The world is in the midst of an informatics revolution. Informatics is reconfiguring our world view from linear, hierarchical, and separate structured realities to overlapping, interacting concepts and disciplines (Nelson & Staggers, 2008). Recognizing this revolution, the federal government first called for an Electronic Health Care Record for the majority of Americans by 2014 (Raymond, 2004). President Obama’s stimulus package, the American Recovery and Reinvestment Act of 2009, addresses the improvement of health care services by specifically targeting health information technology (Title XIII) and the development and implementation of electronic health record systems (EHRS). All three major professional nursing associations, as well as a national nursing informatics coalition, have published policy statements that support competency in nursing informatics for all practicing nurses, as well as nursing students (American Association of Colleges of Nursing [AACN], 2008; American Nurses Association [ANA], 2008; National League for Nursing [NLN], 2008; Technology Informatics Guiding Education Reform [TIGER], 2009). The NLN identified the importance of preparing the next generation of nurses to practice in a technology-rich environment and called on faculty, deans, administrators, and the NLN itself to advocate that all students graduate with up-to-date knowledge and skills in each of three critical areas: computer literacy, information literacy, and informatics (NLN, 2008).
The Institute of Medicine’s (IOM) Quality Chasm series identified that the quality of patient care would improve when safety is assured. To that end, the faculty members of the Quality and Safety Education for Nurses (QSEN) panel adapted the IOM’s competencies for nursing by proposing definitions that described essential features of respected and competent nursing (Cronenwett et al., 2007). Knowledge, skills, and attitudes (KSAs) for each defined competency were developed for prelicensure nursing education programs. Of the six competencies identified by the IOM and defined by QSEN, informatics was listed last because informatics KSAs were deemed essential for developing the other five QSEN competencies. By achieving KSAs in informatics, nursing graduates will have the ability to apply information and technology to communicate, manage knowledge, mitigate error, and support decision making (Cronenwett et al., 2007, p. 129).
Nurses must have immediate access to current patient data to deliver safe and effective care. The goal of all EHRS is to allow that immediacy of access and facilitate communication among multiple caregivers. Nursing students and new graduates who are competent in the use of EHRS will be competitive in the professional marketplace. As a key to safe patient care outcomes, informatics has been incorporated by the AACN as an essential curricular component necessary for accreditation of baccalaureate nursing programs (AACN, 2008). With informatics competencies, nursing students will learn about the strengths and limitations of EHRS to access essential information at the point of care, communicate across disciplines and settings, coordinate care, and guide patients more effectively through the many transitions that comprise the health care experience. The new nurses’ KSAs will develop as the professional nurse develops and participates fully in design, selection, and evaluation of information technologies that support safe patient care (Cronenwett et al., 2007, p. 130).
Most health care organizations are slowly adopting EHRS, and nursing students are being introduced to this technology. However, to have informatics successfully integrated throughout nursing curricula, there is another challenge that must be addressed first: nursing faculty must become knowledgeable about EHRS. In a survey of undergraduate deans and directors of 266 U.S. nursing programs, faculty members were rated at the “novice” or “advanced beginner” level in teaching informatics content (McNeill et al., 2003). In research evaluating computer competencies in a BSN program, Ornes and Gassert’s (2007) findings supported earlier reports that nursing faculty were the greatest block to incorporating technology into curricula. Fetter (2008) surveyed nursing faculty at one mid-size sectarian university and reported that participants admitted the need to embrace information technology. In the Fetter study, faculty recommended that they themselves acquire more consistent and advanced knowledge and skills and that, like students, expectations for faculty performance in informatics should be standardized and documented. The NLN (2008) reported considerable confusion among the 2,097 deans, directors, and nursing faculty respondents to a 2006 e-mail survey regarding what nursing informatics entails and what constitutes the necessary knowledge to practice in an informatics-rich environment. Regarding acquisition of informatics knowledge and skills, 80% of faculty in the NLN survey stated that they were self-taught.
