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CIN: Computers, Informatics, Nursing:
doi: 10.1097/NCN.0b013e318224e78f

A Training Model for Orienting Newly Hired Nurses to an Organization's Electronic Health Record

Stromberg, Shawn C. BSEd, LPN

Section Editor(s): Thede, Linda Q. PhD, RN-BC

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Clinical Applications Analyst, Jefferson Regional Medical Center, Hillsboro, MO.

Key Points:

* Training that mirrors "real-life" roles and situations

* Training that is not overwhelming

* Opportunities to repeat sessions for information that are still unclear

The important undertaking of orienting newly hired nurses and other nursing caregivers to an organization's systems and processes has grown more challenging with the increasing presence of electronic record technologies in the healthcare environment. Will employees be comfortable with the computer? How are new users introduced to the system? How much training is enough? These are only a few of the questions relevant to creating successful electronic record training platforms.

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When the implementation team at our hospital, a 200-plus-bed general hospital in a mixed rural-suburban area of the Midwest, deployed our electronic record, it experienced difficulties in establishing an effective training platform. One of the things we observed was that levels of familiarity with computers varied greatly among new employees. In trying to accommodate these disparate experience levels, while at the same time providing a solid foundation from which our staff can safely and efficiently utilize our Health Care Information System (HCIS), we have gone through many iterations of our training program.

Initially, we were allotted two 9-hour days to conduct training. All new care providers, including nursing assistants/care technicians (NAs/CTs), nurses, and unit secretaries (USs), attended training together. We tried to organize class material such that we could, at least in theory, know which people needed to be in attendance for the full training days versus which ones could expect to be done early. Ultimately, this proved both difficult to consistently regulate and very disruptive, yet was only one of the many problems in our orientation processes.

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As the capabilities of our system expanded, so did the volume of material we needed to present during those two 9-hour orientation days. Although students each had a computer during training and did interact with various system routines as a part of their class time, much of the instruction took the form of a demonstrative lecture with minimal return demonstration. Over time, we saw evidence that the training needed revision. Documentation was being entered incorrectly or missed altogether; order details were being misinterpreted or improperly entered, creating delays or mistakes in patient care, and patient care plans were both poorly managed and clinically insufficient.

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We sought feedback from our staff and learned that, among those surveyed, far too many of them remained both uncomfortable with the system and less than proficient in its use, even after having weeks or even months of use since their classes. In an effort to change this situation, considerable time was spent conversing with nursing leadership and frontline caregivers about their perceptions of not only the system, but also the training they received.

One of the most common complaints regarding our initial training involved the length of the sessions and the amount of information presented. Essentially, the consensus was: "It's too much, too fast, in too little time." Further, users with little computer experience prior to attending training reported struggling to keep up with the intense pace of class. There were also criticisms relating to the practice of assembling all types of caregivers together during training, with many staff relating how easily bored or distracted they became when subjects irrelevant to their duties were presented. Not surprisingly, all of these observations made sense given what study findings have noted regarding students' ability to remain focused.1 The implications of this information were that there were long periods of inattention during those extended 9-hour days. Consequently, four of the main goals in redesigning training were to create discipline-specific training sessions, reduce the total amount of time spent in the classroom on any given day, present material in smaller packages, and expand the amount of time devoted to each topic.

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We now have separate training for nurses, NAs/CTs, and USs, with NAs/CTs receiving approximately 3 hours of training and USs receiving 6.5 hours of training. Nurses receive 23 total hours of training occurring over 4 separate days. The NA/CT and US sessions were easily accommodated, but the nursing class sessions took considerably more logistical effort to plan. Consideration had to be given to the order in which subject matter was addressed, how much material should be presented during a given class session, and how the training should be formatted.

Ultimately, the members of our informatics team, our nursing leadership, and our super users decided that learning to document effectively in the system would be of greater importance to a newly hired nurse than learning to place orders. The rationale behind this decision is that nurses' roles generally require more documentation than order entry; therefore, their ability to chart is more valuable than their ability to place orders.

We now have an arrangement whereby our nurses attend class on 4 separate days, two on the Thursday and Friday of their first week of orientation, and two more classes 1 week later. The material presented during all 4 days is structured to follow existing hospital processes. Also, students are given 5- to 10-minute breaks approximately every 45 minutes in order to help prevent learner overload. The rationale for training 2 days in 1 week and two more the next is to allow students more time to absorb the material, while at the same time giving them a few days to work on their respective units using what they have learned, before returning for their remaining training. They can then bring questions or concerns arising from their initial experiences to the next class, allowing further reinforcement of existing knowledge along with the presentation of additional subject matter.

