Der-Fa Lu, PhD RN
& Kathy E. Wilson, PhD RN
Stephens-Lee, C., Lu, D., and Wilson, K. (2013). Preparing Students for an Electronic Workplace. Online Journal of Nursing Informatics (OJNI), vol. 17 (3), Available at http://ojni.org/issues/?p=2866
This article outlines a project that explored how nursing informatics could be integrated into an undergraduate nursing curriculum in a Canadian university. Faculty members recognize the need to ensure that future graduates are prepared for an electronic environment, but they are challenged with how to best accomplish this task.
A two-step iterative approach was used to align informatics outcomes with the five curricular abilities in a bachelor of nursing program. An email questionnaire to key faculty teaching in each of the four years of the program and a careful review of program course blueprints were conducted. The overarching framework for integrating informatics into the undergraduate program followed the three dimensions recommended by the Technology Informatics Guiding Educational Reform (TIGER, 2009) collaboration: basic computer skills, information literacy, and information management. Two Canadian frameworks were used to develop learning outcomes for the information management domain (Hebert, 1999 & Nagle, 2001). Recommendations to further integrate informatics into the curriculum are provided for each of the TIGER domains.
Keywords: basic computer skills, information literacy, information management, nursing informatics education.
Nursing informatics (NI) science and practice integrates nursing, its information and knowledge, and their management with information and communication technologies to promote the health of people, families, and communities worldwide (International Medical Informatics Association-Nursing Informatics, 2009). The breadth of NI science as well the absence of a standardized set of outcomes often presents challenges to nursing educators who are attempting to include NI concepts across curricula. In this article, the authors describe the process used to develop an integrated approach to assist educators as they introduce and level NI concepts in undergraduate nursing curricula to improve nurses’ capacity to use NI science to guide their practice.
In 2007, faculty members at a Canadian Bachelor of Nursing (BN) program embraced a paradigm shift and realigned their undergraduate curriculum with five abilities-based learning outcomes developed using a collaborative, iterative and intentional process (McCloskey, Tamlyn, Wilson & Woodside, 2010). The five abilities included, knowledge and its application; skills of analysis/critical thinking; communication; professional identity and ethics; and social justice/effective citizenship (see Table 1)” (Thompson, 2009, p.10). These abilities provided the organizing framework for the curriculum, each further explicated through related program outcomes leveled across each of the four years, and then more specifically expressed in course outcomes (McCloskey et.al, 2010). Watson (2006) described an ability as being something beyond competence; it is “giving an account of what one does in practice, rather than simply doing it through the mastery of specific skills” (p. 623). An ability represents the knowledge, skills, dispositions, and attitudes required to synthesize theory and practice through critical analysis, and fostering the deep and persistent learning required of a professional nurse across contexts (Thompson, 2009; McCloskey et.al, 2010).
Three documents were instrumental in developing an approach for integrating NI competencies into the aforementioned nursing curriculum. The Data, Information, Knowledge and Wisdom (DIKW) framework proposed by Englebardt and Nelson (2002) provided a structure for teaching information management concepts. This framework addresses the information processes underlying nursing care. Using the framework, nurses gather and enter data on the client’s record. This data combined with data entered by other disciplines or departments (i.e. lab values, radiology, and administrative data) informs users of the client’s condition. Nurses interpret and synthesize the data into information for the purpose of planning client care. Information on a client’s record combined with the information of other clients may lead to the development of new knowledge to inform practice.
Leaders in informatics in the United States have further contributed to the standardization of NI curricula with the development of the Technology Informatics Guiding Educational Reform (TIGER) collaboration. The TIGER collaboration identified three essential components of nursing informatics competencies: basic computer competencies, information literacy, and information management. The standard recommended for basic computer competencies is the European Computer Driving License (ECDL). Information literacy is standardized to the Information Literacy Competency Standards for Higher Education (ALA, 2010) and information management is standardized to the Electronic Health Record Functional Model – Clinical Care Components (Health Level 7).