Recognizing the challenges of threading informatics throughout nursing curricula, nursing faculty from a large urban public university with a diverse student population received a grant to increase skills in the use of health-related technology-based information systems. The nursing school’s mission is to address the health care issues of urban, underserved populations in New York City. About 70% of the undergraduate prelicensure nursing students (N = 200) are members of racial and ethnic minorities, and most of the graduates remain in nursing positions within New York City (Ebenstein, Weinberg, Dale, & Croke, 2009). The nursing school is part of the nation’s largest public urban university system and is bordered on both sides by large public hospitals: the flagship of the largest municipal hospital system in the United States and a federal medical center. Clinical rotations occur in these, as well as in many academic medical centers and voluntary hospitals.
Purpose and Conceptual Framework
The aim of this research was to explore nursing faculty perceptions of teaching undergraduate nursing students documentation skills using either paper-based or EHRS. The researchers were interested in conducting this exploration within the context of the self-efficacy model. Educational systems have undergone fundamental changes during historical periods of cultural and technological change (Bandura, 2006). In her concept analysis of self-efficacy, Zulkosky (2009) underscored the roles of beliefs, perceptions, and experiences of mastery and defined self-efficacy as a person’s perceived capability to perform a behavior. Perhaps Bandura (1982) best explained the phenomenon of faculty persistence to overcome obstacles and develop new skills within the construct of perceived self-efficacy—the causal predictor (motivation) of behavior is one’s belief in the capability to perform an act. Furthermore, self-efficacy explains a situation-specific confidence that indicates the level at which one believes one can successfully perform a task (Bandura, 1997). Faculty are motivated to acquire a new skill if they have confidence that they will succeed and if they believe in the outcome. Key to the successful learning of new skills is the cyclical nature of self-belief, self-confidence, and self-efficacy: “Greater efficacy leads to greater effort and persistence, which leads to better performance (a new mastery experience), which in turn leads to greater efficacy” (Woolfolk Hoy, 2004, p. 2). Nursing faculty are aware that persistence and practice are foundational for the self-efficacy that leads to successfully acquiring new knowledge and skills. Positive attitudes lead to knowledge and skills that, when successfully acquired, result in ongoing positives attitudes that continue the process of successful learning.
Research studies document the role of self-efficacy in successful learning outcomes for nursing students who gain confidence, comfort, and competence as they begin working with real patients (Jenkins, Shaivone, Budd, Waltz, & Griffith, 2005), as they engage in health promotion principles in their daily practice (Laschinger, McWilliam, & Weston, 1999), and as they become more aware and practiced in providing cultural care (Lim, Downie, & Nathan, 2004). The same concepts of self-efficacy apply to nursing faculty as they continue to navigate new technology territory and are renewed and motivated by new successes.
The study protocol was approved by the college’s institutional review board. Participation was voluntary and participants had the right to withdraw from the study at any time. Faculty members were interviewed by the one researcher (P.Y.M.) who was not a member of the college’s Personnel and Budget Committee and who therefore was not involved with decisions regarding hiring, reappointment, tenure, and promotion considerations. The project’s administrative assistant transcribed the interviews, and confidential identifier codes were assigned. No identifying information was used at any time. The interviews were stored and secured on the computer in password protected files.
Letters of invitation to participate and informed consent were mailed to all faculty teaching prelicensure nursing students in hospital settings. Each potential participant received a letter describing the study and a written consent form. Interested faculty made an appointment with the faculty interviewer at a mutually convenient time. Each confidential, in-person interview took approximately 25 to 50 minutes to complete and consisted of the faculty interviewer, the faculty participant, and the research assistant who assisted in transcribing events occurring during the interview. The guide questions consisted of 13 items—7 closed-ended questions and 6 open-ended questions. After each interview was transcribed, the faculty participants were offered the opportunity to review their transcript for accuracy.
