Ethical predicaments and countermeasures in nursing informatics

Abstract

With the increasing use of technology in nursing, how nurses perform practice care has changed, inevitably leading to ethical concerns that differ from original ethical norms in nursing. Studies have focused on ethical issues in health informatics from clinicians’ or patients’ perspectives, while nurses’ perspective is needed. This paper conducts a theoretical study on ethical predicaments that arise in nursing informatics from nurses’ perspectives. Why and how these predicaments emerge are elaborated. Also, this paper offers countermeasures in realistic contexts from technique, education, and leadership aspects. Collaborations between governments, administrators, educators, technicians, and nurses are needed to step out of these predicaments.

Keywords

Information technology nursing informatics nurse ethics issue

Introduction

The rapid advancement of technology has propelled us into the information age, the research and application of technologies such as big data and artificial intelligence (AI) have triggered a veritable “spring” of information development within the health industry. In this context, the integration of nursing and information has become an inevitability. The employment of information technology has fundamentally transformed the nursing environment, exposing nurses to ethical quandaries pertaining to information with increased frequency beyond traditional ones.¹ Therefore, it is imperative to clarify the ethical predicaments arising from the fusion of technology and nursing. We use “predicament” here because compared to common words “dilemma” and “issue”, this word highlights being trapped in a difficult, unpleasant, or embarrassing situation that requires resolution, which is what the nursing information practice meets.² Analyzing ethical predicaments in nursing informatics would not only aid in enhancing nursing quality, but also promote the iterative transformation of information technology under the guidance of ethical thinking, thereby ameliorating nursing challenges in a more effective manner. Based on ethical considerations most frequently discussed in current literature, this paper conducts a theoretical study about six ethical predicaments in nursing informatics: information disclosure, information distortion, information alienation, information injustice, information autonomy, and nursing unprofessionalism. Also, it offers actionable countermeasures in realistic contexts for better integration of information and nursing care.

Nursing informatics and nursing ethics

The term “Nursing Informatics” (NI) first appeared in the literature in 1984. Since then, NI has gradually been acknowledged as a discipline within the field of nursing.³ In 1992, the American Nurses Association (ANA) officially recognized NI as a nursing specialty.⁴ Currently, the International Medical Informatics Association (IMIA) defines NI as a science and practice that integrates nursing, information, knowledge, and management with information communication technologies to promote the health of individuals, families, and communities around the world.⁵

Nursing ethics is a discipline that studies ethical principles within nursing practice.⁶ It encompasses the codes of conduct and norms for nursing professionals to adjust the relationship between individuals and others, as well as between individuals and society. There are several ethical norms proposed by institutions for nursing professionals, including the ANA’s nine codes of ethics for nurses providing a framework for ethical nursing care,⁷ the International Council of Nurses’ (ICN) code of ethics for nurses stating professional values and responsibilities of nurses,⁸ and the four fundamental ethical principles widely accepted within the health community, which include autonomy, non-maleficence, beneficence, and justice.⁹

Ethics in nursing informatics

The application of information technology in nursing care is becoming increasingly widespread, from gadgets like personal digital assistants (PDA) to large-scale systems like nursing information systems (NIS). These advancements in information devices are optimizing nursing processes and methods while also inevitably leading to the emergence of new ethical norm constraints.¹⁰ As a result, the concept of ethics in nursing informatics has been introduced. However, at present, the concept of ethics in nursing informatics has yet to be clearly defined. Some scholars have mentioned in their descriptions of related concepts of ethics in medical informatics that it has progressed with medical informatics and medical ethics and is necessary for resolving the ethical issues caused by medical information technology.^11,12 On the grounds of this, we believe that ethics in nursing informatics is the fusion of nursing informatics and nursing ethics, aimed at addressing the ethical problems encountered by clinical nurses in the application of information technology.

