Health care’s information technology (IT) revolution is rapidly raising expectations for novice nurses. Information technology has been identified as essential for improving care quality, access, and safety and as a core competency for all health professionals (American Academy of Nursing, 2003; Bakken, Cimino, & Hripcsak, 2004; Institute of Medicine, 2000, 2001a, 2001b, 2003b, 2004a, 2004b). The federal government’s mandate to link all health records electronically by 2014 will lead consumers to expect even more from nurses, who will be asked to provide health promotion and surveillance interventions across all levels of prevention (Booth, 2006; Ellis, 2004; Hersh, 2002; Nursing Informatics Collaboration Task Force, 2004; Saranto & Hovenga, 2004; Thompson & Brailer, 2004; U.S. Department of Health and Human Services, 2004). Health care institutions expect new nursing graduates to learn information systems quickly and to easily adopt evidence-based practice and emerging technologies (McCannon & O’Neal, 2003). However, there are no specific nursing accreditation standards guiding curricula or student outcomes in IT and information literacy.
Colleges of nursing vary considerably in their degree of infusion of these skill areas in theory and clinical courses (Carty & Ong, 2006). In 2006, a coalition of informatics, industry, nursing, and health care groups recognized a national problem and announced the Technology Informatics Guiding Education Reform (TIGER) Initiative (2006). The group aims to advance the integration of informatics core competencies into nursing education nationwide to bridge the quality chasm. One of the aims of TIGER is to advance nursing education and practice through the sharing of best practices. This report describes how one college of nursing pilot tested student evaluation using established informatics competencies to benchmark its graduates’ performance. The process yielded valuable insight for curriculum development and evaluation and policy.
Previous research informed the study, which was a larger evaluation project fulfilling a strategic plan objective. Evaluating nursing students’ IT competencies has been of interest since the mid-1980s (Hobbs, 2002; Staggers & Gassert, 2000; Stronge & Brodt, 1985). Staggers (1994) advanced informatics assessment by developing a data-based, comprehensive informatics competency instrument. Later work by Staggers, Gassert, and Curran (2001, 2002) served as the existing standard for competencies articulation, leveling, and measurement. Expert consensus was used to define informatics competencies for novice and experienced nurses, informatics nurse specialists, and nurse informatics innovators. These role definitions and related competencies were incorporated into the American Nurses’ Association’s (ANA) (2001) position statement articulating the scope and standards of nursing informatics practice.
Nursing students’ IT abilities and interventions designed to improve these competencies have been explored. In general, nursing students have been evaluated with weak to moderate informatics and technology knowledge, attitudes, and skills (Austin, 1999; Bryson, 1991; Gassert & McDowell, 1995; Jones, Navin, Barrie, Hillan, & Kinane, 1991; Staggers, 1994; Stronge & Brodt, 1985). Following formal training and hardware provision, modest improvements in basic knowledge and skills and fewer gains in advanced skills and information literacy have been found (Birx, Castleberry, & Perry, 1996; Cole & Kelsey, 2004; Graveley, Lust, & Fullerton, 1999; Marini, 2000; McDowell & Ma, 2007; Verhey, 1999). Improved skills have been associated with specific approaches, such as distance learning, (Cole, 2006; Kenney, 2002), the Nightingale Tracker system and personal digital assistants (PDA) (Miller et al., 2005; Ndiwane, 2005), and clinical simulation methods (Rhodes & Curran, 2005). Two recent surveys documented current and projected informatics and technology competencies for baccalaureate nursing graduates and raised concerns about how colleges of nursing are preparing future nurses.
In a national survey of 2000 randomly selected members of the Association of Nurse Executives, documentation and familiarity with medication administration systems were identified as critical new graduate competencies, and improved incorporation of these skills into nursing curricula was recommended (McCannon & O’Neal, 2003). These conclusions were seconded in a survey of 266 deans and directors of undergraduate and graduate programs (McNeil et al., 2003). Computer and information literacy skills were expectations of graduates at 80% of the schools surveyed, but the majority reported no formal evaluation of student competencies and rated faculty teaching informatics content at the “novice” or “advanced beginner” level. Thus, improving the integration and evaluation of IT competencies is a significant problem for nursing education.
The Staggers, Gassert, and Curran (2001) articulation of 43 novice nurse competencies serving as the foundation for the ANA’s Nursing Informatics: Scope and Standards of Practice (2001) served as the foundation for the project and survey instrument. The investigator (M.S.F.) adapted a survey instrument based on Staggers’ competencies that had been used successfully with faculty for students (Fetter, 2007). On each of the 43 novice nurse competencies, students were asked to rate their personal skill level using the following 3-point scale (i.e., 0 = no experience, 1 = minimal skill, 2 = some or moderate skill, and 3 = good skills or competent). Open-ended questions gathered student perceptions regarding theory and clinical courses, hardware and software requirements and skills, and general comments. Data regarding the competencies were tallied and compared; open-ended question responses were recorded and analyzed by content.
