CIN: Computers, Informatics, Nursing:
Collaborating to Optimize Nursing Students' Agency Information Technology Use
FETTER, MARILYN S. PhD, APRN
Author Affiliation: Villanova University, College of Nursing, Bryn Mawr, PA.
The author declares no conflict of interest.
Corresponding author: Marilyn S. Fetter PhD, APRN, Villanova University, College of Nursing, 820 Gatemore Rd, Bryn Mawr, PA 19010 (firstname.lastname@example.org).
As the learning laboratory for gaining actual patient care experience, clinical agencies play an essential role in nursing education. With an information technology revolution transforming healthcare, nursing programs are eager for their students to learn the latest informatics systems and technologies. However, many healthcare institutions are struggling to meet their own information technology needs and report limited resources and other as barriers to nursing student training. In addition, nursing students' information technology access and use raise security and privacy concerns. With the goal of a fully electronic health record by 2014, it is imperative that agencies and educational programs collaborate. They need to establish educationally sound, cost-effective, and secure policies and procedures for managing students' use of information technology systems. Strategies for evaluating options, selecting training methods, and ensuring data security are shared, along with strategies that may reap clinical, economic, and educational benefits. Students' information technology use raises numerous issues that the nursing profession must address to participate in healthcare's transformation into the digital age.
Improving collaboration between nursing education programs and clinical agencies to produce graduates with information technology (IT) competencies is a significant priority for the nursing profession. Computing, informatics, and information literacy skills are considered essential for beginning nurses.1-9 However, in two decades of research, most efforts to raise students' performance beyond basic levels in the area of computer skills have been minimally successful.10,11 Furthermore, experts in education and informatics cannot agree on the most effective strategies for teaching elementary computing skills and more sophisticated informatics and information literacy learning.12 That a large percentage of nursing education takes place in healthcare institutions and community agencies further complicates the problem. Clinical practicums allow students to gain hands-on experience in taking care of actual patients, apply evidence to practice, use the latest informatics system and technology advances, and learn critical thinking skills. However, little is known regarding the agency IT experience of nursing students and the best methods to promote their use of IT to incorporate evidence-based practice.
Experts contend that basic IT competencies can be acquired in classrooms, learning laboratories, simulation experiences, and online.13-16 However, to master more advanced skills, such as using clinical decision support systems, evaluating evidence for practice application, and teaching patients and families how to search for online resources, application of learning in actual practice settings is considered desirable.10,17-19 Institutions value developing students' competencies but are challenged managing nursing programs' IT needs.20 Agencies already are under pressure to meet the federal government's mandate for a fully electronic health record by 2014.21,22 In terms of faculty and students, yearlong, repeated rounds of day, evening, and weekend training and monitoring are required. Developing policies and mechanisms to ensure safe technology use, appropriate care documentation, system security, and data privacy places significant demands on agency informatics, education, and management staff. Furthermore, agencies bear the cost of training and other resources consumed in the process. Optimizing learning experiences also taxes nursing programs. Evidence shows that many nursing faculty lack the expertise necessary to teach IT content at even the baccalaureate level.18,23,24 Current and projected faculty shortages only exacerbate this problem.25,26
Two recent projects underscore the significance of improving the integration of IT into nursing education and practice. In 2006, the Technology Informatics Guiding Educational Reform (TIGER) Initiative, a coalition of nursing informatics, clinical, management, education, and policy experts and vendors, reached consensus on an agenda for improving the integration of IT into nursing education.27,28 In its 3-year action plan, the TIGER Initiative calls for agencies, vendors, and educational institutions to collaborate to develop and disseminate best practices to bridge the education-IT chasm (Table 1). While not specifically addressed, nursing students' IT learning in clinical agencies is a critical dimension of this issue. The Quality and Safety Education for Nurses (QSEN) initiative specifically addresses the role of informatics in achieving the Institute of Medicine's competencies for nursing during prelicensure education.29 Therefore, this discussion presents key agency and nursing program parameters defining student IT practice and specific strategies that will enable safe, cost-effective, and educationally sound nursing student IT access and practice. Nursing students' IT use has legal, educational, policy, and research implications that must addressed to prepare a cadre of practitioners capable of realizing the potential of "e-health."
