Today, most health care settings include some form of nursing informatics. The need for quality teaching of nursing informatics content for students to achieve competency has reached a critical point. In 2007, the Quality and Safety Education for Nurses (QSEN) project identified 6 competencies, and informatics was one of those.1 Establishing informatics competency as a priority in nursing has had far reaching implications from accreditation standards to nursing licensure examinations. The purpose of this article is to provide an overview of how to structure informatics content for undergraduate and graduate nursing programs either as a course or integrated into the curriculum. A summary of resources available for teaching and assessing learning outcomes is provided.
Nursing informatics encompasses almost every aspect of nursing care in every setting. The American Nurses Association (ANA) described nursing informatics as a nursing specialty that includes various analytical and information sciences. Nursing informatics identifies, defines, manages, and communicates along the continuum of data information, knowledge, and wisdom in nursing practice.2 Nursing informatics is built upon information, computer, cognitive and library sciences, and information management3—all informed by human factors engineering. The metastructure for nursing informatics was developed based on the way nurses interact and use clinical information systems.2 In the ANA description, “data, information, knowledge, and wisdom” form the metastructure, which increases in complexity as work increases in interactions and interrelationships.2 Both the sciences and metastructure form the framework for understanding nursing informatics.
The QSEN has defined both prelicensure and graduate nursing informatics as the domain in which nurses “use information and technology to communicate, manage knowledge, mitigate error, and support decision making.”4 The definition includes specific knowledge, skills, and attitudes (KSAs) that are leveled according to entry level and graduate nurses. Nurses are expected to possess informatics KSAs that reflect the ability of the nurse to practice competently in a technology-rich nursing care environment. The QSEN initiative helped to move informatics content into mainstream nursing education by defining the KSAs needed by a newly licensed nurse. Teaching the QSEN KSAs with consideration for the defining characteristics, sciences, and metastructure of nursing informatics can be difficult yet attainable. Accreditation standards help: the American Association of Colleges of Nursing (AACN) requires that nursing programs have visible content related to informatics in the curriculum.5,6 The AACN calls for nursing informatics content at the graduate level under “Section III Informatics and Health care Technologies”5 and at the undergraduate level under “Section IV Information Management and Application of Patient Care Technologies.”6 Each of these documents influences curricular design and integration of nursing informatics concepts.
Common misconceptions about nursing informatics are prevalent in the literature. In 1 study, most undergraduate nursing programs had integrated informatics content throughout the curriculum, but many faculty equated preparing students in informatics with providing “distance learning, online learning, and web-based instruction.”7 Although taking an online course can help undergraduate students navigate content of a course, solely taking an online course regardless of the topic does not constitute informatics education. Inconsistencies were found to prevail in content, as well as variation, across curricula and programs.8 If various nursing programs lack consistent, standardized informatics content and directors and deans misunderstand what constitutes nursing informatics, the resulting imbalance can disrupt our undergraduate and graduate KSAs.
Balancing the QSEN informatics competencies with traditional curriculum content can also pose a challenge. Curriculum compression is experienced by many faculty who are trying to fit additional content requirements into an already tightly “packed” nursing curriculum.1 Whereas some undergraduate programs offer a stand-alone nursing informatics course, other programs opt to integrate the content throughout the curriculum. Regardless of method, the content should be visible and identifiable within the program. Finding time and dedicating resources to nursing informatics education are key to achieving competency outcomes.
Another challenge is faculty’s lack of knowledge or specialty certification in nursing informatics.8 Often, nurse educators with no specialty training, education, or experience teach the topic based on convenience rather than competence. Fortunately, proficiency in nursing informatics content is achievable through resources from several organizations. The resources include leveled teaching strategies, faculty education to support teaching, and a curricular crosswalk with QSEN, the AACN Essentials, and the Technology Informatics Guiding Education Reform. Table 1 includes selected Web sites and a description of resources for nurse educators.