The school of nursing is focusing initial efforts to integrate technology in the prelicensure undergraduate programs because these students are younger, probably digital natives, and have had no prior exposure to EHRS in clinical settings. To gain insight into the perceptions of nursing faculty teaching these prelicensure students, the researchers surveyed full-time and part-time faculty who taught undergraduate nursing students in clinical settings. Sixteen full-time faculty were eligible and invited to participate in the survey, and 15 full-time faculty accepted and completed the survey (94% response rate). Fourteen part-time adjunct faculty were eligible, and 10 accepted and completed the survey (71% response rate). In total, 25 of 30 eligible faculty were surveyed (83% response rate). Participants were experienced faculty; they had taught in this school of nursing a median of 3 years (range, 1 to 19 years); taught clinical courses a median of 5 years (range, 1 semester to 25 years); and had practiced nursing with a minimum of a masters degree in nursing for a median of 11 years (range, 1 to 31 years).
Because this was an exploratory study, the qualitative constant comparative method (CCM) was used to analyze the data and identify significant patterns across individuals and among groups. This process was repeated until the researchers assessed the saturation point of data clustering and recurring patterns of theme identification. The research team chose the CCM because it is an analytic procedure for generating theory in a systematic way. The constant comparison of incidents on the basis of as many of their similarities and differences as possible brings out underlying uniformities and diversities and accounts for differences with single, higher level concepts (Glaser, 1965, p. 444). The goals of the CCM are to discern conceptual similarities, to refine the discriminative power of categories, and to discover patterns. In this way, researchers can develop a theory inductively by categorizing, coding, delineating categories, and connecting those categories (Boeije, 2002).
The process of CCM is both descriptive and explanatory. CCM internal validity occurs when data categories are understood within context (Dye, Schatz, Rosenberg, & Coleman, 2000), and internal validity of findings increases when comparisons are highly regarded (Boeije, 2002). External validity is achieved when data are understood through comparison (Dye et al., 2000). Sampling that has been conducted in a reasonably homogeneous sample provides the basis for generalizing the concepts and relationships between them to units that may be absent from the sample but which represent the same phenomenon (Boeije, 2002, p. 393).
As a team, all three researchers reviewed the transcripts, noted responses across each open-ended survey item within each interview, and coded categories of responses to determine the core message or the storyline. The team then compared each response to open-ended items on the interview guide across interviews and coded categories of responses to determine patterns and themes. Categories were compared until saturated and delimited to achieve parsimony of variables and a more applicable scope of the theory.
Four major themes emerged based on direct quotes, codes, categories, and clusters (Table).
Table: Summary of Major Themes
Theme 1: Teaching Strategies
Without exception, every faculty participant identified teaching documentation skills through a demonstration-return demonstration method. Through both group and one-on-one instruction, faculty reviewed some examples of nursing notes using textbooks or samples from the medical record such as “I first review the hospital’s documentation system… then I orient students to the hospital’s documentation requirements.” Students write a draft note for their assigned patient that faculty correct and edit, and then co-sign after the student entered the information into the clinical documentation system. Continuing group discussion of documentation principles along with individual editing of student’s notes were identified as leading to successful note writing by students. Rationale for this group as well as one-on-one teaching-learning strategy was to enhance documentation skills and stimulate critical thinking. Faculty felt strongly about the value of this method, even though the recurring sentiment was: “It’s very time consuming to check through ten student notes twice—their initial note and then corrected copy and then countersign. But I feel this is the best way.” From participants’ general comments about documentation, almost all faculty wondered if and how much documentation was taught in lecture, as well as in the college laboratory, and believed they taught the bulk of clinical documentation in the clinical areas. For example, “Sometimes documentation material is not covered in lab. This puts both the student and me at a disadvantage because it takes time in pre-conference and post-conference and on the floor to teach the students.” Faculty were most vocal regarding the perceived amount of time spent on teaching documentation in the clinical area both to the group and with each individual student. Respondents reported spending a median of 2 hours (range, 30 minutes to 4 hours) of an 8-hour clinical day on refining documentation skills for a clinical group of 8 nursing students.
