Exploring faculty perceptions towards electronic health records for nursing education Y. Kowitlawakul1 RN, PhD, S.W.C. Chan2 L. Wang3 RA, MPH & W. Wang1 RN, PhD
RN, FAAN, PhD,
1 Assistant Professor, 3 Research Assistant, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore, 2 Head and Professor, School of Nursing and Midwifery, University of Newcastle, Newcastle, Australia
KOWITLAWAKUL Y., CHAN S.W.C., WANG L. & WANG W. Exploring faculty perceptions towards electronic health records for nursing education. International Nursing Review 61, 499–506 Background: The use of electronic health records in nursing education is rapidly increasing worldwide. The successful implementation of electronic health records for nursing education software program relies on students as well as nursing faculty members. Aims: This study aimed to explore the experiences and perceptions of nursing faculty members using electronic health records for nursing education software program, and to identify the influential factors for successful implementation of this technology. Methods: This exploratory qualitative study was conducted using in-depth individual interviews at a university in Singapore. Seven faculty members participated in the study. The data were gathered and analysed at the end of the semester in the 2012/2013 academic year. Results: The participants’ perceptions of the software program were organized into three main categories: innovation, transition and integration. The participants perceived this technology as innovative, with both values and challenges for the users. In addition, using the new software program was perceived as transitional process. The integration of this technology required time from faculty members and students, as well as support from administrators. Limitations: The software program had only been implemented for 2–3 months at the time of the interviews. Consequently, the participants might have lacked the necessary skill and competence and confidence to implement it successfully. In addition, the unequal exposure to the software program might have had an impact on participants’ perceptions. Conclusion: The findings show that the integration of electronic health records into nursing education curricula is dependent on the faculty members’ experiences with the new technology, as well as their perceptions of it. Hence, cultivating a positive attitude towards the use of new technologies is important. Implications for nursing and health policy: Electronic health records are significant applications of health information technology. Health informatics competency should be included as a required competency component in faculty professional development policy and programmes. Keywords: Electronic Health Records, Health Information Technology, Nursing Curriculum, Nursing Education, Nursing Informatics, Qualitative Study, Undergraduate Nursing Students
Correspondence address: Dr Yanika Kowitlawakul, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Block MD 11, Level 2, 10 Medical Drive, Singapore 117597, Singapore; Tel: 65-6601-1766; Fax: 65-6776-7135; E-mail: [email protected].
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Introduction Electronic health records (EHRs) have been implemented rapidly and globally to improve the quality, safety and efficiency of healthcare delivery systems. Nursing faculties have been urged to bridge the gap between educational and clinical settings by training healthcare students to be competent in the use of health information technology (HIT). Several nursing programmes have developed or modified an EHR’s software to fit their curriculum. For example, the University of Victoria designed an EHR educational portal that allowed students to access different EHRs in Canada (Borycki et al. 2009); the University of Kansas modified EHRs to enable nursing students to learn nursing process skills (Kennedy et al. 2009); and the University of Tennessee developed a prototype EHR application called iCare v.1.0 to train nursing students (Wyatt et al. 2012). These software applications will continue to be developed internationally to enhance students’ use of technology. In Singapore, the Ministry of Health had decided that all public hospitals should implement EHRs. Most hospitals in Singapore have now adopted EHRs in their practice. As a result, nurses need to be educated on the use of electronic nursing documentation in providing patient care (Kelley et al. 2011). Nurses who have the knowledge and skills to use EHRs are in high demand, so nurses need to be educated accordingly, especially at the undergraduate level. Nursing students need to be competent using EHRs when they are in nursing school. Students need to be proficient in using EHRs and accompanying technology (Bembridge et al. 2010; Fetter 2008; Meyer et al. 2011). The Electronic Health Records for Nursing Education (EHRNE) software program was recently developed and integrated into the nursing curriculum at our university. The two main purposes of this curriculum change were to enhance students’ learning of nursing informatics and to cultivate their awareness of how HIT is used in clinical practice (Kowitlawakul et al. 2013). The curriculum change aimed to increase students’ awareness of how HIT and EHRs can improve their documentation skills, help prevent medical errors and increase the quality of patient care. The EHRNE software is a stand-alone application with no server. The data are saved as a portable document file on a personal computer. The EHRNE software application consists of different screens (of contents or topics) that have various tab menus, such as admission data, nursing assessment, clinical measurements, downloadable forms, vascular access, nursing notes and case studies. Nursing students tested the EHRNE software before it was implemented. Kowitlawakul et al. (2013) reported that the students found the program had some advantages, such as its simplicity, accessibility and time efficiency, as
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well as being content specific. However, there were limitations, such as the inability to save the data to a database using a laptop in the nursing skills laboratory setting. The EHRNE software was introduced to all nursing faculty members, and they were encouraged to integrate it into their teaching plans. All faculty members who wanted to use the software program for their lessons in the nursing laboratory were trained. They then integrated the EHRNE software into their courses. At the end of the semester, the faculty members who had integrated the EHRNE software application into their courses shared their experiences of implementing technologybased teaching strategies in nursing education. A research team was formed to explore the experiences and the perceptions of the faculty members on the use of the EHRNE software application in teaching and learning activities in the nursing skills laboratory. The two research questions were: (1) What was the experience of the faculty with the use of the EHRNE software? and (2) What were the difficulties engendered by the use of this technology? Successfully teaching students how to use HIT and EHRs depends on the students as well as on the teaching faculty. Thus, the students’ information technology (IT) learning outcomes greatly depend on educators’ IT skills, teaching methods and attitudes towards the use of IT (Van Raaij & Schepers 2008). Several studies have investigated the barriers and challenges of implementing EHRs in education and found that one of the challenges was having fewer faculty members who were competent in utilizing EHR programs (Borycki et al. 2011; Mahon et al. 2010). The successful implementation of IT depends on students’ positive perceptions of IT as well as the competence of the nursing faculty in the use of the technology (Kandeel & Ibrahim 2010). According to Mahon et al. (2010), the use of role-modelling teaching strategies, where faculty members demonstrated positive attitudes towards new technology while teaching their students, resulted in the students adopting attitudes and beliefs that they would gain knowledge and skills using the new technology. Therefore, faculties play a very significant role in the successful implementation of IT in educational settings. In an educational environment, both educators and nursing students are end users of IT. The faculty’s acceptance of and attitudes towards a particular technology are critical in transmitting this knowledge to their students. Acceptance of new technology in daily work is very important to the success of the organization (DeWolf 2014). If faculty members do not accept the technology or have no intention of using it in their teaching, the nursing institution will fail to produce optimal HIT teaching and learning outcomes to their students. Based on this evidence, nursing faculty members have a very critical role in
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facilitating the successful implementation of EHRs into the nursing curriculum.
