The Journal of Continuing Education in Nursing

Teaching Tips 

Using Systems Thinking to Implement the QSEN Informatics Competency

Janet M. Phillips, PhD, RN, ANEF; Ann M. Stalter, PhD, RN, MEd; Karen A. Goldschmidt, PhD, MSN, RN, CNE; Jeanne S. Ruggiero, PhD, RN, CNE; Josette Brodhead, PhD, RN, CNE; Pamela L. Bonnett, DNP, RN, CNE; Robyn A. Provencio, PhD, RN, CNE; Mary Mckay, DNP, ARNP, CNE; Vicki Jowell, MSN, RN; Deborah H. Merriam, DNS, RN, CNE; Carol M. Wiggs, PhD, RN, CNM, AHN-BC; Debra L. Scardaville, PhD, PNP-PC

Abstract

There is an urgent need to improve the use and usability of the electronic health record (EHR) in health care to prevent undue patient harm. Professional development educators can use systems thinking and the QSEN competency, Informatics, to educate nurses about such things as nurse-sensitive indicators in preventing medical errors. This article presents teaching tips in using systems thinking to champion communication technologies that support error prevention (betterment). [J Contin Educ Nurs. 2019;50(9):392–397.]

Abstract

There is an urgent need to improve the use and usability of the electronic health record (EHR) in health care to prevent undue patient harm. Professional development educators can use systems thinking and the QSEN competency, Informatics, to educate nurses about such things as nurse-sensitive indicators in preventing medical errors. This article presents teaching tips in using systems thinking to champion communication technologies that support error prevention (betterment). [J Contin Educ Nurs. 2019;50(9):392–397.]

Today's practicing nurses are faced with the challenges of using the electronic health record (EHR), which was originally proposed to unify health care for individuals nationally, across transitions of care, over 50 years ago. Although the EHR has increased the legibility and comprehensiveness of health records, making it easier to access patients' health information (Atherton, 2011), mounting evidence suggests that EHRs may have unintended consequences, resulting in declining quality of care (Hochman, 2018) and even causing patient harm (Middleton et al., 2013). Nurses have experienced frustration in using the EHR, leading to workarounds resulting in patient harm (Pagulayan, Eltair, & Faber, 2018). Usability issues abound, and nurses are forced to choose between excessive time for documentation versus time spent at the bedside. The EHR needs to be redesigned to meet the needs of clinicians and patients, rather than billers and administrators (Hochman, 2018).

The Quality and Safety Education for Nurses (QSEN) movement (2019) has established one of its competencies, Informatics, for nurses to “use information and technology to communicate, manage knowledge, mitigate error, and support decision making” (Cronenwett et al., 2007, p. 129). Professional development educators are poised to use communication technology to teach nurses about tools such as nurse-sensitive indicators to prevent patient harm. Also, they are in an excellent position to assist nurses in working with EHR vendors to tailor EHR education for best practices in safe and effective use. Systems thinking is needed to develop effective and efficient EHRs to prevent patient harm.

Systems Thinking

Systems thinking is posed as a solution to improve the greater whole of informatics across systems of care. As an applied process, systems thinking is intended to influence cause and effect through collaborative effort. Interprofessional subsistence accomplishes trust and assurance for positive patient outcomes (Dolansky & Moore, 2013). The Systems Awareness Model provides seven steps to foster nurses' understanding of systems thinking and acquiring the necessary skills to lead in complex systems toward quality and safety (Phillips, Stalter, Dolanski, & Lopez, 2016). In this article, the model is modified to address informatics across systems of care, such as with transitions across the care continuum, because it is at such points of care that system-level breakdowns most often occur, resulting in errors, poor health outcomes, sentinel events (Makary & Daniel, 2016), and costly financial burdens (Adler et al., 2018).

The System Awareness Model is modified for informatics betterment and provides professional development educators with guidance to plan learning experiences and assessment activities that develop staff nurse knowledge and skill acquisition related to technology and informatics, which also leads to EHR improvement (Figure 1).

Systems Awareness Model modified for Informatics Betterment.

Figure 1.

Systems Awareness Model modified for Informatics Betterment.

Fundamental to system-level informatics betterment is valuing the QSEN Informatics competency (2019). The QSEN Informatics competency (2019) mandates the development of skills to employ communication technologies that coordinate care for patients. Table 1 is a table of technologies that provides tips (Stalter, Phillips, et al., 2019) to teach nurses about such things as nurse-sensitive indicators and preventing patient harm, which can be applied to more efficient and effective use of the EHR for nurses.

