Journal of Nursing Education

Nursing Information Technology Knowledge, Skills, and Preparation of Student Nurses, Nursing Faculty, and Clinicians: A U.S. Survey

Barbara J McNeil, PhD, RN-BC; Victoria L Elfrink, PhD, RN-BC; Carol J Bickford, PhD, RN-BC; Susan T Pierce, EdD, RN-BC; Suzanne C Beyea, PhD, RN, FAAN; Carolyn Averill, MS, RN-BC; Cari Klappenbach, BS

Abstract

ABSTRACT

Because health care delivery increasingly requires timely information for effective decision making, information technology must be integrated into nursing education curricula for all future nurse clinicians and educators. This article reports findings from an online survey of deans and directors of 266 baccalaureate and higher nursing programs in the United States. Approximately half of the programs reported requiring word processing and email skill competency for students entering nursing undergraduate programs. Less than one third of the programs addressed the use of standardized languages or terminologies in nursing and telehealth applications of nursing. One third of the programs cited inclusion of evidence-based practice as part of graduate curricula. Program faculty, who were rated at the "novice" or "advanced beginner" level for teaching information technology content and using information technology tools, are teaching information literacy skills. The southeastern central and Pacific regions of the United States projected the greatest future need for information technology-prepared nurses. Implications for nurse educators and program directors are discussed.

Abstract

ABSTRACT

Because health care delivery increasingly requires timely information for effective decision making, information technology must be integrated into nursing education curricula for all future nurse clinicians and educators. This article reports findings from an online survey of deans and directors of 266 baccalaureate and higher nursing programs in the United States. Approximately half of the programs reported requiring word processing and email skill competency for students entering nursing undergraduate programs. Less than one third of the programs addressed the use of standardized languages or terminologies in nursing and telehealth applications of nursing. One third of the programs cited inclusion of evidence-based practice as part of graduate curricula. Program faculty, who were rated at the "novice" or "advanced beginner" level for teaching information technology content and using information technology tools, are teaching information literacy skills. The southeastern central and Pacific regions of the United States projected the greatest future need for information technology-prepared nurses. Implications for nurse educators and program directors are discussed.

The U.S. health care system is facing a crisis as it seeks new ways to improve health care quality and safety for Americans. Concurrently, the United States faces a severe nursing shortage, partly as a result of nurses' dissatisfaction with current working conditions (Buerhaus, 2002; "Study finds," 1999). Professional organizations, including the Joint Commission on Accreditation of Healthcare Organizatione (JCAHO) and the American Academy of Nursing (AAN), are searching for solutions to these patient care crises. New and emerging technologies are considered essential to decrease medical errors and ease nurses' paperwork burden (AAN, 2002).

To improve the quality of patient care, the National Committee on Vital and Health Statistics (NCVHS) is developing strategies for a national health information infrastructure (NHII) that will help health care decision makers, including providers and patients, across all settings access and communicate health information in a timely manner (U.S. Department of Health and Human Services, 2001). Although the NHII identifies technology as a secondary concern, the NCVHS report underscores the need for health care providers to be skilled in using technology for these purposes. Because health care delivery increasingly requires timely information for effective decision making, information technology to support practice must be integrated into nursing program curricula to prepare graduates for nursing practice.

LITERATURE REVIEW

The importance of including information technology knowledge and skills (i.e., informatics) in nursing curricula is well supported in the nursing literature. Saba (2001) depicted the future of nursing in the 21st century and advised that computer technology must be part of professional nursing practice. Bakken (2001) stated that informatics competencies are an essential building block for evidence-based nursing practice. Many experts have documented the importance of preparing nurses for informatics practice (Carty & Rosenfield, 1998; Gassert, 1998; McNeil & Odom, 2000; Ronald & Skiba, 1987; Staggers, Gassert, & Curran, 2001). Organizations such as the American Association of Colleges of Nursing (AACN) (1998), the American Nurses Association (ANA) (2001), and the Pew Health Professions Commission (Bellack & O'Neil, 1998) also have established guidelines for inclusion of informatics content in nursing education.