Hebert (1999) and Nagle (2001) outlined work conducted toward developing a national strategy for NI competencies for Canadian undergraduate nursing programs. Hebert (1999) proposed three different NI competency levels: entry level, practicing nurse, and specialist. Nagle (2001) organized NI competencies into six categories: basic NI concepts and operations; social and ethical human issues, productivity tools; communication tools; research tools; and decision support systems. Both reports identified specific competencies to guide the incorporation of NI throughout the curriculum.
By combining the three documents (Hebert, 1999; Nagle, 2001; & TIGER, 2009), a framework (see Table 2) was proposed for mapping NI competencies into a contemporary undergraduate nursing program. The overarching framework was organized around the three competencies proposed by the TIGER collaboration. Work by Hebert (1999) and Nagle (2001) provided the learning outcomes for the information management domain.
The specific purpose of this project was to analyze the current curriculum to determine where informatics concepts were currently addressed in the five program abilities and to provide an analysis of where they could be further integrated into the curriculum. Recommendations were developed and presented to faculty for consideration and feedback.
Prior to the implementation of this project, faculty had identified the need to integrate informatics outcome indicators into the five “abilities based” outcomes to ensure that future graduates were prepared for an electronic environment.
A two-step iterative approach was used to determine what NI concepts students were learning. To determine the courses in the curricula in which NI concepts were addressed, information was gathered from faculty in each of the four years through an email questionnaire and face-to-face meetings. The responses were then reviewed with the members of the curriculum committee.
In the second step, a careful review of the course blueprints for the program was completed. The undergraduate nursing program course blueprints included the description, purpose, and outcomes for each nursing course in the undergraduate curriculum. The program outcomes were mapped into each course and reflected in the blueprints. The blueprints act as guides to ensure that each program outcome is addressed and leveled across the four years of the curriculum to facilitate students’ development of each of the five program abilities. Reviewing the blueprints facilitated further identification of where and how NI concepts were integrated into the curriculum.
Computer literacy content focuses on computer basics and the use of generic software applications such as word processing, databases, presentation software, and the use of electronic communication such as email (National League for Nursing (NLN), 2011). Faculty perceived that most students were well versed in the use of email and Microsoft Office Word and Excel programs. Some suggested that students comfort level may have been connected to their use of social networking media such as Microsoft Social Network (MSN Incorporated, 2010) and Facebook (Facebook Incorporated, 2004). It was also noted that all students had access to computers either at home or at campus-wide computer labs. Faculty indicated that students regularly used laptop computers for note taking in the classroom.
Students learned additional computer skills throughout the program by using the university wide Learning Management System (LMS), to support classroom based courses. The LMS was also used for the delivery of hybrid and online courses. Other technological tools used by instructors to enhance classroom instruction included: Microsoft Office PowerPoint; Audience Response Systems (ARS); YouTube (2005) videos; and accessing professional websites.
A review of the course blueprints for computer literacy competencies determined where NI concepts currently resided in the curriculum and where the concepts could be further developed.
Some outcomes specifically addressed NI concepts. For example, one of the related outcomes for the communication ability stated, “Uses information technologies to support communication in professional and therapeutic contexts.” This outcome was leveled across the four years of the program, outlining learning expectations as students progressed from novices just beginning to use technology to support interdisciplinary communication, to more advanced users who adapt to the technologies available in the workplace. Other program outcomes were written broadly enough to enable NI concepts to be incorporated into learning activities without having to add new outcomes. For example, a second year outcome for the communication ability stated, “Uses the elements of good writing to accurately and concisely communicate credible information in a variety of forms.” The wording “a variety of forms” was sufficiently broad to include using a computer for writing assignments and to document patient care.