Kaltoft described a phenomenon in his study in 2013: when searching “nursing informatics” and “nursing ethics,” respectively, on Medline and CINAHL, it returned hundreds of hits, but it returned no results when combining the searches with “AND.”¹³ When searching the combination like that on Medline, CINAHL, and other databases now, it just returned dozens of results, and relevant ones were fewer. That shows a need for more connection between nursing informatics and nursing ethics, indicating ethics in nursing informatics is easily overlooked. Although scholars have begun to realize ethical issues in eHealth and telehealth, they focused on clinicians’ or patients’ perspectives.^14,15 Patients’ experiences differ from medical professionals’ clearly, while clinicians’ focus is different from nurses’, for clinicians emphasize the cure of diseases and nurses stress people’s need more. Hence, this study decided to discuss ethical predicaments in technology from nurses’ perspectives.

Overall, the emergence of ethics in nursing informatics highlights the importance of ethical considerations in the application of information technology in nursing care. Therefore, it is crucial to further analyze ethical predicaments that arise in nursing practice, which will help to optimize nursing practice in the context of information technology integration in healthcare.

Ethical predicaments

The intersection of technology and healthcare practice is a new trend to empower nursing; however, the integration also introduces complexities that can lead to ethical concerns. This theoretical paper gives an analysis of six ethical predicaments that arise in clinical practice and research. Why and how did these predicaments occur are explained in each subheading. Figure 1 shows the relationship between these ethical predicaments.

Figure 1.

The relationship between ethical predicaments.

Information disclosure

Information disclosure is usually linked to safety and is also an essential part of ethics. Compared to paper-based times, people are constantly exposed to intelligent devices in the digital age, and their data are generated and stored all the time. Therefore, privacy concern stands out more. Taking electronic health records (EHR) as an example, the transition to paperless offices has led to the centralized storage of personal data such as names, addresses, ID numbers, and health statuses within the EHR.^16,17 The high degree of centralization and digitalization has simplified information transmission, making it easy to generate duplicate information without compromising the original data. This, in turn, has lowered the cost of information leakage, increasing the risk of cyberattacks and the likelihood of information disclosure.

In addition, employees are given corresponding authorization for the information systems based on posts and departments. However, because of the need to consult additional information, the access control may not be strict enough, leading to unauthorized entities gaining access to EHRs or authorized persons exceeding their scope of use. Especially within the trend of EHR storage on mobile cloud environments, patients do not know who gets entry to their information and how it would be utilized, and the threat of information disclosure could be more serious.¹⁸

According to International Business Machines Corporation (IBM) security, the cost of healthcare data breaches has increased by 53.3% since 2020.¹⁹ While studies have indicated that almost 70% of data breaches directly or indirectly result from employees’ carelessness or failure to follow security rules.²⁰ Nurses are ethically bound to hold all information confidential; however, some inappropriate behaviors may occur in their practice. Storing unencrypted patient information on their phones and job experience posts on the Internet, all of the above could result in information disclosure, jeopardizing patient trust and safety.²¹

Information distortion

In the field of nursing, information distortion occurs when nurses’ perception, documentation, and provision of nursing care do not align with the actual situation of patients, thereby compromising the accuracy and reliability of the information. Information distortion can be observed throughout the entire nursing process. Now, various healthcare institutions have adopted different standardized nursing terminologies (SNTs) to collect and analyze nursing data. However, when admitting newly transferred patients, there are instances where the SNTs used in health records differ from one hospital to another. This discrepancy has the potential to impact the consistency of information gathered by nursing staff, ultimately leading to information distortion.^22,23 Interoperability, in the context of healthcare, refers to “the ability of two or more systems or components to exchange information and utilize the exchanged information effectively.”²⁴ SNTs play a crucial role in achieving semantic interoperability. Although progress has been made in achieving semantic interoperability compared to times when SNTs were not in use, there is still significant room for improvement. In addition, during the execution of nursing processes, which encompass assessment, diagnosis, planning, implementation, and evaluation, the exchange of health information among health professionals is essential. This exchange enables nurses to obtain a comprehensive and more accurate understanding of patients; however, from the perspective of nurses, the system can be described as “fragmented” since they may not have access to records maintained by other healthcare professionals.^23,25 Therefore, more efforts are needed to advance interoperability in healthcare.

