According to the Bureau of Labor Statistics,1 there will be a 15% increased need in the RN workforce from 2016 to 2026. While more RNs will be needed, there are obstacles to meeting this workforce demand. Evidence shows that the lack of clinical placement settings is the largest impediment to expansion of nursing program enrollment; however, access to clinical sites is not the only concern.2 Nursing faculty are anecdotally reporting that the quality of student clinical experiences is jeopardized, in part because of restricted access to essential patient information via the electronic health care record (EHR) and electronic medication administration record (eMAR).
Nurse educators have been called on to effectively integrate the use of technology and informatics into the prelicensure curriculum, recognizing the demand for newly graduated RNs to be prepared to use EHRs and eMARs upon entry to the workforce.3,4 Informatics is identified as a prelicensure Quality and Safety Education for Nurses (QSEN) competency for nursing students.5 Quality and Safety Education for Nurses describes the skills for informatics competency as the ability to use the EHR to plan, document, and monitor care outcomes.5 In addition, the EHR is used to communicate and coordinate interprofessional care and support clinical decision making.5 Thus, accessing patient information by using the electronic systems is essential to planning and delivering safe health care. Furthermore, the National Council of State Boards of Nursing includes the utilization of information technology related to promoting a safe and effective care environment in the National Council Licensure Examination-RN test blueprint.6
In 2012, the Institute of Medicine described the challenges of protecting patient safety and privacy within complex technological systems such as EHRs and eMAR systems.7 Guarding the integrity of these complex health information systems is the responsibility of health care organizations.8 This includes determining who will have access to the information, training those who have access, and monitoring the systems to detect errors or misuse. Many members of the health care team must access and interact with EHRs and eMARs, and everyone who accesses the record must have his or her own personal username and password to maintain integrity of the EHR.9
The diversity of roles in the health care team contributes to the complexity of assigning access levels corresponding to user needs without increasing the risk to patient information safety.10 Protection of patient health records is essential; however, information access limitations for students and faculty in the clinical setting can pose other risks. Restricted access may result in a student providing care with incomplete information, having insufficient communication with the health care team, and being unable to accurately document care. There is also a potential for health information privacy protection misuses.11
Health care organizations may be unable to provide faculty and students with access to the EHR and eMAR systems because of limitations in their system infrastructure to assign and train student users or concerns about technology competency and data entry errors.12 When access is restricted by the health care organizations, students are stymied in gaining knowledge and skills to develop competency in using health information technology systems. In fact, 76% of new graduates indicate they are not adequately prepared in informatics to access and use EHRs.13
In response to the need to meet the informatics competency as cited in QSEN and the need for health information technology training as identified by the Institute of Medicine, many nursing programs rely on simulated or academic EHRs and eMARs.5,7,14-16 These systems have been shown to be helpful in student engagement and learning.17 However, without exposure to actual direct patient care documentation, there may be a skill gap in the new graduate nurse's transition into the professional nursing role. Although simulated EHR and eMAR experiences contribute to developing nursing students' knowledge and skills in the use of technology, they lack the dynamic clinical context necessary to develop clinical reasoning with integration of information to deliver patient care.18-20
The scope of the restriction of access to EHRs and eMARs for nursing students in their clinical experiences is not known. Therefore, the purpose of this study was to describe prelicensure nursing students' access to, and use of, EHR and eMAR systems in the clinical setting as reported by clinical nursing faculty.
For this descriptive, cross-sectional study, the researchers surveyed a sample of clinical nursing faculty to collect data about the clinical experience of students' use of EHR and eMAR systems using a researcher-designed online survey. Information was gathered about the type of nursing program, faculty and student access to the electronic systems, and the scope of the access. The institutional review board of the first author's affiliated university approved this research before participant invitations. All subjects were provided with an electronic consent form at the start of the online survey.
Registered nurses teaching a clinical course in a prelicensure nursing program in the United States who work with prelicensure nursing students at a clinical site were invited to complete the survey. These instructors were selected as the study population because of their firsthand knowledge of nursing students' access to patient information and documentation via the EHRs and eMARs.
Snowball sampling was used to reach potential respondents from May 5, 2018, to October 18, 2018. The researchers distributed the online survey URL through professional nursing organization networks and email contact lists to reach clinical instructors at schools of nursing. This included distribution through the QSEN Academic Clinical Practice Task Force and announcement at the 2018 annual QSEN conference. In addition, email invitations to participate were sent to school of nursing deans and directors at the researchers' associated colleges and universities, with a request for distribution to their faculty.
The research team drafted the initial survey and distributed it for content review to the QSEN Academic Clinical Practice Task Force membership (n = 35). Revisions were made based on reviewers' recommendations, and the final 29-item survey was approved for face validity by the task force members. The reported results were obtained from 24 of the 29 survey questions: 14 multiple-choice, 3 fill-in-the-blank, 5 dichotomous-answer, and 2 ten-point rating scale questions. At the close of the study period, data were downloaded and imported to IBM SPSS version 24 (2016; IBM Corp, Armonk, New York) for analysis.
