Relationship between Nursing Informatics Competency and Innovativeness among Qualified Nurses

Context: Nursing informatics is an important quality resource for patient care, which in effect promotes, enhances, and increases the organization's growth and influences the innovativeness level of the individuals. Aim: The aim of this study was to assess the relationship between nursing informatics competency and innovativeness among qualified nurses. Methods: Descriptive correlational cross-sectional study design used to conduct this study on all units (57 units) at Benha University Hospital, Egypt. A Convenience sample of all available (223) qualified nurses working at Banha University Hospital Nursing informatics competency assessment tool, and individual innovativeness (II) questionnaire. Results: 28% of the participants rated themselves as experts in the nursing informatics competency. While 40% and 22% were early adopters and innovators respectively regarding the total level of individual innovativeness. There was a positive, highly statistically significant correlation between the overall score of informatics competency and individual innovativeness for qualified nurses (r= 0.263, pvalue = 0.000). A highly statistically significant relationship also detected between the demographic variables in the study and both informatics competency and individual innovativeness for qualified nurses. Conclusion: A positive, highly statistically significant correlation evidenced between the overall score of informatics competency and individual innovativeness for qualified nurses. In order to prepare nursing students to meet the ever-changing technical needs of patients, computer and information skills should be integrated into the nursing curriculum. Also, nursing education programs should utilize educational methods that encourage innovativeness among their students.


Introduction
Developments in information technology have resulted in fundamental changes in healthcare processes focused on the use of computers and the introduction of electronic communication (Terkes, Celik, & Bektas, 2019). Health services are one of the primary fields where innovation occurs, for many reasons, for example, evolving population structure, growing chronic diseases, and patronizing societal expectations. Innovation considered a solution to persistent problems in a complex health care environment (Huber, Bair, & Joseph, 2019). Besides, Innovation is essential in the development and maintenance of quality in nursing care, and for the nurses to be open to novelty in order to recognize and respond to the needs of the patient (Turan, Durgun, & Astu, 2019).
Moreover, healthcare sectors include many technological tools that require nurses to have an understanding of informatics competency in order to manage data and information of patients in a complex health care environment. Therefore, nursing informatics competency has become a fundamental requirement for nurses to fulfill their professional roles safer, more 2 Corresponding author: Aziza Zakaria Faramawy Ali effective, and more efficient (Abd El-Fattah, 2018). Thus, there is growing concern regarding the competency level of nursing informatics and how technological skills can affect innovativeness among the health care providers.
Nursing informatics (NI) is an important quality tool for patient care, which in turn facilitates, improves and increases organizational development as well as influences the value and cost of health care and ultimately improves information management and communication between health care providers (El-Sayed, Hussein, & Othman, 2017). Nurses, as the most substantial proportion of health care providers, should be able to demonstrate competence and feel confident in the use of computers and information technology. Accordingly, in several countries, there has been a great concern to ensure that nurses entering practice settings can use technology in meaningful and productive ways for the benefit of patients and professionals (Kassam, Nagle, & Strudwick, 2017).
Nursing informatics defined as the use of information and technology to reinforce all parts of nursing practice to increase patient safety and improve patient outcomes (Liston, 2019). It described as an integration of basic computer skills, information literacy, and information management, which are vital and essential components of modern nursing practice (Nwozichi, Marcial, Farotimi, Escabarte, & Madu, 2019). Computer Literacy Skills is a skill set, including the psychomotor skills needed to use computer tools and knowledge of underlying hardware and software functionality. Informatics Literacy Skills is a nurse's ability to recognize the need for information and to retrieve, evaluate, and use this information appropriately for patient care. While Information Management Skills is a skill set including the ability to apply data to support clinical decisions, documenting and ensuring data integrity, maintaining confidentiality, and practicing information security. Information management skills encompass the knowledge to articulate the value of information systems in improving patient safety, quality, and outcome (Schleyer, Burch, & Schoessler, 2011).
Consistent attention has been given to the global importance of creativity. A value created especially by novelties parallel with technology and is seen in every sense as the key to growth. Innovation is needed because it involves modifying existing approaches or creating new ones (Huber et al., 2019). Innovation has a significant role in the health sector, as it directly affects human life and quality of life. However, in order to be able to exhibit the "innovative" role in the working environment, nurses must have an innovative way of thinking. Previous research indicated a negative relationship between e-health literacy and individual innovativeness mean scores (Arli, Bakan, & Yildiz, 2019).
Nevertheless, a lack of focus in the research literature on nurses' innovation behavior in general and in the setting of this study in particular. The previous study was conducted by Abd El-Fattah (2018) in a critical care unit at an international private hospital in Egypt. The aimed to measure the relationship between innovation behavior levels and informatics technology guiding education reform (TIGERbased) NI competencies among critical care nurses. The results indicated that more than half of the nurses had a moderate level of innovative behavior. Furthermore, more than 30 percent of the nurses surveyed considered competent in nursing informatics.
Furthermore, a significant positive correlation was evident between innovative behaviors and overall nursing informatics skill levels. However, up to our knowledge, it is the only study conducted in Egypt to study such a relationship, added to that the study was conducted in critical care nurses in a private hospital that may have different characteristics of nurses in governmental hospitals and on other departments. Therefore, testing the relationship between the two variables in a different setting is highly recommended.

