Electronic health records (EHRs) are becoming ubiquitous to support national aims for better health, better health care, and lower costs. To ensure this pursuit supports a “path to value” (Cipriano, 2016, p. 3), health care professionals must simultaneously attend to the foundational elements of delivery system reform. Core elements include better consumer access to EHRs, transparency for providers within EHRs while adhering to the constraints of the Health Insurance Portability and Accountability Act, and interoperability standards and policies across EHRs (Cipriano, 2016). This broad-based emphasis on EHRs creates a strong case for nursing students to acquire the basic competencies related to health care informatics during their formal education. This article presents practical approaches for integrating an academic electronic health record (AEHR) into nursing curricula and innovative ways that instructors can address anticipated barriers.
The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 mandates health care providers to adopt an EHR, show meaningful use, and demonstrate improvements in health care safety and efficiency through the use of health information technology (HealthIT.gov, n.d.). In preparation to fulfill this mandate, professional and governmental organizations propose that nursing schools include information technology (IT) in their curricula (Gardner & Jones, 2012). Leading this charge are the Health and Medicine Division (HMD) of the National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine), the Technology Informatics Guiding Education Reform (TIGER), and the Quality and Safety Education for Nurses Institute (QSEN). A specific goal is to have new graduates who are skilled in navigating and using an EHR.
Nurse educators who write and revise curricula are further called on to develop students' competencies in patient care technology and information management systems, as outlined in Essential IV of the American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education (AACN, 2008). Accreditation standards also include an expectation to use innovative teaching and learning strategies, with the goal of enhancing students' learning (Gardner & Jones, 2012). The American Nurses Association (ANA) Scope and Standards of Practice provides outcomes that address informatics and nurses' use of IT, capabilities to safeguard data, and documentation of accurate, relevant data that simultaneously support quality improvement initiatives (ANA, 2015).
Despite these resources and guidelines, nursing schools continue to struggle to integrate AEHRs into their curricula, with a shortage of competent faculty identified as the major barrier (Gardner & Jones, 2012; Kowitlawakul, Chan, Wang, & Wang, 2014). As a result, 76% of new graduate nurses do not feel prepared to access and use EHR in patient care (Gardner & Jones, 2012). Two common themes include Instructors Who Are Unfamiliar With EHR Skills and Limited Funding to Acquire AEHR Products and Associated Training (2012). Meyer, Sternberger, and Toscos (2011) specified the barriers to competency and positive attitudes as instructors' lack of time, forgetfulness with infrequent use of AEHRs, and resistance to new technology.
Griffin-Sobel et al. (2010). echoed findings and themes:
One of the most significant challenges facing nurse educators is the expectation that graduate nurses have the ability to access and synthesize knowledge and use clinical information and decision support systems.
These scholars discussed the importance of faculty buy-in, training, and leadership support. They highlighted an effective method of gathering a small group who were given release time to learn best practices in teaching with technology (Griffin-Sobel et al., 2010).
Qualitative findings from a study by Kowitlawakul et al., (2014) highlighted nursing faculty perceptions of AEHRs as innovative, but also have advantages and disadvantages for users. Participants expressed a need for time to transition to the use of an AEHR. The study concluded that the integration of an AEHR into nursing curricula relies on faculty perception and experience with technology, as well as a positive attitude toward its use.
Ultimately, little is published about how to integrate an AEHR into a nursing curriculum. Wald, George, Reis, and Taylor (2014) noted that although the HMD strongly encourages EHRs for improving quality patient care, their literature review and experience with undergraduate medical education validated few curricular frameworks for developing EHR use. They suggested a four-step approach: (a) introduce a computer in all clinical settings, (b) provide training to students on EHR skills, (c) promote patient-centered interviewing skills while using an EHR, and (d) foster students' appreciation for the value of an EHR.
A survey of recent literature showed that simulation is the most common introduction to EHRs; however, nursing faculty not only need to address multiple learning styles, but also increase complexity across the program, both of which require more than a singular approach (Gardner & Jones, 2012; Griffin-Sobel et al., 2010; Lucas, 2010; Meyer et al., 2011; Wald et al., 2014). The literature suggests several theoretical frameworks for the integration of EHR education into nursing curricula. Using didactic and interactive learning with opportunities for feedback, as well as a spiraled approach, will develop transformative learning (Wald et al., 2014). Nurse researcher Pobocik (2015) proposed using constructivist educational theory when developing an integrative model for AEHR. The constructivist theory summarizes that students generate knowledge and meaning from an interaction between their ideas and their experiences; therefore, students learn by performing the skill. In keeping with Benner's (1984) novice-to-expert practice theory, implementation of an AEHR should increase in complexity across a curriculum to match students' expected knowledge, skills, and attitudes (KSAs). Knowledge should include the students' ability to recognize the need for information. Skill proficiency should not only address a student's skill to locate information, but also the ability to evaluate it. Attitudes should nurture a positive appreciation for information literacy.
