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The need for academic electronic health record systems in nurse education
Nurse Education Today 54 (2017) 83–88
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Nurse Education Today journal homepage: www.elsevier.com/locate/nedt
The need for academic electronic health record systems in nurse education a,⁎
Joohyun Chung , Insook Cho a b
MARK
b
College of Nursing, University of Massachusetts Dartmouth, Dartmouth, MA, USA Dept of Nursing, Inha University, Incheon, South Korea
A R T I C L E I N F O
A B S T R A C T
Keywords: EHRs Nurse education Nursing documentation
The nursing profession has been slow to incorporate information technology into formal nurse education and practice. The aim of this study was to identify the use of academic electronic health record systems in nurse education and to determine student and faculty perceptions of academic electronic health record systems in nurse education. A quantitative research design with supportive qualitative research was used to gather information on nursing students' perceptions and nursing faculty's perceptions of academic electronic health record systems in nurse education. Eighty-three participants (21 nursing faculty and 62 students), from 5 nursing schools, participated in the study. A purposive sample of 9 nursing faculty was recruited from one university in the Midwestern United States to provide qualitative data for the study. The researcher-designed surveys (completed by faculty and students) were used for quantitative data collection. Qualitative data was taken from interviews, which were transcribed verbatim for analysis. Students and faculty agreed that academic electronic health record systems could be useful for teaching students to think critically about nursing documentation. Quantitative and qualitative findings revealed that academic electronic health record systems regarding nursing documentation could help prepare students for the future of health information technology. Meaningful adoption of academic electronic health record systems will help in building the undergraduate nursing students' competence in nursing documentation with electronic health record systems.
1. Introduction Hospitals with health information technology (HIT) may be able to improve on their quality of care and cost by improving communication, making knowledge more readily accessible, performing checks in real time, and providing decision supports (Bates and Gawande, 2003). Particularly, electronic health record (EHR) systems provide great functionality as a form of HIT (Fareed et al., 2015). Recently, the Office of the National Coordinator for Health Information Technology (ONC) reported that three out of four hospitals (76%) have a basic EHR systems and nearly all reported hospitals (97%) possess a certified EHR technology in 2014 (ONC, 2015). The wide adoption of EHR systems has led the Institute of Medicine (IOM) to emphasize the use of informatics as a core competency required of all health care professions. The 2009 Health Information Technology for Economic and Clinical Health Act (HITECH) directs all health providers to use EHRs. The National League for Nursing (NLN) recommends that nursing faculty should incorporate informatics into all levels of the curriculum (Skiba and Rizzolo, 2009). However, the nursing profession has been slow to incorporate information technology into formal nurse education and practice (Meyer et al., 2011; Pobocik, 2014; The TIGER Initiative,
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Corresponding author. E-mail address: [email protected] (J. Chung).
http://dx.doi.org/10.1016/j.nedt.2017.04.018 Received 19 May 2016; Received in revised form 26 February 2017; Accepted 21 April 2017 0260-6917/ © 2017 Published by Elsevier Ltd.
2017). According to Meyer et al. (2011), most nursing schools continue to educate students in traditional ways. For instance, when nursing faculty teach nursing documentation to undergraduate nursing students in clinical settings regardless of paper-based or electronic documentation, the first major teaching strategies for documentation include the use of paper (Nickitas et al., 2010). Nurses have used paper-based forms for nursing documentation, including narrative notes and flow sheets, to exchange pertinent patient information (Bjorvell et al., 2003a, 2003b; Tapp, 1990). Similar to paper-based documentation, EHRs contain flow sheets. However, EHR documentation also incorporates new features (Ammenwerth et al., 2001). EHRs help nurses practice better nursing care. Some of their functions include supporting standard nursing terminology, incorporating clinical documentation from various sources, supporting standard care plans, guidelines, and protocols, supporting drug interaction checking, presenting alerts for preventive services and wellness, and linking clinical tasks. These features may alter how nurses document, make decisions, and communicate with other healthcare providers (Ammenwerth et al., 2001; Choi et al., 2009; Cho et al., 2010). Because different documentation methods may be used with EHRs than are used with paper-based records, paper-based
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accredited by the Commission on Collegiate Nurse education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN) in the United States. A cluster convenience sampling was used for the data collection. In the United States, 100 undergraduate nursing programs were randomly selected, regardless of Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) programs, from the list of programs accredited by CCNE and ACEN. The selected schools were invited to participate in this study. Only five schools agreed to participate. Among the five schools, two schools had graduate programs (Master of Science (MS)), Doctor of Nursing Practice (DNP) or Doctor of Philosophy (PhD). All undergraduate students and faculty in each school received the information via email. There were 83 respondents to the survey; 21 were faculty and 62 were students (ADN: 21 students, BSN: 23 students, and RN to BSN: 18 students).
instruction may not be sufficient for teaching electronic nursing documentation. In some nursing programs, students are not exposed to electronic documentation until they participate in clinical rotations in local hospitals (Meyer et al., 2011). Unfortunately, during clinical rotations, it is not easy for students to learn about best practices in electronic documentation (Billie, Chadwick, Mann, & Brooke-Read, 2013). However, students can learn to navigate EHRs in simulation labs (Gardner & Jones, 2012). Lucas (2010) has reported partnering with a medical center to provide students access to training with EHRs before the first clinical rotation. These students felt more confident with their documentation. Educating students in a transitional electronic environment is no longer optional for nursing faculty. It is necessary for accurate documentation, transmission, and management of data for improving patient care (Aktan et al., 2011). According to the NLN survey (2008), 80% of faculty reported that they are self-taught on use of EHRs. Faculty are learners themselves in this transition from paper to electronic media for teaching nursing documentation. Considering that the national average age of nursing faculty is about 53.5 years (AACN, 2013), most nursing faculty have long practiced paper-based documentation. It follows that they will likely feel more comfortable in a paperbased teaching environment (Nickitas et al., 2010). Also, nursing faculty now experience a new challenge in teaching the use of different EHRs in various clinical settings when they teach nursing documentation. The fact that EHR systems are designed to force the user to follow correct procedures for the default safety protocols sometimes presents faculty with obstacles to providing adequate education about electronic nursing documentation (Mahon et al., 2010). Several studies show that nursing students are not comfortable using healthcare technology, and nurses in practice are not comfortable using EHRs (Fetter, 2009; Kelley et al., 2011). Several studies demonstrate that nurses report that EHRs are extensive and time consuming (Saarinen and Aho, 2005; Scott et al., 2005). About three quarters of nurses reported spending at least 50% of their time using the EHRs, which means less time for patient care (Johnson et al., 2008). Another recent study reported that bedside nurses spend 4 h per day documenting using EHRs (Penoyer et al., 2014). The high number of hours spent using EHRs may be associated with non-user-friendly systems or nurses' lack of competence with the electronic systems. Some nurses have reported that their critical thinking is reduced by using the EHRs, although most nurses believed that EHRs are beneficial (Fraenkel et al., 2003; Meyer et al., 2011; Moody et al., 2004). It is imperative that the nursing students are able to use EHRs in their education so that they will be more prepared to enter the profession with strong technology skills for nursing documentation (Meyer et al., 2011). The intention of this study was to identify the use of academic EHRs in nurse education and to determine student and faculty perceptions of academic EHRs in nurse education.