Significance of the Study
Improving the quality of care and health service delivery is one of the main benefits of integrating technology and innovation solutions into healthcare. Nursing is an integrated discipline that adapts from conventional understanding to socio-cultural, technological, and scientific shifts. So, it is crucial that nurses can demonstrate competence and feel confident in the use of computers and information technology from the start of education to increase the use of computers in healthcare practice which in turn enhance their innovation level in providing quality nursing care to their patients (Terkes et al., 2019).
The previous studies indicated a relationship between the nursing informatics competency level and patient safety knowledge and attitudes among nursing students. Such results confirmed that learning nursing informatics competencies will emphasize patient safety practices (Abdrbo, 2015). Nurses depend on informatics expertise to support the use of health care data and information to generate new knowledge and wisdom in health IT solutions through innovations for the delivery of high-quality nursing care (Kelley, 2019). Thus, it is vital to assess the current nursing level of informatics competencies and how it correlates to their innovativeness.

Theoretical Framework
The study's theoretical framework based on nursing informatics competencies and Rogers's innovativeness model. Nursing informatics competencies defined as basic computer skills, information management, and information literacy. Basic computer skills are essentially needed for either communication or documentation. These skills encompass an individual's ability to use a computer's basic functionalities. Information literacy is the ability to interpret relevant and irrelevant information by using critical thinking skills and retrieving, evaluating and using information, and Information management is the ability to use information for decision making by collecting, processing, and presenting data and applying the data for decision support (Staggers, Gassert, & Curran, 2002;Liston, 2019).
Rogers defines innovation as "an idea, practice, or object that is perceived as new by an individual or other units of adoption" (Rogers, 2003). Individual innovativeness defined as developing, adopting, or implementing an innovation (Yuan & Woodman, 2010). Rogers (2003) explained the characteristics of people into five classes. Innovators (risk-takers willing to take the lead and try something new), Early Adopters (tend to be respected group leaders, the individuals essential to adoption by whole group), Early Majority (the careful, safe, deliberate individuals unwilling to risk time or other resources), Late Majority (those suspect of or resistant to change. Hard to move without significant influence), and Laggards (those who are consistent or even adamant in resisting change. Pressure needed to force change).

Aim of the study
This study aimed to assess the relationship between nursing informatics competency and innovativeness among qualified nurses

Research Questions
-What is the level of nursing informatics competency among the qualified nurses? -What are qualified nurses' individual innovation level? Article number 16 page 3 of 9 -Is there a relationship between nursing informatics competency level and the level of innovation among the qualified nurses?