In 1997, the Division of Nursing of the Health Resources and Services Administration (National Advisory Council on Nurse Education and Practice, 1997) convened the National Nursing Informatics Work Group, composed of 19 U.S. experts, to advise the National Advisory Council on Nurse Education and Practice on priorities for nursing informatics education and practice in the United States. From these recommendations, the National Informatics Agenda for Nursing Education and Practice was generated, as well as recommendations for including core computing and nursing informatics concepts in nursing curricula (National Advisory Council on Nurse Education and Practice, 1997).

The ANA (2001) recently revised the Scope and Standards for Nursing Informatics Practice. Within these standards, computer literacy skills, information literacy skills, and overall informatics competencies are delineated for beginning nurses, experienced nurses, and the informatics nurse specialists. Computer literacy skills include using word processors, databases, spreadsheets, e-mail, and other information technology applications to document care. Information literacy is a skill set that enables nurses to locate, access, and evaluate information. Access includes nurses' ability to conduct bibliographic retrievals and locate, retrieve, and evaluate information from the Internet. Overall informatics competencies are those relating to patient care, such as interpreting patient and nurse information, using informatics applications for nursing, and addressing information privacy, confidentiality, and security in nursing practice (ANA, 2001).

A complete review of empirical studies conducted in the past 15 years addressing the integration of information technology competencies and the progression of information technology in nursing education can be found in a recent article by Staggers et al. (2001). They concluded the integration of information technology knowledge and skills into nursing education curricula has been a slow process and no consistent curricula for nursing information technology exist in nursing education programs.

The article by Staggers et al. (2001) is the most recent work promoting information technology in nursing education. Using a literature review from 1986 to 1998 and input from a panel of nursing informatics experts, Staggers et al. (2001) developed 304 nursing informatics competencies for four levels of practicing nurses (i.e., beginning nurses, experienced nurses, informatics nurse specialists, informatics innovators). The broad categories and accompanying specific competencies should guide nurse educators in designing curricula to prepare nurses for all levels of professional practice.

The current study builds on recommendations from the National Informatics Agenda for Nursing Education and Practice (National Advisory Council on Nurse Education and Practice, 1997) and from professional organizations, as well as previous research, and seeks to determine:

* The extent to which nursing programs have incorporated recommendations for including information technology skills and knowledge into nursing curricula.

* How prepared nursing faculty are to teach information technology and use information technology tools.

* Perceived information technology knowledge, skills, and tools required by practicing nurses.

RESEARCH QUESTIONS

This article reports findings of a study examining perceived information technology competencies of nursing faculty, practicing nurses, and baccalaureate and master's prepared student nurses in the United States. The research questions were:

* What specific information technology knowledge and computing skills currently are being taught in nursing education programs across the United States?

* To what extent are faculty members prepared to teach this knowledge and these skills?

* What are the perceived current and future uses of information technology tools by practicing nurses?

METHOD

Instrument

The principal investigator (B.J.M.) secured a small faculty development grant from a regional state college in Idaho to partially fund the development of an online survey. The Information Technology Education in Nursing Curricula Survey was developed on paper and refined for submission to an online service, which reformatted the survey and managed responses.

Survey questions were developed from the literature, and content validity was established through review by nursing informatics experts serving on the ANA's Committee on Nursing Practice Information Infrastructure and the ANA's Nursing Information and Data Set Evaluation Center. The initial paper survey contained 11 broad categories of questions that resulted in an online survey version containing 37 discrete questions (Table 1).

Sample and Procedure

The AACN was contacted to first rent mailing lists of applicable individuals and later purchase a nie of e-mail addresses of deans and directors of baccalaureate and higher nursing programs in the United States. After obtaining human subject approval from the college's institutional review board, the principal investigator created mailing labels for all 672 member and nonmember baccalaureate and higher nursing programs in the United States, including the territory of Puerto Rico.

A letter outlining the purpose of the research, assigning a pass code for the online survey, indicating a deadline for submittal, and providing contact information for further questions was mailed to each dean or director. The letter also included a statement explaining that survey completion constituted consent to participate. Program deans and directors were encouraged to complete the survey or assign the task to an appropriate member of their programs.