3.2. Qualitative Data A purposive sample of nine nursing faculty (seven women and two men) was recruited from one university in the Midwestern United States. 3.3. Instruments To address aims, faculty and students' perceived knowledge of academic EHRs was measured with the researcher-designed instruments. The instruments were designed to measure both nursing faculty and nursing students' perceptions of the need for academic EHRs. The survey included three sections: 1) demographics, 2) perceived knowledge, and 3) attitude toward electronic nursing documentation and academic EHRs. The survey consisted of 15 items excluding demographical questions. This survey assessed knowledge of and attitude toward electronic nursing documentation. It used a 5-point Likert scale ranging from “strongly disagree” (1) to “strongly agree” (5) or from “lacking understanding” (1) to “solid understanding” (5). 3.4. Data Collection Procedure Approval from the Institutional Review Board at a university in the Midwestern United States was obtained prior to data collection, which was conducted in mid-March 2015. For the quantitative data, the selected schools were invited to participate in the study. A survey link and a brochure were sent to the nursing departments/colleges. Deans/ chairs were responsible for disseminating the survey link to nursing students and faculty. For the qualitative data, an in-depth, exploratory approach to data collection from nursing faculty was taken, employing five semistructured interview questions (Appendix I). The interviews were conducted in faculty members' own offices. The recorded interviews lasted 5 to 25 min (average 16 min). Additionally, demographic information was collected including gender, age, and years of teaching experience.
2. Methods A quantitative research design with supportive qualitative research was used to gather information on nursing students' and nursing faculty's perceptions of academic EHRs in nurse education. For quantitative data, a cross-sectional descriptive design was developed, in which a questionnaire-based survey was used to examine nursing students' and faculty's perceptions of academic EHRs. For qualitative data, the semi-structured interview guideline was created after discussions with researchers.
3.5. Data Analysis Related to the quantitative data, statistical analysis was performed using SAS version 9.4 (SAS Institute Inc., NC). Descriptive statistics were used to describe frequency and percentage. Chi-Square statistics were used to determine the variances between programs (ADN, BSN, and RN-BSN) and pre licensure students (ADN and BSN students)/post licensure students (RN-BSN students). Related to the qualitative data, all interviews were transcribed verbatim for analysis. The two researchers were independently coded. The transcribed text was carefully read and thematic segments were identified. Data segments were grouped based on commonalities within the descriptions of nursing students' perceptions of academic EHRs. For credibility and trustworthiness, data were collected by the 1st author
3. Samples and Setting 3.1. Quantitative Data Participants in this study were nursing undergraduate programs 84
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and analyzed by both authors independently and then together to reach consensus.
Table 1 Students and faculty demographics for quantitative data. Variables
4. Results Gender
4.1. Quantitative Findings
Age
In total, 62 nursing undergraduate students and 21 faculty members completed the questionnaire. 4.2. Students
Ethnicity
Related to the students' information, overall 89% (N = 55) of the student sample was female while 11% (N = 7) was male. In total, 47% (N = 29) of the student sample came from Associate of Nursing Programs, 24% (N = 15) came from Bachelor of Nursing programs, and 28% (N = 18) were from RN-BSN programs. The average age of participants was 33 years. The majority of participants were Caucasian (70%). Of the sample, 44% had earned a high school diploma or GED, 31% had completed a two-year degree (AS) program, and 31% had completed an undergraduate (BS) program. A few participants (N = 2) had completed graduate degrees (Table 1).. About half of the participants (45%) rated their educational experience regarding nursing documentation as excellent or above average (Table 2). One fifth of participants (21%) had never been provided EHR education. Among those who had been provided EHR education, 51% (N = 25) experienced it in nursing school while the other half experienced EHRs during hospital training (N = 14), clinical nurses (N = 6), through work (N = 2), or former place of employment (N = 1). Of the participants who were given EHR training in nursing school, a majority of students (76%) learned nursing documentation using EHRs in a fundamental nursing course (e.g., nursing intervention course) or health assessment course. Of the participants who were
Education
Experiences
Female Male 18–24 25–34 35–44 45–54 55–64 65–74 Caucasian American Indian Asian African American Hispanic Others High school diploma/GED Completed two-year (AS) degree Complete undergraduate (BS) program Completed MS degree Completed doctorate degree Less than a year 1 to 5 years 6 to 10 years 11 to 20 years More than 20 years
Students (N = 62)
Faculty (N = 21)
55(89%) 7(11%) 18(29%) 21(33%) 15(24%) 7(11%) 0(0%) 1(2%) 43(70%) 1(2%) 6(10%) 5(8%) 5(8%) 1(2%) 27(44%) 19(31%) 19(31%) 2(3%) 0(0%)
18 (90%) 2 (10%) 0 (0%) 0 (0%) 2 (10%) 2 (10%) 14 (70%) 0 (0%) 19 (95%) 0 (0%) 0(0%) 1 (5%) 0 (0%) 0 (0%)
12 (67%) 6 (33%) 0 (0%) 3 (17%) 3 (17%) 5 (28%) 7 (39%)
provided with EHR education, 36% responded that their educational experience was excellent or above average (good) (Table 2). One fifth of participants responded that they were not prepared for electronic nursing using EHRs. During the clinical rotation, 17% of participants found the EHR system was not easy to use. About half of the participants (56%) felt the interaction with the EHR system in the clinical setting was difficult, and 65% of participants agreed interacting
Table 2 The student perceptions and faculty perceptions of academic EHRs. Variable for students
Variable for faculty
How would you rate your education experience regarding nursing documentation?
How would you rate your teaching experience regarding nursing documentation?
Did the faculty in your nursing education provide the most current information related to nursing documentation?
To what extent do you think you provide the most current information related to nursing documentation?
To what extent do you think your education experiences regarding nursing documentation have leaded you to prepare the electronic nursing documentation in EHRs (Electronic Health Record Systems)?
To what extent do you think your teaching experiences regarding nursing documentation have leaded you to prepare the electronic nursing documentation in EHRs (Electronic Health Record Systems)?
During the clinical, I find the system (EHRs) at the clinical settings easy to use
During the clinical, I find the system (EHRs) at the clinical setting easy to use
Interaction with the system (EHRs) at the clinical settings is difficult
Interaction with the system (EHRs) at the clinical settings is difficult
Overall, to what extent do you think Academic EHRs regarding nursing documentation have leaded you to prepare for the future of health information technology by supporting programs that offer practical EHRs experience?
Overall, to what extent do you think Academic EHRs regarding nursing documentation have leaded you to prepare for the future of health information technology by supporting programs that offer practical EHRs experience?
85
Excellent Above average Average (reasonable) Below average Very poor Strongly agree Agree Somewhat agree Disagree Strongly disagree Strongly agree Agree Somewhat agree Disagree Strongly disagree Strongly agree Agree Somewhat agree Disagree Strongly disagree Strongly agree Agree Somewhat agree Disagree Strongly disagree Strongly agree Agree Somewhat agree Disagree Strongly disagree
Students (N = 62)
Faculty (N = 21)
8 (15%) 16 (30%) 27 (51%)
2 (12%) 11 (65%) 4 (24%)
2 (4%) 0 (0%) 8 (15%) 16 (60%) 27 (51%) 2 (4%) 0 (0%) 7 (13%) 20 (36%) 15 (27%) 12 (22%) 1 (2%) 3 (6%) 17 (32%) 24 (45%) 9 (17%) 0 (0%) 3 (6%) 5 (9%) 15 (28%) 27 (51%) 3 (6%) 8 (15%) 23 (43%0 18 (33%) 5 (9%) 0 (0%)
0 (0%) 0 (0%) 0 (0%) 12 (67%) 5 (28%) 1 (6%) 0 (0%) 3 (17%) 5 (28%) 7 (39%) 2 (12%) 1 (6%) 1 (6%) 4 (22%) 8 (44%) 2 (11%) 3 (17%) 3 (17%) 3 (17%) 5(28%) 4 (22%) 3 (17%) 0 (0%) 7 (41%) 7 (41%) 2 (12%) 1 6%)
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with the system required a lot of mental effort, although a majority of participants (79%) responded that the EHR systems enhanced problem solving or critical thinking. There were significant differences between pre-and post-licensure students in their perceptions of difficulty in interacting with EHR systems in the clinical settings (P = 0.031) and in their perceptions of the faculty providing the most current information related to nursing documentation using academic EHRs (p = 0.025). For comparison between ADN, BSN, and RN-BSN students, there were significant differences in the perceptions of the faculty members who provided the most current information related to nursing documentation using academic EHRs (p = 0.049). Most participants (85%) agreed that faculty in nursing programs provide the most current information related to nursing documentation. One fifth of participants (19%) disagreed that their nurse education provided the most current information related to nursing documentation using academic EHRs. Related to nursing documentation, the majority of participants (94%) agreed that they were given detailed nursing documentation education about administering medications by common routes (per oral (PO), subcutaneously (SC), intramuscular (IM), Intravenous (IV)), nursing processes using nursing diagnosis (NANDA, the North American Nursing Diagnosis Association), and performing nursing intervention using nursing language (Nursing Intervention Classification (NIC), Nursing Outcome Classification (NOC)). Nearly all the students (98%) agreed that academic EHRs training regarding nursing documentation should be completed before or during the clinical rotation. All of the student participants agreed that academic EHRs can help to prepare students for the future of health information technology by supporting programs that offer practical EHR experience (Table 2).