An AEHR can provide students with learning opportunities through the navigation of technology, patient assessment, and decision making, and expose them to standardized nursing language, evidence-based practice, and the ability to document patient information. In the current nursing classroom, it is common to use case studies to enhance student learning. Adding an AEHR to case study work further enhances critical thinking. Pobocik's study (2015) demonstrated that the integration of an AEHR with case studies better prepares nursing students to recognize critical patient cues within patient data, leading to more appropriate nursing diagnoses. In another study, Kowitlawakul, Chan, Pulcini, and Wang (2015) concluded that attitudes toward AEHRs were improved in students with higher self-efficacy. Those students perceived an AEHR as helpful to their learning when it was easy to use.
A quasi-experimental study of health informatics students allowed participants to gain hands-on experience with an AEHR. Competencies measured before and after AEHR access demonstrated statistically significant improvement in competency development. Study findings also concluded that students became more sensitive and understanding about how an EHR reduces medical error (Borycki, Griffith, Reid, Kuo, & Kushniruk, 2014).
It is commonly thought that students will gain knowledge of EHRs through their clinical experiences; therefore, why would instructors need to add this objective to an already loaded curriculum? Nursing students not only must be able to locate data but also need guided education to synthesize knowledge and use clinical reasoning to make informed patient care decisions. Coincidental exposure to clinical situations is inadequate preparation for new graduates. AEHRs can be integrated easily into a classroom setting, allowing theoretical perspectives, such as constructivism, transformative learning, and novice-to-expert, to come to life while creating real world problem solving.
After meeting to review related nursing literature and learn about effective strategies from a faculty champion, small groups of nursing faculty at a western university in the United States agreed to incorporate an AEHR into their courses. At the launch of this approach, a few instructors were integrating AEHR work into their courses, but only minimally, typically by referring to the selected AEHR product, but without having any hands-on experience. In a comprehensive effort, interactive teaching strategies were integrated into classrooms, as well as skills and simulation laboratories. For this curricular innovation, the first objective was to provide faculty with simple teaching strategies that promoted the ease of integrating an AEHR across a curriculum. A trained and experienced AEHR core faculty member was assigned workload credit to help all instructors in AEHR course integration, including hands-on training and strategy recommendations. The skills and simulation laboratory coordinator provided further assistance with AEHR integration in scheduled laboratories. In addition to having these faculty point people, instructors had a multitude of resources from the selected AEHR product representative. The second objective was to steadily increase students' use of an AEHR. Initially, the same core AEHR faculty member provided students' training in the use of the selected AEHR.
In undergraduate foundational-level nursing courses, an objective for integrating an AEHR in classrooms and skills laboratories was to facilitate the ability to locate information and the development of patient-centered care plans. The faculty assigned activities, such as seek and find, which occurred in the classroom as students learned about documentation. Specifically, students were to locate and find the appropriate area of the chart for vital signs, physician notes, laboratories, and other data. This approach allowed the student to appreciate the intuitiveness of the AEHR, thus decreasing any intimidation. When learning specifically about vital signs in the classroom, students reviewed a case in the AEHR and discussed trends, as well as appropriate nursing interventions. This activity was simple yet interactive. In subsequent lectures, students used the AEHR to develop care plans for a specific disorder being taught. This additional step allowed the instructor to note any gaps in learning, while the students again practiced using the AEHR for data entry.
Use of the AEHR in learning laboratories was equally effective. Students documented relevant skills, such as wound care and the assessment of nasogastric tubes. Medication administration included the use of a medication administration record and barcode scanner. These common simulations allowed them to further hone their documentation skills. In health assessment skills laboratories, students were able to document assessments of their laboratory partner's body systems in the AEHR, rather than on a narrative note or laboratory book. This approach provided opportunities to become acquainted with various screens and related data entry. In a subsequent health assessment skills laboratory, students were introduced to a unique simulation strategy. One of the nurse educators hid behind a life-like silicone mask and wardrobe and presented herself as an older woman named Lily to bring the story of this patient to life. Prior to caring for Lily, students accessed the AEHR to review the patient's data. Students subsequently completed an assessment and documented their findings.