content areas. Each participant was given a code number from P1 to P7 to protect their identity in the results section.
Aims
Ethical considerations
This qualitative study aimed to explore the nursing faculty’s experiences with and perceptions of the EHRNE software application, and to identify the key factors (values and barriers) influencing the successful implementation of this technology into the nursing curriculum.
Because the study involved faculty members in the university, ethical approval was obtained from the university institutional review board (IRB reference code 11–299) before data collection. The nature and purposes of the study were explained to participants. The participants were also assured that their personal details would be kept confidential and that no identifiable information would be collected. A signed consent was then obtained from the participants. The participants’ personal information, such as names, was not recorded on the transcripts or in the research report to ensure anonymity and confidentiality. In the research report, all participants were assigned a code number for identification. All participants’ data were stored in a locked draw in the principal investigator’s office, and only the principal investigator had access to the data. Participation was voluntary, and participants could withdraw from the study at any time without explanation. All interviews were conducted by a qualified RA, who was trained to ensure that the participants could freely present their opinions.
Methods Design and setting
An explorative, qualitative approach was adopted to explore the faculty’s experiences with and perceptions of the EHRNE software application. Semi-structured questions were used to guide the face-to-face interviews. The interviews mostly took place in participants’ offices to ensure privacy and comfort. Sample
A purposive sampling was used to ensure that the main teaching staff members involved in the undergraduate nursing programme were represented. The inclusion criteria were faculty members who integrated the EHRNE software program into their nursing skills laboratory lessons, and faculty members who used the program in at least one session during the first semester of the 2012/2013 academic year. Eight faculty members were invited, of whom seven met the inclusion criteria and participated in the study. The majority of the participants were female (six out of seven) and had been teaching nursing for at least 2 years. The average age was 42.14 years old and the average number of years of teaching experience was 6 years. None of the participants had used the EHRNE software program in the skills laboratory before the 2012/2013 academic year. All participants were individually trained by a research assistant (RA) to use the program as part of this research study. Table 1 presents participants’ profiles and
Data collection
Data were collected at a nursing department in Singapore. The interviews were conducted over a period of 2 months (January to February 2013), and each interview took approximately 45–60 min. A semi-structured interview guideline, with openended questions, was used to explore participants’ perceptions about the use of the EHRNE software in their teaching. This interview technique provided participants with the opportunity to respond freely in their own words (Streubert Speziale & Carpenter 2010). In addition, the interviewer (RA) took field notes during the interviews and recorded them using an integrated circuit recorder. Field notes were used to record information and understand the data (Polit & Beck 2010). The interview questions and prompts were developed on the basis of
Table 1 Participants’ profiles and content areas Age range of faculty (years)
Years of teaching experience
Content of modules where EHRNE was used
Number of sessions
36–48 38–45 38–45
2–9 5–10 5–10
Medical–surgical nursing I, II and III Health assessment Fundamentals of nursing
1–8 6–10 6–10
EHRNE, Electronic Health Records for Nursing Education.
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the literature review and discussions among the research team. Examples of the questions and prompts used to guide the interviews were (1) What does the experience of using the EHRNE software in the classroom mean to you when you are teaching?; (2) Tell me your perception of the experiences of other lecturers using the EHRNE software; (3) Tell me about your experience of being taught to use the EHRNE software; (4) What facilitated your understanding of how to use the EHRNE software?; (5) What made learning how to use the EHRNE software difficult?; (6) Describe how the EHRNE software impacts the way you teach; (7) Complete the sentences: the EHRNE software is useful for . . . the EHRNE software is not useful for . . .; and (8) What features made the EHRNE software easy/hard for you to use? The interview questions/prompts and the data collection procedure were examined by four nursing faculty members who did not participate in the study. The reviewers were satisfied and the questions remained unchanged. An RA interviewed all participants. An integrated circuit recorder was used to record the discussions during the interviews. This method was used to ensure data accuracy and increase data reliability. Data collection was ceased once the data saturation was obtained, as demonstrated by repetitions of the information provided by all participants (Berg & Lune 2012). Data analysis
The demographic data of the participants were analysed using descriptive statistics. The interview records were listened to repeatedly and transcribed verbatim. The transcription accuracy was checked by comparing the transcripts with the tapes and the RA’s notes. The RA read each interview transcript carefully to ascertain its entirety. Content analysis was then used to analyse the data, which mainly involved coding and developing subcategories and categories (Berg & Lune 2012). The researcher read and reread each interview to understand the interview as a whole as well as identify the important words or phrases that described the experiences and perceptions of the faculty members in using the EHRs. The data were coded according to the meaning of the sentences, and coding was used to identify the subcategories of the experiences and perceptions reported by faculty members. Frequently occurring codes that appeared to deal with the same content were grouped into subcategories. Similar and overlapping subcategories were clustered into one category. This categorizing process captured the holistic perceptions of the faculty members (Berg & Lune 2012). Rigor and trustworthiness
The transcriptions were sent to each participant to validate the information. This ‘member checking’ procedure was used to
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ensure the credibility of the research findings and confirm that the findings were not modified by the researcher. Dependability is a criterion met once the credibility is demonstrated (Streubert Speziale & Carpenter 2010). Confirmability refers to the congruence of data between different independent researchers, including aspects like data accuracy and meanings (Polit & Beck 2010). In the study, a trained and experienced RA conducted all the interviews to ensure a high level of consistency. The data were examined by three researchers (the principal investigator, co-investigator and RA) repeatedly in order to immerse them in the data.