Demographics of Respondents
Of the 274 survey respondents who signed into the survey, 61 did not agree to the consent, and 20 others did not complete any information after consenting, resulting in a sample of 193 clinical nursing faculty who taught in a prelicensure program. The respondents had a mean age of 53.58 years, with a mean of 9.6 years of experience as clinical faculty. Most respondents were female (95.9%) and white (88.6%) and held a graduate degree (85%). Some respondents (9.3%) taught in more than 1 type of program, but 43.5% taught exclusively in an associate degree in nursing (ADN) program, whereas 47.2% taught solely in a BSN program. Most respondents were part-time clinical faculty (60.9%) who spent a mean of 92.67% of their time in clinical instruction. Full-time non–tenure-line faculty spent an average of 60.12% of their teaching time in the clinical setting, whereas those who were on the tenure track averaged 45.37% of their time in clinical instruction. There was a mean of 7.96 (range, 4-14) students in each clinical group. Faculty represented all areas of acute care nursing practice (medical-surgical, obstetrics, pediatrics, mental health, and critical care). Twenty-five states were represented in the sample throughout all regions of the United States: northeast (39.9%), midwest (22.8%), west (18.1%), and south (13.5%).
Access to Patient Information
Faculty rated the process for being given EHR access for themselves and for students using a score of 1 to 10, with 1 being the easiest and 10 being the most difficult. They rated the process for themselves as moderately easy (mean, 4.3) and the process for students as slightly more difficult (mean, 5.04). Although the majority of faculty (92.2%) reported they had access to the EHR at the clinical agency where they teach, when asked whether they were restricted from accessing information that would be helpful to providing care or teaching students, 13.3% agreed. On the other hand, only 78% of students had personal access to the EHR at their clinical agency, with almost 30% of them having more restricted access than their faculty member. Reported EHR restrictions included read-only access, an inability to see diagnostic results, and limitations in documentation. There was no difference in EHR access between faculty and students; however, there was a statistically significant difference between the restrictions imposed on faculty versus students' EHR access, with students having more restricted access (χ2[1, N = 188] = 10.73, P = .001). Despite having their own access, the majority of students (64%) who had a personal login to the EHR still used their clinical faculty's (46%) or staff nurse's (18%) EHR access to some degree.
There was no difference in faculty access to the EHR based on region in the United States, but there was a statistically significant difference in student access to the EHR across regions (χ2[3, N = 182] = 11.354, P = .01). Students in the midwest were the most likely to have their own access to the EHR (93.2%), followed by the west (85.7%) and south (80.8%). Students in the northeastern United States were the least likely to have personal access to the EHR (68.8%). Moreover, there was a statistically significant difference in student restrictions within the EHR based on region (χ2[3, N = 182] = 10.497, P = .015), with the northeast having the most restricted access (50.1%), followed by the west (45.7%) and south (30.8%). Students in the midwest had the least restricted access (22.7%). There was no statistically significant difference in EHR access for students based on program type (ADN or BSN), clinical unit type (medical-surgical, obstetrics, pediatrics, mental health, or critical care), or clinical group size.
Among the respondents, there was a significant difference between faculty and student eMAR access (r = 0.254, P = .001), with 71.7% of clinical faculty having personal access to the eMAR and only 13.9% of students having direct access to the eMAR. There was a statistically significant difference in faculty access to the eMAR based on US region (χ2[3, N = 166] = 37.293, P < .001). Faculty in the northeast were most likely to have access to the eMAR (88.2%), followed by faculty in the midwest (80.9%) and west (58%). Only 28% of faculty in the south had eMAR access. Of students who did not have personal login access to the eMAR, 66.2% used their faculty member's access, and 33.8% used the staff nurse's access to administer medications. Moreover, 69.7% of the students without personal access to the eMAR documented medication administration using their faculty's or staff nurse's eMAR account. There was no significant correlation between students' EHR restrictions and eMAR access.
Despite personal access to the EHR, many students used either their faculty's or staff nurse's login information to access patient information and document care in the EHR. Notably, students who had their own access but used either their faculty's or staff nurse's access to document were more likely to document vital signs, intake and output, physical assessment, and delivered patient care, than students who documented under their own login. This difference, however, was not statistically significant. Overall, the majority of students with their own EHR access were able to document vital signs, intake and output, patient care, physical assessment, and risk assessments, whereas less than half of students without personal access were able to document in any area of the EHR (Table). A significantly higher percentage of students who had their own personal EHR access, even if the access was restricted, documented in the EHR as compared with students who did not have personal access to the EHR (Supplemental Digital Content, Table, available at http://links.lww.com/NE/A737).
