Dr. Kennedy is Clinical Assistant Professor, Dr. Pallikkathayil is Associate Professor, and Dr. Warren is Christine A. Hartley Centennial Professor, School of Nursing, University of Kansas, Kansas City, Kansas.
The authors thank Dr. Helen Connors, Associate Dean of Academic Affairs, and Karen Miller, Dean, School of Nursing, University of Kansas, for their contributions to the development of the SEEDS learning innovation. This study was funded by the 2004 Taunton Millennium Scholar Award from the School of Nursing, University of Kansas. This article was presented at the 10th Kansas Nursing Research Exchange, Overland Park, Kansas, November 2005.
Address correspondence to Diane Kennedy, PhD, ARNP, Clinical Assistant Professor, School of Nursing, University of Kansas, 3901 Rainbow Blvd., Kansas City, KS 66160; e-mail: email@example.com.
At the turn of the century, faculty from a midwestern university school of nursing implemented a new learning method that reflects the burgeoning technology of current health care systems (Connors, Weaver, Warren, & Miller, 2002). An electronic health record created by a premier vendor of health care information technology was modified to introduce beginning nursing students to the concepts of documentation, nursing process, and embedded low-level decision support. The impetus for the curricular innovation came from landmark studies conducted by the Institute of Medicine that recommended the use of information technology to improve health care quality and minimize human error (Institute of Medicine Committee on Quality Health Care in America, 2000a, 2000b).
The Simulated E-hEalth Delivery System (SEEDS) project includes small groups of beginning nursing students, led by a nursing instructor, who are given written case studies for the purpose of entering patient data in the modified electronic health record. During four 90-minute SEEDS classes, each student and the teacher had individual computer access that provided hands-on navigation through the modified electronic health record. Using the technology, a care plan for the patient and family in the case study was developed by each student.
To support further curricular improvement, a rich description of the students’ educational experience with the SEEDS project was needed. Therefore, the purpose of the study was to describe the experiences and behaviors of beginning nursing students using a modified electronic health record to develop a care plan for case study patients. Two research questions were posed regarding use of a modified electronic health record with low-level decision support during formal didactic instruction:
- What experiences and behaviors were reported and demonstrated when beginning nursing students entered, analyzed, and interpreted patient data from written case studies?
- What experiences promoted and what behaviors demonstrated an active and engaged learning process?
The sensitizing literature suggested that the preferred future of safe, effective health care must begin with curricular innovation that incorporates clinical informatics in nursing education. To survive in the information age, professional nurses must quickly assimilate new information and knowledge in developing a care plan (McBride, 2005). According to the American Association of Colleges of Nursing (1997), nurses must be formally prepared:
as knowledge workers—able to manage information and high technology on the one hand and complicated clinical judgments on the other. (p. 5)
Nurse educators must effectively use technology as a learning tool (National League for Nursing, 2005
) and prepare lifelong learners who can function in an information-rich world (Connors et al., 2002
Clinical informatics allows health care providers to electronically record, retrieve, integrate, analyze, and interpret data (Meadows, 2002). The information technology becomes the vehicle for interpreting multiple perspectives and constructing contextually appropriate knowledge (Jonassen, 1999). Snyder-Halpern, Corcoran-Perry, and Narayan (2001) described the dynamic clinician roles in informatics. First, the nurse must be an astute data gatherer who collects information useful in creating a realistic care plan. Second, the nurse is an information user and knowledge user who evaluates patient progress and modifies care according to evidence-based knowledge. Finally, the expert nurse is a knowledge builder who aggregates clinical data, examines patterns, and compares trends to findings in extant literature (Berger & Berger, 2004).
Patient safety and staff efficiency improved when nurses and other providers acclimated to these roles (Kawamoto, Houlihan, Balas, & Lobach, 2005; Priselac, 2003; Sipe, Marthinsen, Baker, Harris, & Opperman, 2003). As the practice environment improved, open learning teams were able to devote more time for evaluation of clinical patterns, as well as application and development of new knowledge (Deese & Stein, 2004; Pipe, Wellik, Buchda, Hansen, & Martyn, 2005). To enable this level of sophistication and team participation, nurse graduates must be “techno-savvy” (Sipe et al., 2003, p. S35).
Design and Method
Case study design was used to yield descriptive data (Yin, 1994). The case was a seminar group of 8 beginning nursing students led by a teacher. The group composed a criterion, nonprobability sample from a school of nursing in a midwestern university medical center located in a metropolitan area. Our investigation was approved by the university institutional review board and written consent for videotaping participants and verbal consent for interviews were obtained. Investigational procedures included:
- Observation of the four SEEDS seminar sessions with simultaneous videotaping.