Data, including date and pass code number for each participating program, were tracked on a weekly, then monthly, basis by the online service. This service, which was blinded to respondents, also managed the data collection. E-mail reminders of the deadline for participation were sent to deans and directors who had not responded after the first 6 weeks of the study. A second e-mail message notified deans and directors that data collection was extended for 2 months (i.e., until the end of July 2001). The reminder e-mails also included a link to the online survey.

A Web search was conducted to obtain names and email addresses for deans and directors whose e-mail was returned (re = 33). Twelve of 33 e-mail addresses were not found. Some respondents (n = 37) indicated reasons for not submitting the survey:

* No longer in director position (n = 10).

* On vacation, on sabbatical leave, or out of the country (re = 9).

* Not knowledgeable about the content (re = 8).

* Unable to access the survey (re = 10).

Three hundred fifty-seven deans and directors did not respond and did not provide reasons.

Attempts then were made to identify the appropriate individuals to complete the survey at programs that did not respond initially. Seven schools reported difficulty with link activation. Support from the online service was solicited to help respondents who reported they were unable to access the survey. In most cases, investigation revealed the inability to access the survey was due to the configuration of the school's computer systems. Requests (n = 7) for a faxed, rather than online, survey were filled.

Table

TABLE 1Categories of Questions on the Information Technology Education In Nursing Curricula Survey

TABLE 1

Categories of Questions on the Information Technology Education In Nursing Curricula Survey

The survey collected both quantitative and qualitative descriptive data. A spreadsheet data file obtained from the online service provided the data for generation of frequencies and cross tabulations using the Statistical Package for the Social Sciences (SPSS). Qualitative data were analyzed using Spradle/s (1979) ethnographic method and will be reported in a future article.

RESULTS

Two hundred sixty-six of 672 programs completed the survey, for a return rate of 40%. Of this sample, 172 (65%) were nursing program administrators, directors, managers, or deans, and 74 (28%) were nurse educators. Respondents represented all states within tibe United States and the territory of Puerto Rico, with the largest number of responses from the southeastern (i.e., District of Columbia, Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia.) and northeastern central regions (i.e., Illinois, Indiana, Ohio, Michigan, Wisconsin). Almost 50% of the respondents' programs served urban settings (n = 131, 49%), less than 33% served rural areas (re = 81, 31%), and almost 20% reported serving a combination of urban and rural constituencies (re = 46, 17%). Respondents' perceptions of information technology knowledge, skills, and competencies among students, faculty, and practicing nurses were identified.

Table

TABLE 2Categories and Specific Content Areas From the Information Technology Education in Nursing Curricula Survey

TABLE 2

Categories and Specific Content Areas From the Information Technology Education in Nursing Curricula Survey

Undergraduate Nursing Programs

Information Technology Knowledge and Skills. Information technology content categories are presented in Table 2, and frequencies of responses for nursing programs are shown in Table 3. For 50% of respondents (n = 132), the information technology content reported most frequently was "accessing electronic resources." Slightly less than 50% of respondents reported the "ethical use of information systems" (n = 121, 46%) and "computer-based patient records" (n = 121, 46%) were taught.

Thirty-seven percent of the programs (n = 98) reported "evidence-based practice" was a component of their curricula. Forty percent of the respondents (n = 105) selected "information technology nurse competencies" as content taught within their programs. Specific information technology content areas reported to be the least visible were the Unified Medical Language System (n = 30, 11%); data/information systems standards such as the American Society for Testing and Materials, the American National Standards Institute, and Health Level 7 (n = 15, 6%); and the Nursing Information and Data Set Evaluation Center standards for information systems (n = 14, 5%).

Computer Competencies Required for Entrance and Graduation. Perceived information technology skills or competencies required for entering undergraduate nursing programs are identified in Table 4. It is remarkable that only approximately 50% of U.S. baccalaureate nursing programs require undergraduate nursing students to enter with basic word processing (n = 135, 51%) and e-mail skills (n = 124, 47%). Approximately 25% of respondents expected students to enter with information literacy skills such as bibliographic retrieval via librarybased resources (n = 67, 25%) or the Internet (n = 59, 22%). Thirty-seven percent (n = 98) of programs required students to be proficient in use of the Internet and World Wide Web.

