delayed basis. Delays persist after
adjusting for age, history, preoperative TIA, ABCD2 score, degree of stenosis, unilateral symptoms, and
symptomatic stenosis.34 Findings most concerning because female gender is a known, negative, independent
risk factor for higher mortality for all major PV extremity surgery (amputation, revascularization).35
Although PAD has higher prevalence in women,36 women with PAD incur greater and more rapid functional
decline than men.37 Women with PAD have 2-3 times greater risk of stroke or MI, yet physicians neglect
treating this major source of morbidity and mortality.36
Access to ICU
Fewer women (40%) than men (60%) were admitted to ICUs, especially those ≥50 years, even after control
for diagnosis and comorbidity.38
After transport to ED for chest pain, women less likely than men to be admitted to hospital, sent to cath lab or
admitted to ICU. Differences persist after controls for age and ACS diagnosis.39
Benchmarks of
Care in ED
Mean door-to-ECG time for chest pain (AHA: ≤10 min) delayed for all, but nearly twice longer for women (53
min) than men (34 min); 49% of men had ECG in ≤10 min vs 32% women.40,41
In large adult ICU samples in the United States and Canada, despite greater illness severity in women, men
Level of Care
Received in ICU received more aggressive care (mechanical ventilation, vasoactive medications, intravenous fluids, central
catheters, arterial lines, PA catheters, CABG, thrombolytics, ICP monitoring),42,43 especially women older than
50; women had higher ICU mortality.38
Risk Factor
2-part design compared physicians’ attitudes with clinical practice in managing CAD risk factors. Attitudes
survey of how they would treat 2 hypothetical 58-year-old patients with identical clinical data and mild coronary atherosclerosis. Actual practice examined angiographic records of patients with CAD for LDL levels and
lipid-lowering medications. Attitude results: Despite same findings, physicians prescribed aspirin for 91% of
males and 77% of females and lipid-lowering medications for 67% of males and 54% of females. Actual
practice (LDL >110 mg/dL): physicians prescribed lipid-lowering medications for 77% of males and 47%
females. Clear evidence of gender bias in attitudes and clinical practice.44
Practice Area
Risk Factor
Therapies to prevent risk factors are less often ordered for women vs men.45-49 When women are treated for
hypertension45,47 or high LDL,47-49 they are less likely to meet recommended goals.
In national cohort of patients with CVD, women—despite higher LDL levels than men—were less likely to
receive statins or high-intensity statins as guidelines recommend. Female gender was independently associated with a lower likelihood of receiving statins.50
Acute Chest Pain
Women who present with chest pain treated much less aggressively than men, who are more likely to be
admitted to ICU; have cardiac enzymes drawn; emergency cardiology consult completed; and receive aspirin,
heparin, nitroglycerin, and thrombolytics. Women most often receive controlled substances and anxiolytics.51
Of consecutive transports for chest pain, males significantly more likely than females to receive aspirin and
have 12-lead ECGs taken.52
Women with chest pain receive fewer cardiac diagnostic assessments and less aggressive therapies than
men in all settings: primary care,53 outpatient,54 inpatient,55-59 and ED.60-64
Women have longer prehospital delays in care from symptom onset.65
Females with acute chest pain were significantly less likely than males to receive aspirin, nitroglycerin, or
have intravenous access started during prehospital care.39
Of ED patients with chest pain, women less likely than men to be told their symptoms could be CHD related
or to have cardiovascular testing or catheterization recommended, less likely to receive inpatient cardiac
catheterization, referral for stress testing, cardiac catheterization, or cardiology consult. As inpatients,
women more likely to be told no further testing needed.66
Coronary Artery
As outpatients with positive stress tests for possible CAD, 62% of women received no further diagnostic
Disease: Access to testing vs 38% of men.67
Women presenting to ED with ACS less likely than men to be admitted or to receive coronary revascularization.68
Care, Diagnostic
Tests, Pharmaco- In management of patients with CHD and type 2 diabetes mellitus: men treated more consistent with guidelogic Management lines than women. Men were significantly more likely to receive oral combination drugs, ACE inhibitors,
calcium channel blockers, and aspirin.69 Comparable findings in Finland, Italy, UK, and Argentina (despite
women’s higher risk profiles) and included less aggressive secondary prevention at discharge.70
In Canada, women less often treated with platelet inhibitors, heparin, and glycoprotein IIb/IIIa inhibitors than men.71
In 6 Middle East countries: significantly fewer women than men with ACS received ACE inhibitors, aspirin,
clopidogrel, β-blockers or statins at discharge.72 Another study found lower use of antithrombotics for
women vs men: clopidogrel, antiplatelet glycoprotein IIb/IIIa inhibitors.73
In China, only 8.9% of women received all 6 recommended medications.74
Access to care may account for disparities in mortality between sexes. Canadian study of adults admitted to
the hospital for ACS found women less likely than men to receive care within benchmark times for ECGs or
fibrinolysis. Women with STEMI were less likely than men to undergo reperfusion therapy (PCI or fibrinolysis) and women with non-STEMI or unstable angina less likely to undergo nonprimary percutaneous coronary intervention.41
Coronary Artery
Fewer women than men sent for cardiac catheterization after MI despite greater functional disability from angina.75
Disease: Referrals CABG performed less often for women (5.9%) than men (12.7%) with CAD and angina75; same finding for
for Cardiac
cardiac catheterization 18 years later.76
Of 9800 adults with CAD or heart failure, women less likely than men to have consults for both conditions
and had 15% fewer follow-up consultations.77
Men given CABG for CAD more than twice as often as women, who are more likely to be prescribed nitroglycerin
despite comparable findings.15
Only 25% of women received reperfusion (PCI or CABG). Of these, 74% received PCI rather than CABG.15,74,75,78
CABG not likely provided without angiographic evidence71,72 and significantly fewer women with CAD receive
coronary angiography.79,80
Women with CAD have fewer PCI procedures than men.72,73,79
Women are less likely to be given reperfusion for STEMI.41,73,79
Women with non-STEMI or unstable angina are less likely to undergo PCI compared to men.41
Acute Coronary
Unstable Angina,
In hospitalized patients with chest pain, angina, or acute MI, women less likely than men to have coronary
angiography and revascularization, even after controlling for potentially confounding variables.81
Women with nonobstructive CAD and MI are less likely to be prescribed medications for secondary prevention
of MI and have increased rates of readmission, reinfarction, and death in first year after MI.70,82-84
10.2% of men vs 3.5% of women had ICD implanted for primary prevention of SCD.85
After MI, for primary prevention of SCD, women are significantly less likely than men to have an ICD
Of Canadians with acute MI, men were 3 times more likely than women to receive an ICD for both primary
and secondary prevention. Neither age nor comorbidities accounted for differences.89
Vol 37, No. 2, APRIL 2017
Practice Area
Women with nonobstructive CAD and MI are less likely to be prescribed medications for secondary prevention
Acute Coronary
(antiplatelet agents, statins),84 yet have higher rates of readmission, reinfarction, and death first year after MI.70,82,83
Unstable Angina, Women had longer prehospital delay from onset of symptoms than men.65
Formal reports summarize research about women with CAD/ACS in Europe and Asia experiencing substandard
levels of care, more complications, and worse outcomes compared to men.90 Comparable reports relate to
women in India,79 China,74 and Western Asia.91
Women much less likely to participate in or be prescribed CR after AMI. Although referral to CR is a performance
measure of quality care,92,93 CR has failed to reach >80% of eligible women in the last 3 decades.92,94-98 A
primary predictor of dismal attendance is lack of physician endorsement of CR.99,100
Female STEMI patients ≤45 years had significantly poorer quality of care with longer delays in door-tothrombolytic time,101 and significantly longer prehospital scene time, transport time, and total scene-tohospital time compared to men.102
Upon arrival at the hospital, women with STEMI experienced more delays than men in door-to-code and codeto-balloon times. Female sex is independent determinant of delays.103
Women have lower rates of hospitalization for AMI and lower rates of PCI to treat AMI compared to men.104
Women with in-hospital STEMI were less likely to have cardiac catheterization or PCI than men.105
After AMI, women are less likely than men to receive ACE inhibitors, angiotensin receptor blockers, and
β-blockers after discharge.106
Women are less likely to receive primary PCI or CABG,107 have longer symptom-onset-to-balloon time, more
likely to receive only medical management, less likely to receive β-blockers or statins at discharge.108
AHA’s first Scientific Statement on Acute MI in Women,109 notes that “despite dramatic declines in cardiovascular
deaths among women over the past decade . . . women still fare worse than men.” Compared to men, women
tend to be underdiagnosed, undertreated, and less likely to receive guideline-recommended medications.57,71,110
Cardiac Arrest
Women presenting with cardiac arrest less likely to undergo therapeutic procedures (coronary angiography,
PCI, TTM) for ventricular tachycardia/fibrillation, pulseless electrical activity/asystole. Women were 25% less
likely to undergo angiography or angioplasty and 19% less likely to undergo TTM.111
Acute Stroke
Numerous quality indicators (resembling those for management of chest pain, CAD, ACS, MI) for women
receiving a significantly lower level of care across all settings than men: delays in provision of care, less likely
to receive recommended treatments and medications, less likely to meet established quality benchmarks:
– Prehospital recognition of stroke significantly lower in women.112
– Prehospital delay in studies finding differences, women arrived later in all.113-117
– In-hospital delay “door-to-doctor” time: women had longer delays.113,118,119
– In-hospital delay “door-to-scan/image” time: women had longer delays.119-123
– In-hospital use of intravenous thrombolytics (alteplase) in eligible patients. Women with stroke less likely
to receive alteplase.124-129
– Performance on all “Get With the Guidelines” measures significantly lower for females, even after
controlling for age, risk factors, comorbidities.130
Lack of access to optimal care: Undertriage of patients >65 years. Males significantly more likely to be transported131 or admitted132 to a trauma center than females.