A vast body of literature supports the potential for IT to improve healthcare safety,30,31 access,32 efficiency,33-35 and quality36 and its importance for nursing education.3,7,8,27,29 McBride's37 integrative review describes the evolution of IT in nursing and its implications for nursing education. This discussion focuses on clinical agencies' expectations and experiences with regard to nursing student IT learning and practice, which has received relatively little study.38 Experts contend that nursing education has embraced instructional technologies, particularly clinical simulation, distance, and online instruction, as cost-effective alternatives to traditional teaching methods.39-42 Incorporating informatics practice applications and information literacy into curricula has been a much slower and more difficult process.43-45 Recent successful efforts significantly enhancing students' competencies have featured intensive, integrative efforts infusing technology and training throughout curricula.30,46-52
Research and evaluation substantiate IT competency deficits, particularly beyond basic computing skills, in nursing education and agency concerns. In Austin's53 survey of 183 nurse educators from 18 programs, only three of 60 identified computer literacy skills were integrated into curricula. Nursing deans and directors cited strengthening informatics teaching as a critical but as yet unevaluated goal and evaluated informatics instructors as novices.23 A qualitative analysis of these data reinforced the conclusion that most faculty were still focused on basic computer skills acquisition.24 A national survey of nurse administrators identified general and nurse-specific skills, such as documentation and medication administration systems familiarity, as critical new graduate competencies.54 Employers' expectations significantly exceeded students' activity regarding general computer applications and their and faculty use of hospital information system applications. Managers recommended improving the incorporation of these competencies into nursing curricula, since an estimated one-fifth of the faculty did not include any IT content in their courses. The ability of educational programs to prepare students for the workforce was questioned. Faculty competency deficits have been cited as a major barrier to student IT learning and a significant contributor to the problem.25,55 A comprehensive evaluation of one program's curriculum and learning experiences confirmed this assertion.18 Student IT competency deficits, particularly for skills beyond basic computing, have been documented internationally,56-61 evidence that some contend makes it a global norm.39,62
The paucity of research and discussion regarding nursing students' clinical agency IT access and use raises concerns in light of some recent reports. A case study of six British students and their clinical nurse mentors found that information and communication technologies were not being used in a structured and systematic way.63 Maag64 surveyed 743 baccalaureate and higher-degree nursing students from 21 institutions. Most ascribed moderate to strong positive attitudes regarding health computing, but less than 10% reported exposure to higher-level skills. Significantly, juniors and seniors had the most exposure to IT overall, in clinical placements. A baccalaureate program surveyed 21 clinical affiliates, who reported problems regarding access, training, resources, and supervision.20 Some agencies reported allowing students and faculty to use staff nurses' passwords to access medication administration and documentation systems, a significant liability concern. Poor communication, late practicum assignments due to faculty shortages and turnover, and poor IT appreciation and skills by nonclinical faculty and administrators were reported.
Limiting nursing and other healthcare students' access to agency IT systems can also be deleterious to patient care as well as educational quality.33,65,66 A recent study identified no or incomplete access, along with poor instructor-student-staff communication, as a chief condition conducive to students' medication errors.67 However, IT access adds another arena to existing obligations for educational institutions as well as clinical agencies to document and monitor training and compliance with governmental privacy68,69 and hospital accreditation70 regulations. Research, policy, and common sense dictate that collaboration between nursing programs and healthcare organizations will improve nursing students' IT knowledge and skills, prevent health errors, promote privacy and system security, and maximize efficiency. While awaiting TIGER Initiative and QSEN outcomes likely to address this issue, agencies and programs must act now to share best practices.