Theme 2: Learning from Experts
This theme arose from discovering ways of knowing that came from two primary expert sources: the nursing faculty and the staff nurses in the clinical setting. Faculty highlighted well-written staff RN notes to emulate, helping students write organized, succinct, and meaningful notes: “I look for good examples written by the staff nurses and have students follow that example.” Not only did students learn from the role-modeling provided by faculty and staff, but the students themselves also role-modeled as a result of faculty’s structured critique in each clinical course:
- I try to pair a student who is good at documenting with one who needs a lot of help. It usually works out well.
- In post-conference, I have the students read their progress notes out loud. The other students correct it… [and] it gets better as the semester goes along.
In clinical settings using EHRS, faculty noted that both they and their students were highly reliant on staff nurses who were proficient in the hospital’s EHRS. Faculty in these settings reported EHRS challenges centered on inordinate amounts of time necessary for orientation to the system, establishing passwords, and acquiring access to the system. Obstacles to the flow of faculty work included staff nurses who were unable to sufficiently assist faculty and students, insufficient numbers of computers for faculty and student use, time taken to log on with each student and multiple time-outs (automatically logged off) per session, and repeating this sequence of time-consuming activities for each clinical setting because different hospitals had different EHRS. Faculty who felt they and their students had met with success documenting using the hospital’s EHRS credited finding reliable staff nurses who could assist them and the students to “problem-shoot” and “find shortcuts.”
Most faculty recognized the potential increased convenience of computer-based documentation, but a few expressed doubt that documenting in electronic records contributes to nursing expertise:
- Students are more motivated to learn but I do not know if electronic documentation is helping them to document.
- Endless drop-down menus are annoying, take too much time, and don’t promote critical thinking.
Theme 3: Road from Novice to Expert
This theme emerged as students’ experience grew, skills were honed, and perceptions of professional roles broadened as they progressed through the program. Initially, faculty identified that students must “unlearn” inadequate writing habits, although all of the undergraduate students had completed at least 60 credits of liberal arts requirements before entering the nursing program. In the first clinical course, Fundamentals of Nursing, faculty identified challenges in paper-based documentation that focused on students’ varying language abilities, including limited English proficiency, grammar, syntax, legibility, and spelling. A frequent observation by faculty was students’ unfamiliarity with medical terminology and incorrect use of abbreviations. Frustration was expressed at students’ inability to develop a written entry that was organized and succinct:
- Students over documented.
- Students had too many anecdotals and did not focus.
- Students need to write more specifics on goals that were set. They forgot to write how they would revise plans, goals, and treatments.
Faculty noted that the “challenge in each semester is how to translate clinical assessment into clear and precise documentation.” They also said, “Students must overcome emotional block to fear and hard time assessing patient.”
To help students overcome these challenges, faculty reported success over time with paper-based documentation through the process of repeated student note writing, faculty edit, and student rewrite of corrected note. Faculty cited that “practice is key” for successful documentation in a paper-based system and that frequent reinforcement of the nursing process framework, body systems entries, SOAP (Subjective, Objective, Assessment, Plan) notes, SBAR (Situation, Background, Assessment, Recommendation) notes, or other agency-specific documentation policy formats was time consuming but productive. Faculty noted that in junior year many students are told by staff RNs that they were writing too much. By senior year, faculty noted that this rarely happens and staff usually described senior student notes as clear and concise: “Juniors wrote too much info according to staff, not me. Seniors received repeated feedback…staff describe their notes as clear and concise.”