Table 3 Faculty demographics for qualitative data. Characteristics Age
Race/ethnicity Gender Education
Frequencies (%) 35–44 years old 45–54 years old 55–64 years old 65 years or older Caucasian Female Male Completed MS degree Completed doctorate degree (e.g., PhD, EdD, DNP)
2(22%) 3(33%) 3(33%) 1(11%) 9(100%) 6(67%) 3(33%) 7(78%) 2(22%)
4.5. Awareness In this study, the meaning of “awareness” was related to knowledge or perception of a situation in which nurse education had been impacted by technology, especially the use of academic EHRs. “Awareness” also included knowledge or perception of the need for change in nurse education due to the significant role information technology plays in healthcare. Most faculty participants (N = 8) expressed perception of their own awareness. There were two subthemes to this theme reflecting awareness. One sub-theme concerned positive awareness of academic EHRs. “We know it's changing … being thrilled about it”. “It becomes a healthcare system. (It has become obvious that the paper record system is incapable of supporting caregivers with all the patient information they need)… EHRs will be required…we need an affordable system.”
4.3. Faculty
The other sub-theme was about negative awareness of academic EHRs.
Seventy percent of the faculty sample consisted of 55–64 year-olds, 90% (N = 18) of whom were female. The majority of faculty participants (95%, N = 19) were Caucasian. One third of the faculty (33%, N = 6) had completed a doctoral degree. The average years of experience in nurse education was 18 years (ranged from 2 to 41 years, Table 1). A majority of faculty participants (76%) rated their teaching experience regarding nursing document as excellent or above average (Table 2). Two-fifths of participants (39%) are currently using academic EHRs in their nursing programs, although a majority of faculty participants (77%) agreed that academic EHRs enhance students' problem solving or critical thinking ability. During the clinical rotation, 28% of faculty found the EHRs were not easy to use. More than half the faculty (62%) responded that interaction with the system at clinical settings was difficult. Although almost all faculty (95%) responded that they provided the most current information related to nursing documentation, only 35% of faculty reported that they provided the most current information related to nursing documentation using academic EHRs. Nearly all of the faculty participants (94%) agreed that offering academic EHRs regarding nursing documentation should be required before or during clinical rotations. A majority of faculty participants (82%) agreed that academic EHRs could help students prepare for the future of health information technology by supporting programs that offer practical EHR experience.
“We know it's changing but we can't… we teach what we can teach”. “No. They used all different systems. Even at the same hospital, different units use different systems (ER vs. Med-Surg Unit at one hospital). We can't … No…” 4.6. Barriers Nursing faculty mentioned the barriers to adoption of academic EHRs into nurse education. The barriers included any other obstacle that prevented adoption of academic EHRs. Also fears and beliefs make adoption of academic EHRs difficult. This theme had three sub-themes: lack of resources, resistance, and lack of knowledge. 4.6.1. Lack of Resources The narratives conveyed a feeling of a lack of funding and resources that may hinder faculty's abilities to implement and support students. Half (N = 5) of the nursing faculty interviewed (N = 9) stated that they were dissatisfied with the level of funds for supporting students using academic EHRs. One comment was related to software issues (the access of EHRs during clinical rotations or in the lab). Another was related to hardware issues (no availability of computers in the lab). “We don't have computers or anything in the lab”.
4.4. Qualitative Findings
“One of problems, they (hospitals)… don't allow it (EHRs)… It's very hard to access…”.
Nine nursing faculty participated in a one-on-one interview. Characteristics of the participants are shown in Table 3. As indicated by the table, the majority of participants were female faculty. The age of the nursing faculty ranged from 35 to 66 years old. The number of years of experience in teaching ranged from 2 years to 35 years. The average teaching experience was 11 years. Five sub-themes were derived from the interviews and clustered within three themes.
4.6.2. Resistance This theme refers to a refusal to accept or adopt academic EHRs. Some faculty (N = 4) mentioned that the academic EHRs are not necessary in nurse education because paper charting is the same as 86
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provided EHR education/training. This study supported current literature reporting that students in some programs are not exposed to electronic documentation until they participate in clinical rotations in local hospitals (Meyer et al., 2011). There was a growing consensus of opinion regarding use of academic EHRs between students and faculty. Quantitative findings showed that almost all participating students (98%) and faculty (94%) agreed that exposure to academic EHRs regarding nursing documentation has prepared students for the future of health information technology by supporting programs that offer practical EHR experiences. Both a majority of faculty (77%) and students (79%) agreed that academic EHRs enhance students' problem solving or critical thinking abilities. Similarly, as shown in qualitative findings, most faculty participants are aware that nurse education has been impacted by use of EHRs and the transition from paper forms to electronic nursing documents entails more than a mere replication of paper forms in an electronic format. Unfortunately, we, as nursing educators, might be resistant to the use of academic EHRs for nursing documentation due to lack of knowledge/resources or a perception that paper charting is basically the same as computer charting. One faculty mentioned, “EHR education should be for job training purposes, not education… no need to be taught.” However, there is a need to adopt academic EHR training when teaching nursing documentation. Quantitative results show that half of the student participants (56%) and faculty participants (62%) felt the interaction with the system (EHRs) in the clinical setting was difficult. Although nearly all faculty (95%) and students (85%) responded that they provided (were provided with) the most current information related to nursing documentation, one-fifth of student participants (19%) and about two-fifths of faculty participants (35%) disagreed that faculty provided (were provided with) the most current information related to nursing documentation using academic EHRs. Moreover, there were significant differences between pre- and post-licensure students in their perceptions of difficulty in interacting with the systems (EHRs) in the clinical setting (P = 0.031) and the perception of the faculty providing the most current information related to nursing documentation using academic EHRs (p = 0.025). Those findings support imperative needs for academic EHRs in nurse education. A majority of faculty reported that they are self-taught in terms of nursing documentation using EHRs. Faculty are learners themselves in the paper to electronic transition in nursing documentation. Additionally, cost may prohibit the adoption of EHRs in some nurse education programs, especially if they are small in size. The cost of EHR training systems being offered in nurse education programs through vendor partnerships is very high (an average of $15,000 (US dollars) to $35,000 (US dollars) per school program). According to Kushniruk et al. (2014), a cloud-based solution was introduced to allow access to EHRs in a way that was both educationally and cost effective. Relevant literature explains that the availability of informatics tools for EHRs and clinical documentation systems is limited, though these need to be covered in pre-licensure course work (Skiba and Rizzolo, 2009; Kushniruk et al., 2014). The use of academic EHRs is a key to helping nursing instructors be prepared to meet the learners' needs, as well as the needs of future employers, although there were no known needs of future employers for preparedness of nursing students in terms of use of EHRs and electronic nursing documentation. Patient safety can be attributed to nursing competence (Girot, 2000; Tanner, 2005). If students lack confidence in nursing documentation with EHRs, students become at risk for unsafe nursing documentation, such as an error in nursing documentation, and less effective communication within EHRs. Providing valuable experience and virtual practice with EHRs in nurse education could help to reduce the gap in the paper to electronic transition in nursing documentation. Ultimately the use of EHRs is able to build the evidence base for nursing practice (McBride, 2005; Borycki et al., 2010).
