FEEG, VERONICA D. PhD, RN, FAAN; SABA, VIRGINIA K. EdD, RN, FAAN, FACMI, LL; FEEG, ALAN N. BA, BSEE
With the proliferation of information technologies (ITs) in hospitals today and the transition from paper to online documentation, nurse educators are challenged to prepare new nurses able to work in an "informatics-rich" environment.1 Because many experts have questioned how we begin to transform nursing education activities to integrate electronic tools related to patient care in the curriculum, new strategies need to be developed and tested that enable students to acquire knowledge and skill in the practice-based use of technologies ubiquitous in healthcare and foundational for evidence-based practice (EBP).2-4 In addition, these strategies must be cost-effective for nursing education programs so that opportunities can be available across all nursing programs. "Clearly, the objective of any academic nursing program is to develop skills among students so they can efficiently access information and use that information to guide their nursing practice."5(p175)
Schools of nursing are only beginning to find ways to integrate the essentials of IT beyond computer-based learning or e-mail.6 Yet, it is difficult-if not impossible-to teach electronic clinical care documentation to students in the classroom due to a variety of cost, time, and system compatibility constraints. In a study by Chastain7 of graduating baccalaureate students, faculty, and employers, employer expectations significantly exceeded the student and faculty activity in general computer application use and knowledge. Almost 20% of the faculty members had not included IT in any of the courses they taught. In a national survey of nursing informatics knowledge and competencies in nursing education programs, only half of undergraduate programs were teaching information literacy skills, and the least taught informatics content was related to information system data standards and languages.8
Nonetheless, it is becoming more urgent for new nurses to master basic IT and standardized terminologies, because they are now required to function in increasingly automated clinical environments. Because all schools of nursing must produce graduates who are able to operate in the electronic environments of their knowledge-intensive discipline, a low-cost application that could be integrated into the learning process across clinical sites would provide both process and product of learning computerized documentation. The purpose of this study was to test an inexpensive software application developed to assist students to learn how to document nursing care in the laboratory using a standardized nursing language, the Sabacare Clinical Care Classification system (CCCS).9-14 The program can be downloaded from the Internet and is free.
According to Staggers et al,15 nurses should be able to see relationships among data elements, make judgments based on trends, and use informatics solutions. But where are these skills developed and how can nurse educators prepare graduate nurses to use the technical tools needed to adapt and thrive in a world with diverse work, where health IT systems vary in functionality and operations? Can nursing programs find alternatives to expensive health IT systems for the learning environment and accomplish objectives to prepare students for a future electronic environment? The answer lies in teaching the structure of a standardized nursing language in a curriculum for which the nursing process is inherent. Nurse educators must teach the foundations of nursing classification and terminologies in conjunction with providing opportunities to use software for managing clinical data so that students can then demonstrate knowledge of the principles and format conventions. Several large system developers have used standardized languages for nurses and have begun to infiltrate the educational environments, but these projects are few and expensive. Students need to see electronic documentation operationalized with an inexpensive application that can be generalized in their future work settings. These applications need to be developed and tested.
The Institute of Medicine's report on quality called upon all healthcare professionals to gain competency in informatics with the belief that through IT, there is a potential for reduction of error, better management of knowledge and information, enhanced decision making, and communication.16 Numerous professional organizations have argued that informatics skills are essential to evidence-based nursing practice, including the American Association of Colleges of Nursing (AACN),17 the American Nurses Association (ANA),18 the National League for Nursing,19 the Pew Health Professions Commission,20 the International Medical Informatics Association,21 and the National Advisory Council on Nursing Education.22 According to Trangenstein and Weiner, "today's nurses need to be well prepared with informatics skills in conjunction with the other criteria set forth by the AACN Essentials [documents and terminal objectives] for baccalaureate, master's, and doctoral programs."23(p206) They specify competencies in clinical practice courses such as (1) using computerized patient monitoring systems, (2) using applications to document and plan care, including discharge planning, (3) retrieving data for clinical decision making, and (4) synthesizing data and information for clinical decision making. In their article on meeting the informatics needs of today's nursing students, they list informatics competencies and propose multiple strategies to organize specific informatics topics to be covered in courses. Central to the discussion of health informatics is the understanding of standardized language and taxonomies in the disciplines. Nurses are required to learn an institution's language upon hire to communicate what they do; they have become a driving force in the justification of nursing documentation.