Nurses’ records are gradually shifted from paper-based formats to computerized systems due to the time-saving benefits offered by the latter. However, studies have indicated that the implementation of electronic health records (EHRs) can also lead to an increase in nursing documentation tasks like nursing assessment forms and administration of medication.²⁶ Consequently, the workload of nursing professionals might even intensify. Given nurses’ heavy workload and limited work time, copy and paste function (CPF) is commonly used as a time-saving and efficiency-increasing technique. Furthermore, in certain developed urban areas²⁷, there is a growing emphasis on accelerating health data exchange. This trend provides nurses with increased access and resources to make use of CPF. Nonetheless, a potential pitfall arises when nurses employ CPF without due consideration for the evolving nature of a patient’s condition. Mindless copying can heighten the risk of misattributing information.²⁸ Therefore, it is imperative for nurses to exercise caution and discernment when utilizing CPF to ensure the accuracy and integrity of patient records.

The excessive reliance on intelligent devices like NIS is also a significant contributing factor to information distortion. Nurses’ overdependence on system recommendations leads to discrepancies between case information and the actual patient data. The limited nature of templates in NIS is closely associated with many healthcare institutions procuring information systems externally. This limits the adaptability of information systems to accommodate changes and evolving clinical needs. Consequently, there are numerous clinical scenarios and changes in patient conditions that templates cannot fully encompass. When nurses strictly adhere to templates in their practice, there is a risk of a one-size-fits-all approach. This approach may not align with the actual patient conditions, resulting in discrepancies in nursing diagnoses and care plans. This, in turn, can hinder the provision of appropriate nursing interventions based on accurate nursing diagnoses and care plans.

Information alienation

The term “alienation,” derived from German philosophical terminology, is used to depict scenarios in which individuals or subjects become estranged from certain opposites during specific stages of development, transforming into an external and unfamiliar force.²⁹ The concept of information alienation amalgamates this notion and pertains to the imbalance in the relationship between information producers and the information object during the processes of information creation, dissemination, and utilization. Therefore, the subject loses control and becomes subject to domination by the object in return.³⁰

In the nursing context, the process of information transmission can be likened to the interaction between nurses and computer systems. The integration of convenient intelligent technology may serve as a significant catalyst for information alienation. For example, monitoring devices are used as effective assistance for patient surveillance and management. However, paying too much attention to these devices perhaps results in a decrease in direct observation of patients, raising the risk of failing to notice subtle changes in patients’ condition and endangering their safety. Moreover, the Nursing Decision Support System (NDSS), capable of automatically generating nursing decisions based on the analysis of clinical data, is embraced for its precision, efficiency, and consistency. However, this very convenience holds the potential to foster complacency among nurses, leading to increased dependency on technology and a potential erosion of their clinical skills. Consequently, they may find themselves less adept at addressing clinical challenges without the assistance of intelligent systems.³¹

Furthermore, it is worth noting that some nurses, particularly those with limited experience, may not fully grasp the fundamental role of humans in the realm of information relations. They may view technology as a shortcut, which elevates the risk of excessive reliance on intelligent technology and a singular focus on digital outcomes, potentially at the expense of addressing the genuine needs of their patients, which could weaken nurse–patient communication and affect rights and interests of patients.³²

Information injustice

Injustice is a long-standing social issue, and its contents have expanded with the development of information technology. The ever-changing information technology brings many opportunities to nursing, which requires good informatics competency. The information competency consists of three parts: basic computer competencies, information literacy, and information management (including the use of EHR).³³ A deficiency in any of these areas can have an adverse impact on the quality of nursing care. However, informatics competency differences exist between older nurses and younger ones. Older nurses are more likely to report challenges in operating systems, which can subsequently affect the timeliness and quality of care delivery. These disparities may even influence employee engagement and overall job satisfaction among nursing professionals.^25,34

What’s more, the gap between wealth would also affect information injustice. Developed areas have greater financial support, resources, and experts to drive advancements in information technology, while less developed areas lack these resources. Similarly, there can be disparities between hospitals at different levels within the same region. Currently, there are some means to balance resources, such as telemedicine and expert assistance. Telemedicine, for instance, was intended to improve access to healthcare for those in rural or remote areas. However, due to poor signal and network coverage in these regions, the extent and capacity for achieving equitable balance are limited.¹⁹ In consequence, the digital and care divide may become even more pronounced.