Male trauma patients more often given priority 1, transported straight to trauma center, and allocated highest
level of prehospital competence than females. Differences by sex remained after adjusting for age, type and
mechanism of injury, and prehospital cardiac arrest.133
Prehospital pain management: Women less likely than men to receive prehospital analgesia for extremity injuries.134
Prehospital opioids for pain: Among Australian adults with trauma and GCS >12 with pain, males significantly
more likely to receive morphine than females even after controls for age, type, and severity of pain.135 Five
years later, study repeated for 2 years with sample 10 times larger: males still had significantly greater odds
than females of receiving opioid (morphine or fentanyl).136
Triage of Severely-Injured Trauma Patients: Despite guidelines to ensure triage based on patients’ physiologic
and injury status, of severely injured (ISS >15) trauma patients (35% women), study had 3 findings5:
1) EMS personnel less likely to transport severely injured women from field to trauma center compared to
comparably injured men
2) Of patients transported to nontrauma facilities, physicians less likely to transfer injured females to trauma
centers compared to males
3) Among comparably injured trauma patients, significantly fewer women than men are triaged to a trauma
center by either EMS in the field or physicians in nontrauma facilities. Outcomes persisted after controlling
for potentially confounding variables and despite evidence-based guidelines for triage and transfer.
Abbreviations: ACC/AHA, American College of Cardiology/American Heart Association; ACE, angiotensin-converting enzyme; ACS, acute coronary syndrome; AMI,
acute myocardial infarction; CABG, coronary artery bypass graft; CAD, coronary artery disease; CEA, carotid endarterectomy; CHD, congenital heart defect; CR, cardiac
rehabilitation; CVD, cardiovascular disease; ECG, electrocardiogram; ED, emergency department; EMS, emergency medical service; GCS, Glasgow Coma Scale; ICD,
implantable cardioverter defibrillator; ICP, intracranial pressure; ICU, intensive care unit; ISS, Injury Severity Score; LDL, low-density lipoprotein; MI, myocardial
infarction; PA, pulmonary artery; PAD, peripheral arterial disease; PCI, percutaneous coronary intervention; PV, peripheral vascular; SCD, sudden cardiac death; STEMI,
ST-segment elevation myocardial infarction; TIA, transient ischemic attack; TKA, total knee arthroplasty; TTM, targeted temperature management.
Strategies to Mitigate Gender Bias in
Health Care
A number of approaches have been employed to
help prevent or reduce implicit bias in health care. A
frequent starting place is to help health care professionals gain some awareness of their own vulnerability to
this form of prejudice. This step is often accomplished
using the Implicit Association Test (IAT)—software that
measures automatic associations evoked by rapid reactions in response to specific visually presented features
representing various races, genders, ages, and sexual
orientations. As different features are presented, the
computer-based program tracks changes in response
latency that reveal implicit bias. The IAT has been used
in hundreds of studies across many disciplines and can
be previewed at Harvard’s Project Implicit website.137
Merely exposing health care workers to the IAT may
not alter attitudes or beliefs, however, so multiple
strategies are often used, including combinations of
education about implicit bias, prejudice, and stereotyping; peer discussions and focus groups; self-reflection;
reading about implicit bias; and practicing skills aimed
at countering stereotypical responses. To date, none of
these has produced any blockbuster success. According
to Zestcott et al,138 more research is needed to determine
which of these interventions are effective, to understand
how provider bias affects care, and how to motivate providers to control implicit bias.
One window into understanding these dynamics may
have opened recently and surreptitiously, while shining
a plausible and promising path to success.
An Unanticipated Breakthrough in Helping
to Eliminate Gender Bias in Health Care
In 2005, after a random chart audit in a few high risk
patient areas revealed that only 33% of vulnerable
patients had received appropriate venous thromboembolism (VTE) prophylaxis, patient safety staff at Johns
Hopkins Hospital launched a collaborative program to
maximize adherence to VTE prophylaxis guidelines by
means of a checklist.139 Further examination of these
findings revealed that whereas 31% of male trauma
patients did not receive VTE prophylaxis, for female
trauma patients, that failure rate was 45%, making
women nearly 50% more vulnerable to thrombi/emboli.140
Checklists were used as clinical decision support devices
based on their effectiveness in improving compliance
with other guidelines related to infection control141 and
Vol 37, No. 2, APRIL 2017
reducing postoperative complications.142 Among the
lessons learned with this project was that while many
interventions to foster staff buy-in for this effort may
have contributed to substantial improvements in VTE
prophylaxis compliance observed in successive project
reports,143-145 2 other aspects were requisite for success:
(1) The checklist order sets must be evidence based, user
friendly, efficient, smoothly integrated into normal workflow, and enable real-time performance monitoring, and
(2) physician participation in completing all checklist
requirements needs to be mandatory to achieve consistent compliance.139 In addition to the checklists, a “culture of safety” should include instruction in safety science,
recognition of possible safety problems, design of evidencebased solutions, monitoring for improvements, and
empowerment of all caregivers to halt procedures when
safety appears to be compromised.146
Continued work with these computer-based mandatory checklists as clinical decision support tools has
not only expanded their application as effective means
for maximizing staff compliance with best practices,
but has also afforded an apparent breakthrough into
achieving desired clinical practice results while erasing
disparities ascribed to race and gender bias. Lau et al145
describe attainment of significantly improved VTE
prophylaxis compliance for hospitalized medical and
trauma patients with concurrent elimination of preexisting racial and gender disparities. For medical patients,
compliance with prescribed risk-appropriate VTE prophylaxis improved from 70% for black patients and 62%,
for white patients (P = .015) before protocol implementation to 92% for black patients and 88% for white patients
with no differences in compliance between the races
(P = .082). Similarly, for trauma patients, the proportion of males prescribed VTE prophylaxis before the
protocol was significantly higher than for female trauma
patients (70% vs 55%, P = .045), whereas after protocol
implementation, compliance increased for both male
(86%) and female (81%) trauma patients (P = .078).145
Although other reports have highlighted the strong
association between strict adherence to established
guidelines and improved patient outcomes,147-149 Lau et
al rightly underscore their unique findings of mutual
and simultaneous benefits in both optimal and equitable patient care: “These findings highlight the potential
of health information technology approaches to improve
the quality of care for all patients and eradicate healthcare disparities.”145(p6)
How Critical Care Nurses Can Contribute
to Eliminating Gender Bias
Some of the cumulative lessons that critical care
nurses can take away from these studies:
• Evidence of gender bias against women in delivery
of health care services is pervasive and persistent.