Curricular buy-in for informatics content is critical for student learning. Incorporating nursing informatics competencies into the curriculum evaluation plan highlights where content is found and draws attention to gaps in learning. To strengthen nursing informatics content, nurse educators can access existing resources and network with other professions to assist with teaching specific content. For example, a librarian can teach content on information literacy, database searching, and accessing evidence. The potential for partnerships with agencies for assistance with education about health information technology, electronic documentation, databases for quality information, telehealth, and quality improvement activities can help bring current practice information to the nursing informatics course. Partnership possibilities also can address gaps in nursing informatics content in the curriculum.
Some of the same and unique challenges exist within a graduate nursing program. At the graduate level, student preparation varies because students may have taken an informatics course in their prelicensure program, whereas others may not have had a formal informatics course. Similarly, students in DNP programs may not have had previous nursing informatics education. Although the level of informatics knowledge varies, the common thread is that almost all students have experiences using technology in the clinical setting. These experiences can be leveraged when designing a course to build higher levels of understanding.
Assessing informatics competency based on the QSEN KSAs can pose a challenge for the educator. Although the literature is saturated with types of competencies, the measurement of informatics competencies is emerging. Most competency evaluations are in the form of self-reports and self-assessment using surveys15,16 and include items in Table 1.9-14 There is a lack of robust evidence on how best to evaluate most competencies. The strategies presented are based on pedagogical best practices of aligning the competency outcome with teaching and assessment strategies rather than on evidence.
Course Development Strategies
Informatics content can be integrated into the curriculum with clear evidence of outcomes or taught in a stand-alone course. For a single course, dividing the content into manageable portions is easier after identifying its major concepts. Examples of the major defining concepts could be patient care technologies and communication, clinical information systems, workflow and care processes, safeguards and decision supports, and standard terminologies. Each of these concepts encompasses smaller topics for each week. For instance, workflow and care processes can have 1 week on clinical decision support systems, 1 week on technology-supported care processes, and 1 week on informatics and evidence-based practice. Then, for each week, the teacher can examine the topic for how best to address it and the associated KSAs.
A nursing informatics course meets QSEN competencies when it is coordinated with the clinical setting where direct patient care is provided and enables students to master the informatics KSAs. The first step to identifying where informatics content should be placed is to determine which of the competencies can best be achieved in a stand-alone course and which could be integrated into other courses or taught in clinical settings. For example, certain informatics KSAs can be taught and evaluated in clinical courses but still require explanation for prelicensure nursing students. Meanwhile, RN-to-BSN students may already possess many KSAs and only need an understanding of how they fit into informatics.
The following KSAs can be achieved in the clinical setting:
- Navigate the electronic health record
- Document and plan patient care in an electronic health record
- Use communication technologies to coordinate care for patients
- Respond appropriately to clinical decision-making supports and alerts
- Use information management tools to monitor outcomes of care processes1
Prelicensure students can learn the requisite KSAs as they interact with an electronic health record in clinical practice or in a simulation, watch a nurse navigate the health record, or use a program that simulates an electronic health record. To assess the student’s informatics competence in the clinical setting, a single KSA can be assigned for each clinical experience to help students to focus their clinical experience. Students can explain in a postclinical conference how they met the competency KSA. A self-assessment reflection journal entry also can be used to assess students’ achievement of the assigned KSA. In addition, creating a guide that includes the KSA, what the student experienced that related to the KSA, how it met the KSA, and how the KSA related to safe patient care can help to evaluate the student’s understanding of the competency.
To address the other KSAs, it is helpful first to examine the curriculum and courses systematically. Quality and Safety Education for Nurses informatics KSAs can guide the development of a single course or identify options for integrating KSAs into courses as educators adjust for the level of student (associate degree, baccalaureate, RN-BSN, and graduate nursing students). A key first step is mapping the curriculum and determining where specific informatics KSAs are taught and assessed with measureable outcomes. In the mapping, each KSA can be labeled to identify where the content is taught. The result is illustrated in Table 2, which identifies how each KSA is addressed in a course on informatics for prelicensure students. The same mapping can be used for graduate courses or mapping KSAs in an integrated curriculum.