As we delve into the era of AI, algorithms have been integrated into healthcare to improve health services. Despite the numerous advantages that AI brings, it also introduces certain risks, with algorithmic bias being one of the most pressing concerns.³⁵ Algorithmic bias refers to “the instances when the application of an algorithm compounds existing disparities in socioeconomic status, race, ethnic background, religion, gender, disability, or sexual orientation to amplify them and adversely impact inequities in health systems.”³⁶ There has been proved that a widely utilized algorithm discriminates black patients—Blacks are significantly sicker than Whites at the same algorithm-predicted risk.³⁷ We do not know how it occurs because of the black box—the decision-making process is opaque,³⁸ but the problem does exist. This issue carries significant implications, as vulnerable groups may not access appropriate care due to algorithmic bias, thus posing threats to their safety and well-being.

Information autonomy

Autonomy is one of the central principles in healthcare practice, which is defined as receiving information as a prerequisite and then making decisions as an action.³⁹ In nursing practice, nurse autonomy may be hindered by the implementation of health information technology. Using barcode medication administration (BCMA) as an example. BCMA is an informatics tool to reduce medical errors through barcoding patient-specific wristbands and medication containers. BCMA always has a schedule about the time specified in the order, while nurses have their own work schedule to complete work effectively, which contradicts BCMA. When nurses have to adhere to BCMA’s schedule, they can’t adjust the medication-given time based on knowledge and clinical judgment; thus, their autonomy is affected, associated with decreasing efficiency and satisfaction.⁴⁰ Moreover, health information technology might not consider nurses’ work characteristics. The computer system may prioritize drugs and IV fluids administration over attending to patients’ basic needs. Given that nurses are tied to computers now, they have to follow the computer, which constrains nurse autonomy to take primary nursing responsibilities, empathy and compassion—the humane aspects of nursing might be reduced.^41,42

Patient autonomy is represented evidently in informed consent. Informed consent refers to the process by which a competent individual, after receiving sufficient information, comes to a reasoned decision regarding whether or not to agree with a proposed therapy, procedure, or the sharing of personal information.⁴³ With the advent of the information age, an increasing number of nations have turned to electronic informed consent (eIC) in nursing practice as a means of obtaining patients’ informed consent. However, eIC perhaps does not promote patients’ autonomy to some degree. Unlike face-to-face discussions with paper-based consent forms, eIC requires patients to sign their names at the bottom of the webpage after reading all given information without feedback mechanisms to assess patients’ apprehension. Consequently, there is no guarantee that patients fully comprehend the information presented, and their decisions may not be thoroughly considered.

Mobile health (mhealth) has been popular over the past decade, which prompts many applications like smartphone apps to manage public health. It’s known that one will be given informed materials when opening these apps for the first time. Nevertheless, due to the large and mixed information about privacy policies (PP) and terms of service (TOS) policies (especially applications developed within commercial contexts and brought into medical settings that combine lots of commercial and medical terms) in the material, the informed consent forms are often become lengthy, cumbersome, and overly technical.^44,45 It is likely that patients may not allocate enough time to read and may simply click the “I agree” button, which might increase the risk of “uninformed” consent, undermining the autonomy of patients.⁴⁶

Nursing unprofessionalism

In fact, the five issues mentioned above would all lead to nursing unprofessionalism. In addition to these, there are other significant factors to consider. The era of information explosion provides people with greater access to knowledge. When patients have access to an excessive amount of information regarding possible medication adverse effects without the ability to discern which ones correlate to their specific conditions, it could cause unnecessary anxiety. Furthermore, if patients get inaccurate information, they may be misguided.⁴⁷ These all result in nurses spending an increased amount of time reassuring and directing patients.^48,49 Despite the heavy workload that nurses already face, the added responsibility of reassuring and directing patients only serves to increase their burden. Given the constraints of limited work hours, nurse burnout becomes a significant concern, which is associated with deteriorating safety and quality of care, decreased patient satisfaction, and nursing productivity, therefore undermining professionalism.⁵⁰ What’s more, as patients are exposed to more information, there is a possibility that nurses may find it challenging to give satisfactory answers to patients during consultations, further affecting professionalism.