computer charting. “No…I believe basic is same. For instance, basic assessment is same… Not necessary to use academic EHRs…” “We do paper charting…” (by shaking her head the participant expressed resistance non-verbally). “We don't need… we cover what we are supposed to…”. Two participants mentioned that the academic EHRs should not be necessary because training on this software needs to be done in job training at the hospital, not at school. “It should be job training purpose… not in education. No need to be taught…” “No time for that. It's for job training, orientation after being hired or only for preceptor students…” 4.6.3. Lack of Knowledge This theme includes a feeling of uncertainty/unsureness or lack of knowledge of academic EHRs. “I guess I don't know what question I have and what I can answer… I don't know…” “I can't speak about it. Not much… I'm not just… No…” 4.7. Adoption Readiness Another theme was associated with the adoption of academic EHRs. A majority of faculty believed that they were not ready, and they were fearful that they couldn't use the software properly. “How can we give a grade? How?? Can we change what they've done???” “I'm not ready….I don't know much… how to do.” There were three nursing faculty who responded positively about the adoption of academic EHRs. “Ideally maybe… changing by home computers, labs… depending on how could we…, we can..” “If we have, we love to do… we can use every single lab… and give an assignment for that.” Two participants expressed the idea that academic EHRs could be connected with care plans and course management systems together. “We can use it for care plan. Two different way to do… just free text or enter in that.” “Can we interface with Canvas (a course management system)? If we can do it with Canvas, it would be easy for grading and giving assignments.” One faculty recommended developing a customized charting system for specific groups or specific purposes. “One of the things I'd like to do is admission assessment using computer charting… But.. I hope the system has a specific charting for pediatrics… Different developmental stages… we need different assessment skills necessary. For example, growth chart, immunizations, etc.” 5. Discussion This study explored student and faculty perceptions of academic EHRs in nurse education. About 40% of participating faculty responded that they currently use academic EHRs in their nursing programs, and one-fifth of participating students (21%) reported never having been 87
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6. Conclusion This study suggested that faculty and nursing students should not only to be familiar with EHRs for data entry but also with the meaningful use of academic EHRs in learning/teaching more efficiently throughout the curriculum. Adoption of academic EHRs includes how to assess EHRs in order to make clinical decisions for patients, to understand overall condition, to communicate and collaborate effectively, to understand plans of care, and to evaluate responses to treatment. It will also help in building undergraduate nursing students' competence in nursing documentation within EHR systems and in using standardized nursing language. Appendix I Example of semi interview questions 1. What are the challenges/issues of teaching nursing documentation in terms of changes of EHRs (called as electronic nursing documentation)? 2. During the clinical, what are the challenges/issues of providing/ using EHRs education to students? 3. What are the challenges/issues of adopting academic EHRs in nursing education? 4. How would you like to use/utilize the academic EHRS in your nursing program? 5. Any other comments? References AACN, 2013. 2012–2013 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Author, Washington. Aktan, N.M., Tracy, J., Bareford, C., 2011. Computerized documentation and community health nursing students. J. Nurs. Educ. Pract. 1 (1). Ammenwerth, E., Kutscha, U., Kutscha, A., Mahler, C., Eichstädter, R., Haux, R., 2001. Nursing process documentation systems in clinical routine—prerequisites and experiences. Int. J. Med. Inform. 64 (2), 187–200. Bates, D., Gawande, A., 2003. Improving safety with information technology. N. Engl. J. Med. 348 (25), 2526–2534. Billie, L., Chadwick, S., Mann, R., Brooke-Read, M., 2013. A survey of student nurses’ and midwives’ experiences of learning to use electronic health record systems in practice. Nurse Educ. Pract. 13, 437–441. http://dx.doi.org/10.1016/j.nepr.2012.10.003. Bjorvell, C., Wredling, R., Thorell-Ekstrand, I., 2003a. Experiences of using the VIPSmodel for nursing documentation: a focus group study [corrected]. J. Adv. Nurs. 43 (4), 402–410. Bjorvell, C., Wredling, R., & Thorell-Ekstrand, I. (2003b). Prerequisites and consequences of nursing documentation in patient records as perceived by a group of Registered Nurses. J. Clin. Nurs., 12(2), 206–214. Borycki, E., Kushniruk, A., Armstrong, B., Joe, R., Otto, T., 2010. Integrating electronic health records into health professional and health informatics education: a continuum of approach. Acta Inf. Med. 18 (1), 20–24. Cho, I., Kim, J., Kim, J.H., Kim, H.Y., Kim, Y., 2010. Design and implementation of a standards-based interoperable clinical decision support architecture in the context of the Korean EHR. Int. J. Med. Inform. 79 (9), 611-22. Choi, W., Park, Y., Cho, I., 2009. A comparison of the nursing records of hysterectomy
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Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/locate/nedt
The need for academic electronic health record systems in nurse education a,⁎
Joohyun Chung , Insook Cho a b
MARK
b
College of Nursing, University of Massachusetts Dartmouth, Dartmouth, MA, USA Dept of Nursing, Inha University, Incheon, South Korea
A R T I C L E I N F O
A B S T R A C T
Keywords: EHRs Nurse education Nursing documentation
The nursing profession has been slow to incorporate information technology into formal nurse education and practice. The aim of this study was to identify the use of academic electronic health record systems in nurse education and to determine student and faculty perceptions of academic electronic health record systems in nurse education. A quantitative research design with supportive qualitative research was used to gather information on nursing students' perceptions and nursing faculty's perceptions of academic electronic health record systems in nurse education. Eighty-three participants (21 nursing faculty and 62 students), from 5 nursing schools, participated in the study. A purposive sample of 9 nursing faculty was recruited from one university in the Midwestern United States to provide qualitative data for the study. The researcher-designed surveys (completed by faculty and students) were used for quantitative data collection. Qualitative data was taken from interviews, which were transcribed verbatim for analysis. Students and faculty agreed that academic electronic health record systems could be useful for teaching students to think critically about nursing documentation. Quantitative and qualitative findings revealed that academic electronic health record systems regarding nursing documentation could help prepare students for the future of health information technology. Meaningful adoption of academic electronic health record systems will help in building the undergraduate nursing students' competence in nursing documentation with electronic health record systems.
1. Introduction Hospitals with health information technology (HIT) may be able to improve on their quality of care and cost by improving communication, making knowledge more readily accessible, performing checks in real time, and providing decision supports (Bates and Gawande, 2003). Particularly, electronic health record (EHR) systems provide great functionality as a form of HIT (Fareed et al., 2015). Recently, the Office of the National Coordinator for Health Information Technology (ONC) reported that three out of four hospitals (76%) have a basic EHR systems and nearly all reported hospitals (97%) possess a certified EHR technology in 2014 (ONC, 2015). The wide adoption of EHR systems has led the Institute of Medicine (IOM) to emphasize the use of informatics as a core competency required of all health care professions. The 2009 Health Information Technology for Economic and Clinical Health Act (HITECH) directs all health providers to use EHRs. The National League for Nursing (NLN) recommends that nursing faculty should incorporate informatics into all levels of the curriculum (Skiba and Rizzolo, 2009). However, the nursing profession has been slow to incorporate information technology into formal nurse education and practice (Meyer et al., 2011; Pobocik, 2014; The TIGER Initiative,
⁎
Corresponding author. E-mail address: [email protected] (J. Chung).
http://dx.doi.org/10.1016/j.nedt.2017.04.018 Received 19 May 2016; Received in revised form 26 February 2017; Accepted 21 April 2017 0260-6917/ © 2017 Published by Elsevier Ltd.