Theme 4: Legal-Ethical-Institutional Issues
The last theme concerns legal-ethical-institutional issues. Institutional policies on documentation, all designed to assure patient protection, served as an enormous constraint on faculty and students alike. Fifty-eight percent reported experience teaching EHRS. One faculty participant stated, “The training process for the hospital’s computerized system takes away too much time from clinical…. There is limited availability of computers on the unit for student use.” Every faculty respondent identified similar circumstances along with their concern for fulfilling legal and ethical responsibilities to the patient in terms of adequately documenting the care provided by the students they supervise. Faculty expressed concern about potential liability issues because “I have a code for medication administration—only I (the instructor) have a code…. Students use my code.” Each clinical setting only issued an EHRS access code to the faculty instructor and then each of the 10 students in the instructor’s group used the faculty member’s code.
This study explored how nursing faculty perceived teaching documentation skills to prelicensed nursing students in clinical settings that have either paper-based systems, electronic systems, or both. Findings demonstrated how faculty attempt to overcome the myriad obstacles encountered during the process: time expenditures and constraints, language challenges for a diverse student population, lack of access to secure patient documentation systems (software), and insufficient numbers of computer terminals (hardware).
Strengths include reporting faculty perceptions of their experiences teaching documentation across the undergraduate clinical courses and comparing their solutions to continuing obstacles in both paper-based as well as EHRS. With a national average of faculty age well in the 50s (AACN, 2005), most nursing faculty have long practiced paper-based documentation. The uniformity of responses underlying the first major theme of teaching strategies for documentation using paper that is filed in a paper-based medical record reveals that faculty have attained a plateau of comfort in this area. Regardless of setting, faculty members express confidence teaching paper-based documentation skills because of long-standing experience and success in this medium. Faculty cited obstacles to success in teaching paper-based systems as attributable to student factors such as students’ lack of familiarity with terminology or students’ inexperience in general. System or faculty (self) related problems were not cited.
In a paper-based system, faculty efforts have been rewarded and reinforced many times over the years, and faculty respondents in this study expressed the level of confidence expected in the context of self-efficacy theory—that is, success is reinforced by prior successes. Faculty viewed themselves as proficient in hand-written documentation and as one of the experts identified in the theme of “learning from experts.” It is learning from expert faculty that makes possible the theme of “from novice to expert” for students in clinical rotations. Faculty presence, guidance, and modeled expertise help transform the student learners to recognizable clinicians. In this way, students moved from just citing the elements of a good note to actually writing one and thus becoming visible in the patient record as a provider of care.
When new challenges present themselves in each new clinical setting using different EHRS, the learning curve is steeper and the energy required to persist, problem solve, and skillfully use the system is greater than that required for success using the familiar paper system. Faculty expressions of frustration and inability to teach using an EHRS reflected the many obstacles identified by the respondents. EHRS are designed to thwart—that is, designed to force the user to follow correct procedure in order not to bypass the system’s default safety protocols. Faculty’s motive to work around programmed safety features is understandable, as is the emergence of the major theme of legal and ethical issues. How can any patient receive medications on time when there are 10 students assigned to 10 or more patients, and the one faculty is the only person with a password to the EHRS? Students use the faculty member’s password because faculty are seeking to provide a thorough, timely learning experience that, ironically, helps ensure that all rights of patient medication administration are enacted, including documentation. The ethical and legal conundrum for faculty—provide a quality learning patient care experience for students or follow strict EHRS documentation protocol—leads faculty to question their ability to teach in the face of such persistent obstacles. Faculty’s perceived self-efficacy, their belief in their own capacity to optimally perform, is diminished.
A serious limitation was failing to capture faculty views of their own ability to transition from paper to electronic record systems. In addition, it became apparent to the researchers that there were other critical questions that emerged. For example, how do faculty view themselves assuming the role of both student and teacher while developing proficiency in EHRS after spending years, or even decades, in a paper-based system? Do faculty embrace the new electronic health record, or do they practice avoiding it? During this time of paper-to-EHRS transition, how do faculty succeed? And how do faculty acquire the necessary knowledge, skills, and attitudes to successfully transition and impart these skills to students?