Some overlap of KSAs is expected between clinical and classroom courses. When the mapping is completed, an assessment of where the topics are taught emerges and helps to target areas that need to be addressed. In addition, this mapping clarifies the teaching strategies used to meet each competency. Mapping also allows the nurse educator to judge the value to assign each assessment method used to demonstrate competency outcomes. For instance, if half of the competencies are met using a discussion format, then the discussions might be worth half the total points in the course.
Regardless of the educational level, each student should understand foundational nursing informatics competencies, sciences, and metastructure. Dedicating 1 to 3 weeks, for example, for foundational concepts in informatics courses across all programs helps to level students’ knowledge for the rest of the course. This instruction might entail a discussion forum (if online) or an active face-to-face classroom dialogue, in which students discuss experiences using technology within the framework of the data-to-wisdom metastructure. Such discussions can help students develop an awareness of how nursing informatics, technology, and patient care are interrelated. This basic understanding can be consolidated early on as a foundation for future coursework. Using student experiences in the health care setting helps students to understand how the concepts work in clinical practice. Once basic knowledge is established, students can be taught to apply and synthesize informatics knowledge and use what they know to solve problems creatively.
Teaching informatics at the RN-to-BSN and graduate levels requires attention to adult learning theories and immediate application of learning. As adult learners, nursing informatics students must be engaged to share experiences from the clinical setting or apply concepts to nursing practice. This direct application helps students to clearly understand how the concept is experienced in practice. Strategies to engage these students includes sharing of their experiences, discussions that involve exemplary and less-than-desirable scenarios on a given topic, and self-reflection and self-awareness of KSAs.
A wide variety of creative ideas for teaching informatics and assessing outcomes can be found in Web sites, in articles, and through networking with other faculty. Although some are targeted for a specific population (prelicensure or graduate), most can be adjusted to level the assignment for various levels of students. Provided are examples of teaching strategies developed based on the major informatics competencies as defined by the AACN5,6 with leveling where appropriate.
Basic Computer Competencies
Although most students enter nursing programs with basic computer knowledge and skills, we cannot assume that all students are equal in their understanding. Nursing informatics competency tests vary from vague to highly specialized, and an Internet search shows a wide variety of competency tests. One site with a repository of various computer knowledge and skill self-tests is the Nursing Informatics Learning Center.17 Nurse educators can select specific tests for students as a pretest or posttest for the course. The assessment can require a certain percentage or score to be achieved before access is granted to the course. As a caution, if passing a competency test is a course requirement, there must be resources provided to help students learn the content.
Prelicensure nursing students are expected to understand and use databases in their future practice. Those KSAs will improve as students access databases from a variety of sources. One way of meeting this KSA is to have students access data from different databases and then make inferences about the population health care in any geographical area. They might glean population data from census or federal health care sites and combine it with what they learn from medical Web sites (see Table, Supplemental Digital Content 1, http://links.lww.com/NE/A379).
Graduate students can work with data sets similar to the undergraduate assignment, with the difference that they can download and manipulate the data into reports and graphs, draw logical conclusions about the data, and synthesize the data to make decisions. Both RN-to-BSN and graduate level students can also find their own data sets and use criteria to appraise the quality of the source. Health on the Net Foundation18 maintains standards for gauging the quality of health information Web sites. Students can use such standards to judge the quality of any health-related Web site. For each such standard, nurse educators would assess the strength of the student’s evaluation.
Patient Care Technologies/Clinical Information Systems
A written assignment could require students to propose a new technology that is not currently used in their current clinical setting; such a paper can relate to many of the KSAs and demonstrate competency in multiple areas. The assignment might require students to propose a new form of technology to address improving communication, facilitating safe patient care, increasing patient care quality outcomes, improving efficiency of care, or eliminating redundancies. The RN-to-BSN level assignment should include a clear guide with specific criteria for content inclusion and instructions to follow the nursing process for clarity. At minimum, the paper should include the background of the quality problem that the technology is designed to fix (assess, diagnose), specifics on the technology including costs (plan), implementation with change theory (implement), stakeholders affected and roles (implement), and desired outcomes from the technology including quality measures and impact on nursing care (evaluate). Creating a rubric that describes the desired performance in each area and points allotted guides students in preparing the paper and identifying how they will be evaluated. The robust nature of the paper coupled with a familiar framework encourages students to learn about informatics and its influence on nursing care while it introduces the project management role of a nurse informaticist.