Electronic Nursing Documentation
Although the transition from paper to online documentation presents challenges to implementation, several studies have evaluated the impact of computerized clinical documentation in nursing. In a study on nurses charting with the early versions of "point of care" (POC) technologies using bedside computers, Happ24 found that the computer-based documentation was not different in quality but patients had a higher perception of nurses who charted on the computer. Dennis et al25 reported an improvement in nurse charting compliance following implementation using a modified form of the JCAHO medical record audit tool. Minda and Brundage26 and Pabst et al27 studied time differences in handwritten charting and computer documentation of nursing assessments. They found a reported decrease in time spent charting by computer compared with paper charting and a concurrent increase in time spent in direct patient care. Overall, the quality of charting improved or was unchanged, while the efficiency of nurses' time was enhanced with electronic documentation.
Smith et al28 studied the implementation of computerized nurse care planning and documentation in a 370-bed academic hospital using the standardized languages of NIC and NOC as organizing frameworks. The purpose of the study was to determine the impact of online documentation on staff attitudes, completeness of documentation, and the time needed for documentation. The quasi-experimental design demonstrated statistically significant differences in nurses' attitudes toward computerized documentation before and after implementation of the project, with more negative attitudes after computerization. The authors could not distinguish the actual source of the frustration as related to the increased learning curve, technical system, or introduction of a new framework for practice. Sixty charts were audited before computerization, and 81 charts were audited after implementation of the project. There were significant improvements in the completeness of some areas of charting (34%), there were no difference in others (60%), and there were only a few areas that were less complete (5%). For the variable of documentation time, the activity of nurses charting was not significant, indicating that time spent charting was comparable before and after implementation. Thus, results were mixed. Charting electronically did not appear to save time and unearthed a need for more training to mediate frustration with learning a new system. The quality of charting, however, showed significant improvement in terms of completeness.
As hospital information systems proliferate and the electronic health record technologies incorporate evidence-based protocols, supplemented patient assessments, and nursing care planning, electronic charting will continue to improve the process and quality of information captured and reported. Electronic charting of the routines of nursing assessment, interventions, and patient evaluation of outcomes will provide the documentation of nursing care that can be aggregated into reports for analysis. Nursing students need exposure to the information systems that will serve their professional practice to provide documentation for the patient care they provide.
Student Use of Computers for Documentation
Several large, enterprise-wide health IT systems have emerged in hospitals in the last decade. Students who plan to work in these environments will be called upon to use these systems proficiently, generally with only modest training. Their nursing education experience should prepare them for learning complex systems essential for performing their new jobs. Yet, integration of expensive health IT systems into academic or clinical laboratory settings is expensive, complex, and exists in few places other than schools with private vendor partners.29
Several recent efforts have been made to develop applications for students to document patient care using electronic methods. In a major partnership, the University of Kansas with Cerner Corporation developed a Simulated e-Health Delivery System (SEEDS), which allows students to practice using a live production information system designed for care delivery.30 The objectives of SEEDS included the following: (1) to enhance critical thinking and problem solving in a data-driven way, (2) to reveal the components of professional standards of practice, (3) to demonstrate the impact that structured data and information have on patient care, and (4) to appreciate the requirement for the use of standardized clinical terminology. The project is the culmination of an arrangement between vendor and school of nursing. It has been successful and has introduced opportunities for meeting challenges that would be inherent in any large system application, but it is unlikely to be implemented in small programs or settings.