MANAGING THE PROCESS
To optimize students' IT use and learning, clinical agencies and nursing programs need to collaborate and follow parallel, standard processes. Because e-health will soon be standard care,41 even environments with little or no IT integration are encouraged to establish mechanisms to manage student practice and set future goals. Complete nursing student and faculty access to all relevant clinical and unit management IT systems has been recommended but is far from the national norm. Therefore, educational programs as well as healthcare institutions need to articulate a mission, vision, and annual objectives for accelerating nursing students' agency IT access and use and allocate appropriate resources. Strategic planning, long established in management, has been recommended as a specific strategy for nursing education to advance IT integration in curricula.71 A survey of the IT plans and funding of 190 schools of nursing found that the majority lacked a comprehensive plan and were underfinanced.44 Less than one-third of the programs surveyed addressed IT in their curricula. While inadequate resources and managerial leadership have been cited as significant barriers to student IT practice,63 the benefits have been found to outweigh costs.72 With leadership, educational programs can enter partnerships to share costs and resources.43,49,73,74
Healthcare institutions and units within agencies should reaffirm their educational mission and resources to provide a philosophical underpinning for education program selection and placement options, in conjunction with IT access and use policies. Clinical rotations are rightly viewed as a resource, and agencies need to consider several factors when assigning programs and students. Maximizing opportunities for baccalaureate and higher-degree students in highly IT-integrated agencies and units has the potential to cultivate and accelerate needed expertise development. However, agency employment realities may counterbalance profession priorities. Some specialty and highly IT-integrated agencies or units, such as home health, the Veteran's Administration, and operating rooms, do not hire or report difficulty recruiting new graduates. Thus, they may need to give preference to programs whose graduates are likely to seek employment, for example, graduates of associate degree and RN-BSN programs. Along with understanding educational role, agencies should confirm the resources committed to the numerous aspects of student IT use. Contracts with vendors and educator resources need to be evaluated to establish realistic training options.
To manage nursing students' IT use, agencies and educational programs should identify current and planned IT systems, practices, and policies. The first step of this process is for agencies and programs to define IT and its elements. Because of the lack of consistency in terminology and definitions, systems and technologies included under the IT umbrella are very idiosyncratic. Therefore, it is recommended that agencies and programs work from established competency standards as they embark upon this process. The Nursing Informatics standards of practice published by the American Nurses' Association (ANA),4,5 based on extensive research by Staggers and colleagues,75,76 remain the standard and philosophical underpinning of all IT competency articulation in nursing. For baccalaureate students, the Association of College Research Library's (ACRL)1 information literacy standards complement many of the ANA beginning nurse competencies and facilitate evidence-based practice. However, agency perspectives are also critical. Nursing staff and programs need to be aware of the array of equipment, systems, and practices covered by school and agency policies to minimize misunderstanding and potential threats to safety. For example, some agencies consider blood glucose meters and programmable pumps as IT related. Nursing programs need to conduct this assessment for each clinical practicum unit site and instructor due to the individual variability in nursing education. A systemwide and unit-by-unit assessment and documentation process will enable institutions to capture IT integration variances.20 Surveys should include the following IT functions: patient demographics, medication administration, clinical documentation, order entry, nurse staffing, discharge planning/utilization, patient/family education, referrals, outpatient visit recording, library access, institution intranet, and adverse event reporting. Annual, and preferably biannual, assessment is necessary to keep pace with innovations. Staff members who manage educational placements should maintain the database, which can be a standardized online assessment instrument that includes all current, pilot, and projected IT systems and projects. Educational programs are advised to incorporate IT competencies into course and clinical objectives. Figure 1 depicts an illustration of a sample undergraduate program IT competency documentation tool that incorporates the ANA, ACRL, and affiliating agency competencies. Since the ACRL standards are rather global, it uses a hierarchy of cognitive learning for leveling these competencies. Such a document can be modified for agency and unit use. Ideally, an outcome of the TIGER Initiative will be collaborative national guidelines for agencies and educational programs to direct clinical placement, learning, and supervision.