Teaching Strategies and Tips Using TechnologyTeaching Strategies and Tips Using Technology

Table 1:

Teaching Strategies and Tips Using Technology

Action Items

To apply systems awareness theory to practice, professional development educators can consider these key actions (Table 2). Each is aligned with the Alliance for Continuing Education in the Health Professions Continuing Education Health Professions (2014) (CEhp) National Learning Competency (NLC) Areas 1 to 4 to promote a systems perspective on fostering informatics betterment. CEhp NLC Areas 5 to 7 are inherent within continuing education program design, and CEhp NLC Area 8 (Alliance for Continuing Education in the Health Professions, 2014) focuses on systems thinking, which is subsumed in the process of a system-focused betterment program.

Key Actions to Apply System Awareness Model (SAM) to Practice for QSEN Informatics Competency and CEhp NLC Competency Areas

Table 2:

Key Actions to Apply System Awareness Model (SAM) to Practice for QSEN Informatics Competency and CEhp NLC Competency Areas

Future

Systems thinking for quality and safety may be integrated into health care through the QSEN Informatics competency by using teaching technologies to make improvements in the EHR, which can lead to improved patient outcomes related to quality and safety. For example, the Omaha System has been proposed as the most comprehensive system-level information model that embeds the EHR and measures outcomes and health quality. The Omaha System is accessible at the point of care for all professionals to use. It is an especially powerful tool for nursing practice, education, and research because it offers users simple words such as skin or pain in four domains (environment, psychosocial, health-related behaviors, and physiological) to classify outcomes. The Omaha System can be used in teaching practicing nurses about preventing patient harm (Eardley & Monsen, 2019).

A crosswalk (Stalter, Harrington et al., 2019) comparing QSEN (Cronenwett et al., 2007) and Technology Informatics Guiding Education Reform (2017) Competencies/Healthcare Information and Management Systems Society Competencies validated that the Omaha System encompasses informatics as a reasonable standardized language and classification system for specifying competency-based, inter-professional interventions that affect health outcomes across the health care continuum. Crosswalk authors recommended that nurse educators use creative approaches for teaching nurses how to use the Omaha System in education, practice, and research. The benefits of doing so result in informatics betterment or a redesigned EHR that meets the quality and safety needs of clinicians and patients, rather than business-focused assessments.

The QSEN Informatics competency suggests that nurses be involved with improving the EHR, which can also be used in the development of precision health and narratives for improving patient outcomes. According to Indiana University Precision Health, precision health enhances “the prevention, treatment and health outcomes of human diseases through a more precise analysis of the genetic, developmental, behavioral, and environmental factors that shape an individual's health” ( https://precisionhealth.iu.edu/). Another way to improve patient outcomes through the EHR has been seen in the THYME project (Temporal History of Your Medial Events), which is a joint project between the Mayo Clinic, the Children's Hospital of Boston, and the University of Colorado Boulder. It is funded by the National Institute for Health and aims to create novel technologies for processing clinical free text (narratives) to understand the time line of clinically relevant events for translational research to generalize large amounts of data (THYME, 2019), especially related to precision medicine.

In conclusion, professional development educators can use systems thinking to implement the QSEN Informatics competency to reap the benefits through a redesigned EHR, which meets the quality and safety needs of clinicians and patients, rather than business-focused assessments.

