Vana, Kimberly D. DNP, RN, FNP-BC, FNP-C; Silva, Graciela E. PhD, MPH
Nursing students should learn to navigate the complexities of the healthcare arena, including integrating electronic health record (EHR) systems and online drug reference databases into patient care. A pharmacology course is a perfect environment, whether in the classroom or online, to introduce nursing students to EHRs and meet the recommendations by the American Association of Colleges of Nursing (AACN),1 the Institute of Medicine (IOM),2 The Technology Informatics Guiding Education Reform (TIGER),3 and the Quality and Safety Education for Nurses (QSEN).4 Students need to master accessing patients’ diagnoses, medication lists, vital signs, and laboratory reports to administer medications safely. In addition, students should access online drug reference databases to determine drugs’ indications; categories or classifications; black box warnings; adverse drug reactions; and potential drug interactions. Using a simulated patient EHR and an online drug reference to complete a patient case-study worksheet within a class period improves nursing students’ perceived competencies in accessing and using EHRs and online drug references.
In 2008, the AACN1 noted that nursing graduates are expected to meet the core competencies for healthcare professionals identified by the IOM2 and QSEN.4 Competent nursing graduates should understand pharmacologic concepts and recommended monitoring parameters to provide quality care and ensure patient safety. In this technologic age, graduates need to access current medication information competently from online drug reference databases. Thus, nursing educators try to ensure that their students have ample opportunity to learn these technologic skills, preferably initiating this educational activity within a nonthreatening classroom environment before practicing in the clinical arena.
The TIGER Initiative3 also supports the need for nursing graduates to be competent in the use of EHR and online drug reference databases. A limitation in preparing graduate nurses technologically has been the reliance on healthcare organizations’ permissions for students to access their EHRs.3 Because not all healthcare organizations are willing to allow students access to their patients’ health records, schools of nursing may use EHR simulation software, such as SimChart (Elsevier, Philadelphia, Pennsylvania), to provide EHR experiences during patient-simulation case studies as recommended by the TIGER Initiative.3 To prepare our students for using an EHR, we chose to introduce them to SimChart within a baccalaureate nursing pharmacology course before their scheduled patient-simulation case studies.
By introducing nursing students to EHR simulation software and an online drug reference database (Epocrates Online, Epocrates, San Mateo, California), nursing educators provide a simulated technologic environment in which students are encouraged to practice data retrieval and critical thinking skills to ensure quality care and safety, which are essential competencies in QSEN.4 Specifically, the nursing students are asked to “demonstrate effective use of technology and standardized practices that support safety and quality.”4(p128) While reviewing a simulated EHR, nursing students practice identifying possible hazards and communicating concerns4 about pharmacologic therapy. Reviewing a simulated EHR also allows students to practice accessing data and determining drug appropriateness, effectiveness, possible hazards, and recommended monitoring. An in-class exercise allows students to become more comfortable with an EHR program while stimulating critical thinking.
The simulated EHR and the online drug reference database encourage experiential learning. Students are provided an opportunity to assume an unfamiliar role.5 Although nursing students become competent in accessing information from an EHR and an online drug reference database, these students also need to learn to process the retrieved information into meaningful decisions and actions. Without guidance from teachers, nurse educators, or faculty members, the students may be preoccupied by tasks.6 Focusing on tasks may overshadow the importance of evaluating the appropriateness of pharmacologic therapy and communicating concerns to the healthcare team. The relational aspects of the simulated EHR case study assist students in creating nursing knowledge.6 A simulated EHR provides a real-life approximation of an actual health record, which allows students to interact with a record similar to those records they will encounter in clinical nursing units.
Ideally, best educational practices maximize students’ learning during a simulation exercise and increase critical thinking, knowledge, skill attainment, confidence, and learner satisfaction.7 Instructors are encouraged to give clearly written, specific directions to facilitate learning toward intended outcomes,7,8 identify timeframes for the activity and debriefing before the exercise, and provide cues and coaching during the exercise to stimulate critical thinking and skill attainment while creating an atmosphere free from harm for students and patients.7 The level of complexity ideally should match the knowledge and skill levels of the nursing students, stimulating growth without frustration.7,9 Students need to be self-motivated, which is more likely if they feel safe and sure of the ground rules, and be encouraged to select data on which to base care decisions.7 In addition, prompt feedback through debriefing is essential.7 Discussions among students and instructor can create a sense of collegiality and promote attainment of desired educational outcomes.7 Assisting students in recognizing overlooked important aspects of documentation during debriefings can enhance student learning.10 In addition, students are provided the opportunity to practice communicating their ideas to classmates and being held accountable for their contributions.11 In a simulated EHR exercise, the instructor coaches students on data retrieval from the health record and online drug reference and encourages students to use the patient’s health history, medication list, vital signs, and other record parameters to determine appropriate monitoring, patient education on medications, and mitigation of adverse drug reactions and drug interactions. Students learn to recognize and interpret salient documentation in the EHRs and plan interventions accordingly.10
The purpose of this study was to determine how using a simulated EHR and an online drug reference to answer questions on a patient case study affected baccalaureate students’ perceived competencies in finding patient information in the EHR and drug information in online references. We also chose to evaluate students’ satisfaction with the educational strategy of using a simulated EHR and online drug reference while completing a simulated-patient, case-study worksheet.