Results After rigorous data analysis and reviews by the research team, three main categories were identified: innovation, transition and integration. Innovation
Participants repeatedly stated that using the EHRNE software application in teaching and learning activities was a new experience for them. It was clear that the EHRNE software was perceived as an innovative tool for teaching students to document medical records electronically. . . . for many years, we have been teaching lab and using manual documentation, so if we are talking about experiences with EHRNE, this is definitely a new experience. (P2) In general, I welcome the ideas of using EHRNE in skill lab, it is something new, we are not familiar. (P6) Briefly, I would say . . . using this program is positive due to the lack of experience. (P5) Because it was new, the participants had mixed perceptions towards this innovative technology. Some participants found that the EHRNE software was challenging to use, and they were not convinced that the software application would be useful. Some participants found that using the EHRNE software was very time consuming and created a larger teaching workload for them. I doubt it is useful for them . . . it makes me feel lousy because I have to ask students to do it when I am not convinced myself . . . It is pretty hard. (P4). It becomes a bit of challenge me. So it means that it is a new skill, a new thing for me to introduce . . . it becomes like additional task for me . . . (P2) However, other participants felt that the EHRNE software was a valuable teaching tool. They felt positive about using the
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EHRNE software to prepare students to document medical records electronically before they practice in real clinical settings or hospitals. Some participants agreed that the software program helped the students to become more aware of errors and also made the students feel more comfortable to document electronically. In addition, they valued the EHRNE software because at the end of the lesson the students had a chance to document the health data, which made the lesson more comprehensive. EHRNE in the skills lab allows me to get students to practice electronic documentations together with skills I teach them . . . and it makes the lesson more complete. (P1) I think using EHRNE to facilitate the learning of the students in the lab is definitely something that will be useful and beneficial for students learning, because nowadays the hospital is going toward electronic recording using electronic data and also it will prevent errors . . . and this will prevent mistakes or misinterpretation of data. (P6) This is also helps students, those people who are very nervous or scared to touch the computer even though they are IT savvy . . . sometime they don’t know to get information. (P7) Transition
The interview revealed that using the EHRNE software application in teaching and learning was a transitional process. Participants recognized that healthcare organizations have been using EHRs in clinical practice. The EHRNE software provided students with an opportunity to document clinical data electronically in an educational setting before they practice in clinical settings. The students used the printed electronic documents as a tangible reminder to improve their documentation skills. It allows me to train the students that you know in the current healthcare industry we are using electronic health records . . . (P1) I think we can cut down on the paper. Then students can try an error and without having a paper to do this. Then we can also track back to how the students can record, not worry about the student forgetting to bring or loose the hardcopy. (P5) At least, they feel that they will remember it is kind of reflection what they did and if they do anything wrong when they document it, then they will learn a lesson, then to do some improvement for their practice. (P3) Integration
The participants suggested that more time should be allocated to each educational session when integrating the EHRNE soft-
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ware application into the nursing curriculum. The objectives of using the EHRNE software should be incorporated into the course learning plan early in the curriculum. They also suggested that the EHRNE software application needs to be web based so students can access it and complete the documentation via their mobile phones or smart phones. . . . time is a very challenging factor for us to use EHRNE because the skill lab time, as you know, is very short, and we have a lot of content to cover. (P6) So far, when I look at lesson objective a lot of time, EHRNE is not in it. (P2) I’m not sure if the student wants to bring their own laptop with EHRNE installed, but looking at some of the things like having able to see the trend, and then being able to save the data for future lab sessions . . . it will be good if there is a central station, like there is a server . . . or maybe change to a handle device [mobile phone or smart phone]. (P1)
Discussion The faculty member interviews showed that the EHRNE software application was perceived as an innovative tool that had advantages and challenges. The EHRNE software application was the first HIT application to be integrated into the nursing curriculum in Singapore. Faculty members and students had limited time and opportunities to use HIT in the nursing skills laboratory because the objectives were focused on other nursing skills. Unlike in America and Canada, faculty members must consider the IT initiatives, required competency and their ability to incorporate the IT content into the curriculum (Jones & Donelle 2011; Taylor et al. 2010). In this study, participants had similar perceptions whether they had been teaching nursing students for 2 or 10 years as this technology was a new experience to them. This reflected that the faculty had not been exposed to EHRs in educational settings. HITs have both material and non-material elements that play an important role in producing outcomes (Ramacciati 2013). One of the non-material elements is the nursing standards of practice required for HIT content to be integrated into the curriculum. However, student learning outcomes on this topic essentially rely on faculty members’ competency and advanced knowledge in the use of HIT (Fetter 2008; Kandeel & Ibrahim 2010). One of the barriers preventing the integration of HIT (such as EHRs) into health professional education is a shortage of faculty members who are familiar with different types of EHRs (Borycki et al. 2011). In this regard, developing the faculty to become competent in HIT is imperative. Nursing school administrators must make the integration of HIT