Research design
Descriptive correlational cross-sectional study design was used to describe the variables in this study and to examine the relationships among these variables where data was collected at one point in time.

Research Setting
The study conducted in all units (57) at Benha University hospital. The total number of beds at this hospital is 880. The hospital composed of three separated buildings, medical building that include 478 beds, surgical building that include 384 beds, and Ophthalmology building that include 18 beds.

Subjects
A Convenience sample of all available qualified nurses (223) who are working in the above-mentioned study setting, at the time of study and agree to participate after clarification of the purpose of the study and have a minimum of one-year job experience.

Tools of the study
Data for the present study were collected by using selfreporting questionnaires which includes three tools

A structured interview questionnaire
This questionnaire developed by the researchers based on the review of the related literature for examining, demographic details of qualified nurses such as; (sex, age), professional background (education, years of nursing experience, job title), and computer use (previous computer education, and computer users experience).

4.4.2.
Nursing Informatics Competency Assessment questionnaire (NICAT). Rahman (2015) to assess the level of nursing informatics competency. It is composed of three dimensions. They are computer literacy assessment (which contains ten items, e.g., Recognize the basic components of the computer system such as a mouse, screen, and workstation). The second domain is informatics literacy assessment (which contains 13 items, e.g., use the internet to locate and download items of interest), and informatics management skills assessment (which contains seven items, e.g., protect confidential patient data by logging out, suspending sessions, and password protection). The internal consistency for the NICAT was reported by El-Sayed et al., (2017) to be 0. 976 , indicating the high reliability of the tool. In this study, Cronbach's alphas were (r= 0.861), indicating the high reliability of the tool. Scoring system:

Procedures
The operational design for this study included three stages; preparatory phase, pilot study, and fieldwork.
Preparatory phase started from the beginning of December 2018 to the beginning of February 2019. It included the following: Reviewing related national and international literature using journals, textbooks, scientific web site, and theoretical understanding of the different aspects of the study subject. Tools translated into Arabic language and back translation to check its accuracy.
Tools validity: The tools' contents were developed and tested for its content and face validity through a jury of five academic staff in nursing administration from different faculties of nursing in Egypt namely; Benha faculty of nursing, Ain shams faculty of nursing, El Menoufia faculty of nursing, Tanta faculty of nursing and Helwan faculty of nursing. The validity of the tools aimed to judge its clarity, simplicity, accuracy, comprehensiveness, and relevance. All items were reviewed and accepted by the jury committee.
Official letter requesting permission to conduct the study has issued from the Dean of faculty of nursing Benha University. It sent to the director of the hospital explaining the aim of the study. Then, the researcher met the hospital administrator, assured complete confidentiality of the obtained information, and the study would not affect in any way the work.
A pilot study carried out in February 2019 on 10% of study subjects that included (25 qualified nurses) before starting the actual data collection to ascertain the clarity and applicability of the study tools and the feasibility of the research process. It has also served in estimating the time needed for filling the tools. It ranged between 25-30 minutes. The pilot study served to assess the reliability of data collection tools. The pilot study, participants included in the study because no modification was done in the study tools.
Fieldwork: Data collection took about one month from the beginning of March 2019 to the 1 st of April 2019. The researcher met qualified nurses and explained the aim and the nature of the study and the method of filling the questionnaire. Data collected individually or through group meetings. Researchers distributed the questionnaire sheets to the qualified nurses during work hours that scheduled before with the head nurse of each unit according to their workload. It took from 25 to 30 minutes to complete the questionnaire sheet. Data collected three days /week on Sunday, Monday, and Thursday in the morning and afternoon shifts in the presence of the researcher to clarify any ambiguity.
Ethical Considerations: Oral informed consent obtained from the participants. They were informed about their rights to refuse or withdraw from the study with no consequences. They reassured about the anonymity of the information collected, and it would be used only for scientific research. No harmful maneuvers were performed or used, and no foreseen hazards anticipated from conducting the study on participants

