Dr. Flood is Professor, Dr. Gasiewicz is Assistant Professor, and Dr. Delpier is Professor, Northern Michigan University, Marquette, Michigan.
Address correspondence to Lisa Sue Flood, DNP, RN, CNE, Professor, Northern Michigan University, 1401 Presque Isle Ave., Marquette, MI 49855-5301; e-mail: firstname.lastname@example.org.
Nursing, as the largest group of the health care workforce, is at a pivotal junction of identifying and incorporating information technology to improve patient outcomes. Expanding sources of information in health care present both an opportunity and a challenge for nurses. According to the Boyer Commission (1998), “If anything is evident, it is that the more information a person can obtain, the greater the need for judgment about how to use it” (p. 26). The danger of missing key information while drowning in data is real. One way to meet this challenge is with information literacy, the ability to “recognize when information is needed and the ability to locate, evaluate, and use effectively the needed information” (American Library Association [ALA], 2000, p. 2).
For nurses to optimize patient health, they must be “information integrators at the patient level” (Staggers & Thompson, 2002, p. 259). However, nursing must take considerable steps to meet this goal. Research indicates that currently RNs may not be prepared to meet the challenge (Pravikoff, Tanner, & Pierce, 2005). Evidence exists indicating that a majority of the State Boards of Nursing have no current or future plans to address informatics in education or practice requirements (Technology Informatics Guiding Education Reform [TIGER] State Boards of Nursing Work Group, 2008a, 2008b). However, there is some assurance that informatics is beginning to become part of nursing’s professional competencies. Information technology is currently included in the NCLEX-RN® Examination test plan (National Council of State Boards of Nursing, 2006), and both the National League for Nursing (2008) and the American Association of Colleges of Nursing (2008) advocate for inclusion of informatics in nursing programs.
Nursing education should be a key proponent in successfully preparing future nurses with technology and information capabilities (Simpson, 2007). To prepare graduating nurses to practice in an increasingly technological, data-rich health care system, faculty must determine effective teaching methods. However, nurse educators are still in the beginning stages of identifying teaching strategies (Nelson, 2000).
Nurse educators are also confronted with how best to incorporate informatics into an already burgeoning curriculum. Integration of informatics concepts into the curriculum has been recommended by Skiba (2006) as one method of addressing this challenge. The informatics concept of interest here is information literacy. This article aims to offer a systematic approach of incorporating information literacy, one component of informatics, across a baccalaureate of science in nursing (BSN) curriculum.
In their 2003 publication, Health Professions Education: A Bridge to Quality, the Institute of Medicine (IOM) endorsed development of five competencies, essential for all health care providers:
- To provide patient-centered care.
- To work in interdisciplinary teams.
- To use evidence-based practice.
- To apply quality improvement.
- To use informatics.
The competencies are conceptualized as overlapping; change in one area will affect all other competencies. Competency in informatics may be especially germane to competency in evidence-based practice (EBP) which is described in part as the ability to search and evaluate sources of evidence.
Informatics competencies specific to nursing have gradually evolved. Staggers and Gassert (2000) conceptualized nursing informatics competencies as an integration of knowledge, skill, and attitudes, and they proposed different levels of competencies. At the lowest level, nurse graduates should possess computer literacy skills to be able to use computer technology, but they also need information literacy skills to first recognize the need for information and then locate, evaluate, and use the information (American Nurses Association, 2001; Staggers, Gassert, & Curran, 2001).
Recently, two new efforts to define informatics competencies have emerged: the Technology Informatics Guiding Education Reform (TIGER, 2007) initiative, and Quality and Safety Education for Nurses (QSEN) (Cronenwett et al., 2007). The TIGER Initiative was convened to formulate a unified vision of nursing informatics as a core competency. The TIGER Initiative has spawned the TIGER Informatics Competencies Collaborative (2007) for the purpose of developing a set of informatics competencies across all levels of nursing education and nursing practice. The TIGER Informatics Competencies Collaborative initial work has resulted in the recommendation to use the Knowledge, Skills, Attitudes competency framework with beginning competency recommendations (TIGER Informatics Competencies Team, 2008).