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content in the curriculum a requirement and provide faculty members with opportunities for international collaboration to become familiar with different types of HIT. Other studies have shown that the attitude of the faculty is one of the key factors for HIT acceptance (Mahon et al. 2010; Van Raaij & Schepers 2008). Cultivating a positive attitude towards the use of new technologies and how these technologies can enhance students’ learning outcomes is crucial for successful implementation. According to the findings, the use of workshops and individual training to enable faculty members to learn how to use the EHRNE software application is highly recommended, along with involving the faculty in the implementation of the new technology in the curriculum. Because EHRs are used in healthcare organizations worldwide, it has been recommended that nursing students be taught to use EHRs when they are in nursing school (Mahon et al. 2010; Meyer et al. 2011). Therefore, it is necessary to prepare undergraduate students to be competent users of EHRs to bridge the gap between the educational and clinical settings. In this study, the participants recognized that adopting the EHRNE software in the curriculum brought their teaching in line with the practices used by healthcare institutions. This is part of a transitional process in teaching and learning methods that is required to bridge the gap between the education system and the workplace. The findings also showed that, during this transition, using the EHRNE software helped participants to trace their students’ performance in documentation skills. The students also used the software to reflect on their documentation mistakes and errors. As a result, the students became aware of the need to use EHRs proficiently and efficiently to improve patient safety and increase quality of care. Moreover, using the EHRNE software reduced the use of the paper, which in turn saved money. These results are similar to those of studies in clinical settings that show EHRs improve patient safety and reduce healthcare costs (Cherry et al. 2011; Murphy 2011). The revolution in computer technology that transformed HIT has become a required part of nursing education (Kandeel & Ibrahim 2010). This fact drives faculty members to adopt HIT software and integrate it into teaching and learning methods. The findings suggest that, when integrating the use of EHRNE software into the curriculum, objectives should be included in each lesson. They also suggest that adequate time needs to be allocated to learn these new electronic documentation skills. Similarly, Nickitas et al. (2010) found that the integration of innovative new technology into curricula requires significant time from the users and support from the administrators. If the faculty members have allocated sufficient time to learn these new documentation skills and have strong adminis-
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trative support, the integration of EHRNE software in the curriculum can optimize the learning outcomes of students. In this study, the participants found that the current EHRNE software program needs to be enhanced to become accessible using mobile phones or smart phones. They also found that its functionality needs to be increased. These results are similar to those observed in another study (Kowitlawakul et al. 2013) that suggests EHRNE software applications should be transformed into web-based applications to increase their functionality and accessibility. Therefore, the development of a newer version of the EHRNE software with web-based applications is highly recommended in the future.
Limitations The EHRNE software application had only been implemented for 2–3 months at the time of the interviews. Consequently, the participants might have lacked the necessary skill and competence and confidence to implement it successfully. A similar study should be conducted 12 months after implementation of the EHRNE program and that educator’ specific needs for in-service and continuing education should be identified and addressed at regular intervals. In addition, one participant used the EHRNE software application for only one session in her teaching and learning activities, while the other faculty members used it for more than four sessions. The unequal exposure to the EHRNE software might have had an impact on participants’ perceptions.
Conclusions Our findings show that the integration of HIT programs, such as the EHRNE software application, is highly dependent on the faculty members’ experiences with the new technology, as well as their perceptions of it. Even though some participants perceived this new technology as a challenge and doubted its capacity to impact on the learning outcomes of students, they also valued it as a new innovation that had a strong potential to train and prepare undergraduate nursing students to be aware of and competent in documenting clinical data electronically. The development of web-based EHRNE applications that can be accessed using mobile phones and smart phones is highly recommended for the new generation of nursing students. More investigation into the potential benefits of HIT on students’ learning outcomes and, eventually, an evaluation of faculty competency of HIT in assisting students with learning is highly recommended for future research studies. Implications for nursing and health policy
The importance of information and communication technologies has been recognized internationally (International
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Council of Nurses 2012). Cultivating positive attitudes and competencies among the faculty using HIT to enhance teaching and learning is important. Nursing departments and schools can include health informatics as a required competency in the faculty’s professional development programme and policy. Participation in international HIT conferences to share and exchange knowledge might be another platform to enhance health informatics knowledge. More investigation into the relationship between the faculty’s health informatics competency and students’ acceptance of the technology and learning outcomes is also recommended for future studies. A series of workshops should be conducted to develop faculty members’ knowledge and health informatics skills. The content of each workshop should include evidence on the usefulness of the technology, how it can enhance faculty members’ teaching and how it can change the learning outcomes of students. Nursing administrators can develop content objectives and guidelines with the faculty members to standardize student competencies throughout the curriculum. It is also highly recommended that sufficient time is allocated in each course for faculty members to learn the new informatics contents and skills. In addition, strong administrative support must be provided to faculty members during the integration of HIT into the nursing curriculum.