Data analysis
Statistical analysis was done using IBM SPSS (Statistical package of Social Sciences) software package version 25. Cleaning of data was done to be sure that there is no missing or abnormal data by running frequencies and descriptive statistics. Data was presented using descriptive statistics in the form of frequencies and percentages for categorical variables, means and standard deviations for continuous variables (e.g., age), Pearson correlation analysis was used for assessment of the inter-relationships among quantitative variables. Cronbach's reliability coefficient was used to test the reliability of the questionnaires. Regression analysis was used to describe the statistical relationship between one or more predictor variables (the three dimensions of nursing informatics competency scale) and the response variable (individual innovativeness). The significant level of all statistical analysis was at < 0.05 (Pvalue). Table 1 shows the total number of qualified nurses was 223. In relation to their age, more than a third of them (33%) were aged 31-35 years old, and the majority of them (93.7%) were females.

Results
Regarding their years of experience in the current job, more than a third of them (40%) had 5-10 years of experience. Regarding their education, only 9.4 % of the studied sample has a master's degree in nursing. Regarding their Current Job position, the majority of them (58%, 83% respectively) were staff nurses and had previous computer education. As far as more than one-third of them (36.3%) had from 5-10 years of experience in uses of computers. Table 2 illustrates that 65% of qualified nurses were experts regarding computer literacy, and 26% of them were competent regarding informatics literacy, while 38% of them were not competent regarding informatics management. Figure 1 portrays that the highest percentage of qualified nurses (28%) were experts regarding the total level of informatics competency. Figure 2 clarifies the total level of individual innovations among the qualified nurses, the highest percentage of them (40%) were early adopters, followed by innovators level (22%). Table 3 shows a positive, highly statistically significant correlation between the overall score of informatics competency and individual innovativeness for qualified nurses. Table 4 displays a positive, highly statistically significant correlation between age, gender, years of experience, education, previous computer science education, the years of experience in uses computer and both informatics competency and individual innovativeness for qualified nurses. Table 5 ascertains that computer literacy was positively and significantly associated with individual innovativeness as when the computer literacy increases by one unit, then the individual innovativeness will increase by 0.81 unit. The model R 2 value was 0.49, indicating that computer literacy explains 49% of the variability/variance in individual innovativeness level.
The table also indicated that there is a significant positive impact on informatics literacy on individual innovativeness as when informatics literacy increases by one unit, then the individual innovativeness will increase by 0.51 unit. The model R 2 value was 0.31, indicating that informatics literacy explains 31% of the variability/variance in individual innovativeness level There is a significant positive impact for informatics management on individual innovativeness as when the informatics management increases by one unit. Then the individual innovativeness will increase by 0.6 units. The model R 2 value was 0.21, indicating that computer literacy explains 21% of the variability/variance in individual innovativeness level.