On the first Thursday of training, nurses learn basic things, for example, how to properly sign in to our system, clinical terminology associated with the HCIS, and how to manage their passwords. They also learn how to initiate and edit patient care plans, enter data on allergies, and how to navigate the electronic chart. A simulated admission is used to teach students the intricacies of our electronic care planning screens. Each student is provided with a different fake "patient" and a clinical scenario that includes needed "patient" information such as assessment findings, some patient history, laboratory values, diagnosis, and other facts critical to the care plan.

Using these data, the students and instructor work together to create a very patient-specific care plan for each patient. They go through various discussions to arrive at decisions regarding each patient's problem, the necessary outcomes, and interventions. The fictitious patient scenario is designed to promote critical thinking. At points during the exercise in which the system can be particularly difficult to manipulate, common errors are introduced. This is not done in any way that "throws" the students or undermines their self-confidence, but instead the instructor makes a mistake, whereupon the students follow. After the teacher reveals the problem, the students and instructor discuss the pitfall and its future avoidance for the purpose of strengthening staff proficiency. At key points in the discussion, questions are presented to stimulate students to think not only about their respective patients, but also about how the electronic care plan directly determines the documentation to be completed for each patient.

For our institution, this new documentation structure has been a big process change because although they should have, our old paper-based care plans did not always drive or correlate directly to the patient documentation. With our electronic system, the care plan absolutely has to incorporate the necessary interventions and outcomes documentation, or sufficient charting cannot be accomplished, and the patient record will not reflect adequate care.

On the first Friday of training, nurses learn about all aspects of clinical documentation. Additionally, detailed information about electronically "signing off" orders is presented. Together, the class members carefully examine how their care plans have inserted necessary interventions and outcomes into the patients' charts for use in documenting their care. They also learn to utilize the electronic medication administration record and incorporate bar-code scanning into their medication administration process. To aid in fully grasping the latter, the students are issued fake patient bar codes for use in actually executing the scanning operation during class. They also learn various "shortcuts" that can assist nurses in using the system more efficiently without compromising the integrity of their work processes or charting.

The third training day, which occurs a week after the first training day, addresses order entry. By the end of the training session, students have placed over 60 orders of various types, including order sets such as cardiac enzymes and insulin algorithms, medication orders, laboratory tests, radiological procedures, diets, and consultations. They have likewise performed myriad order edits, learned to document the collection of specimens that have been ordered, and been thoroughly immersed in the process for electronically "signing off" orders. Because of its critical nature, the proper electronic "sign-off" of new orders is something revisited in small ways on all 4 training days.

The final Friday of training addresses the documentation of patients' home medications and our medication reconciliation process, which is itself an evolving entity. The students actually document a list of 10 home medications for their patients and then perform edits on those. These edits include documenting when the medication was most recently taken, the dosage prescribed, the proper frequency, whether the medicine is scheduled or PRN, and the route of administration. Instructor and students then engage in an extended discussion of potential situations wherein proper medication reconciliation is crucial, focusing particularly on the patient discharge process.

One lead-in used when the group of students is large enough (our groups vary from as few as two students to as many as eight or more) is to open this training day with a game of "telephone." One student is chosen, and the instructor whispers a simple phrase to him/her. He/she whispers it to another student, who passes it to another, and so on, until it comes back to the teacher. Invariably, the phrase returns in an altered, sometimes humorous, form. This is used as a springboard to emphasize the importance of properly reconciling patient medications. The instructor carefully explains how a list that is incorrectly entered on one admission or transfer may be accepted as accurate by the discharging or receiving physician. The physician uses this list, leading to potentially harmful decisions about discharge prescriptions or transfer orders. Adding to the danger is the fact that these are then recorded on subsequent visits as home medications, further distorting the original list. As the entire process degrades, the potential patient risk due to miscommunication becomes ever greater. See Table 1 for a summary of the topics addressed in each session.

Table 1
Table 1
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At the end of the final training day, nurses are provided a training survey and emphatically instructed not to complete it until they have actually worked for at least 2 weeks on their respective units. This delay is to allow new staff sufficient time to actually use the training they have received so they can more accurately assess its real value. When the surveys are returned, they are carefully reviewed and used to make any necessary training improvements.