Acknowledgements This study was funded by the Alice Lee Centre for Nursing Studies (ALCNS), Start-Up Grant at the National University of Singapore (NUS). The authors would like to thank the participants and faculty members at ALCNS/NUS for their great support. Special thanks to the NUHS Medical Publications Support Unit (PSU) and Associate Professor Cathy Kopac, Marymount University, VA, USA, for editing the manuscript.
Author contributions YK: Study conception/design, data analysis, drafting manuscript, revising manuscript. SW-CC: Study conception/design, critical revision of important intellectual content, supervision. LW: Data collection and analysis, administrative/technical/ material support. WW: Study conception/design, data analysis, critical revision of important intellectual content.
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Berg, B.L. & Lune, H. (2012) Qualitative Research Methods for Social Sciences, 8th edn. Pearson Education Inc, Boston. Borycki, E.B., Armstrong, B. & Kushniruk, A.W. (2009) From prototype to production: lessons learned from the evolution of an EHR educational portal. In AMIA 2009 Symposium Proceedings. Pp. 55–59. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2815372/pdf/amiaf2009-55.pdf (accessed 15 March 2013). Borycki, E.M., et al. (2011) Educating health professionals about the electronic health record (EHR): removing the barriers to adoption. Knowledge Management & E-Learning: An International Journal, 3 (1), 51–62. Cherry, B.J., Ford, E.W. & Peterson, L.T. (2011) Experience with electronic health records: early adopters in long-term care facilities. Health Care Management Review, 36 (3), 265–274. DeWolf, J. (2014) The Secret to Nurse Technology Acceptance: Make Sure It Contributes to Patient Care. Available at: http://www.wolfprairie.com/ secret-nurse-technology-acceptance-contribute-patient-care/ (accessed 3 June 2014). Fetter, M.S. (2008) Enhancing baccalaureate nursing information technology outcomes: faculty perspectives. International of Journal of Nursing Education Scholarship, 5 (1), 1–15. International Council of Nurses (2012) Nursing and health policy perspective. International Nursing Review, 59 (4), 435–436. Jones, S. & Donelle, L. (2011) Assessment of electronic health record usability with undergraduate students. International Journal of Nursing Education Scholarship, 8 (1), 1–18. Kandeel, N. & Ibrahim, Y. (2010) Student nurses’ perception on the impact of information technology on teaching and learning. International Journal of Information and Communication Technology Education, 6 (3), 38–50. Kelley, T.F., Brandon, D.H. & Docherty, S.L. (2011) Electronic nursing documentation as a strategy to improve quality of patient care. Journal of Nursing Scholarship, 43 (2), 154–162. Kennedy, D., Pallikkathayil, L. & Warren, J.J. (2009) Using a modified electronic health record to develop nursing process skills. Journal of Nursing Education, 48 (2), 96. Kowitlawakul, Y., Wang, L. & Chan, S.W. (2013) Development of the electronic health records for nursing education (EHRNE) software program. Nurse Education Today, 33 (12), 1529–1535. Mahon, P.Y., Nickitas, D.M. & Nokes, K.M. (2010) Faculty perception of student documentation skills during the transition from paper-based to electronic health records system. Journal of Nursing Education, 49 (11), 615–621. Meyer, L., Stenberger, C. & Toscos, T. (2011) How to implement the electronic health record in undergraduate nursing education. American Nurse Today, 6 (5), 40–44. Available at: http://www. americannursetoday.com/article.aspx?id=7830&fid=7770 (accessed 8 January 2013). Murphy, J. (2011) The journey to meaningful use of electronic health records. Nursing Economics, 28 (4), 283–286. Nickitas, D.M., et al. (2010) Increasing nursing student communication skills through electronic health record system documentation. CIN: Computers, Informatics, Nursing, 28 (1), 7–11.
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RN, FAAN, PhD,
1 Assistant Professor, 3 Research Assistant, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore, 2 Head and Professor, School of Nursing and Midwifery, University of Newcastle, Newcastle, Australia
KOWITLAWAKUL Y., CHAN S.W.C., WANG L. & WANG W. Exploring faculty perceptions towards electronic health records for nursing education. International Nursing Review 61, 499–506 Background: The use of electronic health records in nursing education is rapidly increasing worldwide. The successful implementation of electronic health records for nursing education software program relies on students as well as nursing faculty members. Aims: This study aimed to explore the experiences and perceptions of nursing faculty members using electronic health records for nursing education software program, and to identify the influential factors for successful implementation of this technology. Methods: This exploratory qualitative study was conducted using in-depth individual interviews at a university in Singapore. Seven faculty members participated in the study. The data were gathered and analysed at the end of the semester in the 2012/2013 academic year. Results: The participants’ perceptions of the software program were organized into three main categories: innovation, transition and integration. The participants perceived this technology as innovative, with both values and challenges for the users. In addition, using the new software program was perceived as transitional process. The integration of this technology required time from faculty members and students, as well as support from administrators. Limitations: The software program had only been implemented for 2–3 months at the time of the interviews. Consequently, the participants might have lacked the necessary skill and competence and confidence to implement it successfully. In addition, the unequal exposure to the software program might have had an impact on participants’ perceptions. Conclusion: The findings show that the integration of electronic health records into nursing education curricula is dependent on the faculty members’ experiences with the new technology, as well as their perceptions of it. Hence, cultivating a positive attitude towards the use of new technologies is important. Implications for nursing and health policy: Electronic health records are significant applications of health information technology. Health informatics competency should be included as a required competency component in faculty professional development policy and programmes. Keywords: Electronic Health Records, Health Information Technology, Nursing Curriculum, Nursing Education, Nursing Informatics, Qualitative Study, Undergraduate Nursing Students
Correspondence address: Dr Yanika Kowitlawakul, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Block MD 11, Level 2, 10 Medical Drive, Singapore 117597, Singapore; Tel: 65-6601-1766; Fax: 65-6776-7135; E-mail: [email protected].