2017). According to Meyer et al. (2011), most nursing schools continue to educate students in traditional ways. For instance, when nursing faculty teach nursing documentation to undergraduate nursing students in clinical settings regardless of paper-based or electronic documentation, the first major teaching strategies for documentation include the use of paper (Nickitas et al., 2010). Nurses have used paper-based forms for nursing documentation, including narrative notes and flow sheets, to exchange pertinent patient information (Bjorvell et al., 2003a, 2003b; Tapp, 1990). Similar to paper-based documentation, EHRs contain flow sheets. However, EHR documentation also incorporates new features (Ammenwerth et al., 2001). EHRs help nurses practice better nursing care. Some of their functions include supporting standard nursing terminology, incorporating clinical documentation from various sources, supporting standard care plans, guidelines, and protocols, supporting drug interaction checking, presenting alerts for preventive services and wellness, and linking clinical tasks. These features may alter how nurses document, make decisions, and communicate with other healthcare providers (Ammenwerth et al., 2001; Choi et al., 2009; Cho et al., 2010). Because different documentation methods may be used with EHRs than are used with paper-based records, paper-based
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accredited by the Commission on Collegiate Nurse education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN) in the United States. A cluster convenience sampling was used for the data collection. In the United States, 100 undergraduate nursing programs were randomly selected, regardless of Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) programs, from the list of programs accredited by CCNE and ACEN. The selected schools were invited to participate in this study. Only five schools agreed to participate. Among the five schools, two schools had graduate programs (Master of Science (MS)), Doctor of Nursing Practice (DNP) or Doctor of Philosophy (PhD). All undergraduate students and faculty in each school received the information via email. There were 83 respondents to the survey; 21 were faculty and 62 were students (ADN: 21 students, BSN: 23 students, and RN to BSN: 18 students).
instruction may not be sufficient for teaching electronic nursing documentation. In some nursing programs, students are not exposed to electronic documentation until they participate in clinical rotations in local hospitals (Meyer et al., 2011). Unfortunately, during clinical rotations, it is not easy for students to learn about best practices in electronic documentation (Billie, Chadwick, Mann, & Brooke-Read, 2013). However, students can learn to navigate EHRs in simulation labs (Gardner & Jones, 2012). Lucas (2010) has reported partnering with a medical center to provide students access to training with EHRs before the first clinical rotation. These students felt more confident with their documentation. Educating students in a transitional electronic environment is no longer optional for nursing faculty. It is necessary for accurate documentation, transmission, and management of data for improving patient care (Aktan et al., 2011). According to the NLN survey (2008), 80% of faculty reported that they are self-taught on use of EHRs. Faculty are learners themselves in this transition from paper to electronic media for teaching nursing documentation. Considering that the national average age of nursing faculty is about 53.5 years (AACN, 2013), most nursing faculty have long practiced paper-based documentation. It follows that they will likely feel more comfortable in a paperbased teaching environment (Nickitas et al., 2010). Also, nursing faculty now experience a new challenge in teaching the use of different EHRs in various clinical settings when they teach nursing documentation. The fact that EHR systems are designed to force the user to follow correct procedures for the default safety protocols sometimes presents faculty with obstacles to providing adequate education about electronic nursing documentation (Mahon et al., 2010). Several studies show that nursing students are not comfortable using healthcare technology, and nurses in practice are not comfortable using EHRs (Fetter, 2009; Kelley et al., 2011). Several studies demonstrate that nurses report that EHRs are extensive and time consuming (Saarinen and Aho, 2005; Scott et al., 2005). About three quarters of nurses reported spending at least 50% of their time using the EHRs, which means less time for patient care (Johnson et al., 2008). Another recent study reported that bedside nurses spend 4 h per day documenting using EHRs (Penoyer et al., 2014). The high number of hours spent using EHRs may be associated with non-user-friendly systems or nurses' lack of competence with the electronic systems. Some nurses have reported that their critical thinking is reduced by using the EHRs, although most nurses believed that EHRs are beneficial (Fraenkel et al., 2003; Meyer et al., 2011; Moody et al., 2004). It is imperative that the nursing students are able to use EHRs in their education so that they will be more prepared to enter the profession with strong technology skills for nursing documentation (Meyer et al., 2011). The intention of this study was to identify the use of academic EHRs in nurse education and to determine student and faculty perceptions of academic EHRs in nurse education.
3.2. Qualitative Data A purposive sample of nine nursing faculty (seven women and two men) was recruited from one university in the Midwestern United States. 3.3. Instruments To address aims, faculty and students' perceived knowledge of academic EHRs was measured with the researcher-designed instruments. The instruments were designed to measure both nursing faculty and nursing students' perceptions of the need for academic EHRs. The survey included three sections: 1) demographics, 2) perceived knowledge, and 3) attitude toward electronic nursing documentation and academic EHRs. The survey consisted of 15 items excluding demographical questions. This survey assessed knowledge of and attitude toward electronic nursing documentation. It used a 5-point Likert scale ranging from “strongly disagree” (1) to “strongly agree” (5) or from “lacking understanding” (1) to “solid understanding” (5). 3.4. Data Collection Procedure Approval from the Institutional Review Board at a university in the Midwestern United States was obtained prior to data collection, which was conducted in mid-March 2015. For the quantitative data, the selected schools were invited to participate in the study. A survey link and a brochure were sent to the nursing departments/colleges. Deans/ chairs were responsible for disseminating the survey link to nursing students and faculty. For the qualitative data, an in-depth, exploratory approach to data collection from nursing faculty was taken, employing five semistructured interview questions (Appendix I). The interviews were conducted in faculty members' own offices. The recorded interviews lasted 5 to 25 min (average 16 min). Additionally, demographic information was collected including gender, age, and years of teaching experience.
2. Methods A quantitative research design with supportive qualitative research was used to gather information on nursing students' and nursing faculty's perceptions of academic EHRs in nurse education. For quantitative data, a cross-sectional descriptive design was developed, in which a questionnaire-based survey was used to examine nursing students' and faculty's perceptions of academic EHRs. For qualitative data, the semi-structured interview guideline was created after discussions with researchers.
3.5. Data Analysis Related to the quantitative data, statistical analysis was performed using SAS version 9.4 (SAS Institute Inc., NC). Descriptive statistics were used to describe frequency and percentage. Chi-Square statistics were used to determine the variances between programs (ADN, BSN, and RN-BSN) and pre licensure students (ADN and BSN students)/post licensure students (RN-BSN students). Related to the qualitative data, all interviews were transcribed verbatim for analysis. The two researchers were independently coded. The transcribed text was carefully read and thematic segments were identified. Data segments were grouped based on commonalities within the descriptions of nursing students' perceptions of academic EHRs. For credibility and trustworthiness, data were collected by the 1st author
3. Samples and Setting 3.1. Quantitative Data Participants in this study were nursing undergraduate programs 84
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and analyzed by both authors independently and then together to reach consensus.