Forty-two graduating seniors participated (52% response rate); overall scores ranged from 1.1 to 2.9, with a mean of 1.95. In descending order, the top ranked competencies were: using Internet sources, using word processing, using the networks, using the operating systems, and using the keyboard. The lowest scoring competencies in ascending order were: using applications to document, creating a care plan, valuing informatics knowledge for practice, valuing informatics knowledge for skill development, and using applications for data entry. By comparing content categories, students’ reported strongest skills in computer use for communication and desktop software. Using documentation systems and valuing informatics knowledge were rated lowest.
Open-Ended Question Responses
Two thirds of the respondents submitted comments pertaining to clinical agencies, nursing course and laboratory offerings, and hardware. Students strongly expressed their desire for fair and maximum access to advanced computer technologies. They recommended selecting “super-user” settings and open access in all settings. In limited student access sites, “buddying” with staff nurses was suggested. At agencies, better computer training and support, specific documentation orientation, and reducing redundant training were advised. College learning laboratory access to and technological assistance with agency clinical computer systems was deemed worthwhile. Students claimed that it would expedite orientation, free-up clinical time, enable consistent exposure to and review of a variety of systems, and facilitate tracking of student competencies. Additional technical support for use during evenings, weekends, and “crunch times” was recommended.
Integrating IT into all clinical and theory nursing courses and setting minimum performance standards for students by course and year were recommended. Some students noted that after matriculation they needed a basic course in computing “to get up to speed,” especially prior to computerized testing. An optional minicourse on word processing was proposed, despite already existing in the technology center and online. The need for earlier mastery of skills in desktop publishing, spreadsheets, graphics, and Microsoft PowerPoint® was identified. Putting advanced clinical documentation and management material into a specific course, although not necessarily an informatics one, was recommended to ensure uniform exposure. Students want all course materials posted on the Internet but urged faculty not to abandon interactive teaching. Nearly every respondent wrote a comment recommending computerized testing with NCLEX-RN®-style questions on all examinations. The lack of off-campus availability of reference materials by the Internet was cited as inconvenient and unfair to students searching from clinical agencies and noncampus housing. It was a big concern for older and educationally disadvantaged students and for those placed in agencies lacking or denying Intranet and Internet access. Students called for easier and cheaper searching, interlibrary loan, full-text access, and printing. To improve information literacy, they noted their need for more help evaluating Web sites, particularly for course papers and evidence-based practice.
Computer technologies were endorsed by a majority of the students. PDAs provided by the college were rated very positively and recommended for all students and clinical faculty. More advanced PDAs and Smart Phones allow text messaging and e-mail communication. Therefore, they are useful at sites with limited computer access because they enable communication between clinical groups, agencies, and instructors. Students stated that PDAs facilitated information retrieval and research at the bedside and promoted independence and confidence. Concern was expressed about the emotional and psychiatric effects on patients and staff associated with the heavy use of technologies in clinical agencies, especially regarding the use of computers and PDAs by nurses engaged in direct patient care. Students also recommended requiring access to a laptop computer and mandating the use of a common platform, Microsoft Windows®. Such an initiative was planned by the university for the following year. The theft of expensive devices due to limited locked storage on clinical units was noted as problematic.
Students stated that they and faculty should be given standards and resources and be held accountable to meet performance expectations. Students claimed that some faculty members, particularly those not in clinical settings, seemed unfamiliar with informatics and its significance. They stated that this sent the wrong message to students. Students thought faculty should embrace IT to be proficient as teachers and role models. They stated that the college should develop and enforce IT policies such as required antivirus software and e-mail use, address abuses, and enforce penalties.
Several limitations suggested caution in generalizing the results of this survey. Of note, this evaluation project lacked the rigor of formal research. Students were surveyed using the nursing profession’s existing standards for IT competencies for novice nurses. The instrument was adapted by the investigator, and reliability data on how it performed were not collected. There are concerns that individuals overrate their abilities when using self-assessment scales. However, when compared with faculty ratings, students’ evaluations were lower, a difference that was not significant statistically. While the response rate was high, it is not known whether participants’ self-evaluations and comments are representative of nonresponders. However, students’ scores and remarks provide an in-depth window on graduating students’ perceptions of IT competencies and educational experiences.