As expected, almost 80% of respondents expected students to demonstrate computer literacy skills (e.g., word processing, e-mail) and information literacy skills (e.g., bibliographic retrieval via library-based resources or the Internet, use of the Internet and World Wide Web) when graduating from their programs. Prior to graduation, student competence in using databases and spreadsheets was expected in only approximately 33% of programs. This finding mirrored programs' responses to a survey question related to their perceptions of the computer competencies of practicing nurses in the area - approximately 33% of practicing nurses were using database applications in their clinical work. The majority of programs reported that validation of computer literacy skills occurs indirectly through integrated course assignments. Others reported central validation strategies for students on graduation from the program included demonstration of competencies, completion of a computer course, or a computer literacy examination.

Table

TABLE 3Programs' Perceived Frequencies of Information Technology Content Taught in Nursing Programs (N = 266)

TABLE 3

Programs' Perceived Frequencies of Information Technology Content Taught in Nursing Programs (N = 266)

Graduate Nursing Programs

Information Technology Knowledge and Skills. The three information technology content areas (Table 3) reportedly taught most frequently were "accessing electronic resources" (n = 102, 38%), "ethical use of information systems" (n = 96, 36%), and "evidencebased practice" (n = 91, 34%). Only 34% (n = 91) of programs reported including evidence-based practice. As shown in Table 3, the lowest reported information technology content areas in graduate programs were the same content areas reported for undergraduate curricula - the Unified Medical Language System (n = 44, 17%); data standards such as ASTM1 ANSI, and HL7 (n = 36, 14%); and the Nursing Information and Data Set Evaluation Center standards for information systems (n = 32, 12%).

Information Technology Skills Required for Entrance and Graduation. As shown in Table 4, less than 50% of the respondents reported requiring computer literacy skills related to using e-mail (n = 103, 39%) and word processing (n = 108, 41%). Even lower percentages of respondents required information literacy skills such as use of the Internet and World Wide Web (n = 91, 34%) and bibliographic retrieval via library-based resources (n = 76, 29%) or the Internet (n = 69, 26%). The lowest reported expectations for nurses entering graduate programs were related to use of presentation graphics software (n = 41, 15%), database applications (n = 39, 15%), and spreadsheet applications (n = 32, 12%).

For each information technology skill expected on exit from graduate-level nursing programs, the percentages ranged from 48% to 4%. As expected, the highest percentages were in word processing and e-mail skills, bibliographic retrieval via library-based resources or the Internet, use of the Internet and World Wide Web, and use of presentation graphics software.

Table

TABLE 4Perceived Information Technology Skills Required for Entering Undergraduate and Graduate Nursing Programs (N= 266)

TABLE 4

Perceived Information Technology Skills Required for Entering Undergraduate and Graduate Nursing Programs (N= 266)

Table

TABLE 5Respondents' Perceptions of Information Technology Skills Taught by Nursing Faculty (N= 266)

TABLE 5

Respondents' Perceptions of Information Technology Skills Taught by Nursing Faculty (N= 266)

Faculty Information Technology Teaching and Preparation

Information Technology Skills Taught by Nursing Faculty. Fifty or more percent of nursing programs reported using nursing faculty to teach information literacy skills, such as bibliographic retrieval from both library-based resources (n = 144, 54%) and the Internet (n = 150, 56%) and are using nursing faculty to teach use of the Internet and World Wide Web (n = 132, 50%) (Table 5). Approximately 33% of programs reported nursing faculty are teaching the computer literacy skills of e-mail (n = 94, 35%), database applications (n = 82, 31%), and spreadsheet applications (n = 73, 27%).

Average Level of Faculty Preparedness for Using information Technology Tools and Teaching Nursing Information Technology Content and Skills. Using Benner's (1984) novice to expert framework, only 2 programs rated their nursing faculty as experts in teaching and using information technology. Most nursing programs (n = 103, 39%) rated their faculty at the advanced beginner level. Significantly, 18% (n = 48) of programs reported their faculty as novices. Twenty-nine percent of nursing programs (n = 78) reported their faculty members were at the competent level. However, 46% (n = 122) of programs reported either no future plans or no knowledge of any plans to offer information technology education or training in their region.