Table 1 Students and faculty demographics for quantitative data. Variables
4. Results Gender
4.1. Quantitative Findings
Age
In total, 62 nursing undergraduate students and 21 faculty members completed the questionnaire. 4.2. Students
Ethnicity
Related to the students' information, overall 89% (N = 55) of the student sample was female while 11% (N = 7) was male. In total, 47% (N = 29) of the student sample came from Associate of Nursing Programs, 24% (N = 15) came from Bachelor of Nursing programs, and 28% (N = 18) were from RN-BSN programs. The average age of participants was 33 years. The majority of participants were Caucasian (70%). Of the sample, 44% had earned a high school diploma or GED, 31% had completed a two-year degree (AS) program, and 31% had completed an undergraduate (BS) program. A few participants (N = 2) had completed graduate degrees (Table 1).. About half of the participants (45%) rated their educational experience regarding nursing documentation as excellent or above average (Table 2). One fifth of participants (21%) had never been provided EHR education. Among those who had been provided EHR education, 51% (N = 25) experienced it in nursing school while the other half experienced EHRs during hospital training (N = 14), clinical nurses (N = 6), through work (N = 2), or former place of employment (N = 1). Of the participants who were given EHR training in nursing school, a majority of students (76%) learned nursing documentation using EHRs in a fundamental nursing course (e.g., nursing intervention course) or health assessment course. Of the participants who were
Education
Experiences
Female Male 18–24 25–34 35–44 45–54 55–64 65–74 Caucasian American Indian Asian African American Hispanic Others High school diploma/GED Completed two-year (AS) degree Complete undergraduate (BS) program Completed MS degree Completed doctorate degree Less than a year 1 to 5 years 6 to 10 years 11 to 20 years More than 20 years
Students (N = 62)
Faculty (N = 21)
55(89%) 7(11%) 18(29%) 21(33%) 15(24%) 7(11%) 0(0%) 1(2%) 43(70%) 1(2%) 6(10%) 5(8%) 5(8%) 1(2%) 27(44%) 19(31%) 19(31%) 2(3%) 0(0%)
18 (90%) 2 (10%) 0 (0%) 0 (0%) 2 (10%) 2 (10%) 14 (70%) 0 (0%) 19 (95%) 0 (0%) 0(0%) 1 (5%) 0 (0%) 0 (0%)
12 (67%) 6 (33%) 0 (0%) 3 (17%) 3 (17%) 5 (28%) 7 (39%)
provided with EHR education, 36% responded that their educational experience was excellent or above average (good) (Table 2). One fifth of participants responded that they were not prepared for electronic nursing using EHRs. During the clinical rotation, 17% of participants found the EHR system was not easy to use. About half of the participants (56%) felt the interaction with the EHR system in the clinical setting was difficult, and 65% of participants agreed interacting
Table 2 The student perceptions and faculty perceptions of academic EHRs. Variable for students
Variable for faculty
How would you rate your education experience regarding nursing documentation?
How would you rate your teaching experience regarding nursing documentation?
Did the faculty in your nursing education provide the most current information related to nursing documentation?
To what extent do you think you provide the most current information related to nursing documentation?
To what extent do you think your education experiences regarding nursing documentation have leaded you to prepare the electronic nursing documentation in EHRs (Electronic Health Record Systems)?
To what extent do you think your teaching experiences regarding nursing documentation have leaded you to prepare the electronic nursing documentation in EHRs (Electronic Health Record Systems)?
During the clinical, I find the system (EHRs) at the clinical settings easy to use
During the clinical, I find the system (EHRs) at the clinical setting easy to use
Interaction with the system (EHRs) at the clinical settings is difficult
Interaction with the system (EHRs) at the clinical settings is difficult
Overall, to what extent do you think Academic EHRs regarding nursing documentation have leaded you to prepare for the future of health information technology by supporting programs that offer practical EHRs experience?
Overall, to what extent do you think Academic EHRs regarding nursing documentation have leaded you to prepare for the future of health information technology by supporting programs that offer practical EHRs experience?
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Excellent Above average Average (reasonable) Below average Very poor Strongly agree Agree Somewhat agree Disagree Strongly disagree Strongly agree Agree Somewhat agree Disagree Strongly disagree Strongly agree Agree Somewhat agree Disagree Strongly disagree Strongly agree Agree Somewhat agree Disagree Strongly disagree Strongly agree Agree Somewhat agree Disagree Strongly disagree
Students (N = 62)
Faculty (N = 21)
8 (15%) 16 (30%) 27 (51%)
2 (12%) 11 (65%) 4 (24%)
2 (4%) 0 (0%) 8 (15%) 16 (60%) 27 (51%) 2 (4%) 0 (0%) 7 (13%) 20 (36%) 15 (27%) 12 (22%) 1 (2%) 3 (6%) 17 (32%) 24 (45%) 9 (17%) 0 (0%) 3 (6%) 5 (9%) 15 (28%) 27 (51%) 3 (6%) 8 (15%) 23 (43%0 18 (33%) 5 (9%) 0 (0%)
0 (0%) 0 (0%) 0 (0%) 12 (67%) 5 (28%) 1 (6%) 0 (0%) 3 (17%) 5 (28%) 7 (39%) 2 (12%) 1 (6%) 1 (6%) 4 (22%) 8 (44%) 2 (11%) 3 (17%) 3 (17%) 3 (17%) 5(28%) 4 (22%) 3 (17%) 0 (0%) 7 (41%) 7 (41%) 2 (12%) 1 6%)
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with the system required a lot of mental effort, although a majority of participants (79%) responded that the EHR systems enhanced problem solving or critical thinking. There were significant differences between pre-and post-licensure students in their perceptions of difficulty in interacting with EHR systems in the clinical settings (P = 0.031) and in their perceptions of the faculty providing the most current information related to nursing documentation using academic EHRs (p = 0.025). For comparison between ADN, BSN, and RN-BSN students, there were significant differences in the perceptions of the faculty members who provided the most current information related to nursing documentation using academic EHRs (p = 0.049). Most participants (85%) agreed that faculty in nursing programs provide the most current information related to nursing documentation. One fifth of participants (19%) disagreed that their nurse education provided the most current information related to nursing documentation using academic EHRs. Related to nursing documentation, the majority of participants (94%) agreed that they were given detailed nursing documentation education about administering medications by common routes (per oral (PO), subcutaneously (SC), intramuscular (IM), Intravenous (IV)), nursing processes using nursing diagnosis (NANDA, the North American Nursing Diagnosis Association), and performing nursing intervention using nursing language (Nursing Intervention Classification (NIC), Nursing Outcome Classification (NOC)). Nearly all the students (98%) agreed that academic EHRs training regarding nursing documentation should be completed before or during the clinical rotation. All of the student participants agreed that academic EHRs can help to prepare students for the future of health information technology by supporting programs that offer practical EHR experience (Table 2).
Table 3 Faculty demographics for qualitative data. Characteristics Age
Race/ethnicity Gender Education
Frequencies (%) 35–44 years old 45–54 years old 55–64 years old 65 years or older Caucasian Female Male Completed MS degree Completed doctorate degree (e.g., PhD, EdD, DNP)
2(22%) 3(33%) 3(33%) 1(11%) 9(100%) 6(67%) 3(33%) 7(78%) 2(22%)
4.5. Awareness In this study, the meaning of “awareness” was related to knowledge or perception of a situation in which nurse education had been impacted by technology, especially the use of academic EHRs. “Awareness” also included knowledge or perception of the need for change in nurse education due to the significant role information technology plays in healthcare. Most faculty participants (N = 8) expressed perception of their own awareness. There were two subthemes to this theme reflecting awareness. One sub-theme concerned positive awareness of academic EHRs. “We know it's changing … being thrilled about it”. “It becomes a healthcare system. (It has become obvious that the paper record system is incapable of supporting caregivers with all the patient information they need)… EHRs will be required…we need an affordable system.”
4.3. Faculty
The other sub-theme was about negative awareness of academic EHRs.