• Acknowledging the existence of gender bias against
women is a necessary first step in eliminating it.
• Gaining insight into one’s own biases via the IAT
can be a valuable personal enlightenment.
• Critical care staff who would like to eliminate gender bias at their facility can learn from the experiences of multidisciplinary teams at Johns Hopkins
Hospital as they refined their checklists141,150
designed the culture of safety,146 and implemented
the VTE prevention program.139,143
• Monitoring for gender bias includes observing for
errors, omissions, or deviations from established
protocols, standing orders, and national guidelines
in our own setting as well as upon receipt of patients
from emergency medical services or other facilities.
• Just as with security concerns, the culture of safety
demands that when you see something in a health
professional’s practice that deviates from expectations, you say something so the practice is not permitted to continue or repeat.
If gender bias against women can be reduced by
ensuring that all health care providers follow established protocols for practice in their clinical area, then
we may not have a panacea but surely a promising means
to eradicate a significant proportion of the gender bias
that surrounds us. Critical care nurses can make their
contributions via their insights and participation as
integral members of the collaborative teams tasked
with eliminating gender bias while maximizing compliance with best practices. Critical Care Nurse looks
forward to hearing about your progress against gender
bias, so please keep us informed. CCN
JoAnn Grif Alspach, RN, MSN, EdD
1. Institute of Medicine. Unequal Treatment: What Healthcare Providers Need to
Know About Racial and Ethnic Disparities in Healthcare. Washington, DC:
The National Academies Press; 2002.
2. Risberg G, Johansson EE, Hamberg K. A theoretical model for analysing
gender bias in medicine. Int J Equity Health. 2009;8:28.
3. Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: where do we go from here? The Permanente Journal. 2011; 15(2):71-78.
4. United States Census Bureau. Age and Sex Composition: 2010. 2010 Census
Briefs. http://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf.
Accessed February 1, 2017.
5. Gomez D, Haas B, de Mestral C, et al. Gender-associated differences in
access to trauma center care: a population-based analysis. Surgery. 2012;
6. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the
effect of trauma-center care on mortality. N Engl J Med. 2006;354:366-378.
7. Garwe T, Cowan LD, Neas B, Cathey T, Danford BC, Greenawalt P. Survival benefit of transfer to tertiary trauma centers for major trauma
patients initially presenting to nontertiary trauma centers. Acad Emerg
Med. 2010;17:1223-1232.
8. Haas B, Stukel TA, Gomez D, et al. The mortality benefit of direct trauma
center transport in a regional trauma system: a population-based analysis.
J Trauma Acute Care Surg. 2012;72:1510-1517.
9. Kent JA, Patel V, Varela NA. Gender disparities in health care. Mt Sinai J Med.
10. Alspach JG. Is there gender bias in critical care? Crit Care Nurse. 2012;
11. Yourstone J, Lindholm T, Grann M, Svenson O. Evidence of gender bias in
legal insanity evaluations: a case vignette study of clinicians, judges and
students. Nord J Psychiatry. 2008;62(4):273-278.
12. Diaz-Granados N, McDermott S, Wang F, et al. Monitoring gender equity
in mental health in a low-, middle-, and high-income country in the Americas. Psychiatr Serv. 2011;62(5):516-524.
13. Centers for Disease Control and Prevention. CDC QuickStats. http://
www.cdc.gov/mmwr/preview/mmwrhtml/mm6051a7.htm. Accessed
February 3, 2017.
14. Osika I, Evengard B, Waernulf L, Nyberg F. The laundry-basket project—
gender differences to the very skin. Different treatment of some common
diseases in men and women. Läkartidningen. 2005;102(40):2846-2848.
15. Brännström J, Hamberg K, Molander L, Lövheim H, Gustafson Y. Gender
disparities in the pharmacological treatment of cardiovascular disease and
diabetes mellitus in the very old: an epidemiological, cross-sectional survey. Drugs Aging. 2011;28(12):993-1005.
16. National Institute for Health and Clinical Excellence (NICE). Referral for
suspected cancer: a clinical practice guideline. London. 2005. Clinical
guideline 27. http://www.nice.org.uk/CG027. Accessed February 6, 2017.
17. Rachet B, Maringe C, Nur U, et al. Population-based cancer survival
trends in England and Wales up to 2007: an assessment of the NHS cancer
plan for England. Lancet Oncol. 2009;10:351-369.
18. Scosyrev E, Noyes K, Feng C, Messing E. Sex and racial differences in bladder cancer presentation and mortality in the US. Cancer. 2009;115: 68-74.
19. Lyratzopoulos G, Abel GA, McPhail S, Neal RD, Rubin GP. Gender
inequalities in the promptness of diagnosis of bladder and renal cancer
after symptomatic presentation: evidence from secondary analysis of an
English primary care audit survey. BMJ Open. 2013;3:e002861.
20. Borkhoff CM, Hawker GA, Kreder HJ, Glazier RH, Mohamed NN, Wright
JG. The effect of patients’ sex on physicians’ recommendations for total
knee arthroplasty. CMAJ. 2008;178:681-687.
21. Juni P, Low N, Reichenbach S, Villiger PM, Williams S, Dieppe PA. Gender inequity in the provision of care for hip disease: population-based
cross-sectional study. Osteoarthrit Cartilage. 2010;18(5):640-645.
22. Hame Sharon L, Alexander, Reginald A. Knee osteoarthritis in women.
Curr Rev Musculoskelet Med. 2013;6(2):182-187.
23. Thamer M, Hwang W, Fink NE, et al. CHOICE Study. Choices for Healthy
Outcomes in Caring for ESRD. U.S. nephrologists’ attitudes towards renal
transplantation: results from a national survey. Transplantation.
24. Klassen AC, Hall AG, Saksvig B, Curbow B, Klassen DK. Relationship
between patients’ perceptions of disadvantage and discrimination and
listing for kidney transplantation. Am J Pubc Health. 2002;92(5):811-817.
25. Couchoud C, Bayat S, Villar E, Jacquelinet C, Ecochard R. A new approach
for measuring gender disparity in access to renal transplantation waiting
lists. Transplantation. 2012;94(5):513-519.
Vol 37, No. 2, APRIL 2017
26. Mathur AK, Schaubel DE, Gong Q, Guidinger MK, Merion RM. Sex-based
disparities in liver transplant rates in the United States. Am J Transplant.
27. Lack DZ. Women and Pain: Another Feminist Issue. Women and Therapy.
28. Faherty BS, Grier MR. Analgesic medication for elderly people postsurgery. Nurs Res. 1984;33(6):369-372.
29. Calderone KL. The influence of gender on the frequency of pain and
sedative medication administered to postoperative patients. Sex Roles.
30. Unruh AM. Gender variations in clinical pain experience. Pain. 1996;
31. Wandner LD, Heft MW, Lok BC, et al. The impact of patients’ gender,
race, and age on health care professionals’ pain management decisions.
Int J Nurs Stud. 2014;51(5):726-733.
32. Enriquez JR, Pratap P, Zbilut JP, Calvin JE, Volgman AS. Women tolerate drug therapy for coronary artery disease as well as men do, but are
treated less frequently with aspirin, beta-blockers, or statins. Gend Med.
33. Hernandez-Vila EA. Peripheral arterial disease in women: the effect of
gender on diagnosis and treatment. Tex Heart Inst J. 2011;38(2):154-156.
34. Poisson SN, Johnston SC, Sidney S, Klingman JG, Nguyen-Huynh MN.
Gender differences in treatment of severe carotid stenosis after transient ischemic attack. Stroke. 2010;41(9):1891-1895.
35. Vouyouka AG, Egorova NN, Salloum A, et al. Lessons learned from the
analysis of gender effect on risk factors and procedural outcomes of
lower extremity arterial disease. J Vasc Surg. 2010;52(5):1196-1202.
36. Hirsch AT, Allison MA, Gomes AS, et al. A call to action: women and
peripheral artery disease: a scientific statement from the American
Heart Association. Circulation. 2012;125:1449-1472.
37. McDermott MM, Ferrucci L, Liu K, et al. Women with peripheral arterial disease experience faster functional decline than men with peripheral arterial disease. J Am Coll Cardiol. 2011;57:707-714.
