As the American Association of Colleges of Nursing (AACN) has stated in the AACN: Position Statement: Nursing's Education Agenda for the 21st Century (1993), nursing education must encompass the requirements for entry into practice and, to the greatest extent possible, anticipate the requirements for nursing practice in the future. With the complex clinical practice of the 21st century, nurses will face escalating information management challenges. Not only will they have to process and communicate more information than ever before, but the nature and types of information they must handle will change. Information technologies can help nurses meet the challenges only if nurses can effectively use these technologies. As the use of computer technology and information science increases in nursing practice, education, and administration, so will nurses' need to be skilled and knowledgeable in the use of information technology (Hannah, 1985; Ozbolt, Schultz, Swain, & Abraham, 1985; Ryan, 1985; Saba & McCormick, 1995).
One challenge facing educators is to develop nurses' abilities to handle a wide range of information technologies. Computer equipment permeates all aspects of care. Computerized information systems, electronic monitoring devices, and microprocessor implants are but a few of the computerized devices nurses encounter (Hannah, Ball, & Edwards, 1994; Saba & McCormick, 1995). Besides computerized devices, nursing practice of the future will rely heavily on automated imaging systems, telecomputing, and robotics. Nurse educators face a challenge not only to make nurses technologically competent but also to produce a new type of graduate who will excel in acute care clinical practice through the effective use of information technologies.
Developing technical competence among students necessitates exposure and training in the psychomotor skills necessary to use computers in nursing. However, technical competence includes not only equipment competence but also skill in the efficient use of information (Arnold & Pearson, 1992). Grier (1981,1984) noted the problems that inefficient information handling causes nurses. To avoid incorrect diagnoses, cumbersome assessment strategies, and inappropriate problem identification, it is imperative that nurses recognize from the beginning of their education that, like the basic sciences, information science is a supportive discipline for nursing. Therefore, preparing nurses to face the information challenges of the future requires a solid grounding in information sciences. Simply teaching computer applications in nursing will not provide nurses with the skills to critically appraise their information needs and evaluate the utility of gathering information in patient care (Romano, 1985; Hannah et al., 1994).
This article describes the design, implementation, and evaluation of an integrated nursing informatics curriculum currently in place in the undergraduate nursing program at Frances Payne Bolton School of Nursing of Case Western Reserve University. The undergraduate program includes:
* A focus on acute and critical care nursing.
* A bedside nursing emphasis.
* Strong clinical experience throughout all 4 years, beginning in the first semester of the curriculum.
* Development of a professional nursing identity through personal connections with nurses in clinical settings.
* Well-defined links to three hospitals that provide the clinical experiences for students.
Nursing informatics courses are integrated throughout the 4-year basic nursing curriculum, introducing students to nursing vocabularies, computer systems, and the application of information technologies to patient care (Horsburgh, 1991; Mikan, 1984; Ronald, 1981). Case Western Reserve University was able to carry out the nursing informatics curriculum in part because the University has a well-developed fiber optic network (CWRUNET) that supports a variety of teaching strategies. Students can access the university network from student laboratories and their dormitory rooms. Each dormitory room is equipped with an outlet for connecting to the computer network giving immediate access to the network. Approximately 60% of incoming first-year students own computers (Travis et al., 1991; Travis, Hoehn, Spees, Hribar, & Youngblut, 1992).
FOUNDATION OF THE CURRICULUM
As a first step in designing the nursing informatics curriculum, major schools of nursing were canvassed to learn what informatics coursework they encouraged or required of their students. It was discovered that while all these programs expected their students to be computer literate, their focus was on keyboard and programming skills rather than on the application of information technologies to the science of nursing. An understanding of computers, or computer literacy, is necessary but not sufficient for nursing practice. To ensure that practitioners can meet the challenges the future holds, it is essential to incorporate the full range of informatics into the education of nurses. Educators must assure that nursing students view the integration of technology into the support of patient care as the appropriate focus of nursing. A broad definition of clinical informatics centered on core nursing data supported by material on computers and information technologies was adopted.
Faculty at the school with expertise in informatics, curriculum development, and evaluation met to develop the plan and content of the nursing informatics courses within the context of the undergraduate curriculum. Consultants from nursing operations and nursing information system specialists were included in the discussions to assure an integrated perspective. Recommendations set forth by Peterson and Gerdin-Jelger (1988) and Ronald and Skiba (1987) were reviewed for guidance in the design. The curriculum reflected the advances in technologies and demands of the marketplace as outlined in Neighbors and Eldred (1993) and reported by those who have endorsed specific level requirements for informatics in baccalaureate and graduate education programs (Heller, Damrosch, Romano, & McCarthy, 1989; Heller & Romano, 1988; Romano, Damrosch, Heller, & Parks, 1989).