Nurses’ unprofessional behaviors also cause unprofessionalism. With a closer connection to the Internet, they are unveiled to patients more thoroughly. When nurses and patients become friends on social media platforms, the professional image of the nursing staff may be compromised, for healthcare professionals’ social media accounts may contain inappropriate content, such as offensive photographs or online criticisms of coworkers and managers.^51,52 Additionally, research indicates that nurses are less likely to search for evidence-based information through professional databases; instead, they prefer readily available and non-evidence-based medical information on social media and television. They may also be more willing to spread information without discerning its authenticity, which weakens professionalism.^53,54

Countermeasures

When nurses find themselves facing ethical dilemmas, the quality of nursing care they deliver may become disrupted, potentially jeopardizing both patient satisfaction and safety. Specific countermeasures to six ethical predicaments are listed in Table 1, which includes recommendations from three aspects: technique, education, and leadership.

Table 1.

Specific countermeasures to ethical predicaments.

Ethical predicaments	Countermeasures
Ethical predicaments	Technique	Education	Leadership
Information disclosure	• Blockchain technology, a decentralized recording technique, could be adopted in data management so that any transaction could be easily traced and any illegal access would be reflected	• Nursing educators should provide nurses with safety and legal courses to promote protection behavior and raise awareness of the severity of information breaches	• Leaders could implement mutual supervision and reward and punishment mechanisms to encourage the reporting of information disclosure and potential risks
Information disclosure	• Data protection measures could be taken, including additional biometrics identifiers like finger or retina scans, and encrypting data based on sensitivity level		• Organizational support could ensure the provision of adequate resources for the implementation of relevant initiatives
Information distortion	• Applying data transmission standards such as Fast Healthcare Interoperability Resources (FHIR) introduced by Health Level 7 International (HL7) organization to increase synonymous mapping between SNTs as well as linking healthcare data	• Nursing education programs about common SNT usage are required	• Nursing leaders should consider simplifying nursing documentation based on ensuring patient safety to minimize nursing workload
Information distortion	• NIS could integrate audit tools like text mining algorithms, note splitting, text insertion, and automated highlighting parse notes	• Nursing educators need to emphasize the legal importance of accurate and reliable nursing records	• Leaders could consider developing customized information systems according to hospital characteristics based on common frameworks
Information alienation	• Regular discussions about intelligent devices’ usability between technicians, informatics nurses, and clinical nurses are needed to adjust the technological scheme and meet nurses’ needs	• Nursing educators should help nurses establish the correct information view that nurses, rather than technology, have the final say in patient care	• Nursing leaders must create opportunities for further education and training on information literacy
Information alienation		• Nursing education programs about information literacy are needed
Information injustice	• Technicians need to cooperate with informatics nurses constantly to improve the operability of the system	• Informatics curricula covering fundamental informatics competency and ethical issues are needed to ensure nurses at all levels are prepared for working in an information environment	• Leaders should develop and update guidelines for the implementation of AI for safe use
	• Technicians are obliged to promote transparency in their algorithms and develop interpretable approaches to detect bias		• Leaders in developed could provide technical support and appoint experts to the less developed, from which the less developed can benefit a lot
	• Critical evaluations must be done before any AI-based auxiliary tool is introduced to healthcare
Information autonomy	• Feedback mechanisms based on AI could be included in informed consent to assess the patient’s comprehension level, like a pop-up quiz following a customized and detailed explanation and retest	• Education to health professionals and their business partners about awareness of underregulated informed consent is to be emphasized so that they can take the patient priorities to promote transparency of informed consent	• More regulations like the European Union’s (EU’s) new General Data Protection Regulation (GDPR) are needed to promote informed consent standards
Information autonomy	• Multimedia devices could be applied to enrich interface designs to slow users down in attempts to improve comprehension		• Leaders, as well as technicians, should involve nursing advice in technology improvement to make intelligence support nursing work more
Nursing unprofessionalism	• Technicians and informatics nurses could cooperate to develop standardized responses to common topics, and apply them in official accounts of hospitals or information screens in hospitals to keep patients informed to relieve the nursing workload	• Nursing educators should encourage nurses’ professional improvement by organizing continuing education, including programs and training on behavioral norms and evidence-based practice	• Leaders should create opportunities for nurses to engage in all intelligent device design phases