Once level goals are established, agencies and programs should develop policies and communicate expectations to each other. In general, policies need to address the following functions: access and access termination, training, certification, password protection, privacy, security, patient confidentiality, data deletion and misuse, usage monitoring, firewall protections, quality assurance, missing data/documentation, incident reporting, and liability and penalties for policy violations, health errors, and criminal activity. Using agency systems for non-practicum-related purposes should be expressly prohibited, and usage monitoring for inappropriate, unethical, and criminal behavior needs to be communicated. Collaboration contracts should specify student and faculty access, training, limits, and penalties for policy violations. It is advisable that these policies are in a format that can be easily appended to collaboration contracts and orientation materials. Agencies and programs need to define respective responsibilities. Faculty and students should sign forms acknowledging policy awareness and compliance; copies should be kept on file by the agency and school. Policies and procedures need to be shared with all unit nurses, as well as faculty and students. Given the feasibility and other demands student and faculty IT training necessitate, agencies and programs may consider minimizing site placements and augmenting student exposure to multiple information systems through simulation and laboratory experiences.
Several strategies can be used to implement a nursing student and faculty IT training and monitoring process using best practices. In general, agencies allowing student and/or faculty IT use either perform their own training or have programs conduct orientation using agency materials. Agency-hosted training usually mirrors employee training and is conducted by institution or vendor instructors. Commonly, sessions are truncated because most students do not need as complete access as do staff. Furthermore, agencies report that generic, young-adult students orient more quickly to IT programs than do older nurses.20 When agencies control student training, they can ensure that performance standards are met. However, scheduling and conducting sessions are time and staff intensive. Because of the similarity of academic calendars, two clinical rotations per semester are common; thus, scheduling log jams at the start and midsemester points is predictable. Limited classroom space creates orientation delays and the potential for students practicing on units without system access. Makeup sessions for student absences are also necessary. Employee orientation and advanced training must be scheduled around student orientation crunch times.
Nursing programs can be required to conduct their own systems training using agency materials. Institutions can send files or programs electronically or via a compact disc. Clinical instructors are then responsible for scheduling and conducting training. Instructors or agencies can certify student performance standard attainment and distribute passwords. This approach reinforces informatics as integral to the curriculum and care process and forces faculty to attain competence levels at least as strong as the students' competence levels. However, there is the potential for schools, students, and individual instructors to take shortcuts. As rigorous a process for students and faculty training and certification as for nursing staff is advisable.
Remote student access into agency training via the Internet is technically possible. Institutions would need to set up access and possibly orientation schedules, but would not have to deliver sessions. Clinical groups could train together, with those aforementioned advantages, or self-schedule, desirable for adult, evening and weekend students. Agencies can retain control of sessions and the certification of student and faculty competency. However, this method presents numerous system security and access concerns. Universities are plagued by computer viruses, hackers, file sharing, excessive downloading, and slow connections, particularly at peak use times. Just as with their own staff, agencies need to establish system security with firewalls and monitoring to protect against breaches due to electronic misbehavior. The convenience of this approach for agency informatics instructors, employees, and educational programs warrants attention to these details.
Regardless of the training model, several principles improve effectiveness. Assessing training needs and usability testing of methods have been recommended.77 In an in-depth study of nursing student IT module training at five sites, a number of practical suggestions were made.17 Learner assessment, longer training time, and structured modules were identified as helpful. A lower student-to-instructor ratio, practice before use in the clinical setting, and incorporating exemplar case studies also facilitated learning. In addition, paper versions of instructional materials, using a sample record, repeated practice, experiencing benefits, and sharing the history of adapting technology to clinical care are advised. Involving technical staff in training development and adequate staff for troubleshooting and technical support in laboratories and on units were also recommended.