The baccalaureate curriculum is designed to provide the content needed by nurses working primarily in acute care. The disciplines on which the informatics core of the curriculum rests include nursing science, information science, computer technology, and the quantitative foundations of nursing (Graves & Corcoran, 1989; NCNR Priority Expert Panel on Nursing Informatics, 1993; White, 1987). Supporting coursework in computer science or information science is not required; rather, key content is incorporated into the four courses in the sequence. In developing the curriculum, the following definition of nursing informatics was used. Nursing informatics is a
combination of computer science, information science, and nursing science designed to assist in the management and processing of nursing data, information, and knowledge to support the practice of nursing and the delivery of nursing care (Graves & Corcoran, 1989, p. 228).
Zwolski's (1989) principles related to professional nursing in a technical system were also followed:
technique is distinguishable from technology, a technique cannot produce the philosophy that directs it, technology at its incomplete and imperfect stages creates new problems and technology produces fragmentation (p. 239).
A four-course sequence was established in which each course develops both conceptual and technical skills. Argyris and Schon (1974) suggest that clinical field experience in a professional nursing program should not be designed merely to allow students to learn accepted practices but should also provide students with opportunities to try out new approaches and modalities of care. To accomplish this, the application of information technology was also incorporated into students' clinical experiences. The hospitals serving as clinical agencies are in the process of selecting a nursing information system. Therefore, students have various opportunities to observe applications in the nursing practice environment.
When the informatics sequence was instituted, faculty expertise in nursing informatics and the teaching of informatics was limited. Initially, nursing informatics consultants assisted in presenting the course content. Also, new faculty with expertise in informatics were sought, but this presented a challenge because there was a limited pool of faculty qualified in this field. Consequently, various strategies, including peer coaching and role modeling, were used to assist faculty in developing knowledge and proficiency in nursing informatics. Additionally, attendance at appropriate conferences was supported, and experts were brought in to present 1-day and 2-day conferences on nursing informatics.
Figure 1: Frances Payne Bolton School of Nursing, Case Western Reserve University - Building a solid foundation in nursing informatics.
To increase the application of information technology in clinical experiences in specific nursing courses, the students' mentors and clinical teaching associates attend an all-day conferences on clinical decision making designed to help them increase students' understanding of nursing informatics. Support for the development and purchase of curricular hardware, software applications, and faculty development was received from The Cleveland Foundation, Prentiss Foundation, and an anonymous donor.
Nursing informatics courses are designed to fit with the clinical experience and course progression followed by the nursing students. The three basic components of the model that provide a framework for the curriculum are information, technology, and clinical care process (Figure 1). Each course addresses the three components; however, the emphasis on these components varies.
The first course in the nursing informatics sequence is NURS 120 Nursing Informatics I Introduction (2 credits). The emphasis is on the information and technology components with little involvement with the clinical care process because students have had limited clinical experience. The course is scheduled in the second semester of the first year. The focus is on helping students identify the content, flow, and processing of patient information in the hospital. The hospital is presented as an information processor, and the course is based on the premise that the foundation of interdisciplinary communication and decision making is information generated by the patient and through caring for the patient. The information examined is reviewed within the context of the nursing process and the role of the nurse as the gateway for patient information. The course provides an overview of the key players in the health care environment and the ways in which they influence care delivery. It is also designed to build an understanding of computer technologies and the ways in which nurses can access computers to support them in delivering patient care. The primary objective is to give students a basic understanding of the flow of information through the health care environment and the ways in which information technology can facilitate collecting, processing, and communicating this information.
The second course, NURS 222 Nursing Informatics II (1 credit), prepares students to handle the information encountered in the clinical area. A computerized hospital simulation program, TLC-General Hospital, is used to help students apply classroom concepts to technology and is placed in the campus fiber optics network. This broadbased hospital simulation program presents the student with the opportunity to view a sample electronic patient record not available at local hospital clinical sites. The course focuses on the process of accessing and documenting, as well as critically analyzing, the computerized patient care record. This hands-on introduction to nursing informatics nurtures an exploration of and appreciation for the computerized patient record. It also examines the formation, processing, and examination of data and clinical information generated during care delivery.