Information disclosure

To mitigate the risk of information disclosure, blockchain technology can be employed to safeguard data usage. Blockchain is a decentralized network database that stores data in a distributed and cryptographic manner, rendering data on the blocks highly resistant to tampering, with the added benefit of comprehensive traceability for all operations.^17,18 The adoption of blockchain technology can aid in alleviating concerns associated with centralized databases and inadequate access control measures. In addition, various other data protection techniques can be implemented, including the integration of supplementary biometric identifiers such as fingerprint or retinal scans, along with data encryption based on the sensitivity level of the information.^55,56 Moreover, nurses’ inappropriate behaviors may also contribute to information disclosure, and in such instances, education plays a pivotal role. Educators should provide knowledge pertaining to information security policies, thereby enhancing awareness of the severity of information breaches and promoting information security compliance among nurses.⁵⁵ Within clinical settings, where nurses collaborate as a team, mechanisms for mutual supervision and systems of rewards and penalties can be instrumental in harnessing collective strength, thereby encouraging the reporting of information disclosure incidents and potential risks. The attitude of healthcare institutions is of paramount importance, as organizational support, guided by general deterrence theory, ensures the provision of adequate resources for the implementation of relevant initiatives.

Information distortion

In the context of addressing information distortion, several data transmission standards have been developed to enhance interoperability. For instance, the Fast Healthcare Interoperability Resources (FHIR), introduced by the Health Level 7 International (HL7) organization, is a notable example.^57,58 It is recommended that technical personnel utilize FHIR to facilitate synonymous mapping between SNTs and establish connections within healthcare data. The practicality and usability of systems have been identified as critical issues leading to phenomena such as CPF, making them important contributors to information distortion. One potential solution is integrating audit tools, including text mining algorithms, note splitting, text insertion, and automated highlighting for parsing notes into NIS.^28,59,60 Education plays a vital role in mitigating inconsistent nursing information issues. Training programs related to the common usage of SNTs and nursing information systems should be instituted to address communication and interaction challenges between nurses and the systems, thereby reducing the likelihood of information distortion. Research suggests⁶¹ that when nurses anticipate severe sanctions for unreliable nursing records, they are deterred from engaging in improper conduct. Therefore, enhancing nurses’ awareness of the risks associated with information distortion can be achieved through relevant legal courses or seminars. Heavy workloads can result in CPF, causing insufficient time for modifying nursing documentation and contributing to information distortion. This is a common clinical phenomenon. As nurses increasingly rely on templates within information systems, healthcare leaders should consider the development of customized information systems tailored to the characteristics of individual hospitals, with a focus on common frameworks. This approach enables information systems to be more adaptable to diverse clinical scenarios while enriching the available templates. Furthermore, nursing leaders should consider simplifying nursing documentation based on specific clinical requirements. This approach aligns with the objectives of providing detailed nursing assessments and records while also alleviating nurses’ workloads, ultimately reducing the likelihood of information distortion and ensuring patient safety.

Information alienation

Informatics nurses, serving as the crucial link between nurses and information technology, play a vital role in mitigating the information alienation phenomenon. To this end, healthcare institutions worldwide should expedite the training and development of informatics nursing specialists. Another approach involves enhancing the information literacy of clinical nurses, facilitating smoother communication with technical personnel. It is imperative for technicians to engage in regular discussions with informatics nurses and clinical nurses regarding the usability of intelligent devices and information systems. Such dialogues allow for the adjustment of technological schemes to align with the evolving needs of nurses. Furthermore, addressing nurses’ inaccurate perception of information is of paramount importance and necessitates the intervention of nursing educators. Nursing educators should assist nurses in establishing the correct perspective that, in patient care, it is the nurses who have the ultimate authority rather than technology.⁴⁸ Additionally, educational programs focusing on information literacy are deemed necessary. Only through the enhancement of their ability to identify and filter information can nurses truly take command of the information landscape. Moreover, healthcare leaders must create opportunities for further education and training in information literacy for nurses, reinforcing the importance of these competencies in the nursing profession.