Additional options can or will soon be available for faculty and student IT training and supplemental instruction. An innovative collaboration between nursing programs and a vendor, "Simulated E-hEalth Delivery Systems" (SEEDS), is enabling students to learn how to use actual information systems in their nursing laboratories prior to clinical placements.49,73,74 This consortium is sharing implementation strategies and initial results for use by other programs integrating agency systems into clinical laboratory and practicum courses. The QSEN Web site, available at www.QSEN.org, is another resource for didactic and clinical teaching strategies.29 Distance learning is already a staple in many nursing programs; therefore, synchronous and asynchronous Web and pod casts are possibilities. Vendors could be asked to make such programs available on their own sites, which would be a cost-effective and standardized strategy that would greatly facilitate the integration of IT into nursing education. Such a program might be an excellent first step toward improving the integration of IT into nursing curricula. Another possibility is for vendors or agencies to offer student IT training via established nursing Web sites, such as the ANA'S "Nursing World" (www.nursingworld.org), or other organization of publishers' Web sites. Canada's national nursing organization maintains a free-access Web site that provides access to informatics continuing education for all nurses.78 In the United States and internationally, such an option could be used by association, accrediting, policy, vendor, philanthropic, or entrepreneurial entities. This approach eliminates agency security concerns and reinforces the integral nature of informatics in the nursing process when professional organizations manage the process. Regardless of the delivery method, nursing faculty and student IT training should occur prior to practice on clinical units. Minimal competency standards should be required for faculty and students, and passwords should enable placement length access only. Faculty should be recertified for each rotation to prevent password sharing and after mandatory updates. Ideally, faculty competency standards should be higher than the students' to promote role modeling and IT advances.
Agencies and programs need to have processes in place to evaluate processes and outcomes with respect to nursing student agency IT use.50 A number of outcome indicators should be considered, including measurable student and faculty IT competencies, medication errors, and adverse and other reportable events. The use of nursing-sensitive patient outcomes to evaluate care, such as those included in the "Health Outcomes for Better Information and Care," has been suggested an approach for promoting communication and collaboration between staff and students and patient safety and quality.79 In terms of processes, programs should be rated in terms of their level of cooperation and collaboration with staff, compliance with mandatory training, and documentation. Some of these data are and soon all may be required by nursing and healthcare institution accreditation and certification organizations. Consequently, disseminating best practices is essential. These data can also be used by agencies to inform student placements by program and level. Because of the high variability of healthcare delivery, nursing education, and informatics integration in agencies and programs, regional mechanisms for sharing best practices are recommended. Schools of nursing, especially clinical instructors, should do a better job of communicating to agencies the barriers and facilitators to IT competency attainment. Feedback about training methods, staff support and mentoring, and other data are useful to agencies as they work to manage this process. Another aim of the TIGER Initiative is to foster collaborative research and evaluation between nursing practice and education with respect to IT. At the agency and unit level, nursing students, instructors, and staff are finding ways to promote students' skills and e-health with patients, families, and communities. For example, nurses, students, and instructors could devise strategies to implement during practica for helping patients and families develop personal health records or use health information sites, such as the Veteran Administration's "MyHealtheVet" site.80 Collaboration that not only fosters improved student IT learning and practice but also builds a foundation for future research, practice, and program initiatives is an additional marker of agency and baccalaureate program excellence.
Managing nursing student access to agency IT systems calls attention to the challenges and opportunities the information revolution presents to the nursing profession and, in particular, to educational and healthcare institutions. The agency-nursing education interface is poorly understood, and a lack of collaboration and evidence-based knowledge is thwarting education, clinical, and policy initiatives.25,38 There is a host of unanswered questions regarding how students learn and practice in clinical agencies and how best to prepare them for e-health.81 The profession needs to gain a better understanding of how IT can be used to foster nursing education and, more importantly, patient, family, and community health. Ideally, interdisciplinary as well as collaborative research capitalizing on the talents of nurse scholars and clinical experts will move nurses beyond conscripts to leaders in the information revolution in healthcare.37,74 Legally, student and faculty agency IT access raises several questions.68,69 Clinical information systems that incorporate student and faculty practice enable agencies and payors auditing and data mining that can associate practitioners, including faculty and students, with specific outcomes such as medication errors and infection rates. Agencies and programs, as well as clinical instructors, should consult legal counsel and insurers to ascertain the adequacy of current malpractice policies and limitations for faculty and student practice. The liability associated with inadequate training and monitoring policies warrants profession-wide evaluation. It is important to note that privacy and security breaches, such as when devices containing patient and agency data are lost, stolen, or shared, fall under this domain. Allowing students and faculty access to information and other systems via staff nurses should be prohibited immediately.