In the third course, NURS 345 Nursing Informatics III: Clinical NIS (2 credits), the focus is on the intersections of the three components: information, technology, and clinical care process. The emphasis is on the use of information technologies to support nursing management in clinical applications. This course is offered either in the second semester of the third year or the first semester of the fourth year. It focuses on providing students with an understanding of the relationships between nursing applications and hospital-wide computer applications and the impact of nursing interventions on other departments' information processing. Students also develop a thorough understanding of the current and future state of nursing information systems and physiological monitoring systems and their potential for enhancing the nursing process. In addition, students have an opportunity to examine the process of planning, designing, developing, implementing, and evaluating nursing information systems in a clinical environment.
The benefits of information technology and the application of system analysis concepts to the decision-making process are included. Selection and evaluation of a nursing information system as well as the fit between the nursing information system and the nursing care delivery system are covered. Lastly, ethical issues related to use and storage of patient-related data are addressed.
The fourth and final course, NURS 346 Nursing Informatics IV (2 credits), incorporates the knowledge learned in previous courses to build a perspective on the adoption and use of nursing information systems to assist nurses in their decision making. It is offered in the final semester of the undergraduate program. This course provides hands-on experience for students in selected areas of application in nursing informatics. The course is a project-based course, in which students are grouped into teams of five to seven members to work on agency-specified projects.
The projects that form the core activities of Nursing Informatics TV originate in the hospital and meet needs within the hospital environment. The relationships of the students with clinical agencies help students better understand the nature of information management within the agency and meaningfully participate in informatics projects. To initiate projects, the course instructor meets with key personnel in each of the participating agencies, including nurse administrators, clinical nurse specialists, and information systems coordinators. The concept of nursing informatics projects is explained as encompassing any work required to enhance nurses' ability to obtain, manage, store, or manipulate the data necessary for practice. Agency personnel are asked to identify four to six projects per hospital and to provide the following information for each project: title, objectives, products or outcomes, special considerations, and deadlines. Projects requiring approximately 6 weeks (200 hours) of work are sought. Projects have included:
* Developing a scannable form for recording the critical path of patients with cardiac surgery.
* Constructing a database to help a nurse practitioner-lactation consultant manage her practice.
* Proposing a data access policy for a large university teaching hospital.
* Creating a database to enable staff on a psychiatric inpatient service to conduct follow up on patients.
* Generating charts and graphs from a mainframestored, hours-worked data set.
* Devising a database and screening system to predict patients at risk for discharge planning challenges.
* Establishing the information flow of an out-patient ultrasonography service.
* Providing off-hours backup and training support for a hospital bringing up a new hospital information system.
* Defining the information requirements necessary to support a continuous quality improvement project.
The projects vary in the extent of computing skill necessary to conduct the work and the amount of face-to-face interaction required to complete the tasks. Some projects had no need for computer systems; others, such as the database creation activities, required specific computer skills. All of the projects have challenged students to work with an agency staff member to define project products or outcomes, interact with peers in a task-focused manner, and apply prior nursing informatics knowledge to solve real-world problems.
Effective evaluation of innovative curricula requires appraisal of three dimensions: course evaluation, student performance, and employer appraisal. Course evaluations are conducted using both formative and summative strategies. Course faculty review course objectives and activities, making necessary corrections in the content and workload. Students evaluate each course in terms of the accomplishment of objectives, learning effectiveness, and appropriateness of resource material. Program faculty appraise the articulation of the courses within the entire baccalaureate curriculum.
Course faculty meet on a semester basis. The course objectives were defined in advance of the program's inception, and with one exception, they have been found to be adequate and appropriate. The second course in the sequence was the exception. This course originally emphasized basic mathematics concepts as core content for informatics. The faculty responsible for the course decided that greater emphasis on applications of technology, such as expert systems, would better meet students' learning needs. One challenge faced by course faculty is stimulating participation by students in courses viewed as "not clinical" by members of a clinical major. To solve this problem, faculty increased the clinical relevance of course assignments in the informatics courses. Another ongoing challenge is the disparity between the advanced nursing informatics content presented in the classroom and the lack of sophisticated information technologies for nursing found in the clinical area.
Student evaluations of the informatics courses have ranged from enthusiastic to discouraging. Questioning the relevance of nursing informatics to the curriculum has persisted despite students' appraisals that the courses did achieve course objectives. Students most preferred guest lectures offered by nursing informatics specialists from local hospitals, and they bemoaned the lack of a good, comprehensive, and relevant textbook. Students would have preferred a text to the compilation of articles that were identified for content support. Initially, however, available textbooks concentrated on computer use rather than taking a more comprehensive approach to informatics and were, therefore, too limited to be used for these courses. Textbooks that are more relevant and broader in scope are becoming available.