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Introduction Electronic health records (EHRs) have been implemented rapidly and globally to improve the quality, safety and efficiency of healthcare delivery systems. Nursing faculties have been urged to bridge the gap between educational and clinical settings by training healthcare students to be competent in the use of health information technology (HIT). Several nursing programmes have developed or modified an EHR’s software to fit their curriculum. For example, the University of Victoria designed an EHR educational portal that allowed students to access different EHRs in Canada (Borycki et al. 2009); the University of Kansas modified EHRs to enable nursing students to learn nursing process skills (Kennedy et al. 2009); and the University of Tennessee developed a prototype EHR application called iCare v.1.0 to train nursing students (Wyatt et al. 2012). These software applications will continue to be developed internationally to enhance students’ use of technology. In Singapore, the Ministry of Health had decided that all public hospitals should implement EHRs. Most hospitals in Singapore have now adopted EHRs in their practice. As a result, nurses need to be educated on the use of electronic nursing documentation in providing patient care (Kelley et al. 2011). Nurses who have the knowledge and skills to use EHRs are in high demand, so nurses need to be educated accordingly, especially at the undergraduate level. Nursing students need to be competent using EHRs when they are in nursing school. Students need to be proficient in using EHRs and accompanying technology (Bembridge et al. 2010; Fetter 2008; Meyer et al. 2011). The Electronic Health Records for Nursing Education (EHRNE) software program was recently developed and integrated into the nursing curriculum at our university. The two main purposes of this curriculum change were to enhance students’ learning of nursing informatics and to cultivate their awareness of how HIT is used in clinical practice (Kowitlawakul et al. 2013). The curriculum change aimed to increase students’ awareness of how HIT and EHRs can improve their documentation skills, help prevent medical errors and increase the quality of patient care. The EHRNE software is a stand-alone application with no server. The data are saved as a portable document file on a personal computer. The EHRNE software application consists of different screens (of contents or topics) that have various tab menus, such as admission data, nursing assessment, clinical measurements, downloadable forms, vascular access, nursing notes and case studies. Nursing students tested the EHRNE software before it was implemented. Kowitlawakul et al. (2013) reported that the students found the program had some advantages, such as its simplicity, accessibility and time efficiency, as
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well as being content specific. However, there were limitations, such as the inability to save the data to a database using a laptop in the nursing skills laboratory setting. The EHRNE software was introduced to all nursing faculty members, and they were encouraged to integrate it into their teaching plans. All faculty members who wanted to use the software program for their lessons in the nursing laboratory were trained. They then integrated the EHRNE software into their courses. At the end of the semester, the faculty members who had integrated the EHRNE software application into their courses shared their experiences of implementing technologybased teaching strategies in nursing education. A research team was formed to explore the experiences and the perceptions of the faculty members on the use of the EHRNE software application in teaching and learning activities in the nursing skills laboratory. The two research questions were: (1) What was the experience of the faculty with the use of the EHRNE software? and (2) What were the difficulties engendered by the use of this technology? Successfully teaching students how to use HIT and EHRs depends on the students as well as on the teaching faculty. Thus, the students’ information technology (IT) learning outcomes greatly depend on educators’ IT skills, teaching methods and attitudes towards the use of IT (Van Raaij & Schepers 2008). Several studies have investigated the barriers and challenges of implementing EHRs in education and found that one of the challenges was having fewer faculty members who were competent in utilizing EHR programs (Borycki et al. 2011; Mahon et al. 2010). The successful implementation of IT depends on students’ positive perceptions of IT as well as the competence of the nursing faculty in the use of the technology (Kandeel & Ibrahim 2010). According to Mahon et al. (2010), the use of role-modelling teaching strategies, where faculty members demonstrated positive attitudes towards new technology while teaching their students, resulted in the students adopting attitudes and beliefs that they would gain knowledge and skills using the new technology. Therefore, faculties play a very significant role in the successful implementation of IT in educational settings. In an educational environment, both educators and nursing students are end users of IT. The faculty’s acceptance of and attitudes towards a particular technology are critical in transmitting this knowledge to their students. Acceptance of new technology in daily work is very important to the success of the organization (DeWolf 2014). If faculty members do not accept the technology or have no intention of using it in their teaching, the nursing institution will fail to produce optimal HIT teaching and learning outcomes to their students. Based on this evidence, nursing faculty members have a very critical role in
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facilitating the successful implementation of EHRs into the nursing curriculum.
content areas. Each participant was given a code number from P1 to P7 to protect their identity in the results section.
Aims
Ethical considerations
This qualitative study aimed to explore the nursing faculty’s experiences with and perceptions of the EHRNE software application, and to identify the key factors (values and barriers) influencing the successful implementation of this technology into the nursing curriculum.
Because the study involved faculty members in the university, ethical approval was obtained from the university institutional review board (IRB reference code 11–299) before data collection. The nature and purposes of the study were explained to participants. The participants were also assured that their personal details would be kept confidential and that no identifiable information would be collected. A signed consent was then obtained from the participants. The participants’ personal information, such as names, was not recorded on the transcripts or in the research report to ensure anonymity and confidentiality. In the research report, all participants were assigned a code number for identification. All participants’ data were stored in a locked draw in the principal investigator’s office, and only the principal investigator had access to the data. Participation was voluntary, and participants could withdraw from the study at any time without explanation. All interviews were conducted by a qualified RA, who was trained to ensure that the participants could freely present their opinions.