To increase students' use of the AEHR beyond learning laboratories, a case study approach has been discussed for pilot in pharmacology classrooms. This enhancement allows students to use the full technological capability of the AEHR, as well as the online drug references, built into the AEHR product. The desired outcome is for students to learn the skill of using resources appropriately.
To increase complexity, AEHR assignments at the intermediate level focused on the implementation of information, addressing application, and analysis. An innovative approach included a flipped-classroom reverse case study, replacing traditional lecture. Students were provided access to an AEHR that contained only a patient's name, date of birth, admitting diagnosis, and emergency department physician's note. Using the nursing process, students documented and presented the anticipated nursing assessment, vital signs, narrative nursing admission, care plan, physician orders (including medications), and an educational note highlighting health promotion and discharge planning needs for a patient living with chronic obstructive pulmonary disease. This strategy took the same amount of time as a lecture; however, students were interactive in their learning. Another activity highlighted evidence-based practice. In a skills laboratory focused on urinary catheters, students used the AEHR to review patient data and determine the rationale for this order. The AEHR contained a link to guidelines from the Centers for Disease Control related to catheter-associated urinary tract infections (CAUTI). After completing the skill, they documented in the AEHR. Students then completed a worksheet that guided them through CAUTI guidelines and evidence-based practice. A peer then evaluated their documentation using these guidelines and nurse-sensitive indicators.
More complicated assignments at the advanced nursing student-level focused on caring for complex patients in an acute care setting or in the home. Using now-familiar reverse case studies, students' objectives focused on synthesis and evaluation. A brief overview report at the start of class described how a patient was brought to a hospital unconscious and where the only information available was the bag of medications brought from the patient's home. Students now used the AEHR to access previous patient visit information. Using a team-based learning approach, one objective was for the students to work together in small groups to complete a medication reconciliation record within the AEHR. Students then completed and submitted an SBAR (Situation, Background, Assessment, and Recommendation) report to the patient's health care provider. Other objectives were for students to identify critical cues while developing an accurate medical history and anticipating orders.
To expand use of the selected AEHR, the small groups of nursing faculty involved in integrating an AEHR product were provided leadership support through faculty and student training and guidance. The AEHR was integrated during the academic year to ensure threading throughout the curriculum. Information on the importance of using an AEHR and literature supporting the need to thread it throughout the curriculum were added to the faculty handbook, along with examples of how faculty could use an AEHR in classroom and laboratory settings. Although initially only small groups of faculty were interested in adding AEHR activities to their courses, as time went on, additional faculty sought guidance to add AEHR work into their courses. The number of involved faculty increased, and AEHR use went from being integrated into two courses to being integrated into eight courses and counting. Faculty continue to evaluate, develop, and share innovative ways to integrate AEHR use in the classroom, skills, and simulation laboratory.
Anecdotal faculty feedback stressed an appreciation for having an innovative way to educate nursing students. These faculty members also appreciated having one faculty point of contact not only for training of both faculty and students, but also for helping to develop strategies for AEHR integration within their courses. Two comments from faculty were: “Having someone to provide training has decreased my fears of developing strategies I am not comfortable with” and “Someone providing students training on how to use the AEHR took a huge burden off me. I am barely comfortable myself with technology.” As faculty comfort with AEHR use increased, faculty use of relevant AEHR capabilities for their courses also increased. Of note, alternate teaching strategies with the AEHR increased as well, thus addressing students' multiple ways of learning.
Student feedback and course evaluations were positive, with students noting they enjoyed learning in a different way. Students valued having initial training by the core faculty to become comfortable with the AEHR resource before using it in classes or laboratories. Sample comments were: “I wish we had more activities like this for learning” and “Patient information came alive, and I was able to think about patient care in a different way.” Course examination scores within certain content were higher compared with students in sections that did not use AEHR for learning. These activities allowed instructors to find any gaps in learning. In addition, students noted the intuitive ease of the AEHR, thus decreasing any negative attitudes, such as feeling intimidated.
Ultimately, new graduate nurses must know how to access patient data, document accurately, and synthesize patient information to plan safe, quality care and mitigate potential errors. Nursing faculty should implement AEHRs throughout nursing students' education to increase their readiness for practice through use of IT. In addition, nursing faculty require proper training, support, and guidance to cultivate a positive transition to AEHR use in nursing curricula. In all settings, a positive environment supporting and fostering change and innovation is also necessary. Faculty should continue to share their innovative teaching strategies for AEHR integration. Further research should include measurable outcomes of integrating an AEHR throughout a curriculum. New studies are needed to measure new graduates' preparation and readiness for use of EHRs in patient care.
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