References

  • Adler, L., Yi, D., Li, M., McBroom, B., Hauck, L., Sammer, C. & Classen, D. (2018). Impact of inpatient harms on hospital finances and patient clinical outcomes. Journal of Patient Safety, 14, 67–73. doi:10.1097/PTS.0000000000000171 [CrossRef]
  • Alliance for Continuing Education in the Health Professions. (2014). National Learning Competencies (NLCs). Retrieved from http://www.acehp.org/p/cm/ld/fid=15
  • Atherton, J. (2011). Development of the electronic health record. Retrieved from https://journalofethics.ama-assn.org/article/development-electronic-health-record/2011-03
  • Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J. & Warren, J. (2007). Quality and Safety Education for Nurses. Nursing Outlook, 55, 122–121. doi:10.1016/j.outlook.2007.02.006 [CrossRef]
  • Dolansky, M.A. & Moore, S.M. (2013). Quality and safety education for nurses (QSEN): The key is systems thinking. Online Journal of Issues in Nursing, 18, 1.
  • Eardley, D. & Monsen, K. (2019). Interview [Video file]. In Eardley, D. & Jennen, D.. Using a standardized terminology for PHN assessment, intervention and evaluation: An introduction. Retrieved from https://metrostate.learn.minnstate.edu/shared/projects/OmahaSystem/Introduction/story_html5.html
  • Hochman, M. (2018). Electronic health records: A “quadruple win,” a “quadruple failure,” or simply time for a reboot?Journal of General Internal Medicine, 33, 397–399. doi:10.1007/s11606-018-4337-6 [CrossRef]
  • Makary, M.A. & Daniel, M. (2016). Medical error—The third leading cause of death in the US. British Medical Journal, 353, i2139. doi:10.1136/bmj.i2139 [CrossRef]
  • Middleton, B., Bloomrosen, M., Dente, M. A., Hashmat, B., Koppel, R., Overhage, J.M. & Zhang, J. (2013). Enhancing patient safety and quality of care by improving the usability of electronic health record systems: Recommendations from AMIA. Journal of American Medical Informatics Association, 20, e2–e8. doi:. doi:10.1136/amiajnl-2012-001458 [CrossRef]
  • Pagulayan, J., Eltair, S. & Faber, K. (2018). Nurse documentation and the electronic health record. Retrieved from https://www.americannursetoday.com/documentation-electronic-health-record/
  • Phillips, J.M., Stalter, A.M., Dolansky, M.A. & Lopez, G.M. (2016). Fostering future leadership in quality and safety in health care through systems thinking. Journal of Professional Nursing, 32, 15–24. doi:10.1016/j.profnurs.2015.06.003 [CrossRef]
  • Quality and Safety Education for Nurses. (2019). Informatic competency. Retrieved from http://qsen.org/competencies/prelicensure-ksas/#informatics
  • Stalter, A.M., Harrington, S., Eardley, D.L., DeBlieck, C.J., Blanchette, L.P. & Whitten, L. (2019). A crosswalk between the Omaha System and guiding undergraduate public health nursing education documents. Public Health Nursing, 36, 215–225. doi:10.1111/phn.12585 [CrossRef]
  • Stalter, A. M., Phillips, J. M., Goldschmidt, K., Ruggiero, J. S., Brodhead, J., Bonnett, P. L. & Scardaville, D. (2019, May). Innovative teaching strategies using technology for QSEN integration into practice: Steps to improving safety. Symposium conducted at the Quality and Safety Education for Nurses International Forum. , Cleveland, OH. .
  • Technology Informatics Guiding Education Reform. (2017). TIGER Informatics Definitions v3.0. Retrieved from https://www.himss.org/tiger-informatics-definitions
  • THYME. (2019). Temporal history of your medical events. Retrieved from http://clear.colorado.edu/compsem/index.php?page=endendsystems&sub=temporal

Teaching Strategies and Tips Using Technology

Teaching StrategyTips Regarding Challenges/Benefits/Costs
Unfolding case studies Definition: An electronic case study that can be animated and evolves over time in a manner that is unpredictable to the learner.Benefits: Team learning and collaboration, use of problem solving/decision making, use of technology, and reflection. Educators can assess/observe teams learning, use of technology, and assist learners in problem solving through the unfolding case. Challenges: Time consuming for educators to write/operationalize and grade. Learners find this to be a longer assignment and need time to complete it. Costs: Time for educators and learners. Minimal cost as learners work in groups in the learning management system and/or Google Drive.
Artificial intelligence /Digital Clinical Experience Definition: Smart technology for clinical experiences in online teaching and learning environment.Benefits: Strengthens skills, opportunity for self-reflection, and receives coaching throughout software use. Individualized student reports on areas of strength and weakness. Challenges: Need to be technically proficient and takes time to complete. Costs: Varies by use and educational level—may be able to trial.
E-journals Definition: Narrative writing in an electronic journal to connect theory and practice.Benefits:

Promotes critical thinking development, clinical reasoning, and judgment through educators' feedback.

Active learning/constructivist methodology through meaning-making in experience.

Provides a safe forum for voice and diversity.