Methods Design and setting
An explorative, qualitative approach was adopted to explore the faculty’s experiences with and perceptions of the EHRNE software application. Semi-structured questions were used to guide the face-to-face interviews. The interviews mostly took place in participants’ offices to ensure privacy and comfort. Sample
A purposive sampling was used to ensure that the main teaching staff members involved in the undergraduate nursing programme were represented. The inclusion criteria were faculty members who integrated the EHRNE software program into their nursing skills laboratory lessons, and faculty members who used the program in at least one session during the first semester of the 2012/2013 academic year. Eight faculty members were invited, of whom seven met the inclusion criteria and participated in the study. The majority of the participants were female (six out of seven) and had been teaching nursing for at least 2 years. The average age was 42.14 years old and the average number of years of teaching experience was 6 years. None of the participants had used the EHRNE software program in the skills laboratory before the 2012/2013 academic year. All participants were individually trained by a research assistant (RA) to use the program as part of this research study. Table 1 presents participants’ profiles and
Data collection
Data were collected at a nursing department in Singapore. The interviews were conducted over a period of 2 months (January to February 2013), and each interview took approximately 45–60 min. A semi-structured interview guideline, with openended questions, was used to explore participants’ perceptions about the use of the EHRNE software in their teaching. This interview technique provided participants with the opportunity to respond freely in their own words (Streubert Speziale & Carpenter 2010). In addition, the interviewer (RA) took field notes during the interviews and recorded them using an integrated circuit recorder. Field notes were used to record information and understand the data (Polit & Beck 2010). The interview questions and prompts were developed on the basis of
Table 1 Participants’ profiles and content areas Age range of faculty (years)
Years of teaching experience
Content of modules where EHRNE was used
Number of sessions
36–48 38–45 38–45
2–9 5–10 5–10
Medical–surgical nursing I, II and III Health assessment Fundamentals of nursing
1–8 6–10 6–10
EHRNE, Electronic Health Records for Nursing Education.
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the literature review and discussions among the research team. Examples of the questions and prompts used to guide the interviews were (1) What does the experience of using the EHRNE software in the classroom mean to you when you are teaching?; (2) Tell me your perception of the experiences of other lecturers using the EHRNE software; (3) Tell me about your experience of being taught to use the EHRNE software; (4) What facilitated your understanding of how to use the EHRNE software?; (5) What made learning how to use the EHRNE software difficult?; (6) Describe how the EHRNE software impacts the way you teach; (7) Complete the sentences: the EHRNE software is useful for . . . the EHRNE software is not useful for . . .; and (8) What features made the EHRNE software easy/hard for you to use? The interview questions/prompts and the data collection procedure were examined by four nursing faculty members who did not participate in the study. The reviewers were satisfied and the questions remained unchanged. An RA interviewed all participants. An integrated circuit recorder was used to record the discussions during the interviews. This method was used to ensure data accuracy and increase data reliability. Data collection was ceased once the data saturation was obtained, as demonstrated by repetitions of the information provided by all participants (Berg & Lune 2012). Data analysis
The demographic data of the participants were analysed using descriptive statistics. The interview records were listened to repeatedly and transcribed verbatim. The transcription accuracy was checked by comparing the transcripts with the tapes and the RA’s notes. The RA read each interview transcript carefully to ascertain its entirety. Content analysis was then used to analyse the data, which mainly involved coding and developing subcategories and categories (Berg & Lune 2012). The researcher read and reread each interview to understand the interview as a whole as well as identify the important words or phrases that described the experiences and perceptions of the faculty members in using the EHRs. The data were coded according to the meaning of the sentences, and coding was used to identify the subcategories of the experiences and perceptions reported by faculty members. Frequently occurring codes that appeared to deal with the same content were grouped into subcategories. Similar and overlapping subcategories were clustered into one category. This categorizing process captured the holistic perceptions of the faculty members (Berg & Lune 2012). Rigor and trustworthiness
The transcriptions were sent to each participant to validate the information. This ‘member checking’ procedure was used to
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ensure the credibility of the research findings and confirm that the findings were not modified by the researcher. Dependability is a criterion met once the credibility is demonstrated (Streubert Speziale & Carpenter 2010). Confirmability refers to the congruence of data between different independent researchers, including aspects like data accuracy and meanings (Polit & Beck 2010). In the study, a trained and experienced RA conducted all the interviews to ensure a high level of consistency. The data were examined by three researchers (the principal investigator, co-investigator and RA) repeatedly in order to immerse them in the data.