These results have implications for nursing education, practice, research, and policy. The college concluded that its graduates are attaining a moderate level of novice nurse competencies. However, some striking inconsistencies were observed. Students clearly stated that they want clinical placements in the most advanced IT settings and endorsed enhancing competencies attainment. However, two of the four lowest scoring competencies pertained to valuing informatics knowledge and skill development to improve patient care. This may reflect students’ development in general, in that they may be more focused on learning specific skills prior to progressing to higher levels of competency attainment. Another potential explanation is that the nursing student experience fails to demonstrate IT’s advantages to patients and providers. Preparing written nursing care plans and using agency documentation systems may be perceived as an unnecessary duplication of work. Coupled with concerns that some nursing instructors are nonsupportive or unknowledgeable, a need to improve informatics content and instructional methods still exists. A comprehensive evaluation of one program’s curriculum and learning experiences confirmed this assertion (Ornes & Gassert, 2007). Future nurses need faculty members who role model not only technical skills but enthusiasm and knowledge about the field’s possibilities to improve care quality, access, and efficiency (Barton, 2005; Chastain, 2002).
Students’ described a wide variation of IT in agencies, clinical groups, and courses. Therefore, tracking placements to ensure exposure to highly IT-integrated settings is recommended. Programs should recognize that perceptions of unequal access, inconsistent policies, and redundant training will be reflected in negative evaluations of the teaching-learning environment. Clearly, clinical simulation has enormous potential to “even the playing field” and standardize teaching and evaluation (Jeffries, Rew, & Cramer, 2002; Ravert, 2002; Rhodes & Curran, 2005). That students viewed informatics training as encroachment on clinical time is disturbing. Whether charting on paper or using the most advanced information systems, documentation is a component of the nursing process. The answers to the world’s health problems literally are in the data, including reducing medication errors, analyzing cohort outcomes, and developing strategies to improve outcomes (Goodwin, VanDyne, Lin, & Talbert, 2003; Hripsack, Bakken, Stetson, & Patel, 2003; Lamb, Jennings, Mitchell, & Lang, 2004), Nursing programs are failing their students if they cannot inculcate this value and teach the knowledge and skills that will prepare nurses to advance IT to the next level.
These graduating students interpreted privacy and security issues from a student’s, rather than a patient’s, perspective. They expressed concerns about protecting their own information, hardware, and software. They also critiqued copyright violation resulting from downloading proprietary media and file sharing. Despite mandatory patient privacy and confidentiality education in theory courses and every clinical agency, as well as a formal ethics course, no students discussed these concerns. Experts fear that faculty and students are downloading, but not purging, sensitive clinical and personal patient information data (Ellet, Lane, & Keffer, 2004; Wimberly et al., 2005). The absence of this specific topic from the Staggers competencies may explain students’ failure to raise it in the open-ended comments. However, this topic warrants greater scrutiny for nursing and other affiliated health students in clinical agencies.
These future nurses made sophisticated and thoughtful recommendations that underscored the significance and aims of the TIGER Initiative. Colleges of nursing and health care agencies must collaborate to improve nursing students’ learning environments and experiences regarding informatics and technologies (Connors, Weaver, Warren, & Miller, 2002). Identifying barriers to student and faculty access will enable the development of strategies to enhance student learning. Partnerships between IT vendors, clinical agencies, and colleges of nursing could create solutions to these access problems. Another TIGER goal is the addition of informatics and information literacy variables to nursing education evaluation and accreditation. The use of the standardized competencies in this pilot study provided useful feedback for future instrument development. Some confusion in terminology and operational definitions, inconsistencies in roles and levels, and skills redundancies was evident. This probably reflects the speed of IT innovation and the evolution of the field from a focus on informatics skills acquisition to a focus on information literacy mastery (Barnard, Nash, & O’Brien, 2005). Finding a process for identifying reliable and valid IT nursing education competencies will be a formidable challenge for the profession as it attempts to fulfill this TIGER objective.
Nursing education leadership must answer the health informatics call. While national standards are developed, the Staggers competencies serve as an excellent benchmark for faculty, students, and practicing nurses. Strategic planning to set action plans to enhance faculty competence to teach informatics and conduct IT-related research is recommended (Sackett, Jones, & Erdley, 2005). Initiatives to strengthen faculty members’ informatics attitudes, knowledge, and skills and to support research applications will yield positive results for students, agencies, patients, families, and communities (McBride, 2005). It is time for the information revolution to transform nursing education.
Baccalaureate nurses need to meet current and future IT competency expectations. In a pilot study, a majority of a program’s graduating students rated themselves as having moderate ability on novice nurse standardized competencies. Inadequate access to information systems and technologies in clinical agencies and the college was a significant concern, which has implications for current and future learning, care delivery and quality, and student and program evaluation. Numerous recommendations for enhancing IT integration were elicited. These included improving faculty knowledge, skills, attitudes, and behaviors; standardizing and documenting student and faculty competency expectations and attainment; enhancing access to hardware, software, references, and support in agencies and colleges; improving privacy and security policies and instruction; and mandating specific hardware and software, such as laptops and PDAs. These results underscore the significance of the TIGER initiative as a catalyst for enabling colleges of nursing to cultivate environments in which IT flourishes to create societal health benefits.
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