Information literacy builds on computer literacy. It is the ability to identify information needed for a specific purpose, locate pertinent information, evaluate the information and apply it correctly (TIGER, 2009). Multiple program outcomes captured the concepts of information literacy. In particular, the outcome for the knowledge and its application ability stated, “Seeks, utilizes, and develops knowledge to support and enhance competence in professional nursing practice.” The related fourth year outcome, “Critically examines and integrates evidence-based knowledge from credible sources in nursing and other disciplines,” directly aligned with information literacy concepts. Another possible intersection with NI concepts for this ability is the outcome, “Appraises, provides and modifies nursing actions by synthesizing knowledge from nursing, the arts, and sciences, integrating these with appropriate professional guidelines for best nursing practices.”
Outcomes that incorporate information literacy were also evident in the critical thinking/skills of analysis ability. For instance, the related year two outcome reads, “Begins to develop clinical judgment by gathering relevant knowledge from multiple sources, questioning its use and with some direction applying it to formulate a plan of care.”
The LMS enabled faculty to create easy access to credible website resources such as Health Canada, the Canadian Diabetes Association, and the Heart and Stroke Foundation. For example, in the fourth year leadership course, senior students were required to complete an assignment that compared two health related web sites using the Health on the Net Code (HON, 2010). The goal of the assignment was to help students learn to critically assess frequently used websites prior to referring clients to these electronic resources. Students also retrieved organizational policies and procedures on the practicum facility Intranet to assist them with clinical decision making.
Information management is a process consisting of 1.) collecting data, 2.) processing the data, and 3.) presenting and communicating the processed data as information or knowledge (TIGER, 2009). Ethical and moral abilities related to managing patient information were introduced early in the program. Prior to their first clinical rotation, students were required to complete a privacy module for the practicum facility. These abilities were further developed throughout the program as students applied the concepts of confidentiality, privacy. and security when working in the healthcare setting.
Documentation theory was introduced in the health assessment course in the second year. Clinical skills were taught in a lab setting within the course, and students applied this knowledge in the corresponding clinical courses. As students learned each individual system, they were required to perform and document a detailed health assessment. Concepts taught in relation to documentation included: subjective versus objective data; type of encounter (e.g. emergent, episodic, follow up or complete); and general principles of documenting a health history (biographical data, reason for seeking care, present health or history of present illness, past history, family history, review of systems, functional assessment and health promotion). Students also learned documentation formats such as Subjective, Objective, Assessment, Plan (Weed, 1968) and focus charting using the framework Data, Action, Response and Plan (Kozier, Erb, Berman, Snyder, Buck, Yiu & Stamler, 2010).
Students had an opportunity to apply theoretical and simulated learning related to computer documentation in the lab and clinical setting. They used flow sheets to streamline charting. In the clinical settings, students were exposed to various clinical applications, which depending on the area to which they were assigned for their clinical practice experiences, included: updating patient care plans and retrieving work sheets in Order Entry (Meditech Incorporated, 2010); accessing patient information such as lab and diagnostic tests, patient’s plan of care, and information from prior admissions in Patient Care Inquiry (Meditech Incorporated, 2010); documenting a patient note in the Nursing and Emergency Department Management modules (Meditech Incorporated, 2010) in select care areas and documenting patient care notes in the Dossier (Purkinje Incorporated, 2010) application at community health centers.
In addition to the Meditech and Purkinje applications, faculty described student opportunities to use patient monitoring devices. One example is the Nutritrac software (Mosby’s, 2010), used for an assignment in which students input nutritional data over five days. The data is analyzed and appropriate graphs are printed. Students also used glucometer machines to test the patient’s blood glucose and learned how to conduct a quality assurance (QA) test on the machines. Another tool being trialed by some students and faculty were portable handheld devices used during clinical experiences. The software, downloaded to Smartphone’s or personal computers, provided access to Nursing Central (Unbound Medicine Incorporated, 2010), which offers textbook information and an online database library to support knowledge development and clinical decision making.
Review of the curriculum suggested that some nursing informatics content was addressed and assessed as students developed all five of the abilities-based learning outcomes as they progressed through the program. Additionally, the curriculum framework provided many opportunities and locations for further incorporation of NI learning activities with little adjustment to the outcomes. However, the study found that further development of the NI concepts of clinical decision support (CDS) and nursing minimum data sets (NMDS) was required to assist students to graduate with the skills required for contemporary nursing practice. With modification, CDS could be mapped into the outcomes for the knowledge and skills of analysis/critical thinking abilities. The NMDS concepts dovetail nicely into the communication ability.