Another system at Columbia University, designed and built as a student knowledge and clinical log database, supports the aggregation, analysis, and reporting of graduate students in advance practice. It uses a standardized terminology-based database with a personal digital assistant (PDA) interface for documentation and analysis of student clinical experiences and Web-based information retrieval at the POC (S. Bakken, unpublished data, 2002).31 These programs ambitiously include a variety of coding dictionaries that advance practice nurses need (ie, International Classification of Diseases, Ninth Revision (ICDN); Current Procedural Terminology (CPT); Logical Observations, Identifiers, Names, and Codes (LOINC); and select CCC codes) but are not available or appropriate for undergraduate nursing students.
The Nightingale Tracker (NT), a computerized POC patient information processing unit, used the Omaha Patient Care Record System software incorporated into a hand-held unit. In a collaborative project to evaluate nursing student reactions to the NTs, researchers identified significant increases in positive responses from associate degree students but not from baccalaureate students over time. The researchers reported that the technology's success was dependent on the hardware and technical support available, as it significantly affected student responses.32
There is an urgent call for building informatics competencies into healthcare curricula within the context of promoting patient safety and enabling EBP.33 Nursing education needs to reflect the ubiquitous advance of electronic information and documentation in all aspects of the workplace by preparing future nurses with the literacy they will need to "hit the ground running" on their new jobs. According to McBride, "The promise of IT for nursing education is enormous… [but] there are barriers to achieving the promise… starting with the paucity of nurses prepared to function as IT innovators, lack of funding, high costs, [and] incompatible data bases."2(p186) The aim of this research and development project was to test a software application for students to learn electronic documentation in a clinical laboratory experience to prepare for electronic documentation in their various clinical placements. The system was based on a standardized nursing terminology (CCC) designed to assist students to incorporate all aspects of the nursing process.
Clinical Care Classification System (CCCS)
The ANA has recognized 13 classification languages,34 including the Clinical Care Classification System (CCCS). The CCC (version 2.0) is a nursing terminology system developed by Saba and colleagues9-14,34,36 which documents nursing care based on the conceptual framework of the six-step nursing process with required elements. The CCC provides a unique standardized framework and coding structure for assessing, documenting, and classifying nursing care of patients. The terminology consists of two taxonomies based on its different data concepts-CCC of nursing diagnoses and outcomes and the CCC of nursing interventions and actions (see Table 1).
The purpose of this project was to evaluate the effectiveness of an electronic charting simulation using a bedside personal computer (PC) laptop in the clinical skills laboratory to document patient care planning. The two objectives of the project included the following: (1) testing a software application developed in Microsoft Access (Microsoft, Redmond, WA) using the Sabacare CCCS for teaching students how to record care planning and (2) evaluating the differences in nursing student electronic charting using a randomized design to the PC-based CCCS compared with a text-only, type-in bedside computer in the clinical laboratory. The research questions were as follows:
Can an inexpensive personal computer Microsoft Access application of the Sabacare CCCS be successfully implemented in the learning environment for students to document care planning for simulated patients?
a. Is there a difference in the quality of students' care planning between the data-based CCCS and a type-in text version of recording clinical care using a laptop in the laboratory learning environment?
b. Is there a difference in charting time between the data-based CCC and the type-in text versions of recording clinical care in the laboratory learning environment?
c. Will students rate the data-based CCC care planning system better than the type-in text version of recording clinical care using a laptop in the laboratory learning environment?
A randomized control trial was used to answer the research questions. The experimental group used a PC-developed application of the Sabacare CCC designed with Microsoft Access specifically for the study. The screens were developed in a way that allowed students to enter a patient problem and observe incremental notations added to a summary grid at the bottom of the screen as each problem was recorded. The control group used a type-in text version that was developed using Acrobat Exchange (Adobe Systems, San Jose, CA) presenting the user with a single table of columns that the user could point, click, and type-in free text in each of the areas. Both forms resulted in careplans that could be viewed, saved, and printed.