Quality and Safety Education for Nurses, funded by the Robert Wood Johnson Foundation, was initiated to assist nursing faculty to address the IOM’s recommendations (Cronenwett et al., 2007). The group asserts that there are insufficient teaching examples available to nurse educators. Quality and Safety Education for Nurses is striving to overcome this barrier; beginning efforts have included the development of IOM-inspired definitions and competencies, one of which is informatics. The competencies also use the Knowledge, Skills, Attitudes framework and are applicable to all levels of nursing. Efforts continue with a beginning collection of specific teaching ideas available to nursing faculty on the QSEN Web site ( http://www.qsen.org).
The Current State of Informatics in Nursing Education
A literature review revealed two surveys regarding the current state of informatics use in nursing education. In a national survey, McNeil et al. (2003) concluded that although BSN programs were teaching some computer skills, less instruction was occurring related to informational literacy skills, and skills were not being linked to clinical practice. In an analysis of the qualitative data from the same study, McNeil, Elfink, Beyea, Pierce, and Bickford (2006) noted confusion among faculty regarding informatics. Concerns included:
- Faculty’s lack of a clear understanding of computer literacy or information literacy.
- Faculty’s ambiguous thoughts about what constituted essential informatics content.
- Faculty’s uncertainty about how to integrate this content into the nursing curriculum.
Identified barriers included a shortage of qualified faculty, insufficient resources, and a lack of informatics experiences in clinical settings.
A more recent survey by Smith, Cronenwett, and Sherwood (2007) described the prevalence of the QSEN competencies in undergraduate programs. Findings indicated that only 38% of the programs taught some informatics content. In addition, student achievement related to informatics ranked lowest among the six QSEN competencies.
Evaluation of Program Approaches to Teaching Information Literacy
A literature review regarding program approaches revealed a paucity of evaluation research. Identified methods for teaching and evaluating information literacy in nursing programs included embedding informatics in a single course, offering a course devoted to informatics, or integrating the content over two or more semesters. In many cases, teaching information literacy was incorporated into teaching EBP.
In an early study, Wallace, Shorten, Crookes, McGurk, and Brewer (1999) developed a program of three information literacy activities, offered in a single course. Postprogram questionnaires indicated significant improvements in the students’ library catalogue search skills and bibliography citation skills. However, interpretation of these findings was ambiguous in light of similar skill levels found in the nonprogram comparison group.
Also using a single course approach, Courey, Benson-Soros, Deemer, and Zeller (2006) taught informatics in the context of EBP. Initial instruction was followed by weekly assignments requiring students to access, evaluate, and use literature relevant to their clinical experience. The researchers found that students’ ability to access information improved; however, students’ attitudes about information use decreased. Courey et al. (2006) speculated that a lack of clinical RN role models minimized the importance of informatics for the nursing students.
Using a two-semester approach, Burns and Foley (2005) introduced BSN students to the concepts of informatics and EBP. The students were introduced to database searches in the first semester, then to the Cochrane Database and EBP guidelines the following semester. Course assignments and test questions demonstrated students’ increased understanding and use of informatics and EBP.
At the graduate level, Grant and Brettle (2006) developed a Web-based literature search tutorial as part of a 12-week EBP module for master’s health students. Using a pretest and posttest assessment, the authors concluded that the tutorial was a successful strategy to teach informatics skills within an EBP course for graduate students.
The Kansas University School of Nursing formed a partnership with the Cerner Corporation to employ the Simulated E-Health Delivery System program, a clinical information system designed for use in simulations and teaching (Connors, Warren, & Weaver, 2007). The integrated program promoted student skills related to using electronic patient records and decisional support tools and accessing evidence-based guidelines. Anecdotal evaluation of Simulated E-Health Delivery System indicated that nursing students’ critical thinking improved and the students felt their technical skills would transfer into practice.