Evidence of a Champion of Nursing Information Technology in Nursing Programs. More than 75% of nursing programs indicated there was a champion information technology user in their nursing program. Champion information technology users are individuals who are users, strong advocates, promoters, and/or supporters of the use and adoption of information technology and it applications. This finding reflects support for information technology education in nursing curricula.

Nurses' Use of Information Technology Tools

Information Technology Tools Used by Practicing Nurses. Respondents indicated the information technology tools currently used most frequently by practicing nurses included remote monitoring devices, online consumer health tools, and handheld computers (Table 6). When asked to predict the tools nurses will be using 5 years in the future, respondents identified similar information technology tools (e.g., remote monitoring devices, online consumer health tools, mobile computers, handheld computers) (Table 6).

Need for Information Technology-Prepared Nurses. Seventy-three percent of respondents (n = 194) indicated nurses in their regions currently were performing information technology work. More than 50% of respondents reported a moderate to high need for nurses prepared for information technology positions in health care. In the next 3 years, 81% (n = 213) of nursing programs projected the need for information technology-prepared nurses will increase greatly (n = 108, 41%) or somewhat (TI = 105, 40%).

The greatest percentage of programs per region currently perceiving a moderate to high need for information technology-prepared nurses were from the southeastern central, northeastern central, Pacific, or southeastern regions of the United States. Compared to other regions, respondents from the southeastern central and Pacific regions most frequently projected the need for information technology-prepared nurses will "increase greatly" in the future. Nursing programs in the mountain region of the United States (i.e., Montana, Idaho, Wyoming, Nevada, Utah, Colorado, Arizona, New Mexico) represented the lowest percentage related to planning for information technology training or education for practicing nurses, faculty, or students in the next year.

Table

TABLE 6Respondents' Perceptions of Current and Predicted Use of Information Technology Tools by Practicing Nurses (N =266)

TABLE 6

Respondents' Perceptions of Current and Predicted Use of Information Technology Tools by Practicing Nurses (N =266)

SUMMARY

The findings of this study were used to address the three research questions. The results have implications regarding curricula for preparation of future nurses and nurse educators and their abilities to use information technology tools to manage clinical data.

In examining the findings related to the first research question (i.e., the specific information technology knowledge and computing skills currently being taught in nursing education programs), the data indicated current baccalaureate nursing programs are addressing computer literacy skills, rather than information literacy skills. Expectations for information technology skills are low for students entering both undergraduate and graduate nursing programs. There are many gaps in information technology content taught at both levels. For graduate and undergraduate programs, accessing electronic resources was emphasized, and content related to evidence-based practice was less visible within the curricula.

The findings related to the second research question (i.e., the extent to which faculty members are prepared to teach information technology knowledge and computing skills), are unclear regarding the breadth and depth of the information technology skills possessed by nursing faculty. Many respondents noted that information technology experiences, such as use of databases and spreadsheets, were included in nursing curricula but did not link use of these applications to nursing clinical practice.

Although information technology content and skills may be present in nursing curricula, it is not evident whether nursing faculty are teaching this content and these skills. The data indicate a gap exists in the knowledge needed by nursing faculty to prepare nurses to be skilled in information technology and its use to manage clinical information in daily practice. According to Connors, Weaver, Warren, and Miller (2002), educators who teach with advanced technologies need to "develop new skill sets and reengineer their pedagogical approach so that technology itself remains transparent to the learning process" (p. 233).

The findings related to the third research question (i.e., the perceived current and future uses of information technology tools by practicing nurses) underscore the need for nurse generalists and specialists to be knowledgeable and skillful in using information technology tools. In addition, the findings provide further support for more nurse informatics specialists and nursing faculty with informatics expertise. Therefore, although current baccalaureate education efforts are focused on basic computer literacy, nursing faculty do perceive the need for including information technology skills and literacy skills for data management and data and information processing in nursing curricula.