Clinical decision support is a clinical system, application or process that helps health professionals make clinical decisions to enhance patient care (Healthcare and Information Management Systems, 2010). Clinical knowledge could range from simple facts and relationships to best practices for managing patients with specific disease entities and new knowledge from clinical research that would support evidence based practice.
Examples of CDS systems include quick access to policies and evidence based protocols or clinical pathways such as those found on the organization’s intranet or documentation guidance found in the Health Information System (HIS). Clinical decision support may also include automated reminders or alerts such as flags on abnormal lab values in the HIS.
A Nursing Minimum Data Set (NMDS) is the minimum core data used on a regular basis by the majority of nurses in the delivery of care across settings (Werley, Devine, Zorn, Ryan, & Westra, 1991, p.421). The Canadian Nursing Association has adopted the International Classification of Nursing Practice as the standardized language for documenting nursing care and patient outcomes (CNA, 2003). They propose five essential data elements: client status, nursing interventions, client outcome, nursing intensity and primary nurse identifier (Hannah, 2005). The first three elements align with the focus of concern, interventions and response elements of the regional documentation methodology. The latter two (Nursing Intensity and Primary Nurse Identifier) are essential for managerial decisions relating to workload/staffing. These data elements are stored in a retrievable format in the electronic health record and are used to derive information for clinical, administrative and research purposes. Information about and concepts relating to the NMDS was noticeably absent and will require intentional integration into the program.
Faculty responses to the survey suggested that throughout the four years of the program basic computer skills are reinforced by the nursing faculty in the following ways: communicating via email; having students complete writing assignments using a word processor (e.g. Microsoft Word); using Microsoft Power Point for presentation assignments; and electronically creating a patient teaching pamphlet for health promotion. A more in depth review is recommended to evaluate the consistency of the approaches used among faculty. This review may point toward a standardized approach to the incorporation of basic computer skills throughout the program curricula.
The TIGER Informatics Collaborative adopted the ECDL competencies as the informatics standard for basic computer skills for all nurses. In order for nurses to practice safely and effectively it is essential to have proficiency with the concepts of: information and communication; using the computer and managing files; word processing; web browsing and communication (TIGER, 2009).
International Computer Driving License (ICDL) Canada is the national operator for the ECDL Foundation in Canada. ICDL certification provides objective verification of student skills, increasing their capacity to attain educational goals effectively and efficiently, while providing an internationally recognized qualification (International Computer Driving License, 2010).
Setting the ICDL Start Certification as a prerequisite to entering the BN program would standardize the level of basic computer skills that students have early in the program. This would ensure that students have a consistent foundational level for both coursework and work in the digital workplace. Freshmen who recently graduated from high school may have already learned some of these basic computer skills, while those entering from the workforce may not have had such opportunities. It is recommended that specific criteria be developed to identify those students in the cohort who require the ICDL Start Certification and those who have already mastered these skills.
The current recommendation by the university IL subcommittee is to use the IL Competency Standards for Higher Education (ALA, 2010). These standards are endorsed by the TIGER initiative and provide a framework for performance indicators and outcomes for five IL standards. By achieving the five IL standards, students are able to determine the nature and extent of the information needed; access needed information effectively and efficiently; evaluate information and its sources critically and incorporate selected information into his or her knowledge base and value system; use information effectively to accomplish a specific purpose; and evaluate outcomes of the use of information (ALA, 2010; TIGER, 2009).
Two suggestions are offered to clarify the outcomes for legal, ethical and professional standards relating to NI. First, in year one the words “complies with standards for privacy, confidentiality and security in the management of health information” should be added to the outcome statement. Second, in the outcome statements for years two to four it is proposed that language specific to NI be incorporated into outcomes, especially in years one and two to make information management more explicit.