Face-to-face interview of faculty respondents by a faculty colleague may not be the best procedure for obtaining results. Perhaps a more optimal procedure should be enacted in the future, such as having a non-faculty, non-staff interviewer to produce more candid and reflective responses.
An important implication identified by this research study was the notion of role-modeling. Faculty best integrate new technology throughout the curricula when they consciously use role-modeling as a teaching strategy. Faculty model their attitudes about both gaining knowledge of the new technology and acquiring skills in mastering the new technology. Students are extremely perceptive about the attitudes and beliefs faculty telegraph them. Each of our nursing students can likely answer that question in regard to their lecturer, laboratory instructor, or clinical instructor. As self-efficacy theory posits, our attitudes affect our behaviors and the attitudes and behaviors of those we teach—faculty teach attitude as much as content. Faculty must communicate to students that we truly are lifelong learners, and that includes continuous updating of our skills related to the latest technological advances.
Regarding informatics, 80% of faculty respondents to an NLN (2008) survey reported they are self-taught. Educators should be the first to recognize that such reliance on this method of learning is inefficient. Due to the recent technological revolution, most faculty are learners, so called digital immigrants, within an EHRS setting. And like our nursing students, faculty competencies in the area of informatics must be identified and standardized, as is done for students by NLN and AACN standards. We can share our frustrations over the many glitches we encounter, but we must also balance that with lessons in how we work through the problems inherent to new learning and new technologies. Faculty can model self-efficacy: the patience, support, and persistence that characterize individual development within a professional discipline are how professions grow leaders.
The school of nursing is integrating the results of this research for faculty development related to teaching EHRS as part of a comprehensive plan to integrate informatics throughout the curricula and increase health care information competencies of the nursing students. The college is supporting faculty participation in national efforts, such as the NLN HITS program and the Harvard Institute for Medical Simulation. Novice faculty receive support to attend faculty development programs on informatics and teaching. Faculty share the latest findings and techniques regarding informatics, begin to create and implement plans begun at these national venues, engage a critical mass of other faculty, and systematically integrate informatics throughout the curricula.
Given that the constant comparative method requires gathering data from other core constituencies, further research will explore students’ and clinical staff RNs’ perceptions of teaching-learning documentation to further understanding of the role of self-efficacy as health systems transition to EHRS.
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Summary of Major Themes
|Major Theme||Cluster||Categories||Codes||Illustrative Respondent Quotes|
|Teaching strategies||Teaching/learning||Enhancing skills; group learning exercises; one-on-one instruction; providing documentation, illustrations; stimulating critical thinking; teaching–learning–teaching||Providing illustrations, examplesGroup learning exercisesOne-on-one instructionEnhancing skillsLearning from role modelsStimulating critical thinkingUnlearning/learningRole-modeling through critique||“Faculty reviews note, student documents and faculty counter signs note in chart.”“Review paper and electronic documentation; provides sample.”“Emulated staff RN notes.”“Discussed concepts and reviewed individual documentation.”|
|Learning from experts||Discovering ways of knowing||Enhancing skills; moving from knowledge to application domain; unlearning/learning; visibility/invisibility|
|Road from novice to expert||Role identity/perception||Learn from role models; role-modeling through critique||Teaching, learning, teachingKnowledge to application domainCritical thinkingVisibility/invisibilityEncountering barriers Protection/nondisclosurePatient specificInstitutional and policy issuesLegal and liabilityEthical||“Students wrote too much info according to staff, not instructor.”“Seniors received repeated feedback. Staff describe notes as clear and concise.”“I had a code for medication administration—only instructor had a code. Students used professor’s code…. Paper backup.”“Training process for facility’s computerized system takes away too much time from clinical…. Limited availability of computers on unit for student use.”|
|Legal/ethical/institutional issues||Protection assurance||Institutional and policy issues; legal and liability (ethical); patient specific; encountering barriers|