Experimental Group: Clinical Care Classification Database Version
The database version in Microsoft Access can be launched from the desktop of the laptop computer. The screens and system design are based on the nursing process using definitions of the CCC elements (see Figure 1). Users access the CCC screen through a standard switchboard (see Figure 2) after information is entered about the patient (patient core data) (see Figure 3). (Note: true patient demographic information is not necessary, and users are instructed to create fictitious names in place of patient identifiable information.) The CCC screen, organized according to the nursing process, displays three sections with several drop-down menus and dialog boxes (see Figure 4). The upper left side is used to record diagnosis information, while the upper right is used to record intervention information. Each side connects to three options of outcome "modifiers": (a) expected outcomes of improved, stabilized, or support deteriorated and (b) actual outcomes of improved, stabilized, or deteriorated. Both sides are linked in the coding structure, so entering data on one side automatically populates fields on the other. Users are forced to select at least one of four types of actions (A-assess, T-teach, C-care, and/or M-manage) before a "record" button appears, which subsequently allows the user to view the entered problem on the summary grid.
Two "notes" boxes allow the user to supplement the selections from the drop-down menus for clinical observations (signs and symptoms) on the diagnosis side or details about the intervention. The summary grid displays categories of information, and users can subsequently print a report of the patient's full problem list, displayed with complete documentation, including text from the two notes boxes (see Figure 5). The switchboard can then be used to collate and report a variety of organized data, including frequency of interventions for all patients in the system and types of actions. This feature allows a nursing student to aggregate a collection of all patients entered into the system and easily print a report for the instructor one patient's care plan or a summary of all patient care plans.
Control Group: Clinical Care Classification Type-in Free Text Version
The PC version of the control group "type-in text-only" system was developed using Acrobat Exchange. Users view an empty table in a single PDF file that is also easily launched from an icon (see Figure 6). It allows users to click inside various areas of the table to initiate type-ins. This provides them with a comparable electronic recording system that is easily accessed, includes a structured grid for typing in the care plan, and furnishes them with a mechanism for printing the care plan. It also allows students to compose without constraints.
The study was approved by the Human Subjects Review Board and planned for the summer session. The experimental (database) and control (type-in text) versions of the programs were mounted on laptop PCs, with printers, at each bedside in the nursing clinical laboratory. Two actors were coached on presenting symptoms and complaints from conditions that they would simulate. Each actor was advised to respond to student questions as consistently as possible, using a script designed to reflect authentic patient responses. Students were instructed to interview the two "patients," record the care plans on the PC, and print the care plans on the printer next to it so that written documents could be submitted to the researchers for evaluation. Each actor portrayed one of two patient case descriptions provided to students, including a variety of problems related to their medical diagnoses in the script. For example, one elderly woman with congestive heart failure was confused about her medications. The second scenario involved a patient with pneumonia that was having difficulty breathing.
All nursing students who were enrolled in a summer clinical course were invited to sign up for a "software evaluation project" by the researcher, who attended each of 14 small group clinical orientations. Students in the summer clinical course had completed their junior year of coursework and hospital rotations. Demographics on the final sample who finished the study were not collected; however, the available pool of all students in the course (n = 120) were females (85%), whites (70%), and between 20 and 30 years old (67%). The convenience sample of students who agreed to participate by sign-up sheet (n = 60) were sent information about two sessions and were informed that upon completion of both sessions, they would receive $20, an incentive for making time in their busy schedules. Thirty students attended the first session and signed consents, knowing that they could drop out without jeopardizing their course grades. All participating students were given group instruction about care planning using the nursing process and the CCC terminology, and all had the same clinical experiences. With voluntary participation being voluntary, only half of those who attended the first session returned for the second session. One student left early, leaving a final usable sample of 14 participants and a participation rate of 23% from the volunteers who agreed to participate from the start. Although the sample was small, each participant completed two cases, resulting in 28 usable care plans for the final analysis (n = 28).