Nagle and Catford (2008) described five stages of the Electronic Health Record (EHR) lifecycle: foundational (e.g., infrastructure, laboratory, diagnostic imaging, and pharmacy); documenter (e.g., clinical documentation and order entry); integrative decision support; and knowledge management and knowledge generation. As the EHR evolves to the higher generations, the concepts of the DIKW model evolve as well. At the foundation and documenter levels, the inputs into the health information systems (HIS) are primarily data and information. The helper systems provide integrated decision support and incorporate the concepts of information and knowledge. The last two generations, the partner and the mentor are the expert systems that assimilate the concepts of knowledge and wisdom.
National initiatives are underway to migrate from foundational and documenter systems to more interactive systems that provide decision support and knowledge generation. An understanding of the DIKW concepts and their relationship to an EHR will help students to understand how information management within an EHR impacts nursing.
One strategy for teaching such information management concepts would be to have the students review a “use case,” which is a set of instructions that an individual in a process completes in order to go through one single step in that process. It describes what the user does to interact with a system (Agency for Healthcare Research and Quality, 2012). A use case provides both narrative and graphical descriptions of information flows and health care data exchange, such as requesting or sending a patient’s medication history. The use case could be introduced at various points in the curricula or introduced in year one and further developed over the four years.
NI competencies are crucial to managing the care of clients in all healthcare settings. “Improvement of cost effectiveness and safety depend on evidence-based practice; outcomes research; interprofessional care coordination; and electronic health records, all of which involve information management and technology” (McNeil, Elfink, Beyea, Pierce & Bickford, 2006, p.52). Nursing students require opportunities to help them develop NI skills and abilities to prepare them for contemporary workplaces. The process described in this paper and the recommendations for incorporating NI competencies into undergraduate nursing curricula may provide direction for nurse educators who are currently working to integrate NI concepts into their programs.
This evaluation project specifically identified where NI concepts are currently and where they could be further developed in the undergraduate nursing curriculum of one Canadian university. Further analysis from the perspective of faculty about how to integrate informatics into the undergraduate program is required to determine teaching-learning strategies that will best facilitate student learning.
Subsequent to this project, the Canadian Association of Schools of Nursing (CASN, 2012) developed three nursing informatics competencies and their respective set of indicators for registered nurses. The three competencies are information and knowledge management; professional and regulatory accountability; and information and communication technologies. The framework for this project has implications for other undergraduate nursing programs as it may be used as a model for analyzing program outcomes in relation to the three competencies and indicators (CASN, 2012).
Agency for Healthcare Research and Quality. (2012). Use case: Description. Retrieved from http://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/use-case
Association Library Association. (2010). Information literacy competency standards for higher education. Retrieved from http://www.ala.org/acrl/standards/informationliteracycompetency
Canadian Association of Schools of Nursing. (2012). Nursing informatics entry-to-practice competencies for registered nurses. Retrieved from http://www.casn.ca/vm/newvisual/attachments/856/Media/NursingInformaticsEntryToPracticeCompetenciesFINALENG.pdf
Canadian Nurses Association. (2003). International classification of nursing practice: Documenting nursing care and client outcomes. Nursing Now: Issues and Trends in Canadian Nursing, 14, 1-4. Retrieved from http://www2.cna-aiic.ca/CNA/documents/pdf/publications/NN_IntlClassNrgPract_e.pdf
Englebardt, S. & Nelson, R. (2002). Health care informatics: An interdisciplinary approach. St. Louis: Mosby-Year Book, Incorporated.
Facebook Incorporated. (2004). Facebook Social Networking Portal. Retrieved from http://www.facebook.com/
Hannah, K. J., Hammell, N., & Nagle, L. (2005). Nursing informatics in Canada. In V. K. Saba & K. A. McCormick (Eds.), Essentials of nursing informatics (4th ed.) (pp. 607-619). New York: McGraw Hill.