38. Fowler RA, Sabur N, Li P, et al. Sex-and age-based differences in the
delivery and outcomes of critical care. CMAJ. 2007;177(12):1513-1519.
39. Meisel ZF, Armstrong K, Mechem CC, et al. Influence of sex on the outof-hospital management of chest pain. Acad Emerg Med. 2010;17(1):80-87.
40. Zègre-Hemsey J, Sommargren CE, Drew BJ. Initial ECG acquisition within
10 minutes of arrival at the emergency department in persons with chest
pain: time and gender differences. J Emerg Nurs. 2011;37(1): 109-112.
41. Pelletier R, Humphries KH, Shimony A, et al. Sex-related differences in
access to care among patients with premature acute coronary syndrome. CMAJ. 2014;186(7):497-504.
42. Valentin A, Jordan B, Lang T, Hiesmayr M, Metnitz PG. Gender-related
differences in intensive care: a multiple-center cohort study of therapeutic interventions and outcome in critically ill patients. Crit Care Med.
43. Mahmood K, Eldeirawi K, Wahidi MM. Association of gender with outcomes in critically ill patients. Critical Care. 2012;16:R92. http://ccforum.com/content/16/3/R92. Accessed February 6, 2017.
44. Abuful A, Gidron Y, Henkin Y. Physicians’ attitudes toward preventive
therapy for coronary artery disease: is there a gender bias? Clin Cardiol.
45. Jarvie JL, Foody JM. Recognizing and improving health care disparities
in the prevention of cardiovascular disease in women. Curr Cardiol Rep.
46. Huxley R, Barzi F, Woodward M. Group excess risk of fatal coronary
heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ. 2006;332:73-76.
47. Franzini L, Ardigo D, Cavalot F, et al. Women show worse control of
type 2 diabetes and cardiovascular disease risk factors than men: results
from the MIND.IT Study Group of the Italian Society of Diabetology.
Nutr Metab Cardiovasc Dis. 2013;23(3):235-241.
48. Chou AF, Scholle SH, Weisman CS, et al. Gender disparities in the quality of cardiovascular disease care in private managed care plans. Womens Health Issues. 2007;17:120-130.
49. Vimalananda VG, Miller DR, Palnati M, et al. Gender disparities in
lipid-lowering therapy among veterans with diabetes. Womens Health
Issues. 2011;21(4 suppl):S176-S181.
50. Virani SS, Woodard LD, Ramsey DJ, et al. Gender disparities in evidence-based statin therapy in patients with cardiovascular disease. Am J
Cardiol. 2015;115:21-26.
51. Lehmann JB, Wehner PS, Lehmann CU, et al. Gender bias in the evaluation
of chest pain in the emergency department. Am J Cardiol. 1996;77:641-644.
52. Rothrock SG, Brandt P, Godfrey B, Sal Silvestri S, Pagan J. Is there gender bias in the prehospital management of patients with acute chest
pain? Prehospital Emerg Care. 2001;5(4):331-334.
Vol 37, No. 2, APRIL 2017
53. Bösner S, Haasenritter J, Hani MA, et al. Gender bias revisited: new
insights on the differential management of chest pain. BMC Fam Pract.
54. Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on
physicians’ recommendations for cardiac catheterization. N Engl J Med.
55. Chandra NC, Ziegelstein RC, Rogers WJ, et al. Observations of the treatment of women in the United States with myocardial infarction: a
report from the National Registry of Myocardial Infarction-I. Arch Intern
Med. 1998;158:981-988.
56. Rathore SS, Wang Y, Radford MJ, Ordin DL, Krumholz HM. Sex differences in cardiac catheterization after acute myocardial infarction: the
role of procedure appropriateness. Ann Intern Med. 2002; 137:487-493.
57. Blomkalns AL, Chen AY, Hochman JS, et al. Gender disparities in the
diagnosis and treatment of non-ST-segment elevation acute coronary
syndromes: large scale observations from the CRUSADE (Can Rapid
Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality
Improvement Initiative. J Am Coll Cardiol. 2005;45:832-837.
58. Vaccarino V, Rathore SS, Wenger NK, et al. Sex and racial differences in
the management of acute myocardial infarction, 1994 through 2002. N
Engl J Med. 2005;353(7):671-682.
59. Peterson ED, Shah BR, Parsons L, et al. Trends in quality of care for
patients with acute myocardial infarction in the National Registry of
Myocardial Infarction from 1990 to 2006. Am Heart J.
60. Chang AM, Mumma B, Sease KL, Robey JL, Shofer FS, Hollander JE. Gender bias in cardiovascular testing persists after adjustment for presenting
characteristics and cardiac risk. Acad Emerg Med. 2007; 14:599-605.
61. Mumma BE, Baumann BM, Diercks DB, et al. Sex bias in cardiovascular
testing: the contribution of patient preference. Ann Emerg Med.
62. Takakuwa KM, Shofer FS, Hollander JE. The influence of race and gender on time to initial electrocardiogram for patients with chest pain.
Acad Emerg Med. 2006;13:867-872.
63. Arnold AL, Milner KA, Vaccarino V. Sex and race differences in electrocardiogram use (the National Hospital Ambulatory Medical Care Survey).
Am J Cardiol. 2001;88:1037-1040.
64. Diercks DB, Miller CD. Disparities in the care of chest pain. Can Med
Assoc J. 2008;179:631-633.
65. Nguyen HL, Saczynski JS, Gore JM, Goldberg RJ. Age and sex differences in duration of prehospital delay in patients with acute myocardial
infarction: a systematic review. Circ Cardiovasc Qual Outcomes.
66. Golden KE, Chang AM, Hollander JE. Sex preferences in cardiovascular
testing: the contribution of the patient-physician discussion. Acad Emerg
Med. 2013;20:680-688.
67. Shaw LJ, Miller DD, Romeis JC, et al. Gender differences in the noninvasive evaluation and management of patients with suspected coronary
artery disease. Ann Intern Med. 1994;120:559-566.
68. Kaul P, Chang WC, Westerhout CM, Graham MM, Armstrong PW.
Differences in admission rates and outcomes between men and women
presenting to emergency departments with coronary syndromes. CMAJ.
69. Krämer HU, Raum E, Rüter G, et al. Gender disparities in diabetes and
coronary heart disease medication among patients with type 2 diabetes:
results from the DIANA study. Cardiovasc Diabetol. 2012;11:88.
70. Bugiardini R, Estrada JL, Nikus K, Hall AS, Manfrini O. Gender bias in
acute coronary syndromes. Curr Vasc Pharmacol. 2010;8(2):276-284.
71. Poon S, Goodman SG, Yan RT, et al. Bridging the gender gap: insights
from a contemporary analysis of sexrelated differences in the treatment
and outcomes of patients with acute coronary syndromes. Am Heart J.
72. Shehab A, Al-Dabbagh B, AlHabib KF, et al. Gender disparities in the
presentation, management and outcomes of acute coronary syndrome
patients: data from the 2nd Gulf Registry of Acute Coronary Events
(Gulf RACE-2). PLoS One. 2013;8(2):e55508
73. Hammoudeh AJ, Shobaki N, Hamdan H, et al, and the Jordan Collaborating Cardiology (JCC) Group. Gender disparities in medical care
and early death after acute coronary syndrome in the Middle East: a
study of >4000 cases [abstract 0186]. Circulation. http://circ.ahajournals.org/content/early/2012/04/13/CIR.0b013e31824fcd6b. Accessed
Feburary 6, 2017.
74. Wang N, Zhao D, Jing L, et al. Quality of in-hospital management in
women with acute coronary syndrome in China: results from the bridging the gap on CHD secondary prevention in China (BRIG) project.
Poster presentation P681 from World Congress of Cardiology Scientific
Sessions, Dubai, United Arab Emirates; April 18-21, 2012. http://circ.
ahajournals.org/content/125/19/e741. Accessed February 6, 2017.
Steingart RM, Packer M, Hamm P, et al. Sex differences in the management of coronary artery disease. Survival and Ventricular Enlargement
Investigators. N Engl J Med. 1991;325(4):226-230.
Maserejian NN, Link CL, Lutfey KL, Marceau LD, McKinlay JB. Disparities in physicians’ interpretations of heart disease symptoms by patient
gender: results of a video vignette factorial experiment. J Women Health.