Design and Sample
This study used a pretest and posttest design and included a convenience sample of nursing students newly enrolled in 3 junior-level, baccalaureate, prelicensure, nursing pharmacology courses during the summer and fall terms of 2013. All nursing students in these courses were invited to participate. All students were 18 years or older and spoke English. The participants had to complete a demographic questionnaire, pretest, posttest, and satisfaction questionnaire to be entered into the analyses, and a total of 113 participants were included.
This study was approved by the university’s institutional review board. We explained the study orally and asked students to ask any questions that they might have on the study. During this class period, we also provided a study packet that included a cover letter explaining the study, a demographic questionnaire, and a pretest and a posttest that both inquired about their agreement or disagreement with 11 statements related to EHR and online drug reference competencies. The packet also included a satisfaction questionnaire that inquired about their agreement or disagreement with 8 satisfaction statements related to EHRs and online drug references. We explained that the study packet would take approximately 10 minutes to complete. Students were asked to complete the demographic questionnaire and pretest before the instruction on the simulated EHR and online drug reference and complete the posttest and satisfaction questionnaire at the end of the class period. Each packet had an identifying participant number on each page to match the demographic questionnaire, the pretest, the posttest, and the satisfaction questionnaire to 1 case. Students were assured of their anonymity and that their decisions to participate or not participate would not affect their course grades. Students were asked to place their packets, completed or not completed, face down in a cardboard box before leaving the classroom.
We explained how to access the assigned case study on a patient with diabetes mellitus and heart failure and the online drug reference information over the first 15 minutes of the class period. In addition, we reviewed the educational objectives and case-study directions. During the next 45 minutes, the students worked in groups and completed the worksheets while being coached by the instructor on how to find pertinent pharmacologic or patient information. During the last 15 minutes of class, the student groups were asked to debrief by discussing with the instructor and their classmates the pharmacologic and patient information that they entered on their worksheets. The student groups also were asked to recommend patient teaching topics and monitoring parameters for each drug in the simulated EHR, as well as to note specific potential hazards, such as black box warnings and drug interactions. After the class period, students were asked to complete the posttest and satisfaction questionnaire for the study, if desired, which took less than 5 minutes.
The pretest and posttest were identical and consisted of 11 items that evaluated students’ perceptions of their abilities to access data from the EHR and online drug reference (Table 1). The satisfaction questionnaire consisted of 8 items that evaluated students’ satisfaction with the opportunity to use an EHR and online drug reference. The answers to these items ranged from 1 to 5 for each of these tools: strongly agree (5), agree (4), neutral (3), disagree (2), or strongly disagree (1). Each item measured a different concept, and thus, total scores were not computed for these tools. These tools were evaluated for content validity by the authors before use. The tools’ reliabilities were evaluated with Cronbach’s α values during this study. The pretest and posttest were highly reliable, with Cronbach’s α values of .96 and .94, respectively. The satisfaction questionnaire was highly reliable, with a Cronbach’s α of .92.
The demographic data were analyzed using descriptive statistics and χ2 values. The pretest-posttest median differences were evaluated using Wilcoxon signed-rank tests. The satisfaction results were evaluated by medians and ranges. The analyses were completed using IBM SPSS Statistics 21 (IBM, Armonk, New York). Statistical significance was determined by a P < .05.
A total of 113 of 136 junior-level, baccalaureate nursing students, or 83% of the students in the 3 courses, completed the demographic questionnaire, pretest, posttest, and satisfaction questionnaire. Four additional participants completed the pretest only, and thus, their data were not included in the final analyses. Demographic comparisons between those participants who completed only the pretest and those participants who completed all tests and the satisfaction questionnaire showed no statistically significant differences. The participants were predominantly women (103/113 or 91.2%), white (75.2%), and non-Hispanic (82.3%; See Table, Supplemental Digital Content 1, http://links.lww.com/NE/A135). The participants’ ages ranged from 18 to 49 years, with a mean (SD) of 22.71 (5.87) years (Table, Supplemental Digital Content 1, http://links.lww.com/NE/A135). A statistically significant difference was found among the mean (SD) ages of participants in the 3 courses (Summer 2013, n = 48; Fall 2013, n = 49; Fall 2013, n = 16): 25.21 (7.90), 20.16 (1.43), and 23.00 (3.74) years respectively (P = .0001). However, no differences were found in gender, race, or ethnicity; thus, the data from 3 prelicensure pharmacology courses were combined, and analyses were done on aggregate data.