Healthcare and Information Management Systems. (2010). Clinical decision support. Retrieved from http://www.himss.org/ASP/topics_clinicalDecision.asp
Hebert, M. (1999). National nursing informatics project: Discussion paper. Ottawa: Canadian Nurses Association.
HON (2010). Health on the Net Code. Retrieved from http://www.hon.ch/HON code/Pro/
International Computer Drivers License. (2010). About. Retrieved from http://www.icdl.ca/
International Medical Informatics Association-Nursing Informatics. (2009). Nursing Informatics Definition. Retrieved from http://www.amia.org/programs/working-groups/nursing-informatics
Kozier, B., Erb., G., Berman, A., Snyder, S., Buck, M., Yiu, L and Stamler, L. (2010). Fundamentals of Canadian nursing: Concepts, process and practice (3rd ed.). Toronto: Pearson.
McCloskey, C., Tamlyn, K., Wilson, K., Woodside, R. (2010). Introducing abilities-based learning outcomes in the undergraduate program at the University of New Brunswick (UNB). Info Nursing, 41(3), 14-15.
McNeil, B. J., Elfrink, V., Beyea, S. C., Pierce, S. T., & Bickford, C. J. (2006). Computer literacy study: Report of qualitative findings. Journal of Professional Nursing, 22(1), 52-59.
Meditech Incorporated. (2010). Meditech Product Overview. Retrieved from https://www.meditech.com/ProductBriefs/
Microsoft Office Corporation Incorporated. (2010). Microsoft Social Network Portal. Retrieved from http://ca.msn.com/
Mosby’s (2010). Nutritrac Nutritional Analysis Software. Retrieved from http://www.ramex.com/title.asp?id=2207
Nagle, L. M. (2001). Informatics curriculum task force report. Submitted on behalf of the Ontario Nursing Informatics Group to the Registered Nurses Association of Ontario. Unpublished.
Nagle, L.M., & Catford, P. (2008). Toward a Model of Successful Electronic Health Record Adoption, Electronic HealthCare, 7(1), 84-91. Retrieved from http://www.electronic healthcare.net/content/19838
National League for Nursing. (2012). Computer literacy: Definition. Retrieved from http://www.nln.org/facultyprograms/facultyresources/computer.htm
Purkinje Incorporated. (2010). Purkinje health solutions – Clinic solutions. Retrieved from http://www.purkinje.com/en/healthcare-solutions/solutions-for-clinics
The Tiger Initiative. (2009). Technology informatics guiding educational reform: Informatics competencies collaborative final report. Retrieved from http://tigercompetencies.pbworks.com/f/TICC_Final.pdf
Thompson, J.L. (2009). Reflections on a nursing education that lasts. Info Nursing, 40(3), 8-10. Retrieved from http://www.nanb.nb.ca/PDF/INFO-Winter2009-ENG-web.pdf
Unbound Medicine Incorporated. (2010). Nursing Central. Retrieved from http://nursing.unboundmedicine.com/nursingcentral/ub
Watson, R. (2006). Is there a role for higher education in preparing nurses? Nursing Education Today, 26(8), 622-626.
Weed, L. L. (1968). Medical records that guide and teach. New England Journal of Medicine, 278 (11), 593-600.
Werley, H. H., Devine, E. C., Zorn, C. R., Ryan, P. & Westra, P.L. (1991). The nursing minimum data set: Abstraction tool for standardized, comparable, essential data. American Journal of Public Health, 81(4), 421-426.
YouTube. (2005). YouTube broadcast yourself. Retrieved from www.youtube.com/
Cheryl is a Clinical Applications Consultant at Markham Stouffville Hospital. Her clinical experience includes general surgery, emergency, discharge planning, telehealth and a coordinator for the Emergency Department Information System.
Der-Fa is a faculty member at University of Iowa College of Nursing. She teaches informatics and conducts research in large patient datasets.
Kathy is an associate professor of nursing at the University Of New Brunswick School Of Nursing. She is also the Assistant Dean of Graduate and Advanced RN Studies