Figure 2. Comparison of mean scores of clinical practice scale by level in program and year of entry in program.
Figure 3. Comparison of mean scores of scientific use scale by level in program and year of entry in program.
Program faculty generally have supported the nursing informatics curriculum. Faculty discussions help reduce redundancy in material. For example, clinical faculty are reassured that content about documentation is adequately covered in the nursing informatics courses and does not need to be repeated. Based on the recommendations of faculty, more content was introduced into the informatics sequence to help students deal with basic mathematical concepts necessary for nursing.
A longitudinal study, which has extended over a 5-year period, was conducted to evaluate outcomes with respect to both students' attitudes and knowledge acquired. At the beginning and end of the first course, a survey was administered to evaluate first-year students' attitudes toward computers and nursing informatics and to assess knowledge, usage, and ownership of computers. The instrument that measures students' attitudes and knowledge regarding computers and nursing informatics was adapted from a 22-item questionnaire used by McConnell, O'Shea, and Kirchhoff (1989) in a study of RNs' knowledge and attitudes. The instrument includes three subscales: Clinical Care Process, Scientific Use, and Common Misconceptions. Instrument development and preliminary results have been published (Travis et al., 1991, 1992; Travis & Youngblut, 1993; Travis, Youngblut, & Brennan, 1994).
After each course, the students were assessed on knowledge and attitudes using the same instrument. Data analysis was conducted to evaluate changes in the students' knowledge and attitudes after completing each of the four courses. Repeated measures analysis was not possible because the data was collected in a way to maintain anonymity for students. Data reported in this article includes the first and second groups of students to complete the four informatics courses; there were 93 students in the first group and 89 students in the second group. A comparison of the two groups' mean scores from the instrument's three subscales (clinical care process, scientific use, and myths) is presented in Figures 2, 3, and 4.
The evaluation data suggest that for the students who responded to the survey, attitudes and knowledge about computers and nursing informatics changed over time. Students became less idealistic and more realistic in their appraisals of information technology in nursing.
Students' responses to the survey questions were on a Likert scale from 1 to 5, with 5 representing the most positive. Statistical analysis yielded no significant differences. Because of the low variation in the scoTes, the mean scores are reported. For example, the lower mean scores on Clinical Care Process after the fourth course probably represent the students' attempts to respond to the "gap between education and practice" (Travis, Hudak, & Brennan, 1995). Indeed, scores on this scale were significantly lower for each year after the first year, indicating a continuing process of reconciling theoretical content presented in class with the realities of the clinical setting. Students' knowledge and attitudes about nursing informatics became more practical with increasing exposure to the clinical arena.
Anecdotal information from employers about graduates' performance appraisals was also collected. Preliminary performance appraisals from three hospitals where most graduates were employed indicated the graduates' ability to use informatics within their clinical practice. Anecdotal reports from three agencies were positive and indicated an initial cost savings in orientation to information technology on the nursing units. All agencies reported a decrease in the amount of time required to acclimate the new graduate to existing information systems. One agency indicated that the informatic portion of orientation was substantially decreased, while another said that the informatic portion would be made optional for graduates of this program. In most cases, the graduates were able to effectively use the information resources of their employing institutions well within the orientation period.
Figure 4. Comparison of mean scores of myths scale by level program and year of entry in program.
It is important to note that the informatics curriculum does not include specific orientation to those systems currently in use in employing institutions. It is also interesting that the lack of congruence between various hardware and software configurations of employing hospitals did not pose a problem to graduates of this program. Along with the decreased amount of time required for orientation, this supports the view that when students are exposed to common informatics concepts within the context of information, technology, and the clinical care process they can become contributing members of the health care team within a relatively short period of time.
The four-course sequence continues to be included in the curriculum. Because the current health care environment is characterized by technological advances, external pressures, and rapid change, the four-course sequence continues to evolve to prepare professional nurses to practice in changing environments.
The nursing informatics sequence represents a successful curriculum innovation. The content presented helps students gain conceptual and psychomotor skills necessary to effectively use information technology in practice. Ongoing evaluation by students and faculty ensures the relevance and timeliness of the curriculum and its contribution to students' future development as professional nurses. The curriculum offers one example of a strategy to achieve the AACNs (1993) mandate to prepare students for future practice challenges.
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