At the first 45-minute session, students learned about the study, the standardized language of the nursing process and the CCCS, and the two techniques of electronic charting to be compared. At the end of the first session, students were randomly assigned to groups, and they received the experimental or control CD to be taken home with additional instructions on care planning and a handout on the CCC language. They were scheduled to return for the second testing session in the clinical laboratory. At the testing session, students interviewed the two simulated patient actors with the conditions developed by the researchers (congestive heart failure and pneumonia). They recorded their encounters on the bedside laptop using one of two PC electronic care plan charting methods according to their experimental or control group assignment.
Students were given the patient case descriptions in writing and introduced to the two patients. For each encounter, students were allowed up to 15 minutes to interview and document a care plan on the computer. They were instructed to observe, ask questions, and record notes during the conversation and use the laptop to record their care plan immediately following the interview. They were also informed that their "charting" on the PC would be timed. The actors served as timekeepers, starting the recording when the students stepped to the bedside laptop and ending it when the printer started to print.
Care Planning, Evaluation, and Time Measures
STUDENT CARE PLANNING
All printed care plans were assessed by the investigators and scored using the Evaluation of Documentation Performance (EDP) instrument developed for the study. The instrument was based on assessing the completeness of care planning elements, including the presence of nursing diagnoses, nursing actions, and expected outcomes, with face validity based on juxtaposition of care plan elements with expected performance items. The investigators scored the instrument on seven aspects of the student's printout with "poor," "acceptable," and "comprehensive" ratings (see Table 2). Inter-rater agreement between the two researchers on all items was 98% across all care plans. Items were summed, yielding scores ranging from possible 7 to 24 (coefficient α = .913). Each of the student's two care plan scores was entered into the final analysis.
STUDENT EVALUATION OF PC SYSTEMS
Each student also completed an evaluation of the electronic care planning system with a seven-item instrument developed for the study. Items assessed students' ratings of the application with statements about screen design, ease of use, efficiency, and other aspects of the system, with face validity based on areas of satisfaction with software usability. Choices ranged from "strongly disagree" to "strongly agree" (see Table 3). Scores could range from 7 to 35 (coefficient α = .881).
The time taken by each student to chart electronically on the two patients was measured in minutes and seconds, converted to seconds, and summed for both patients. Actors were instructed to record the time for each student on an index card that was collected after the care plan was printed.
Standard descriptive and comparative statistics using SPSS version 11 (SPSS, Chicago, IL) were calculated to analyze the data. Student t tests were used to test differences between the experimental and control groups for care planning completeness, student evaluations, and charting time. Coefficient α was set at .05. Mean comparisons for the EDP used combined care plan data from both patient scenarios. Power was calculated using a large effect size (0.80) and one-tailed tests. Power was weak (actual power = 0.67) due to the small sample size available for analysis. Nonsignificant results need cautious interpretation.
Student Care Planning
Student care planning comparisons using scores on the EDP demonstrated a significant difference between students who used the PC CCCS Microsoft Access bedside computer and students who used the Acrobat text-based, type-in system on the laptop computers. Completeness of care plans by students who used the data-based method (mean [SD] = 18.1 [2.9]) were significantly higher than the care plans by students who used the type-in system (mean [SD] = 15.3 [4.3]) (t = −2.05, P =.05) (see Table 4). Completeness of student documentation for the pneumonia case and congestive heart failure case appeared to be mixed when compared separately, but findings on separate analysis were based on samples too small to make conclusions. When combined, however, the data-based care plans were demonstrably superior in completeness of student documentation for both patient cases.
Student Evaluation of PC Systems
Students' evaluations of the care planning methods, as measured by ratings on the Student Evaluation of PC Systems, were significantly higher for the data-based version (mean [SD] = 31.8 [5.1]) than for the text-based version (mean [SD] = 25.7 [4.0]) (t = −2.51, P =.025) (see Table 5).
No significant difference between the data-based and text-based PC systems in charting time was found following the simulated patient encounters. Given the small sample size and weak power, nonsignificant findings are difficult to interpret. It should be noted as well that several students seemed to linger over the system, checking and rechecking, using the total amount of time that they were allotted as though the process was an examination. On direct observation, students seemed to demonstrate a greater proficiency with the data-based system than did students who seemed to struggle to compose care plans within the blocks on the type-in version as expected.