- Semi-structured, open-ended interviews with 5 students and the teacher.
- Evaluation of care plans generated during the learning activity.
Data analysis occurred simultaneously with data collection “so that each informed the other” (Mariano, 2001, p. 371). Videotapes were viewed several times so observations and conversations could be recorded accurately. Similarly, audiotaped interview data were transcribed precisely. Raw data were reviewed frequently to identify initial themes. Data were coded and related codes were arranged according to emerging categories. Overlapping categories were collapsed to eliminate redundancies. In the final stage of analysis, two foundational themes and a concluding theme emerged. Several methods were used to ensure trustworthiness of the data:
- Source triangulation.
- Process and terminal member checks.
- Peer debriefing.
- Reflexive journaling.
- Thick description (i.e., rich contextual description of student experiences and behaviors).
Demographic and descriptive data suggested that study participants had significant past exposure to information technology and were current users of technology. The 5 students who volunteered for interviews were in their early 20s. Students and the teacher reported regular use of e-mail, the Internet, and word processors; owned a computer or lap-top; and had at least one educational experience using some form of technology.
Triangulation of Study Data
During each of the SEEDS classes, students worked through the nursing process exercise successfully. From the teacher, they received start-up instructions about the modified electronic health record and quickly became acclimated to the technology. Investigators described:
very attentive students who were interested in the screens and were able to “jump in” and explore the electronic health record without a lot of assistance.
Although visual fragmentation of data may have reduced the students’ ability to grasp an immediate holistic view of the patient, students valued the efficiency in using the technology. They appreciated the visual clarity in identifying problems, missing data, and diagnoses:
because it gave the systems of the body, and you could see that you focused a lot on that system, and I bet there will be a diagnosis that comes out of that system for sure…. I liked how it prompted you for everything.
Although several students recognized that patient data not found on the computer screens could be relevant to care, the technology was viewed as:
efficient for the most part…. It definitely helped you organize your thoughts and have a definite…problem list…. I could see the individual areas that needed special attention or more care.
The teacher summarized the students’ experience with entering and analyzing patient data. She commented:
They are not really learning the electronic health record. They are learning [the nursing] process. I think the actual tool [the modified electronic health record] became invisible to them. They were just going in there and doing it and really learning [the] nursing process.
We agreed with the teacher that the student care plans written during the SEEDS classes were satisfactory. While using their care planning textbooks, students successfully identified patient problems in 25 of 30 care plans. Little evidence in the care plans supported creative approaches if outcomes were not met. However, students overwhelmingly reflected on contextual aspects of care and suggested multiple solutions in achieving desired outcomes.
The blend of technically competent students and the teacher, data-rich case studies for performing the nursing process, and a strong technological infrastructure created a positive learning experience. In addition, students viewed technological decision support and embedded information as helpful. Students described the class as “fun” and desired more experience with the technology:
I wish we would have had more practice…. The class seemed to fly by…. Since I am doing clinicals right now, if I hadn’t been exposed to doing computer charting, I would feel kind of lost and uneasy and uncomfortable with charting on the computers in the hospital.… I’m like oh, this is just like the SEEDS class. It is awesome.
Students viewed the SEEDS activity as a hands-on exercise. They valued the simultaneous seeing, hearing, and doing aspect of the class:
It was the access right there, the computer [was] right there. Actually seeing and doing at the same time, not just learning about it and then going and doing it.
The technology itself allowed a learner-centered application of course content. One student said:
We were kind of putting everything together from lecture and applying it.
Another student identified a distinct difference between the SEEDS classes and the traditional lecture format:
You are more hands-on. And, you’re applying it [theory] more, whereas I get bored in class easily. I kind of space out a lot in lecture. I just sit there, and [think] “what did she say?”…. Yes, I think it is more applying. It is like it makes you start understanding everything and putting everything into place. Whereas in the class, no!
With videotaping during the four 90-minute classes, we captured approximately 230 student-teacher interactions and approximately 70 student interactions. All exchanges were collaborative and often benefited others in the class. The seminar teacher often moved among the students to closely monitor their work and help them at their desks. A student commented:
She [the teacher] would kind of guide us by questioning us back or making us think a little bit harder.
Student-teacher interactions were initiated usually by the student with a question, and without raising a hand. Questions from one student often triggered a question from another, or the question prompted the teacher to address the whole class. A student said:
Well, when we had questions, we asked them…. When they had problems, maybe you were having the same problem.