LIMITATIONS

As with any online survey, variations may exist in respondents' levels of computer literacy and technology available to participate in this type of survey (Schleyer & Forrest, 2000). Limitations of this study include the following:

* All respondents were not sufficiently knowledgeable about the information technology needs of their regions or programs.

* Some information technology terms may have been unfamiliar to respondents.

* Question content possibly was confusing to respondents who were unfamiliar with information technology terms and concepts.

* Reliability of survey questions was not established.

* Only input from baccalaureate or higher nursing programs was solicited.

CONCLUSIONS AND RECOMMENDATIONS

This study provides empirical evidence of the critical need to include information technology concepts, skills, and tools in nursing curricula across the United States. The deans and directors perceived a growing need for information technology specialists and nurse educators prepared to lead changes related to information technology. Noticeably, the data indicated the information technology competencies and tools used most by practicing nurses (e.g., remote monitoring devices, handheld computers, online consumer health resources) currently are not identified as expected outcomes of U.S. nursing program graduates. It would be useful to know how these tools currently are being incorporated into curricula to prepare nursing students for practice.

The majority of nurse educators primarily are at the novice or advanced beginner level regarding use of information technology tools and skills, such as word processing, bibliographic retrieval, and graphics presentation software, and perhaps have had few opportunities to gain expertise with these tools and skills in daily nursing practice. However, the need for information management in daily nursing practice is increasing. Therefore, the need for faculty to be knowledgeable and skilled in information technology is paramount. From the results of this study, it is clear faculty development opportunities in information technology are critically needed to ensure faculty achieve a level of competence needed to prepare future nurses for professional practice.

The fact that 75% of programs reported having a champion information technology user is positive and reflects a group of faculty who are interested in promoting the integration of information technology concepts and skills in nursing program curricula. When considering the competence levels of faculty in this study, it may be that nursing programs should select these champion information technology users for additional faculty development opportunities in this area. Although the majority of programs reported having a champion, it still may be a challenge for nursing programs to find and fund sufficient information technology training to help faculty achieve the necessary level of competence.

It was interesting to find that respondents indicating there were no current opportunities for information technology training also indicated they were unaware of or had no future plans to offer nursing information technology education and training in their region. This finding underscores the need for additional education of nursing directors and faculty specifically addressing the importance of information technology for supporting evidencebased health care. How can nursing graduates be prepared to deliver evidence-based practice within the changing world of nursing information technology if a knowledge gap exists among nurse educators and nursing programs do not include information technology content?

Nursing programs should examine the outcomes of the project entitled ?-Health Delivery System, created by a partnership between the University of Kansas School of Nursing and Cerner Corporation (Connors et al., 2002). ?a this project, curriculum content includes virtual case studies that help students "think in a datadriven mode that, in turn, provides the foundation for evidence-based practice" (Connors et al,, 2002, p. 230). The nursing program uses Cerner Corporation's clinical information system software for order entry, data repository, clinical documentation, and clinical decision support tools in a live-production environment." (Connors et al., 2002, p. 230). Clinical data management concepts are taught through applications within a clinical information system.

The challenge for nursing programs will be to close the ever-widening gap between education and practice. Ongoing funding of baccalaureate nursing education, faculty development opportunities, and creative partnerships is critical to continue fostering the innovations and new models of practice and education that promote integration of information technology solutions in all settings and make evidence-based nursing practice possible.

REFERENCES

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TABLE 1

Categories of Questions on the Information Technology Education In Nursing Curricula Survey

TABLE 2

Categories and Specific Content Areas From the Information Technology Education in Nursing Curricula Survey

TABLE 3

Programs' Perceived Frequencies of Information Technology Content Taught in Nursing Programs (N = 266)

TABLE 4

Perceived Information Technology Skills Required for Entering Undergraduate and Graduate Nursing Programs (N= 266)

TABLE 5

Respondents' Perceptions of Information Technology Skills Taught by Nursing Faculty (N= 266)

TABLE 6

Respondents' Perceptions of Current and Predicted Use of Information Technology Tools by Practicing Nurses (N =266)

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