To the researchers' knowledge, this study was the first to report nursing students' access to and use of EHR and eMAR systems. The results from this survey indicate that there is a great variance in experiences among nursing students related to the use of electronic patient information within the health care setting. Because of this variation, it is difficult to ensure that all students are receiving comparable and adequate clinical experiences to gain the knowledge and skills necessary to develop informatics competency. Notably, the findings of the restrictions placed on nursing students for the documentation of basic nursing care in the EHR, such as vital signs and intake and output, are of great concern. When students are not permitted to document their patient assessment, interventions, and outcomes, they are missing a vital step in the provision of care.
Achievement of the informatics competency for prelicensure nursing students, as defined by QSEN, requires knowledge of technological tools health care professionals use to promote communication, safety, and high-quality care.5 The skills related to the informatics competency include being able to navigate the EHR, use it to document care and monitor outcomes, and use the embedded decision-making tools to support clinical reasoning and identify potential errors. Using the EHR also allows students to gain documentation skills by seeing what experienced nurses have documented.16 Active use of electronic information systems in the context of the clinical experience is a key component of nursing students' experiential learning. Without the opportunity to use the EHR and eMAR in the clinical setting, the development of students' entry-level informatics competency is adversely affected.
These restrictions also limit the students' access to the clinical decision-making tools embedded in the eMAR technology. Because medical errors are now cited as the third leading cause of death in the United States21 and medication errors are the most common type of medical error,22 it is vital that nurses are competent to use medication administration technology. Ultimately, restricted access to health information technologies contributes to a nursing student's failure to learn the skills necessary for competent practice on graduation and licensure. This study supports findings that newly graduated nurses begin their professional practice unprepared to use EHRs.19
The findings of irregular access to patient electronic health information by students whose personal access is restricted raise ethical and legal concerns. When nursing students are restricted in using EHRs and eMARs, they may not know pertinent patient care information, and it is likely that a portion of their patient care is not documented. The results of this study show that students work around this problem by operating within their faculty's or staff nurse's secure electronic access. This is a failure to uphold the ethical obligation for veracity in health care documentation and a violation of the legal requirement limiting authorized users to access health care records to protect patient privacy and confidentiality.23,24 It is the responsibility of the health care organization's privacy or compliance officer to determine electronic records' security access level based on health care worker role, provide adequate training, follow security authorization procedures, and monitor user activity.10 It is equally important for health care information users to abide by access policy. When there is a mismatch of user access need and actual user permission, as described in these results, it is critical that representatives from schools of nursing and clinical practice partners engage in a concerted dialogue to determine the appropriate faculty and nursing student EHR and eMAR access levels.25
The academic-to-practice gap is likely to widen as nursing programs' pedagogical models remain dependent on health care facilities, which curb students' direct care experiences. The rife becomes broader considering disagreement on priorities for newly graduated nurses' entry-to-practice preparation as viewed by nursing educators and potential employers. In a comparison study of the 3 most important knowledge, skills, and attitudes for the QSEN informatics competency, only employers rated the skill to document and plan patient care in an EHR as most important.26 Both faculty and employers rated the attitude to protect confidentiality of patient health information and the skill to respond appropriately to clinical decision-making supports and alerts in the top 3.26 The reported high value placed on entry-to-practice EHR competency by employers is paradoxical with the findings in this study, which found that agencies placed restrictions on students' EHR access. Nursing students should have EHR access during their prelicensure education to develop the employer-valued skill of EHR proficiency.
With the variation in nursing students' use of EHRs and eMARs in the clinical setting, nurse educators are called on to use innovative teaching strategies to ensure all students gain the knowledge and skills needed to develop informatics competency and provide safe, quality patient care using today's health care technology.27 One strategy schools of nursing can adopt is the use of academic EHR and eMAR programs. These software programs provide students, in a simulated setting, an opportunity to practice electronic documentation with faculty instruction.17,23 However, these programs may be cost prohibitive to many nursing programs.
Despite the importance of the results, this descriptive study had limitations. The design of the online survey allowed respondents to select multiple answers to some questions, which limited the extent of the data analysis. In addition, the snowball sampling technique limited the generalizability of the results.
Informatics competency is necessary for all entry-level nurses working in the current health care system; thus, it is critical that all prelicensure nursing curricula have informatics competencies integrated as program learning outcomes and that nurse educators implement appropriate teaching and learning strategies to support informatics education. Yet, across the United States, there is consensus among clinical faculty that students' opportunities to develop informatics competencies are limited because of inadequate EHR and eMAR access in the clinical setting. Future research is needed to more fully understand the effect of limited electronic health information access on nursing students' learning outcomes. Moreover, nurse educators should collaborate with health care organizations to determine appropriate security access levels for students and faculty to promote the delivery of safe and accountable health care.
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