The graduate informatics proposal paper is appropriately in-depth and detailed. Developing the paper by following the Registered Nurses of Ontario eHealth Toolkit provides an evidence-based structure to learn about patient care technology and practice change.13 This toolkit is appropriate for graduate nursing students because it guides them to follow evidence-based steps for implementing technology into practice. Parts of the toolkit and paper include a needs assessment; defining the quality problem; a strengths, weaknesses, opportunities and threats analysis; failure mode and effects analysis; context assessment; stakeholder assessment; implementation strategies; outcome measures; and guided considerations for proposing technology into practice. This type of paper is appropriate for graduate students because advanced practice nurses will use these tools in their future practice. The paper can be used to evaluate students’ achievement of the appropriate graduate KSA competencies.
The competencies for information literacy can be built into both levels of papers by asking students to perform a structured search and develop a search strategy. At a minimum, the search strategy should include the use of Boolean operators, truncation, key words, alternatives, and MeSH terms using a minimum of 4 different databases. In addition, students can be asked to explain how they met the Association of College & Research Library’s information literacy standards, endorsed by the American Library Association.19
Safeguards and Privacy
Regardless of program or level of student, safeguarding patient health information is critical. The National Institutes of Health created several health privacy awareness and health privacy security courses that are open to anyone who registers.20 Each course takes approximately 15 to 30 minutes, and the participant receives a certificate at the end. For the undergraduate student, the certificate and training in both courses (awareness and security) are enough. Furthermore, RN-to-BSN students can explain how they would use this information in the clinical setting or describe an area of new learning from these courses. At the graduate level, students can share a scenario that includes both the right way and the wrong way to safeguard patient data with a subsequent discussion about the problems.
Emerging issues in health information privacy involve the use of social media. Students should understand that, when health care workers post on social media, the impacts can imperil confidentiality and careers. Teaching options include case studies; real-life scenarios; exploring posts by health care workers on sites such as Facebook, LinkedIn, and Twitter; and comparing types of posts for potential liability. All discussions should include the ramifications of inappropriate sharing of information, no matter how innocuous, and potential impact on licensure.
Clinical decision-making supports have evolved into useful and sophisticated tools to help direct nursing care. The first step to sharing these tools is asking prelicensure or RN-to-BSN students to identify decision supports such as point-of-care alerts, warnings, medication dosing alerts, order sets, and other types of technologies that guide patient care in the clinical setting. Students can ask to review the evidence on which the decision support is based and then report back to the class. The point is that not all decision supports are based on evidence and not all evidence for the supports is of high quality. This exercise instills a spirit of critical thinking into students who will work with the technology. At the graduate level, the same type of activity can occur, but students can be asked to retrieve the evidence and appraise the quality based on a reliable appraisal tool. Graduate students can also perform a literature search to identify whether any high-quality evidence exists on the topic that was not included in the rationale for the decision support. At the graduate level, students should not only critically question their practice decisions but also take action to understand their basis. This learning can be evaluated by examining the types of questions raised, databases searched for evidence, and appraisal of existing evidence.
Nursing informatics will continue to play a prominent role in the transformation of health care delivery. It no longer suffices for nursing faculty to think that nursing informatics is taught; state-of-the-science education must be deliberately placed either throughout the curriculum (with visible evidence of outcomes) or as carefully designed stand-alone courses. Resources are available to assist nursing faculty in developing informatics courses and leveling the content. As health care changes, 1 certainty is that nursing informatics content will be increasingly important. Informatics will loom even larger not only for accreditation, nursing certification, and licensure examinations but also for the status of our profession and the security of our patients.
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