There are a variety of efforts underway to address the problem of producing IT-literate graduates from our nursing programs.15,23 These often integrate a framework with a standardized approach using nursing terminology, and they all help shape students' competency in electronic documentation wherever they may practice. Hospital environments vary widely in systems used for nursing, but there is growing attention to finding common ground for communicating.35,36
This study demonstrated that nursing students could efficiently learn how to use an electronic documentation system with a standard terminology to improve patient care plans. Student participants also responded positively to the database method of documentation over the text-based electronic narrative format, scoring it higher in several dimensions. Unlike some studies in which participants were introduced to the standardized language of nursing (coupled with electronic vs paper-and-pencil form of charting),26 these study participants were positive in their evaluation of the CCCS on the PC using Microsoft Access. Although the study did not demonstrate an efficiency of time using the database version of the CCC over typing in text, the students verbalized and wrote comments about its ease of use and efficiency.
There are several limitations of the study that need to be acknowledged. Because of the voluntary nature of participation, the final convenience sample was small and conclusions need to be interpreted with caution, particularly the insignificant findings related to efficiency in time. The measures were developed specifically for this study to evaluate the care plans generated by the students and had adequate reliability but only face validity. In addition, however, the care plans were evaluated by the investigators, who were not blinded to the random assignment and might have been biased in their assessments of the presence or absence of the elements scored on the instrument. Nevertheless, the strength of the study is the randomized design, and even with the small number of students, each student completed two patient care plans that were combined and the significant findings can be attributed to the experimental treatment. The students were all similar in their clinical knowledge and experience. In addition, the study used only two actors who were blinded to the student group assignment and provided consistency across all students with their simulated symptoms.
This study provides evidence to answer the main questions testing the PC-developed data-based application of the CCC program. The cost for each simulated "work station" is the price of an inexpensive PC and printer, less than $1000. In comparison with some of the expensive systems being offered in only a few settings through vendor partnerships-approaching $35,000 per school program-the Sabacare CCCS PC application offers a streamlined method for students to learn nursing terminologies, care planning, and electronic documentation. The PC version is free and can be downloaded with instructions from the Web site http://sabacare.com. Nursing faculty are invited to distribute it to students and collect their reports of multiple patients during a semester.
According to Willmer,37 there is a significant gap in the literature of practical ways that student nurses can apply information and technology within their clinical environments. Many factors have an impact on students' achievement of IT literacy, and there is a need to find ways to provide opportunities. "IT is not just a new tool with which to do traditional tasks, it changes the way people perceive their world."37(p470)
The results of this study support using this inexpensive care planning method in teaching students the nursing process while simultaneously giving them the opportunity to practice using a technology in the laboratory that will emulate the clinical environment. With their experience in the laboratory, students can then transfer the knowledge of electronic care planning and use the software to collect and aggregate a semester of numerous patient assignments in their clinical rotations. Reports can be generated for instructors, which can help in assessing the range of experiences that the student has had in the clinical experiences.
The Sabacare CCCS is an established nursing language that has provided a base of development for numerous patient care information systems in hospitals and home care. This study tested a PC-based version of the system on students' performance of patient care plan documentation. The application was developed as deliverable for any personal computer with Windows and Microsoft Office programs, which are ubiquitous today and readily accessible by students and faculty. The application accessibility is in direct contrast to costly large mainframe "live" systems with their associated patient privacy issues that can complicate learning. The system was tested in a randomized trial with a control group using a type-in, text-based-only comparison, also mounted on the bedside computer for the study. The results demonstrate that the data-based PC application is effective in recording nursing care planning information using the nursing process and capturing patient care information with a language ready for integration with other patient electronic medical record data. Although it needs to be tested further in real clinical environments, this study has clinical implications for nursing faculty in the development and integration of informatics knowledge into the curriculum to prepare nursing students for their future with large enterprise-wide hospital information systems.
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