Allows for educators and learners to note the engagement in various types of reflection present in e-journaling such as technical reflection, personal reflection, and critical reflection (movement along this continuum allows for systems thinking development).

Challenges:

Engagement in narrative writing and foundational principles of reflective practice.

Lack of previous professional and personal experiences in journaling may lend to a stressful learning experience.

Familiarity with a model or approach to guide e-journaling required to insure greatest benefits; method or model selected may vary with the past experiences of the learners.

Costs: Nominal for online course management or can use simple e-mail journal submissions.
Discussion boards and e-tutorials Definition: Discussion boards are online bulletin boards where nurses can leave and expect to see responses to messages you have left. Definition: E-tutorials are online educational self-studies.Benefits: The tutorials are interactive for video, audio, images, and quizzes. Learners can use on smartphone, tablet, laptop, or desktop. Challenges: Learning how to use. Costs: Individual or institutional licenses are available (ranges per agreement).
Evidence-based streaming videos Definition: An on-demand streaming video platform providing learners with a large collection of films and documentaries.Benefits: Emphasizes the affective domain of learning. Challenges: Learners must have fast and reliable internet to stream videos and gain access to online data-based library resources. Costs: Free.
Institute for Healthcare Improvement School Definition: Online training and tools for delivering excellent and safe care.Benefits: Comprehensive education of quality and safety basics; certification for learner portfolio and program marketing. Challenges: Aligning assignments to course objectives; maintaining up-to-date directions and Institute for Healthcare Improvement course numbers from one semester to the next. Costs: Free.
Gaming Definition: Online interactive educational games.Benefits: Engaging learning activity, well-received by learners, and allows for assessment of knowledge attainment. Challenges: Requires some technology knowledge and software. Costs: Varies by product.
Collaborative Learning Definition: Instructor-led online group learning.Benefits: Interactive learning and an engaging and novel approach to interprofessional education. Challenges: Can be resource intensive. Costs: Related to supplies needed.
Videos for peer review Definition: Use of shared videos for peer evaluation of learning.Benefits: Can effectively assess learners' application of knowledge, skills and attitudes in an online environment; peer interaction/review: self-reflection; coaching and mentoring; and debriefing. Challenges: Need to be technically proficient; progression depends on learner participation for series of assignments. Costs: Varies by use; may be able to trial.
Wikis Definition: Online asynchronous work-space for teams.Benefits: Appeals to adult learners, teamwork and collaboration, peer review, develops writing and technical skills, content expert. Challenges: learning curve, time consuming, requires technical savvy. Costs: None.
Voice-over feedback Definition: Use of audio or video feedback from instructors on learners' assignments.Benefits: Help learners achieve a greater level of comprehension of feedback from educator; feedback is more personalized; promotes a sense of belonging in relation to the program of study and in relation to the educators. Challenges: Easy to use, easy to embed/link audio or videos in a learning management system. Costs: Free or cost of purchase of software.
Vlog Definition: Video log or video blog combining video with text, images and other online data.Benefits: Can be used for later viewing or do live broadcasts. Potential for increased educator-to-learner and learner-to-learner interaction. A classroom vlog (video log) might consist of learners sharing their educational journey through the program or course. Challenges: The vlogger needs to be tech savvy; privacy settings need to be employed. Costs: Equipment costs include a computer with a microphone and camera.
Video conferencing Definition: A virtual set of tools designed for communication via audio, video, text chat, file sharing, whiteboard in real time and also can be recorded.Benefits: Promotes learner to learner interaction; records/captures class lectures; Learners can collaborate on team projects and shared documents; facilitates learners' discussions for distance education; learners can watch and attend presentations and repeat as needed; able to communicate with the presenter and collaborate with remote participants. Challenges: Learning curve (i.e., it is important to learn how to connect, set up audio controls and feel comfortable on screen). Costs: A health care organization subscription. If this is in place, typically no cost to participants for the service. Must have proper equipment and internet access.
Electronic rubrics Definition: An electronic scoring tool with performance expectations for a learner's assignment with varying levels of mastery.Benefits: Fair and equitable measurement of learning occurs—expectations are known by the rater and the student. Challenges: Rubric standards need to be evidence-based, valid, and reliable—training sessions will be needed for interrater reliability. Costs: Costs may include paying for valid and reliable instruments, or the cost of time and expert consultants to create the valid and reliable rubric may be incurred.