Previous Experiences With EHRs and Online Drug References
Most participants had no previous experiences with EHRs (85.8%) or online drug reference databases (90.3%; Table, Supplemental Digital Content 1, http://links.lww.com/NE/A135). Participants’ EHR experiences ranged from reading 0 to 80 health records per week, with a mean (SD) of 2.83 (10.49) records per week. The participants’ previous online drug reference experiences ranged 0 to 5 times per week, with a mean (SD) of 0.20 (0.75) times per week.
Pretest and Posttest Item Scores
The participants’ posttest item median scores were higher than the pretest item median scores for all items (Table 1). The pretest median scores for the items ranged from 3 to 4 and indicated that the participants generally agreed that they could calculate and interpret a body mass but felt neutral about the other statements before the case study. In contrast, the posttest median scores for the items ranged from 4 to 5 and indicated that the participants generally strongly agreed that they could calculate and interpret a body mass index, find a drug’s black box warning, and find a patient’s vital signs in the EHR. The participants agreed that they felt comfortable using EHRs and could find a patient’s diagnosis, laboratory results, and medications in an EHR. Likewise, the participants agreed that they could find the drug indications, drug categories or classifications, and potential drug interactions for medications listed in the EHR with the use of an online drug reference. The differences between pretest and posttest median item scores were highly significant (P < .0001) for all items (Table 1). The participants’ assessments of their abilities to use EHRs and online drug references positively increased from neutral and agree to agree or strongly agree for all items. These perceptions were supported by the correct student answers to the worksheet during the case study debriefing.
Satisfaction Questionnaire Responses
The median scores of all items on the satisfaction questionnaire were 5, with ranges of 3 to 5, indicating that participants generally strongly agreed that the pharmacologic case study increased their comprehension of EHRs and pharmacologic concepts (See Table, Supplemental Digital Content 2, http://links.lww.com/NE/A136). The range of mean scores for the items was 4.54 to 4.73 (See Table, Supplemental Digital Content 2, http://links.lww.com/NE/A136). The participants were “glad” that they had the opportunity to use an EHR and online drug reference tool and desired to use both technologies in future nursing courses, including assignments and clinical experiences.
We designed the strategy to encourage students to find essential empiric data, as well as recognize data patterns that suggest potential quality or safety concerns related to medications, such as contraindications, adverse effects, and drug interactions. Students were guided to identify important monitoring parameters and patient education topics for prescribed drugs, while keeping patients’ health histories in mind. However, many of the nursing students in the first semester of nursing courses had no previous opportunity to review patient health records or start clinical experiences. Many students had not seen a paper record or EHR nor understood how health records were organized before the class activity.
Providing a controlled environmental context, such as a patient narrative, can make learning new pharmacologic concepts more meaningful and, thus, easier to comprehend. Carefully constructed EHRs allow students to explore pharmacologic concepts collaboratively in a nonthreatening and controlled environment.12 Ideally, the EHR simulation should be challenging while allowing success.13 Brookfield14 noted that for students to be self-directed, they must believe that they can do so effectively. Simulations that allow students to face reality-based challenges may increase students’ self-efficacy.15 Thus, giving clear directions and providing cues with coaching increase the odds that students will be successful and will be satisfied with the EHR case study. As in our study, Wilson and Klein13 noted that participants were more confident in their abilities and expressed satisfaction after simulation activities. This confidence building encourages students to be self-directed in class and sets the stage for lifelong learning.14 In addition, asking students to assess their perceived confidence with skills before and after the simulated EHR case study allowed students to recognize their increased confidence with pharmacologic skills and knowledge.14
Because the development of expert skills and knowledge requires considerable time to develop, nursing instructors need to provide ample opportunities for students to learn and hone their expertise.16 Allowing students an opportunity to practice pharmacologic skills in a safe environment before clinical placements is essential for patient safety and student confidence, while decreasing student duress.16 In addition, introducing EHRs during a nursing pharmacology course provides students opportunities to apply their newfound knowledge to a simulated clinical case. Adult learners are more engaged in learning when the new knowledge and skills are seen as pertinent and directly applicable to their interests, for example, their chosen careers.17 Ideally, the instructor engages students in a “process of mutual inquiry” during “life-centered” learning experiences.17(p12) Using a simulated EHR allowed students to explore a “life-like” career experience in a nonthreatening environment with peer and instructor support.