Seventy percent of the faculty sample consisted of 55–64 year-olds, 90% (N = 18) of whom were female. The majority of faculty participants (95%, N = 19) were Caucasian. One third of the faculty (33%, N = 6) had completed a doctoral degree. The average years of experience in nurse education was 18 years (ranged from 2 to 41 years, Table 1). A majority of faculty participants (76%) rated their teaching experience regarding nursing document as excellent or above average (Table 2). Two-fifths of participants (39%) are currently using academic EHRs in their nursing programs, although a majority of faculty participants (77%) agreed that academic EHRs enhance students' problem solving or critical thinking ability. During the clinical rotation, 28% of faculty found the EHRs were not easy to use. More than half the faculty (62%) responded that interaction with the system at clinical settings was difficult. Although almost all faculty (95%) responded that they provided the most current information related to nursing documentation, only 35% of faculty reported that they provided the most current information related to nursing documentation using academic EHRs. Nearly all of the faculty participants (94%) agreed that offering academic EHRs regarding nursing documentation should be required before or during clinical rotations. A majority of faculty participants (82%) agreed that academic EHRs could help students prepare for the future of health information technology by supporting programs that offer practical EHR experience.
“We know it's changing but we can't… we teach what we can teach”. “No. They used all different systems. Even at the same hospital, different units use different systems (ER vs. Med-Surg Unit at one hospital). We can't … No…” 4.6. Barriers Nursing faculty mentioned the barriers to adoption of academic EHRs into nurse education. The barriers included any other obstacle that prevented adoption of academic EHRs. Also fears and beliefs make adoption of academic EHRs difficult. This theme had three sub-themes: lack of resources, resistance, and lack of knowledge. 4.6.1. Lack of Resources The narratives conveyed a feeling of a lack of funding and resources that may hinder faculty's abilities to implement and support students. Half (N = 5) of the nursing faculty interviewed (N = 9) stated that they were dissatisfied with the level of funds for supporting students using academic EHRs. One comment was related to software issues (the access of EHRs during clinical rotations or in the lab). Another was related to hardware issues (no availability of computers in the lab). “We don't have computers or anything in the lab”.
4.4. Qualitative Findings
“One of problems, they (hospitals)… don't allow it (EHRs)… It's very hard to access…”.
Nine nursing faculty participated in a one-on-one interview. Characteristics of the participants are shown in Table 3. As indicated by the table, the majority of participants were female faculty. The age of the nursing faculty ranged from 35 to 66 years old. The number of years of experience in teaching ranged from 2 years to 35 years. The average teaching experience was 11 years. Five sub-themes were derived from the interviews and clustered within three themes.
4.6.2. Resistance This theme refers to a refusal to accept or adopt academic EHRs. Some faculty (N = 4) mentioned that the academic EHRs are not necessary in nurse education because paper charting is the same as 86
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provided EHR education/training. This study supported current literature reporting that students in some programs are not exposed to electronic documentation until they participate in clinical rotations in local hospitals (Meyer et al., 2011). There was a growing consensus of opinion regarding use of academic EHRs between students and faculty. Quantitative findings showed that almost all participating students (98%) and faculty (94%) agreed that exposure to academic EHRs regarding nursing documentation has prepared students for the future of health information technology by supporting programs that offer practical EHR experiences. Both a majority of faculty (77%) and students (79%) agreed that academic EHRs enhance students' problem solving or critical thinking abilities. Similarly, as shown in qualitative findings, most faculty participants are aware that nurse education has been impacted by use of EHRs and the transition from paper forms to electronic nursing documents entails more than a mere replication of paper forms in an electronic format. Unfortunately, we, as nursing educators, might be resistant to the use of academic EHRs for nursing documentation due to lack of knowledge/resources or a perception that paper charting is basically the same as computer charting. One faculty mentioned, “EHR education should be for job training purposes, not education… no need to be taught.” However, there is a need to adopt academic EHR training when teaching nursing documentation. Quantitative results show that half of the student participants (56%) and faculty participants (62%) felt the interaction with the system (EHRs) in the clinical setting was difficult. Although nearly all faculty (95%) and students (85%) responded that they provided (were provided with) the most current information related to nursing documentation, one-fifth of student participants (19%) and about two-fifths of faculty participants (35%) disagreed that faculty provided (were provided with) the most current information related to nursing documentation using academic EHRs. Moreover, there were significant differences between pre- and post-licensure students in their perceptions of difficulty in interacting with the systems (EHRs) in the clinical setting (P = 0.031) and the perception of the faculty providing the most current information related to nursing documentation using academic EHRs (p = 0.025). Those findings support imperative needs for academic EHRs in nurse education. A majority of faculty reported that they are self-taught in terms of nursing documentation using EHRs. Faculty are learners themselves in the paper to electronic transition in nursing documentation. Additionally, cost may prohibit the adoption of EHRs in some nurse education programs, especially if they are small in size. The cost of EHR training systems being offered in nurse education programs through vendor partnerships is very high (an average of $15,000 (US dollars) to $35,000 (US dollars) per school program). According to Kushniruk et al. (2014), a cloud-based solution was introduced to allow access to EHRs in a way that was both educationally and cost effective. Relevant literature explains that the availability of informatics tools for EHRs and clinical documentation systems is limited, though these need to be covered in pre-licensure course work (Skiba and Rizzolo, 2009; Kushniruk et al., 2014). The use of academic EHRs is a key to helping nursing instructors be prepared to meet the learners' needs, as well as the needs of future employers, although there were no known needs of future employers for preparedness of nursing students in terms of use of EHRs and electronic nursing documentation. Patient safety can be attributed to nursing competence (Girot, 2000; Tanner, 2005). If students lack confidence in nursing documentation with EHRs, students become at risk for unsafe nursing documentation, such as an error in nursing documentation, and less effective communication within EHRs. Providing valuable experience and virtual practice with EHRs in nurse education could help to reduce the gap in the paper to electronic transition in nursing documentation. Ultimately the use of EHRs is able to build the evidence base for nursing practice (McBride, 2005; Borycki et al., 2010).