Cook NL, JZ Ayanian, EJ Orav, LRS Hicks. Differences in specialist consultations for cardiovascular disease by race, ethnicity, gender, insurance
status, and site of primary care. Circulation. 2009;12;119(18): 2463-2470.
Worrall-Carter L, McEvedy S, Wilson A, Rahman MA. Gender differences in presentation, coronary intervention, and outcomes of 28,985
acute coronary syndrome patients in Victoria, Australia. Womens Health
Iss. 2016;26(1):14-20.
Pais P, Xavier D, Gupta R, et al. Characteristics, treatments and outcomes
in young as compared with elderly acute coronary syndrome patients in
India (CREATE registry). Poster presentation P178 from World Congress
of Cardiology Scientific Sessions, Dubai, United Arab Emirates; April 18-21,
2012. http://circ.ahajournals.org/content /125/19/e741. Accessed February 6, 2017.
Worrall-Carter L, McEvedy S, Wilson A, Rahman MA. Impact of comorbidities and gender on the use of coronary interventions in patients
with high-risk non-ST-segment elevation acute coronary syndrome.
Catheter Cardiovasc Interv. 2016;87(4):E128-136.
Ayanian JZ, Epstein AM. Differences in the use of procedures between
women and men hospitalized for coronary heart disease. N Engl J Med.
Roe MT, Harrington RA, Prosper DM, et al. Clinical and therapeutic
profile of patients presenting with acute coronary syndromes who do
not have significant coronary artery disease: the Platelet Glycoprotein
IIb/ IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial Investigators. Circulation. 2000;102:1101-1106.
Patel MR, Chen AY, Peterson ED, et al. Prevalence, predictors, and outcomes of patients with non-ST-segment elevation myocardial infarction
and insignificant coronary artery disease: results from the Can Rapid
risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE) initiative. Am Heart J. 2006;152:641-647.
Maddox TM, Ho PM, Roe M, Dai D, Tsai TT, Rumsfeld JS. Utilization
of secondary prevention therapies in patients with nonobstructive coronary artery disease identified during cardiac catheterization: insights
from the National Cardiovascular Data Registry Cath-PCI Registry. Circ
Cardiovasc Qual Outcomes. 2010;3:632-641.
Gauri AJ, Davis A, Hong T, et al. Disparities in the use of primary prevention and defibrillator therapy among blacks and women. Am J Med.
2006;119:167, e17-e21.
Curtis LH, AL Khatib SM, Shea AM, et al. Sex differences in the use
implantable defibrillators for primary and secondary prevention of sudden cardiac death. JAMA. 2007;298:1517-1524.
Hernandez AF, Fonarow GC, Liang L, et al. Sex and racial differences in
the use of implantable cardioverter-defibrillators among patients hospitalized with heart failure. JAMA. 2007;298:1525-1532.
Crilly MA, Bundred PE, Leckey LC, Johnstone FC. Gender bias in the
clinical management of women with angina: another look at the Yentl
syndrome. J Womens Health (Larchmt). 2008;17(3):331-342.
MacFadden DR, TU JV, Chong A, et al. Evaluating sex differences in
population-based utilization of implantable cardioverter-defibrillators:
role of conditions and non-cardiac co-morbidities. Heart Rhythm. 2009;
European Institute of Women’s Health. Gender bias continues in heart
health. 2012; Accessed 10/05/2012. http://eurohealth.ie/2012/04/23/
gender-bias-continues-in-heart-health. Accessed October 5, 2012.
El-Menyar AA, Suwaidi JA. Impact of gender in patients with acute coronary syndrome. Expert Rev Cardiovasc Ther. 2009;7(4):411-421.
Drozda J Jr, Messer JV, Spertus J, et al. ACCF/AHA/AMA-PCPI 2011
performance measures for adults with coronary artery disease and
hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures
and the American Medical Association-Physician Consortium for Performance Improvement. Circulation. 2011;124:248-270.
Thomas RJ, King M, Lui K, Oldridge N, Pina IL, Spertus J. AACVPR/
ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services:
a report of the American Association of Cardiovascular and Pulmonary
Rehabilitation and the American College of Cardiology Foundation/
American Heart Association Task Force on Performance Measures.
Circulation. 2010;122:1342-1350.
Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the
prevention of cardiovascular disease in women—2011 update: a guideline
from the American Heart Association. Circulation. 2011; 123:1243-1262.
Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other
atherosclerotic vascular disease: 2011 update: a guideline from the
American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:2458-2473.
Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac
rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac
Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and
Prevention, and Nutrition, Physical Activity, and Metabolism; and the
American Association of Cardiovascular and Pulmonary Rehabilitation.
Circulation. 2007;115:2675-2682.
Balady GJ, Ades PA, Bittner VA, et al. Referral, enrollment, and delivery
of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation. 2011;124:2951-2960.
Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/
PCNA/SCAI/STS guideline for the diagnosis and management of patients
with stable ischemic heart disease: a report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses
Association, Society for Cardiovascular Angiography and Interventions,
and Society of Thoracic Surgeons. Circulation. 2012;126:e354-e471.
Grace SL, Gravely-Witte S, Kayaniyil S, et al. A multisite examination of
sex differences in cardiac rehabilitation barriers by participation status.
J Womens Health (Larchmt). 2009;18:209-216.
McCarthy MM, Vaughan Dickson V, Chyun D. Barriers to cardiac rehabilitation in women with cardiovascular disease: an integrative review.
J Cardiovasc Nurs. 2011;26:E1-E10.
Bangalore S, Fonarow GC, Peterson ED, et al. Age and gender differences in quality of care and outcomes for patients with ST-segment elevation myocardial infarction. Am J Med. 2012;125:1000-1009.
Aguilar SA, Patel M, Castillo E, et al. Gender differences in scene time,
transport time, and total scene to hospital arrival time determined by
the use of a prehospital electrocardiogram in patients with complaint of
chest pain. J Emerg Med. 2012;43(2):291-297.
Dreyer RP, Beltrame JF, Tavella R, et al. Evaluation of gender differences
in Door-to-Balloon time in ST-elevation myocardial infarction. Heart Lung
Circ. 2013;22:861-869.
Singh JA, Lu X, Ibrahim S, Cram P. Trends in and disparities for acute
myocardial infarction: an analysis of Medicare claims data from 1992 to
2010. BMC Med. 2014;12:190.
Kaul P, Federspiel JJ, Dai X, et al. Association of inpatient vs outpatient
onset of ST-elevation myocardial infarction with treatment and clinical
outcomes. JAMA. 2014;312:1999-2007
Lauffenburger JC, Robinson JG, Oramasionwu C, Fang G. Racial/Ethnic
and gender gaps in the use of and adherence to evidence-based preventive therapies among elderly Medicare Part D beneficiaries after acute
myocardial infarction. Circulation. 2014;129:754-763.
Gnavi R, Rusciani R, Dalmasso M, et al. Gender, socioeconomic position, revascularization procedures and mortality in patients presenting
with STEMI and NSTEMI in the era of primary PCI. Differences or
inequities? Int J Cardiol. 2014;176:724-730.
Yu J, Mehran R, Grinfeld L, et al. Sex-based differences in bleeding and
long term adverse events after percutaneous coronary intervention for
acute myocardial infarction: three year results from the HORIZONS-AMI trial. Catheter Cardiovasc Interv. 2015;85:359-368.
Mehta LS, Beckie TM, DeVon HA, et al, for the American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology
and Prevention, Council on Cardiovascular and Stroke Nursing, and
Council on Quality of Care and Outcomes Research. Acute myocardial
infarction in women: a scientific statement from the American Heart
Association. Circulation. 2016;133:916-947.
Koopman C, Vaartjes I, Heintjes EM, et al. Persisting gender differences
and attenuating age differences in cardiovascular drug use for prevention
and treatment of coronary heart disease, 1998-2010. Eur Heart J. 2013;
Vol 37, No. 2, APRIL 2017
111. Kim LK, Looser P, Swaminathan RV, et al. Sex-based disparities in incidence, treatment, and outcomes of cardiac arrest in the United States,
2003-2012. J Am Heart Assoc. 2016;5:e003704.