Furthermore, having students discuss their findings and recommendations with other students and the instructor during the case study activity and debriefing allowed them to refine relational skills.5,6,11 Not only were the students confident in their abilities to access drug-related information from the EHR and online drug reference, but they also presented their findings competently and explained their plans for monitoring adverse drug reactions and educating the patient on the prescribed drugs, improving patient outcomes and providing for safety.18 Each student group presented additional content and interventions that were not discussed by a previous group. With the facilitation by the instructor, a comprehensive patient plan was developed that exceeded the depth of individual groups’ plans. The selection of a relevant EHR assisted the students in developing cognitive skills, as well as psychomotor skills.16 Debriefing was essential to allow students to reflect on their ideas and proposed interventions and identify pharmacologic concepts that could be transferred into future practice.19 The back-and-forth dialogue among students and instructor created a sense of camaraderie and spontaneity during the learning process,17 which focused on improving future practice and maximized teamwork,12 as well as safety.18
Strengths of the study include maintaining a consistent context while increasing the sample size. Administering the case study to students in 3 nursing pharmacology courses, taught by the same instructor, provided a larger sample size for analysis while maintaining the same course structure for all participants. This larger sample size across 3 cohorts increased the generalizability of the study’s findings.
Because of the class time limitation, each student in the group had a deep learning experience regarding 2 to 3 drugs before sharing insights with the small group members and the entire class. This collaboration allowed the students to complete the worksheets in 45 minutes but may have inhibited the breadth of learning. The pretest, posttest, and satisfaction questionnaire were validated for content through agreement of the authors. These outcomes are specific to baccalaureate nursing students who have entered their first semester of nursing courses within their junior year and who have not had exposure yet to EHRs or clinical assignments.
Although the students reported that that the educational strategy was worthwhile, we recommend extending the time for worksheet completion by 15 minutes or assigning 5 drugs in the medication list to each student group to fit the 90-minute timeframe. The case study also may be used to enhance learning about specific drug categories rather than the ability to access data from an EHR and online drug reference. When focusing on specific drug categories, we recommend a pretest and posttest to evaluate student learning. We also recommend emphasizing the importance of pharmacologic concepts in planning quality nursing care, rather than just performing the psychomotor task of accessing information pertinent to medication administration. Furthermore, we suggest that additional pharmacologic case studies be developed to investigate pharmacologic concepts related to other drug classifications, such as anticoagulants and narcotics. We also recommend that EHR case studies be tested in other didactic and clinical nursing courses, in addition to junior-level, nursing pharmacology courses. In addition, nursing students should be provided ample opportunities to use simulated EHRs, so that they may review patient histories, test results, medications, and other data competently before their scheduled clinical experiences.20
Because the cost of simulated EHRs may be included in student fees or bundled with textbooks, schools of nursing are encouraged to make full use of this technology in didactic and clinical courses. Currently, at our institution, online student access for SimChart is $73.75 for 6 months or $261.25 for 2 years (B. Kastenbaum, personal communication, February 28, 2014). Faculty taskforces may be formed to choose the desired simulated EHR program and to plan how each course in the nursing curriculum will use this technology. Importantly, content leveling of the planned EHR learning activities over the span of the nursing curriculum may benefit students significantly.9 In our curriculum, the pharmacology course is the first course to introduce students to this technology. Thus, we focused on the ability to find data within an EHR. The largest challenge is to develop a case study that has the breadth of content to discover drug interactions and abnormal vital signs and laboratory results. Thus, we recommend developing a written template of essential case study information before inputting the content into a simulated EHR.
When choosing a simulated EHR, teachers, nurse educators, or faculty members should evaluate if the EHR supports clinic and hospital charting and data collection. Electronic health records bundled with students’ textbooks may result in lower EHR fees. In addition, we recommend that nurse educators investigate the ease of providing feedback on charting and care plans created within the EHR. Ideally, the EHR also links to nursing resources, such as laboratory test results, pharmacology databases, and nursing diagnoses. Nurse educators also may inquire which EHR program best aligns with the EHRs being used in students’ areas of clinical placement and whether students can see charting by other disciplines. The learning platforms may differ in ease of use. Ultimately, the EHR provider’s willingness to support the nurse educator’s development of simulation patients is essential.
This study demonstrated that a simulated EHR case study can be used effectively to introduce nursing students to an EHR and an online drug reference tool. An early introduction to an EHR allows students to become more familiar with the organization of health records before clinical experiences; whereas, an introduction to an online drug reference tool allows students to become more adept in finding pharmacologic information, exploring possible drug interactions, and planning patient monitoring and medication education. The results supported that a simulated EHR case study can increase students’ confidence in their abilities to use EHRs and online drug references effectively before actual clinical experiences, leading to students’ satisfaction. The use of simulated EHR case studies should be used in nursing didactic and clinical courses to decrease the gap between education and practice.
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