Students inquired about prioritizing problems, terminology, disease processes, physical assessments, problem statements, and navigational issues. One student said:
I liked the small group. Like I always feel a lot more comfortable asking questions with just a few people around.
With the teacher as the facilitator, a genuine student-centered learning experience occurred. According to one student:
I felt like we talked a lot and we were helping each other…like just kind of all learning together how to work the program itself, and more kind of discussion on what would be the best first priority diagnosis to use…just debating back and forth.
Thematic Interpretation of Findings
Although our sample was small, data saturation from all data sources occurred with several key points. The points are noted in the two foundational themes and the concluding thematic statement (Figure).
Figure. Foundational Themes.
Techno-savvy Students and Teacher, Simulated Technology, and Data-Rich Case Studies: A Valuable Hybrid SEED for Learning. During the SEEDS seminars, the underpinnings for success in learning the nursing process were integrated. The 3-part integration produced a valuable hybrid SEED for student-centered learning. A strong technological infrastructure provided fertile soil for planting the hybrid SEEDS that blossomed quickly into the next foundational theme.
Seeing, Hearing, and Doing: A Catalyst for Application and Spontaneous Interaction. Students viewed the SEEDS classes as a fun, interactive, seeing-hearing-doing experience that enabled application of theory. Creating a care plan generated frequent questions about the technology and nursing concepts. The triangulated data suggested that the SEEDS classes promoted an engaged, hands-on learning. Through these simulated activities, students experienced gathering data and using data while performing the nursing process. As a result, the concluding thematic statement became apparent.
Honing the Data Gatherer and Data User Roles With a Modified Electronic Health Record: An Authentic, Learner-Centered Experience. The technology provided an interactive venue for developing nursing process skills by linking assessment data from case studies with foundational concepts in nursing. Questions and discussions were usually driven by the learning needs of the students. Real-time student needs were handled promptly after they completed the nursing process exercises. The experience was authentic, dynamic, and learner centered.
The evidence base for contemporary learning approaches in formal nursing education can be informed and strengthened with qualitative findings that provide a descriptive richness (Sublett, 2006). When students have fun in a class, teachers can feel encouraged. If teachers embellish the seeing, hearing, and performing activities of the SEEDS method, Neuman’s (2006) futurist vision of electronic nursing education is reinforced.
Students appreciated the visual prompts provided by the technology, which could train the mind to develop critical thinking habits. Critical thinking computer prompts may afford developmental triggers that accelerate the journey from novice to expert.
Building the modified electronic health record so data from other patient care settings are included in the SEEDS activity could bridge the data user to the next level of information user. “Writing the electronic patient story” (Deese & Stein, 2004, p. 341) can produce a powerful narrative for decision making. When using stored electronic data to augment the case study, the contextualized learning described by Jonassen (1999) comes alive. Role-play simulations and video clips of nurses working with patients have improved student confidence (Goldenberg, Andrusyszyn, & Iwasiw, 2005; McConville & Lane, 2006). Similarly, including a virtual reality of patient care vignettes during the SEEDS sessions could extend the hands-on activity to another realm of authenticity and may promote student confidence and poise.
Seminar sessions following clinical practice set the stage for dynamic discussions about patient care. In seminars, students may work as an open learning team (Korhonen & Paavilainen, 2002). The group may discuss the patient’s story and use the electronic health record to document assessment data and develop a care plan. Students would be using informatics to manage information and collaborating to meet evidence-based standards, which are educational goals described by the Institute of Medicine Committee on the Health Professions Education Summit (2003).
Descriptive empirical evidence that demonstrated student support for learning with technology was encouraging. However, whether the SEEDS activity accelerates learning and improves learning outcomes has not been measured. The following hypotheses build on the study themes:
- During postclinical conferences, technologically competent students who use a modified electronic health record for documentation of patient data and care planning for the next day of practice will demonstrate more interactive discussion among students and teacher, experience greater learner satisfaction, and demonstrate better nursing process skills than will students who participate in the traditional postclinical group discussion about patient care.
- Following didactic instruction about nursing care of a patient with a specific disease, technologically competent students who use a modified electronic health record with embedded decision support to enter patient assessment data from a case study about the disease and then develop a care plan will communicate greater learner satisfaction, demonstrate better nursing process skills, and attain higher test scores on the specific topic than will students who organize the assessment data and develop a care plan with paper and pencil.
In our study, beginning nursing students acknowledged the value of information technology in learning the art and science of nursing. Using a modified electronic health record to develop a care plan for patients in case studies was a student-centered, positive experience. We are encouraged that the technology-based underpinnings of the SEEDS project may prove to nourish the seeds of authentic learning for many generic nursing students.
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