112. Govindarajan P, Friedman BT, Delgadillo JQ, et al. Race and sex disparities in prehospital recognition of acute stroke. Acad Emerg Med. 2015;
113. Menon SC, Pandey DK, Morgenstern LB. Critical factors determining
access to acute stroke care. Neurology. 1998;51(2):427-432.
114. Cheung RT. Hong Kong patients’ knowledge of stroke does not influence time-to-hospital presentation. J Clin Neurosci. 2001;8(4):311-314.
115. Barr J, McKinley S, O’Brien E, Herkes G. Patient recognition of and response
to symptoms of TIA or stroke. Neuroepidemiology. 2006;26(3):168-175.
116. Mandelzweig L, Goldbourt U, Boyko V, Tanne D. Perceptual, social, and
behavioral factors associated with delays in seeking medical care in
patients with symptoms of acute stroke. Stroke. 2006;37(5):1248-1253.
117. Foerch C, Misselwitz B, Humpich M, et al. Sex disparity in the access of
elderly patients to acute stroke care. Stroke. 2007;38(7):2123-2126.
118. McInnes C, McAlpine C, Walter M. Effect of gender on stroke management in Glasgow. Age Ageing. 2008;37(2):220-222.
119. Gargano JW, Wehner S, Reeves MJ. Do presenting symptoms explain
sex differences in emergency department delays among patients with
acute stroke? Stroke. 2009;40:1114-1120.
120. Engelstein E, Margulies J, Jeret JS. Lack of t-PA use for acute ischemic
stroke in a community hospital: high incidence of exclusion criteria. Am
J Emerg Med. 2000;18:257-260.
121. Yu RF, San Jose MC, Manzanilla BM, Oris MY, Gan R. Sources and
reasons for delays in the care of acute stroke patients. J Neurol Sci.
122. Frankel M, Hinchey J, Schwamm L, et al. Prehospital and hospital delays
after stroke onset—United States, 2005–2006. MMWR Morb Mortal
Wkly Rep. 2007;56:474-478.
123. Jungehulsing GJ, Rossnagel K, Nolte CH, et al. Emergency department
delays in acute stroke: analysis of time between ED arrival and imaging.
Eur J Neurol. 2006;13:225-232.
124. Reed SD, Cramer SC, Blough DK, Meyer K, Jarvik JG. Treatment with
tissue plasminogen activator and inpatient mortality rates for patients
with ischemic stroke treated in community hospitals. Stroke. 2001;
125. Brown DL, Lisabeth LD, Garcia NM, Smith MA, Morgenstern LB.
Emergency department evaluation of ischemic stroke and TIA: the
BASIC Project. Neurology. 2004;63:2250-2254.
126. Schumacher HC, Bateman BT, Boden-Albala B, et al. Use of thrombolysis in acute ischemic stroke: analysis of the Nationwide Inpatient Sample 1999 to 2004. Ann Emerg Med. 2007;50:99-107.
127. Deng YZ, Reeves MJ, Jacobs BS, et al. Paul Coverdell National Acute
Stroke Registry Michigan Prototype Investigators. IV tissue plasminogen activator use in acute stroke: experience from a statewide registry.
Neurology. 2006;14;66(3):306-312.
128. Gargano JW, Reeves MJ. Sex differences in stroke recovery and strokespecific quality of life: results from a statewide stroke registry. Stroke.
129. Reid JM, Dai D, Gubitz GJ, Kapral MK, Christian C, Phillips SJ. Gender
differences in stroke examined in a 10-year cohort of patients admitted
to a Canadian teaching hospital. Stroke. 2008;39:1090-1095.
130. Reeves MJ, Fonarow GC, Zhao X, et al. Quality of care in women with
ischemic stroke in the GWTG program. Stroke. 2009;40:1127-1133.
131. Chang DC, Bass RR, Cornwell EE, Mackenzie EJ. Undertriage of elderly
trauma patients to state-designated trauma centers. Arch Surg.
132. Hsia RY, Wang E, Saynina O, Wise P, Perez-Stable EJ, Auerbach A. Factors associated with trauma center use for elderly patients with trauma:
a statewide analysis, 1999–2008. Arch Surg. 2011;146(5):585-592.
133. Rubenson Wahlin R, Ponzer S, Lövbrand H, Skrivfars M, Lossius HM,
Castrén M. Do male and female trauma patients receive the same prehospital care? An observational follow-up study. BMC Emerg Med. 2016;16:6.
134. Michael GE, Sporer KA, Youngblood GM. Women are less likely than
men to receive prehospital analgesia for isolated extremity injuries. Am
J Emerg Med. 2007;25(8):901-906.
135. Lord B, Cui J, Kelly AM. The impact of patient sex on paramedic pain management in the prehospital setting. Am J Emerg Med. 2009;27(5): 525-529.
136. Lord B, Bendall J, Reinten T. The influence of paramedic and patient
gender on the administration of analgesics in the out-of-hospital setting.
Prehosp Emerg Care. 2014;18(2):195-200.
137. Harvard University. Project Implicit. https://implicit.harvard.edu
/implicit/. Accessed February 6, 2017.
Vol 37, No. 2, APRIL 2017
138. Zestcott CA, Blair IV, Stone J. Examining the presence, consequences,
and reduction of implicit bias in health care: a narrative review. Group
Process Intergroup Relat. 2016;19(4):528-542.
139. Streiff MB, Carolan H, Hobson DB, et al. Lessons from the Johns Hopkins Multi-Disciplinary Venous Thromboembolism (VTE) Prevention
Collaborative. BMJ. 2012;344:e3935
140. Nordell J. A fix for gender bias in health care? Check. The New York Times.
https://www.nytimes.com/2017/01/11/opinion/a-fix-for-gender-biasin-health-care-check.html. Accessed February 3, 2017.
141. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease
catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;
142. Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study
Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist- based surgical safety intervention. BMJ Qual Saf. 2011;20:102-107.
143. Haut ER, Lau BD, Kraenzlin FS, et al. Improved prophylaxis and
decreased preventable harm with a mandatory computerized clinical
decision support tool for venous thromboembolism (VTE) prophylaxis
in trauma patients. Arch Surg. 2012;147(10):901-907.
144. Zeidan AM, Streiff MB, Lau BD, et al. Impact of a venous thromboembolism prophylaxis “smart order set”: Improved compliance, fewer events.
Am J Hematol. 2013;88:545-549.
145. Lau BD, Haider AH, Streiff MB, et al. Eliminating Healthcare Disparities
Via Mandatory Clinical Decision Support: The Venous Thromboembolism (VTE) Example. Med Care. 2015;53(1):18-24.
146. Johns Hopkins Medicine. News release: Safety Checklist Use Yields 10 Percent Drop in Hospital Deaths. January 31, 2011. http://www.hopkinsmedicine .org/news/media/releases/safety_checklist_use_yields_10_percent
_drop_in_hospital_deaths. Accessed February 3, 2017.
147. Napolitano LM. Guideline compliance in trauma: evidence-based protocols to improve trauma outcomes? Crit Care Med. 2012;40:990-992.
148. Rice TW, Morris S, Tortella BJ, Wheeler AP, Christensen MC. Deviations
from evidence-based clinical management guidelines increase mortality
in critically injured trauma patients. Crit Care Med. 2012;40:778-786.
149. Graham G, Xiao Y-YK, Rappoport D, Siddiqi S. Population-level differences in revascularization treatment and outcomes among various
United States subpopulations. World J Cardiol. 2016;8(1):24-40.
150. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into
practice: a model for large scale knowledge translation. BMJ. 2008;
Copyright of Critical Care Nurse is the property of American Association of Critical-Care
Nurses and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder’s express written permission. However, users may print,
download, or email articles for individual use.
Nursing Informatics 2016
W. Sermeus et al. (Eds.)
© 2016 IMIA and IOS Press.
This article is published online with Open Access by IOS Press and distributed under the terms
of the Creative Commons Attribution Non-Commercial License.