The literature review suggests positive effects associated with incorporating concepts of informatics literacy into nursing curricula. However, specific examples of how informational literacy skills may be integrated into a nursing curriculum are relatively sparse. Therefore, motivated by the IOM report, guided by the initial TIGER competency framework, and using the specific QSEN informatics competencies, the authors have proposed an integrated approach to teaching information literacy across a BSN curriculum emphasizing clinical applications.
Information Literacy Assignments
The process of developing a new five-semester BSN curriculum presented faculty with an opportunity to integrate information literacy through the curriculum in an organized fashion with increasing incremental degrees of difficulty. The assignments meet program and course objectives and are threaded through clinical courses. The assignments are designed to increase students’ awareness of the need for information (i.e., knowledge); advance students’ abilities to locate, evaluate, and use information (i.e., skills); and foster a positive appreciation for informatics literacy (i.e., attitudes) in planning safe, effective patient care (Cronenwett et al., 2007). Conceptually, the assignments have been developed for three levels of students—novice, intermediate, and advanced. The overarching goal is to prepare BSN graduates for a beginning level of informatics practice to benefit patient care (Staggers et al., 2001).
The information literacy assignments were not designed as a complete effort to develop informatics competencies. They build on a curriculum which already incorporates informatics in a variety of ways, such as WebCT® assignments and computer simulation. Students are presumed to have computer access, as the university has a campus-wide laptop program. For purposes of clarity, all assignments described herein use diabetes as a common health concern.
In the first semester of the curriculum, the assignment focuses on accessing and evaluating information. First, students are oriented to library searches through collaboration with a university librarian. The instruction consists of orientation to the library’s physical and electronic resources and information search and evaluation strategies. Students are also able to review the orientation information via the library’s Web site. Second, students are assigned to work in pairs to find a scholarly article related to their care of a patient with diabetes. Students evaluate the article using criteria that include authority and credibility, accuracy, objectivity, currency, and coverage and purpose. During a clinical conference, each pair of students discusses their evaluation. Finally, each team submits a brief written synopsis of their article evaluation for grading.
Assignments at the intermediate level focus on implementation of information. Examples of assignments include: designing a teaching brochure and evaluating a nursing procedure. In the first assignment, the student prepares a teaching brochure for a clinic patient newly diagnosed with diabetes. The student first identifies a teaching need and completes a literature review to locate appropriate information; then, a brochure is developed. The brochure is shared with the clinic group and a copy of the brochure and information is submitted for grading.
For the second assignment, students identify an organizational policy or procedure that relates to the care of their assigned diabetic patient. Students then complete a literature review to compare current practice with EBP. A written evaluation with recommended revisions is submitted for grading.
Assignments at the advanced level focus on role development. The first informatics assignment is designed for students in clinical courses with emphasis on caring for complex patients in an acute care setting or in a community setting. Students work in teams to search for relevant information to plan care related to a specific health concern, such as diabetes, from the perspectives of patients and families, acute care nurses, home health nurses, clinical nurse leaders, home health managers, discharge planners, and public health nurses. Students then evaluate the information and identify clinical applications. Each team’s findings are discussed during clinical conferences and via a short reflective paper.
For the second informatics assignment, students, who are completing an intensive externship in either a community-based or an acute health care setting, identify examples of how informatics and health care information are used within their respective settings to make clinical and organizational decisions. If possible, students spend time with information managers to gain an appreciation for information systems and technology used in a clinical setting. The students share their written reflections using an asynchronous discussion format via the course Web site.
Although current research regarding effective informatics teaching strategies is sparse and competencies have not yet been finalized, nurse educators have been challenged to include informatics throughout the curriculum “so that it is ubiquitous and pervasive as a component of nursing practice” (Skiba, 2006, p. 336). This current project is one endeavor to provide nursing faculty with a much needed example of integrating information literacy assignments through a curriculum. It is anticipated that this example will encourage ongoing discussion and promote the necessary evaluation to determine teaching effectiveness. However, it must not stop here.
Neuman (2006) challenges nurse educators to develop designs that move nursing beyond the information age and to create innovative ways of thinking to influence the health care issues looming on the horizon. Nurses must be literate in informatics, and nurse educators cannot afford to be complacent on this issue; too much is at stake.
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