Nursing education and healthcare institution accrediting organizations have been very slow to address the issue of student and faculty IT competencies and IT use.43 Mandatory, measurable, and regularly updated competencies for computing, informatics, and information literacy for nursing faculty and students are long overdue.82 Recently, a partnership between the National League for Nursing and the University of Kansas was funded to train cohorts of nursing faculty as Health Information Technology Scholars.83 The program will use an innovation diffusion model to train faculty IT champions to advance IT curriculum integration. In addition, schools of nursing must do a better job of measuring and documenting IT competencies for students as well as faculty.18,54,55 Regardless of the degree of exposure to agency systems, prelicensure programs can ensure student competency development through more appropriate and effective use of clinical simulation,16,81 incorporating standardized IT modules,48,49 and a national core IT curriculum integrated across student levels.64 Including electronic charting with all clinical simulation activities has also been recommended. Furthermore, nursing programs need to track errors committed by students and faculty and use risk management processes to prevent future mistakes and improve student learning. The Institute for Safe Medication Practices67 data reveal the threat that the lack of national standards poses to patient safety. The institute's report advises effective collaboration and communication between students, staff nurses, and instructors, in addition to improved systems and policies; these suggestions have implications for agencies, educational programs, and vendors. Compatible platforms, standardized terminology, and student-faculty practice and training accommodation are also needed for safety and education reasons. Collaborative relationships, such as the one between the University of Kansas, Cerner Corporation (Kansas City, MO), and participating nursing programs,49,73,74 are needed to protect patients and bridge the agency-education IT divide.
The role of IT vendors with respect to nursing education requires greater focus. Ideally, all vendors would voluntarily incorporate faculty and student practice in their systems and share them pro bono with appropriate copyright protections with educational institutions. Notably, the most highly publicized collaborative venture, between Cerner Corporation and a consortium of educational institutions, was a joint venture partially funded by the educational institution.73 At present, many nursing programs lack the vision and/or resources to enable such an initiative71 absent policy and funding support. In addition, although students in the SEEDS project gain expertise with one system, learning which is arguably transferable, the larger problem for nursing programs and agencies of training students for all of the systems they will encounter during their undergraduate experiences remains unsolved. The TIGER Initiative calls for voluntary collaboration to promote IT interoperability and educational integration and also suggests that policy action may be needed to accelerate these goals. The government and other payors, healthcare and educational accreditation organizations and, most importantly, agency managers can encourage vendors to "give back" by sharing systems and training methods that foster student IT competency attainment.25 Beginning nurses constitute their future markets. Not only is building nursing students' IT competence in their best interests, but most importantly, it is essential for healthcare safety and quality.
Improving nursing students' IT access and skill has major advantages for healthcare providers and consumers, but it will take the proverbial village to accomplish this goal.62 Managing the process requires agencies and educational programs to work together, along with vendor cooperation. Organizations must articulate an IT vision and mission and allocate adequate resources. Current and planned IT systems and competencies should be assessed and documented using standardized, shared tools. Through partnerships, agencies and programs can establish and communicate policies, training strategies, and monitoring processes. By evaluating and sharing outcomes regularly, improved patient, student, and agency outcomes are possible. Clinical agencies and nursing educational programs need each other but are not currently collaborating effectively to meet the nation's 2014 IT targets. They should remember that the information revolution is foremost focused on improving healthcare access, quality, and efficiency for patients, families, and communities. Educational programs, faculty, and healthcare agencies face a critical choice. They can embrace e-health and its potential by working together to promote nursing students' IT access, or they and their patients will be left behind by a paradigm shift in healthcare.
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