Project Management: Essential Skill of
Nurse Informaticists
Carolyn SIPES
Chamberlain College of Nursing, NI Research Team
National Management Offices, 3005 Highland Parkway, Downers Grove, IL 60515
Abstract: With the evolution of nursing informatics (NI), the list of skills has
advanced from the original definition that included 21 competencies to 168 basic
competencies identified in the TIGER-based Assessment of Nursing Informatics
Competencies (TANIC) and 178 advanced skills in the Nursing Informatics
Competency Assessment (NICA) L3/L4 developed by Chamberlain College of
Nursing, Nursing Informatics Research Team (NIRT). Of these competencies,
project management is one of the most important essentials identified since it
impacts all areas of NI skills and provides an organizing framework for
processes and projects including skills such as design, planning, implementation,
follow-up and evaluation. Examples of job roles that specifically require project
management skills as an essential part of the NI functions include management,
administration, leadership, faculty, graduate level master’s and doctorate practicum
courses. But first, better understanding of the NI essential skills is vital before
adequate education and training programs can be developed.
Keywords: nursing informatics, project management, education, essentials,
Introduction: History and Definitions
In today’s high-tech world, expectations of the healthcare industry is that nurses will
have informatics competencies including project management skills which are critical
for improved quality outcomes and safety for patients. This is not only true for nurses
in graduate courses, clinical practice management roles but administrative and other
leadership roles as well. The expectation is that all of these roles as well as others
described below will bring well-developed skills to the job.
Nursing Informatics (NI) has evolved beyond the definition of data management
defined early on by Staggers, Gassert, and Curran [1] but is still considered by many as
the primary and only skill of a nursing informaticist. Today, the American Nurses
Association’s (ANA) expanded definition of NI suggests that, “Nursing Informatics
(NI) is the specialty that integrates nursing science with information and analytical
sciences to identify, define, manage and communicate data, information, knowledge
and wisdom in nursing practice. NI supports nurses, consumers, patients, the
interprofessional healthcare team, and other stakeholders in their decision- making
in all roles and settings to achieve desired outcomes.” (p. 1-2) [2].
Corresponding author: Dr. Carolyn Sipes, PhD, CNS, APN, PMP, RN-BC; Chamberlain College of Nursing,
Downers Grove IL. National Management Offices, 3005 Highland Parkway, Downers Grove, IL 60515;
email: csipes@chamberlain.edu
C. Sipes / Project Management: Essential Skill of Nurse Informaticists
In order to meet the Institute of Medicine (IOM) mandate of developing the
nursing workforce of 2020, we must provide a mechanism to first assess and
understand competencies/skills needed by the workforce [3]. While project
management as NI skills are more the expectation of healthcare providers and nursing
leadership, there remains a lack of understanding of what these are and how they are an
essential competency of NI. McGonigle, Hunter, Sipes, and Hebda, suggest that even
today “there is a lack of understanding of exactly what nursing informatics is in the
way of skills needed or how they can and should be applied to practice” [4].
Presently, NI has a much broader definition, evolved from the 21 essential
competencies defined by Staggers, et al., to 167 basic skills defined in the TIGER-based
Nursing Informatics Competencies (TANIC) developed by Hunter, McGonigle, and
Hebda, and the 178 advanced items in the Nursing Informatics Competency Assessment
(NICA) – L3/L4 self-assessment tools developed by McGonigle, Hunter,, Hebda, and Hill
[1,6,7,10]. Chamberlain College of Nursing, Nursing Informatics Research Team (NIRT)
(Hunter, et.al, 2014) developed expertise designing competency skill-assessment
instruments as well as conducting research studies on competency utilization, and as
such, has implemented the tools for students to self-assess skills in the NI courses [7].
The ANA (2015) Nursing Informatics Scope and Standards outlined above
clearly defines specialty of NI as the skill to integrate sciences into nursing practice using
skills to “identify, define, manage and communicate data, information, knowledge …
(p.1-2).” The standards further suggest that NI supports judgments in all positions,
functions and settings; the support is achieved through the use of information constructs
and information methods and practices – attributes of a NI. [2] Although the skills are
now attributed to NI, historically these were originally defined as concepts of project
management defined by the engineering community in the 1950s.
Sipes references the history of project management through an article by Cleland
and Gareis, who relate that “…in the 1950s, project management was formally
recognized as a distinct contribution arising from the management discipline” (pp. 1–4)
[8, 9]. Sipes further discusses how engineering, at the forefront of project management,
has become a “key management strategy in large corporations, such as IBM, and more
recently, in healthcare, where there is a need to put formalized structure and
management to organizational tasks” (p.12). Sipes adds that nurses “….use a structured
approach when providing care to patients such as the nursing process. Patient care
management requires an organizational framework—processes similar to those used in
project management are used to manage patient care” (p.12) [8].
The three larger categories, defined in the tools, TANIC and NICA-L3/4, discussed
above, are computer, informatics knowledge, and informatics skills. The skill sets have
been extended to include major subcategories as systems integration, selection and
maintenance, quality improvement, data terminologies, impact analysis,
privacy/security, systems input/output, usability, data mining and structures and project
Project management is one of the largest but least understood essentials of the NI
knowledge and skill set. It includes five major steps: Design/Initiation, Plan,
Implementation, Monitor/Control and Evaluation/Lessons Learned
In the discussion below, methods of how the tools, TANIC and NICA – L3/L4, are
applied in Chamberlain’s graduate courses to self-assess the NI students current skills on
four levels including the project management skills. As more information is shared, such
as in American Association of Colleges of Nursing (AACN) webinars presented by
Chamberlain NIRT, the competency self-assessment tools are being requested by
C. Sipes / Project Management: Essential Skill of Nurse Informaticists
healthcare leadership to integrate into job roles and requirements. More detail of project
management attributes applicable in job roles and requirements is presented below.
Many of the same project management attributes are also required for graduate students
as they develop and implement practicum projects as the master’s and doctoral levels.
2. Method
The methods to self-assess NI skills were implemented by Chamberlain in the
graduate NI specialty track in order for the faculty to better understand student skill
needs, As faculty analyze students’ results, they can determine gaps/needs in skill sets.
Then based on analysis of the information, curricula are developed to mitigate gaps
in skill levels needed by students and most importantly, as they enter the 2020
workforce. The model used in graduate courses is discussed below. Employing this
process further enhances the practicum experiences as it provides an organizational
framework in which to work.
2.1 Utilization of information from analysis
The NI competency self-assessment tools add clarity and specificity to better
understand exactly what skills are required as awareness of project management (PM)
skills become more evident. To determine NI skill levels in graduate student population
at Chamberlain, the TANIC and NICA – L3/L4 tools are integrated into master’s level
core courses. Students self-assess skills beginning the program and then again at the
end of their master’s graduate practicums. The application of project management
skills are fully implemented in the two Chamberlain graduate NI specialty practicums –
I and II. Students are required to apply skills as they develop and plan a project in
Practicum I, then implement and evaluate projects at a clinical site in Practicum II, thus
utilizing PM skills developed during practicums. These same skills are required in most
job roles in healthcare. They learn to apply skills which are needed to be successful in
both the practicums and their “real-world” projects.
3. Results
Feedback from students at the end of their practicums emphasizes the success of this
model as students realize the value of the skills they just implemented at a healthcare
site on an actual project. Now, they say they would not only use these skills in their job
roles but see how they can use them when managing everyday tasks. Today, project
management skills are more recognized as a need. The organizing framework of project
management is applicable in graduate level practicums, clinical practice, healthcare
administration and leadership. Below are examples of some of the roles that require
project management skills today.
3.1 Project Management as an essential skill of NI
National organizations discussed above deliberate how nursing leaders must have
computer and informatics knowledge and skills in order to be effective in their roles.
C. Sipes / Project Management: Essential Skill of Nurse Informaticists
The skills discussed are project management competencies as well as others in
informatics. Yet, according to McGonigle, Hill, Hunter, Sipes, and Hebda, “trying to
reach the goals set forth by these organizations has been hindered by a lack of
procedures and assessments available for determining nurses’ informatics
competencies- what they actually require in order to be competent in their job roles” [4,
pp. 104-112]. The project management skills of NI can be applied universally in many
settings and job roles. Students developing projects for their practicums or research
studies and everyday tasks would benefit from a more formalized structure and
According to Sipes the partial list of project management skills and competencies
includes such tasks as: development/implementation of work plans,
design/development of systems, function as lead/project manager in all phases of the
systems life cycle, and development and implementation of all organizational
documents required as a project manager to successfully manage a project [8, pp.143158]. Examples of specific project management skills listed above are seen in
advertised job descriptions as well as graduate level courses, including those for the
role of nurse administrators, such as nurse executives (NE), nurse managers, nurse
practitioners (NP), clinical nurse specialists (CNS), informatics nurse specialist (INS),
chief nurse informatics officer (CNIO), chief nursing officer (CNO), and doctor of
nursing practice (DNP) student in the final practicum before graduation.