Discussion
The advent of the new century has created groundbreaking health care challenges. Great value is placed on technology to deliver innovative bedside treatments and analyze large amounts of data related to quality outcomes (Godsey, 2015). Thus, there is growing concern regarding the competency level of nursing informatics and how technological skills can affect innovativeness among the health care providers. Thus, this study aimed to assess the relationship between nursing informatics competency and innovativeness among qualified nurses.
Regarding the level of nursing informatics competency among the qualified nurses, the highest percent (more than one fourth) of qualified nurses have an expert level in nursing informatics competency. This finding may be due to that the majority of the participants already have previous computer education. Added to that nursing curriculum for bachelor nursing education includes a computer science that helped qualified nurses to enhance their competency level.
This result agreed with El-Sayed et al., (2017), who conducted a study to assess the correlation between nurses' attitude toward evidence-based practice and nursing informatics competency among oncology center qualified nurses, Mansura University, Egypt. The findings indicated that the highest percentage of qualified nurses in the study sample have competency level varied from proficient to expert level. This finding signified a high competency level in nursing informatics among the studied subjects.
The finding disagreed with a previous study conducted by Liston (2019), who assess the level of advanced informatics competencies among nurses working at Sutter Maternity and Surgery hospital. The results indicated a low level of informatics competency and also disagreed with Fargaly & Abd El-Wahab (2016), who conducted a study to assess nurses' readiness for using electronic information system at a selected hospital in Giza Governorate in Egypt. The findings indicated that the majority of nurses are found at unacceptable computer skills level. However, the majority of nurses in such a study had a technical diploma in nursing who may have different characteristics and different education courses than qualified nurses (nurses who graduated from faculties of nursing) in this study.
Regarding the innovativeness level among the participants, the results indicated that nearly half of the participants rated themselves as early adopters, and about one fourth rated themselves as innovators. This finding indicated that the qualified nurses in this study are risk-takers who are willing to take the initiative and time to try something new and tend to be respected group leaders. This result agreed with Coklar (2012), who examined individual innovativeness levels of educational administrators, the results indicated that the majority of the educational administrators considered themselves as early adopters.
This result also agreed with Ozden et al., (2019), who conducted a study to determine the effect of online information searching strategies on individual innovativeness in students taking the course of information technology in nursing. The results showed that individual innovativeness levels of the students were moderate. They were individual innovators in the early majority style. The results also agreed with Abd El-Fattah (2018), who found that more than fifty percent of the participants had a moderate level of innovative behavior. The finding disagreed with Arli et al., (2019), who conducted a study to examine the relationship between e-health literacy and individual innovation in university students enrolled in health-related departments. The classification of the participants, according to their innovativeness scale scores, showed that the highest percent of the participants were laggards, which means that they are consistent or even adamant in resisting change while no students found to be innovators.
Regarding the relationship between the qualified nurses' informatics competency score and their innovativeness scores, the results show a positive, highly statistically significant correlation between the overall nursing informatics competency scores and individual innovativeness scores of the qualified nurses. All the dimensions of nursing informatics competency (computer literacy, informatics literacy, and informatics management) have a highly statistically significant relation with the innovativeness level. However, the computer literacy dimension has the highest effect on qualified nurse's innovativeness level, followed by informatics literacy, as indicated in the regression model. Regarding the relation between nursing informatics competency and the demographic characteristics of the qualified nurses, the results displays that there was positive highly statistically significant correlation between age, gender, years of experience, education, previous computer science education, the years of experience in uses computer and both informatics competency and individual innovativeness for qualified nurses.
This result agreed with Kinnunen et al., (2019), who reported that competency to use the electronic health records was associated with the education level among the studied sample and also agreed with Yang et al., (2014), who study perspectives of nurse managers regarding informatics competencies. the studied nurses reported that education level had a significant impact on informatics competencies. This result also coincides with Fehr (2014); Hsu, Hou, Chang, & Yen, (2009), who declared that nurses' age and years of experience are essential factors in nursing informatics competency. While disagreed with Liston (2019), who reported that age, experience, education level, and gender were not statistically significant in affecting the scores of informatics competency.

Conclusion
In light of the main study findings, it can be concluded that: the highest percentage of qualified nurses were experts regarding the total level of informatics competency. Regarding the total level of individual innovativeness, the highest percent of the qualified nurses were early adopters, followed by innovators level. There was a positive, highly statistically significant correlation between the overall score of informatics competency and individual innovativeness among the qualified nurses. There was a positive, highly statistically significant correlation between age, years of experience, education, previous computer education, years of experience in uses computer and both informatics competency and individual innovativeness for qualified nurses.

Recommendations
-Informatics and information competencies must be integrated into the nursing curriculum to equip nursing graduates to meet the ever-changing technological needs of patients -Nursing education programs should utilize educational methods that encourage innovativeness among their students -Future researches are needed to examine the effect of NI and the innovativeness of nurses on patient and nurse outcomes.