Key Actions to Apply System Awareness Model (SAM) to Practice for QSEN Informatics Competency and CEhp NLC Competency Areas

Key Actions to Apply SAM to Practice for QSEN Informatics CompetencyCEhp NLC Competency Areas
Offer staff development opportunities that teach and review EHR and technology basics.CEhp NLC Area 1.1 Apply adult learning principles in CEhp activities/interventions and overall program planning.
Employ technology that promotes active learning in staff development programming.CEhp NLC Area 1.2 Apply organizational learning principles in CEhp activity and overall program planning.
Provide digitally enhanced case studies to emphasize agency challenges.CEhp NLC Area 2.1–2.2 Implement CEhp activities/interventions to close health care professionals' practice gaps and address underlying learning needs. Develop CEhp activities/interventions with content that is valid, independent from the influence of commercial interests, balanced, and evidence based.
Establish QSEN Champions across the system who promote quality and safety among staff at vulnerable junctures, such as transition of care.

Educate QSEN Champions.

Evaluate QSEN awareness and adoption.

CEhp NLC Area 2.1–2.2

Implement CEhp activities/interventions to close health care professionals' practice gaps and address underlying learning needs.

Develop CEhp activities/interventions with content that is valid, independent from the influence of commercial interests, balanced, and evidence based.

CEhp NLC Area 3.1 Use evaluation and outcomes data to assess and determine:

The educational outcomes/results of the CEhp activities/interventions on participants' attitudes, knowledge levels, skills, performance, and/or patient outcomes.

Unmet learning needs.

The quality and success of CEhp activities/interventions.

Collaborate with health care technology personnel to develop templates within the EHR systems (i.e., EHR vendors) that demonstrate that safe and quality care has been carried out.CEhp NLC Area 3.2 and 4.1 Use evaluation and outcomes data to evaluate the impact of the overall CEhp program. Collaborate with internal stakeholder groups that can help maximize the impact of CEhp activities/interventions.
Collaborate with an Informatics nurse to monitor data related to quadruple aims correlating patient experiences: Aim 1 = outcomes, Aim 2 = lowered costs, Aim 3 = health care team well-being, and Aim 4 = best practice interventions and outcomes.CEhp NLC Area 3.2 and 4.1 Use evaluation and outcomes data to evaluate the impact of the overall CEhp program and its effectiveness in meeting the CEhp program. Collaborate with internal stakeholder groups that can help maximize the impact of CEhp activities/interventions.
Establish benchmarks and/or comparison trends within the system that infuse quadruple aims.CEhp NLC Area 4.1 Collaborate with internal stakeholder groups that can help maximize the impact of CEhp activities/interventions.
Exploit data across the system to demonstrate technology successes and failures, suggesting betterment actions: (a) Present what is working or what is not working to Evidence-Based Practice Council, Safety Team Meeting, or the like, (b) Present at professional conference venues.CEhp NLC Area 4.1 and 4.2 Collaborate with internal stakeholder groups that can help maximize the impact of CEhp activities/interventions. Collaborate with external stakeholder groups and key partners that can help maximize the impact of CEhp activities/interventions.
Authors

Dr. Phillips is Clinical Associate Professor, Indiana University School of Nursing; Dr. Stalter is Professor, Wright State University College of Nursing and Health, Dayton, Dr. Bonnett is Professor of Instruction, University of Akron, Akron, Ohio; Dr. Goldschmidt is Associate Clinical Professor, Drexel University, Philadelphia, Pennsylvania; Dr. Ruggiero is Associate Professor, Dr. Scardaville is Professor, New Jersey City University, Jersey City, New Jersey; Dr. Brodhead is Assistant Professor, Dr. Merriam is Assistant Professor, Daemen College, Amherst, New York; Dr. Provencio is Nursing Faculty and Lecturer, California State University, Stanislaus, California; Dr. Mckay is Associate Clinical Professor, University of Miami School of Nursing, Miami, Florida; Ms. Jowell is Clinical Instructor and Lecturer, University of Texas, Tyler, and Dr. Wiggs is Associate Professor, University of Texas Medical Branch, Galveston, Texas.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Janet M. Phillips, PhD, RN, ANEF, Clinical Associate Professor, Indiana University School of Nursing, 600 Barnhill Drive, Indianapolis, IN 46202; e-mail: janephil@iu.edu.

10.3928/00220124-20190814-04

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