Information injustice

In addressing the issue of information injustice, it is essential to consider the operational challenges faced by nurses with varying levels of information literacy. Focusing on the needs of clinical nurses and leveraging the role of informatics nurses can help improve system operability, thus reducing disparities.⁶² Additionally, in the context of patient safety, it is imperative that decision algorithms be sufficiently transparent. Therefore, it is the responsibility of technicians to advocate for transparency in their algorithms and develop interpretable methods for bias detection.^63,64 Before the introduction of any AI-based auxiliary tools into healthcare, rigorous evaluations must be conducted to ensure equity.³⁵ In the realm of education, it is crucial to offer informatics curricula that encompass not only fundamental informatics competencies but also ethical considerations. This ensures that nurses at all levels are equipped with the knowledge, skills, and judgment necessary to function effectively in an information-driven environment.^35,36 Leadership plays a vital role in this context, as leaders are expected to formulate and update guidelines for the safe use of artificial intelligence. To bridge information disparities between different regions, it is recommended that leaders in more developed areas provide technical support and appoint experts to assist less developed regions, thereby facilitating substantial benefits for the latter.

Information autonomy

Owing to the wide spread of information technology, AI in all forms could be fully used as a means to amend eIC forms to cope with the information autonomy challenge, for example, by adding feedback mechanisms through a pop-up quiz following a customized and detailed explanation and retest,^43,65 or enriching interface designs to slow users down in attempts to improve comprehension.⁶⁶ Moreover, for the irresistible trend of health management, which blends healthcare and business, education to health professionals and their business partners about awareness of underregulated informed consent is to be emphasized so that they can take the patient priorities to promote transparency of informed consent.⁴⁴ And more regulations like the European Union’s (EU’s) new General Data Protection Regulation (GDPR) are needed to promote informed consent standards. In addition, given nurses are the primary users of computers, leaders as well as technicians ought to involve nursing advice in technology improvement to make intelligence support nursing work more.

Nursing unprofessionalism

To address the issue of nursing unprofessionalism, a collaborative effort between technicians and informatics nurses is recommended, particularly given the frequent repetition of patient inquiries. This collaboration could result in the development of standardized responses to common topics, which can be subsequently implemented in the official communication channels of hospitals, such as hospital websites or information screens, to ensure that patients are well-informed. This proactive measure can help alleviate the nursing workload. Additionally, a strong emphasis should be placed on continuous education opportunities aimed at nurses’ professional development. This includes the implementation of educational programs and training sessions focusing on behavioral norms and evidence-based practice. Such initiatives can enhance the competence and professionalism of nursing staff. Furthermore, healthcare leaders play a pivotal role in promoting professionalism by affording nurses the opportunity to participate in all phases of intelligent device design actively. By involving nurses in the design process, these devices can be tailored to serve as effective tools for relieving the nursing workload. This collaborative approach ensures that the devices are aligned with the specific needs and requirements of the nursing profession.³⁵

In essence, stepping out of these predicaments requires a collaborative effort from governments, administrators, educators, technicians, and nurses.

Conclusion

In the information age, the traditional “nurse–patient” relationship is evolving into a trilateral “nurse–computer–patient” dynamic.^42,67 This transformation necessitates careful consideration of both the advantages and disadvantages that information technology brings to nursing practice. Also, it signifies a significant shift in the healthcare landscape, underscoring the importance of adaptability and ethical considerations in nursing practice. Our research delved into six ethical predicaments within the realm of nursing informatics, namely, information disclosure, information distortion, information alienation, information injustice, information autonomy, and nursing unprofessionalism. Through comprehensive literature analysis, we have put forth a set of countermeasures to address these predicaments. As we navigate this evolving landscape, collaboration among governments, administrators, educators, technicians, and nurses becomes paramount to ensure the ethical and effective use of information technology in healthcare. It is our hope that these recommendations can serve as a guiding light, facilitating further exploration and development in the field of nursing informatics.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Health Commission of Zhejiang Province [grant number 2019ZD006].

ORCID iD

Jianan Wang

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