computer charting. “No…I believe basic is same. For instance, basic assessment is same… Not necessary to use academic EHRs…” “We do paper charting…” (by shaking her head the participant expressed resistance non-verbally). “We don't need… we cover what we are supposed to…”. Two participants mentioned that the academic EHRs should not be necessary because training on this software needs to be done in job training at the hospital, not at school. “It should be job training purpose… not in education. No need to be taught…” “No time for that. It's for job training, orientation after being hired or only for preceptor students…” 4.6.3. Lack of Knowledge This theme includes a feeling of uncertainty/unsureness or lack of knowledge of academic EHRs. “I guess I don't know what question I have and what I can answer… I don't know…” “I can't speak about it. Not much… I'm not just… No…” 4.7. Adoption Readiness Another theme was associated with the adoption of academic EHRs. A majority of faculty believed that they were not ready, and they were fearful that they couldn't use the software properly. “How can we give a grade? How?? Can we change what they've done???” “I'm not ready….I don't know much… how to do.” There were three nursing faculty who responded positively about the adoption of academic EHRs. “Ideally maybe… changing by home computers, labs… depending on how could we…, we can..” “If we have, we love to do… we can use every single lab… and give an assignment for that.” Two participants expressed the idea that academic EHRs could be connected with care plans and course management systems together. “We can use it for care plan. Two different way to do… just free text or enter in that.” “Can we interface with Canvas (a course management system)? If we can do it with Canvas, it would be easy for grading and giving assignments.” One faculty recommended developing a customized charting system for specific groups or specific purposes. “One of the things I'd like to do is admission assessment using computer charting… But.. I hope the system has a specific charting for pediatrics… Different developmental stages… we need different assessment skills necessary. For example, growth chart, immunizations, etc.” 5. Discussion This study explored student and faculty perceptions of academic EHRs in nurse education. About 40% of participating faculty responded that they currently use academic EHRs in their nursing programs, and one-fifth of participating students (21%) reported never having been 87
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patients: pre and post implementation of an ICNP-based electronic nursing record system. J. Kor. Soc. Med. Inf. 15 (4), 455–464. Fareed, N., Bazzoli, G.J., Farnworth Mick, S.S., Harless, D.W., 2015. The influence of institutional pressures on hospital electronic health record presence. Soc. Sci. Med. 133, 28–35. Fetter, M.S., 2009. Curriculum strategies to improve baccalaureate nursing information technology outcomes. J. Nurs. Educ. 48 (2), 78–85. Fraenkel, D.J., Cowie, M., Daley, P., 2003. Quality benefits of an intensive care clinical information system. Crit. Care Med. 31 (1), 120–125. Gardner, C.L., Jones, S.J., 2012. Utilization of academic electronic medical records in undergraduate nursing education. Retrieved from Online Am. J. Nurs. 16 (2). http:// ojni.org/issues/?p=1702. Girot, E.A., 2000. Graduate nurses: critical thinkers or better decision makers? J. Adv. Nurs. 31 (2), 288–297. Johnson, K., Valdez, R.S., Casper, G.R., Kossman, S.P., Carayon, P., Or, C.K., et al., 2008. Experiences of technology integration in home care nursing. AMIA Annu. Symp. Proc. 389–393. Kelley, T.F., Brandon, D.H., Docherty, S.L., 2011. Electronic nursing documentation as a strategy to improve quality of patient care. J. Nurs. Scholarsh. 43 (2), 154–162. Kushniruk, A.W., Kuo, M.H., Parapini, E., Borycki, E.M., 2014. A virtual platform for electronic health record (EHR) education for nursing student: moving from in-house solutions to the cloud. Stud. Health Technol. Inform. 201, 48–54. Lucas, L., 2010. Partnering to enhance the nursing curriculum: electronic medical record accessibility. Clin. Simul. Nurs. 6 (3), e97–102. http://dx.doi.org/10.1016/j.ecns. 2009.07.006. Mahon, P.Y., Nickitas, D.M., Nokes, K., 2010. Faculty perceptions of student documentation skills during the transition from paper-based to electronic health records systems. J. Nurs. Educ. 49 (11), 615–621. http://dx.doi.org/10.3928/ 01484834-20100524-06. McBride, A.B., 2005. Nursing and the informatics revolution. Nurs. Outlook 53 (4), 183-91. Meyer, L., Stenberger, C., Toscos, T., 2011. How to implement the electronic health record in undergraduate nurse education. Am. Nurse Today 6 (5). Moody, L.E., Slocumb, E., Berg, B., Jackson, D., 2004. Electronic health records documentation in nursing: nurses' perceptions, attitudes, and preferences. Comput. Inform. Nurs. 22 (6), 337–344. National League for Nursing, 2008. Nursing Data Review, Academic Year 2005–2006: Baccalaureate, Associate Degree, and Diploma Programs. New York. Nickitas, D.M., Nokes, K.M., Caroselli, C., Mahon, P.Y., Colucci, D.E., Lester, R.D., 2010. Increasing nursing student communication skills through electronic health record system documentation. Plast. Surg. Nurs. 30 (2), 103–106. Penoyer, D.A., Cortelyou-Ward, K.H., Noblin, A.M., Bullard, T., Talbert, S., Wilson, J., et al., 2014. Use of electronic health record documentation by healthcare workers in an acute care hospital system. J. Healthc. Manag. 59 (2), 130–144. Pobocik, T., 2014. Using an educational electronic documentation system to help nursing students accurately identify patient data. Int. J. Nurs. Knowl. 26 (1), 26–34. Scott, J.T., Rundall, T.G., Vogt, T.M., Hsu, J., 2005. Kaiser Permanente's experience of implementing an electronic medical record: a qualitative study. Br. Med. J. 331, 1313–1316. Saarinen, K., Aho, M., 2005. Does the implementation of a clinical information system decrease the time intensive care nurses spend on documentation of care? Acta Anaesthesiol. Scand. 49 (1), 62–65. Skiba, D.J., Rizzolo, M.A., 2009. National league for nursing's informatics agenda. Comput. Inform. Nurs. 27 (1), 66–68. Tanner, C.A., 2005. What have we learned about critical thinking in nursing? J. Nurse Educ. 44 (2), 47–48. Tapp, R.A., 1990. Inhibitors and facilitators to documentation of nursing practice. West. J. Nurs. Res. 12 (2), 229–240. The Office of the National Coordinator for Health Information Technology (ONC), 2015. Adoption of Electronic Health Record Systems Among U.S. non-Federal Acute Care Hospitals. Retrieved from. https://www.healthit.gov/sites/default/files/data-brief/ 2014HospitalAdoptionDataBrief.pdf. The TIGER Initiative, 2017. Informatics Competencies for Every Practicing Nurse: Recommendations from the TIGER Collaborative. Retrieved May 1, 2014.
6. Conclusion This study suggested that faculty and nursing students should not only to be familiar with EHRs for data entry but also with the meaningful use of academic EHRs in learning/teaching more efficiently throughout the curriculum. Adoption of academic EHRs includes how to assess EHRs in order to make clinical decisions for patients, to understand overall condition, to communicate and collaborate effectively, to understand plans of care, and to evaluate responses to treatment. It will also help in building undergraduate nursing students' competence in nursing documentation within EHR systems and in using standardized nursing language. Appendix I Example of semi interview questions 1. What are the challenges/issues of teaching nursing documentation in terms of changes of EHRs (called as electronic nursing documentation)? 2. During the clinical, what are the challenges/issues of providing/ using EHRs education to students? 3. What are the challenges/issues of adopting academic EHRs in nursing education? 4. How would you like to use/utilize the academic EHRS in your nursing program? 5. Any other comments? References AACN, 2013. 2012–2013 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Author, Washington. Aktan, N.M., Tracy, J., Bareford, C., 2011. Computerized documentation and community health nursing students. J. Nurs. Educ. Pract. 1 (1). Ammenwerth, E., Kutscha, U., Kutscha, A., Mahler, C., Eichstädter, R., Haux, R., 2001. Nursing process documentation systems in clinical routine—prerequisites and experiences. Int. J. Med. Inform. 64 (2), 187–200. Bates, D., Gawande, A., 2003. Improving safety with information technology. N. Engl. J. Med. 348 (25), 2526–2534. Billie, L., Chadwick, S., Mann, R., Brooke-Read, M., 2013. A survey of student nurses’ and midwives’ experiences of learning to use electronic health record systems in practice. Nurse Educ. Pract. 13, 437–441. http://dx.doi.org/10.1016/j.nepr.2012.10.003. Bjorvell, C., Wredling, R., Thorell-Ekstrand, I., 2003a. Experiences of using the VIPSmodel for nursing documentation: a focus group study [corrected]. J. Adv. Nurs. 43 (4), 402–410. Bjorvell, C., Wredling, R., & Thorell-Ekstrand, I. (2003b). Prerequisites and consequences of nursing documentation in patient records as perceived by a group of Registered Nurses. J. Clin. Nurs., 12(2), 206–214. Borycki, E., Kushniruk, A., Armstrong, B., Joe, R., Otto, T., 2010. Integrating electronic health records into health professional and health informatics education: a continuum of approach. Acta Inf. Med. 18 (1), 20–24. Cho, I., Kim, J., Kim, J.H., Kim, H.Y., Kim, Y., 2010. Design and implementation of a standards-based interoperable clinical decision support architecture in the context of the Korean EHR. Int. J. Med. Inform. 79 (9), 611-22. Choi, W., Park, Y., Cho, I., 2009. A comparison of the nursing records of hysterectomy
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