The project management skills needed by the NP and CNS are important in order
to set up and manage clinics and for a DNP graduate project. An INS would need the
skills above to support an electronic medical record (EMR) implementation and
informatics skills to perform system/workflow analysis for a new computer system.
National organizations such as those previously discussed – the IOM, ANA and others
– identified a need to develop knowledge and skills including more advanced education
of the nursing workforce of 2020. Yet skill sets needed to provide better, safer patient
care and outcomes are sorely lacking. For example, some think that having the skill to
develop a slide presentation is the only “real” skill needed that qualifies as both an
informatics and PM skill. Or that data collection and analysis fulfills the job
descriptions for project management and informatics.
We must assess and understand current competencies/skills, then address gaps in
education by developing more relevant curricula that will meet needs of the workforce for
2020. To that point, McGonigle, Hunter, Sipes, and Hebda, suggest that even today
“there is a lack of understanding of exactly what nursing informatics is in the way of
skills needed or how they can and should be applied to practice” [4].
C. Sipes / Project Management: Essential Skill of Nurse Informaticists
4.1 Need to inform and empower
Today, to be a NI no longer requires just the skills to manage data and databases as
previously discussed. It requires much more and has evolved to nearly 200 advanced
skills – now more than ever expected by healthcare provider and organizational
leadership as well as masters and doctoral level students and faculty. One of the most
essential skills is project management. Education programs must be established that
meet the needs of nurses to develop these skills, as well as empower them to enhance
their practices.
5. Acknowledgements
A special thank you to Chamberlain College of Nursing faculty support from Drs. Toni
Hebda, Dee McGonigle, Kathleen Hunter, Taryn Hill, and colleague Jean Lamblin.
N. Staggers, C. Gassert, & C. Curran, Informatics competencies for nurses at four levels of practice.
Journal of Nursing Education, 40 (7) (2001) 303-16.
American Nurses Association Nursing informatics: Scope and standards of practice; p.1-2 (2nd Ed.).
(2015). Silver Spring, MD: Author.
Institute of Medicine (IOM): The Future of Nursing: Leading Change, Advancing Health.
Committee on the Robert Wood Johnson Foundation initiative on the future of nursing, at the
institute of medicine. (2010), Retrieved from http:wwwthefutureofnursing.org. p.140.
D. McGonigle, K. Hunter, C. Sipes, & T. Hebda, Why nurses need to understand nursing
informatics, AORN Journal, September, (2014).100 (3).
K. Hunter, D. McGonigle, & T. Hebda The integration of informatics content in baccalaureate and
graduate nursing education: A status report. Nurse Educator, 38(3):(2013).110 -113.doi:
D. McGonigle, K. Hunter, T. Hebda, & T. Hill, Self-Assessment of Level 3 and Level 4 NI
http://himss.files.cmsplus.com/FileDownloads/Self- Assessment.pdf.
Hunter, K., McGonigle, D., T. Hill, T. Hebda, & C. Sipes Self-Reported Assessment of Basic and
Informatics Specialist/Innovator Nursing Informatics Competencies: TANIC© and NICA L3/L4©.
Nursing Informatics Today, 29 (2), (2014). 4-6.
C. Sipes, Project Management for the Advance Practice Nurse, Springer, New, York, September;
(2016) (p.12, 113).
D. Cleland & R. Gareis, R. Global project management handbook; (2006) (pp.1-4). New York, NY;
McGraw- Hill Professional.
T. Hill, D. McGonigle, K. Hunter, C. Sipes, & T. Hebda An instrument for assessing advanced
nursing informatics competencies. Journal of Nursing Education and Practice, 4 (7), (2014) 104.
Copyright of Studies in Health Technology & Informatics is the property of IOS Press and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.
health care access across the United
Sexism and Health:
Advancing Knowledge
Through Structural and
States. I highlight the key contributions
made by Rapp et al. and outline how
the field can proceed to build a more
robust knowledge of sexism and health
using structural and intersectional
Structural sexism is theorized to
Patricia Homan, PhD
become embodied and shape popula-
tion health through numerous path-
Patricia Homan is with the Department of Sociology, Florida State University, Tallahassee.
ways, including economic deprivation;
reduced subjective social status and
See also Rapp et al., p. 1796.
uring the first decade of the
sexual violence, women’s health, and
twenty-first century, research on
physician bias. These existing lines of
esteem and autonomy); exposure to
violence, harassment, and unsafe living
or working conditions; and inadequate
research examine important types of
proliferated rapidly, with growing
direct, interpersonal gender-based mis-
attention to factors such as neigh-
treatment, but they do not capture
borhood conditions, housing, employ-
more systemic, institutionalized forms
sexism by being among the first to
ment, transportation, and education.
of sexism. The inequitable gendered
examine how it affects barriers to
Since then, researchers have increas-
distribution of power, status, resources,
health care among women. They find
ingly turned their focus even further
rights, roles, exposures, and opportuni-
that greater exposure to state-level
upstream to examine more macro-
ties that characterizes a society’s
sexism is associated with more barriers
level structural determinants of
gender structure has the potential to
to health care access (particularly
health (e.g., welfare state policy, glob-
profoundly shape the health of its
affordability barriers such as the cost of
alization, income inequality, and
members. Thus, an emerging line of
medical bills, health insurance, pre-
structural racism). This trend reflects
structural sexism and health research
scriptions, and tests) among Black and
increasing awareness of how sys-
has begun to explore the health conse-
Hispanic women in the United States.
temic inequity can be built into the
quences of systematic gender inequal-
In their analysis, the authors control for
fundamental social, economic, cul-
ity between men and women in power
Medicaid expansion under the Afford-
tural, political, and legal institutions
and resources, as manifest in institu-
able Care Act, as it is not central to their
health care.1,2 Rapp et al. make a major
contribution to knowledge of structural
that shape individuals’ daily living
tions, interactions, and individuals.
argument, but there is clearly a need
conditions, medical care, and, ulti-
Higher levels of structural sexism in
for future scholarship that more closely
state-level political, economic, and cul-
analyzes the connections between
Yet, one structural determinant in
tural institutions have been linked to
structural sexism and specific health
particular has received comparatively
more chronic conditions, worse self-
care policies.
little attention in public health until
rated health, and worse physical func-
mately, health.
recently: sexism. In fact, the word
“sexism” rarely appears in the pages of
tioning in US men and women.
The article by Rapp et al. in this issue
October 2021, Vol 111, No. 10
the social determinants of health
psychosocial resources (e.g., self-
The findings of Rapp et al. also suggest that in addition to health care policy, any policies promoting gender
leading public health journals. There
of AJPH (p. 1796) builds on this nascent
equity are also likely to improve health
are, however, substantial bodies of
line of research by examining the rela-
care access among women of color.
research examining sexual harassment,
tionship between structural sexism and
Health care is only one pathway
through which sexism can harm health;
therefore, much more research is
shaping health, it is important to
defined by specific constellations of
examine structural sexism in other
individual-level statuses (e.g., race, gen-
this relationship. Future research
social contexts. A more complete pic-
der, class, sexuality, nativity, and disabil-
exploring the social mechanisms will
ture of structural sexism and health
ity).6 For example, future research can
allow the development of other social
requires additional research examining
examine how structural racism, class-
policy interventions that can reduce
structural sexism in other settings,
ism, and cissexism combine to shape
gender inequity and shape social deter-
such as religious institutions, neighbor-
the health of Black trans women.
minants in ways that improve popula-
hoods, community organizations,
Although no single study can account
tion health.3
schools, occupations, workplaces, and
for the myriad of intersecting identities
health care facilities.
and axes of oppression, a synthesis of
Rapp et al. is their addition of new
Purchase answer to see full

error: Content is protected !!