Posttraining evaluations are new to us, as we did not implement any such feedback mechanism with our original training program. With regard to the surveys, we have admittedly encountered inconsistencies relating to the delay period between the time they are distributed and the time we expect them back. Some are never returned, while others are returned incomplete. Of those fully completed, a few are less than useful as improvement guides because all feedback will be entirely positive, as though our program is already perfected. We are working to develop a more structured, electronic, trackable process for managing the surveys with the hope of being better able to gain meaningful data from the responses and increase end-user participation. Nonetheless, at least 50% of the surveys we currently receive are useful to us in that they provide honest assessments of our platform.

The revolving, consistent schedule for our training sessions allows nurses, or their managers, to easily schedule repeat training. For example, if a nurse is having difficulty with manipulating the electronic care planning screens, but is comfortable with the other areas of the system, then he/she can arrange to attend that session the next time the topic is taught. The training schedule essentially repeats every 2 weeks, and complete details regarding the content of each session are electronically posted for the entire year. Although most trainees do not repeat sessions, input from the few who have indicates that these users find the option beneficial. More important, our staff leadership has expressed that the option provides a sort of "comfort level" simply by its existence. They know that more training is readily available should the need arise. The decision to offer the repeat sessions was in part based on Booth's2 research, which found that subjects tested 20 minutes after presenting new material had forgotten 47% of the information. Testing after 1 day increased the forgotten material to 62%, and after 2 days, 69% was forgotten.

We also offer training to other staff who may need or wish to gain a better understanding of what the nursing staff see when interacting with the system. Recently, three members of our pharmacy team, whose order-entering screens differ considerably from those seen by nursing, attended our order management training so as to be better able to assist nurses via telephone with the entry of complex medication orders. Since that time, members of both our nursing and pharmacy staff have expressed that fewer ordering difficulties occur.

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Since transitioning to this divided format, we have trained approximately 125 new employees. Because our group sizes vary from between two and about eight employees at a time, 125 is a very significant number for our organization as it represents many months of training cycles. The feedback we have received from staff leadership regarding the effectiveness of our new training model has been positive. Although to this point we have done no formal analysis or statistical review, unit managers have uniformly reported that the new training has produced staff members who are, on the whole, much better prepared to use the system than those trained under our previous model. The user-related issues we encounter are not only fewer, but also much less often related to training problems than when we first adopted our HCIS. In addition, nursing perception of our efforts has grown much more supportive because nursing leadership, end users, and the informatics team were jointly involved in the training modifications. As our hospital continues to grow, the training will surely evolve along with our systems, but because of its success, the basic arrangement is unlikely to change. Additionally, it readily accommodates things such as system changes and upgrades, hardware migrations, and other metamorphoses inevitable with the concurrent growth of technology's presence in healthcare.

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We have thus far learned the following through all these collective experiences:

* continually evaluate results of training and make needed revisions,

* listen to users' perceptions,

* match information to roles,

* break out training sessions over time to provide time for needed review,

* use real-life situations in training,

* evaluate after having had time to use the system, and

* provide review sessions on an elective basis.

We still have much to do in our quest for the "perfect" training environment. We hope to soon develop computer-based, interactive presentations of the same material currently offered in the classroom environment, not for the purpose of cutting corners on training, but with the goal of allowing self-paced new employee education with self-evaluative, scored, posttraining quizzes to assess understanding of the information. Also, such an electronic format would allow trainees more flexibility in terms of when or where training occurs. In addition, the electronic quizzes would help us track which topics may be causing the most difficulty among users and even which users might need follow-up assistance. We have recently purchased a software product that we believe will allow us to develop the electronic format we desire, but as of this writing, the informatics team members are still in the process of mastering it themselves. Our goal though is in sight, and our progress thus far has clearly illustrated that we have chosen a successful path to achieve it.

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1. Middendorf J, Kalish A. The "change-up" in lectures. Teaching Resources Center. Indiana University. National Teaching and Learning Forum. 1996;5(2):1.∼tchsotl/part3/Middendorf%20&%20Kalish.pdf. Accessed November 30, 2010.

2. Ebbinghaus H. Memory: a Contribution to Experimental Psychology. 1885. Translated by Henry AR, Clara EB (1913). Originally published New York: Teachers College, Columbia University. Cited by Booth A. Using evidence in practice. Journal Compilation Health Libraries Group. Health Inf Libr J. 2007;24:145-149. Accessed November 30, 2010.

© 2011 Lippincott Williams & Wilkins, Inc.



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