Results After rigorous data analysis and reviews by the research team, three main categories were identified: innovation, transition and integration. Innovation
Participants repeatedly stated that using the EHRNE software application in teaching and learning activities was a new experience for them. It was clear that the EHRNE software was perceived as an innovative tool for teaching students to document medical records electronically. . . . for many years, we have been teaching lab and using manual documentation, so if we are talking about experiences with EHRNE, this is definitely a new experience. (P2) In general, I welcome the ideas of using EHRNE in skill lab, it is something new, we are not familiar. (P6) Briefly, I would say . . . using this program is positive due to the lack of experience. (P5) Because it was new, the participants had mixed perceptions towards this innovative technology. Some participants found that the EHRNE software was challenging to use, and they were not convinced that the software application would be useful. Some participants found that using the EHRNE software was very time consuming and created a larger teaching workload for them. I doubt it is useful for them . . . it makes me feel lousy because I have to ask students to do it when I am not convinced myself . . . It is pretty hard. (P4). It becomes a bit of challenge me. So it means that it is a new skill, a new thing for me to introduce . . . it becomes like additional task for me . . . (P2) However, other participants felt that the EHRNE software was a valuable teaching tool. They felt positive about using the
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EHRNE software to prepare students to document medical records electronically before they practice in real clinical settings or hospitals. Some participants agreed that the software program helped the students to become more aware of errors and also made the students feel more comfortable to document electronically. In addition, they valued the EHRNE software because at the end of the lesson the students had a chance to document the health data, which made the lesson more comprehensive. EHRNE in the skills lab allows me to get students to practice electronic documentations together with skills I teach them . . . and it makes the lesson more complete. (P1) I think using EHRNE to facilitate the learning of the students in the lab is definitely something that will be useful and beneficial for students learning, because nowadays the hospital is going toward electronic recording using electronic data and also it will prevent errors . . . and this will prevent mistakes or misinterpretation of data. (P6) This is also helps students, those people who are very nervous or scared to touch the computer even though they are IT savvy . . . sometime they don’t know to get information. (P7) Transition
The interview revealed that using the EHRNE software application in teaching and learning was a transitional process. Participants recognized that healthcare organizations have been using EHRs in clinical practice. The EHRNE software provided students with an opportunity to document clinical data electronically in an educational setting before they practice in clinical settings. The students used the printed electronic documents as a tangible reminder to improve their documentation skills. It allows me to train the students that you know in the current healthcare industry we are using electronic health records . . . (P1) I think we can cut down on the paper. Then students can try an error and without having a paper to do this. Then we can also track back to how the students can record, not worry about the student forgetting to bring or loose the hardcopy. (P5) At least, they feel that they will remember it is kind of reflection what they did and if they do anything wrong when they document it, then they will learn a lesson, then to do some improvement for their practice. (P3) Integration
The participants suggested that more time should be allocated to each educational session when integrating the EHRNE soft-
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ware application into the nursing curriculum. The objectives of using the EHRNE software should be incorporated into the course learning plan early in the curriculum. They also suggested that the EHRNE software application needs to be web based so students can access it and complete the documentation via their mobile phones or smart phones. . . . time is a very challenging factor for us to use EHRNE because the skill lab time, as you know, is very short, and we have a lot of content to cover. (P6) So far, when I look at lesson objective a lot of time, EHRNE is not in it. (P2) I’m not sure if the student wants to bring their own laptop with EHRNE installed, but looking at some of the things like having able to see the trend, and then being able to save the data for future lab sessions . . . it will be good if there is a central station, like there is a server . . . or maybe change to a handle device [mobile phone or smart phone]. (P1)
Discussion The faculty member interviews showed that the EHRNE software application was perceived as an innovative tool that had advantages and challenges. The EHRNE software application was the first HIT application to be integrated into the nursing curriculum in Singapore. Faculty members and students had limited time and opportunities to use HIT in the nursing skills laboratory because the objectives were focused on other nursing skills. Unlike in America and Canada, faculty members must consider the IT initiatives, required competency and their ability to incorporate the IT content into the curriculum (Jones & Donelle 2011; Taylor et al. 2010). In this study, participants had similar perceptions whether they had been teaching nursing students for 2 or 10 years as this technology was a new experience to them. This reflected that the faculty had not been exposed to EHRs in educational settings. HITs have both material and non-material elements that play an important role in producing outcomes (Ramacciati 2013). One of the non-material elements is the nursing standards of practice required for HIT content to be integrated into the curriculum. However, student learning outcomes on this topic essentially rely on faculty members’ competency and advanced knowledge in the use of HIT (Fetter 2008; Kandeel & Ibrahim 2010). One of the barriers preventing the integration of HIT (such as EHRs) into health professional education is a shortage of faculty members who are familiar with different types of EHRs (Borycki et al. 2011). In this regard, developing the faculty to become competent in HIT is imperative. Nursing school administrators must make the integration of HIT
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content in the curriculum a requirement and provide faculty members with opportunities for international collaboration to become familiar with different types of HIT. Other studies have shown that the attitude of the faculty is one of the key factors for HIT acceptance (Mahon et al. 2010; Van Raaij & Schepers 2008). Cultivating a positive attitude towards the use of new technologies and how these technologies can enhance students’ learning outcomes is crucial for successful implementation. According to the findings, the use of workshops and individual training to enable faculty members to learn how to use the EHRNE software application is highly recommended, along with involving the faculty in the implementation of the new technology in the curriculum. Because EHRs are used in healthcare organizations worldwide, it has been recommended that nursing students be taught to use EHRs when they are in nursing school (Mahon et al. 2010; Meyer et al. 2011). Therefore, it is necessary to prepare undergraduate students to be competent users of EHRs to bridge the gap between the educational and clinical settings. In this study, the participants recognized that adopting the EHRNE software in the curriculum brought their teaching in line with the practices used by healthcare institutions. This is part of a transitional process in teaching and learning methods that is required to bridge the gap between the education system and the workplace. The findings also showed that, during this transition, using the EHRNE software helped participants to trace their students’ performance in documentation skills. The students also used the software to reflect on their documentation mistakes and errors. As a result, the students became aware of the need to use EHRs proficiently and efficiently to improve patient safety and increase quality of care. Moreover, using the EHRNE software reduced the use of the paper, which in turn saved money. These results are similar to those of studies in clinical settings that show EHRs improve patient safety and reduce healthcare costs (Cherry et al. 2011; Murphy 2011). The revolution in computer technology that transformed HIT has become a required part of nursing education (Kandeel & Ibrahim 2010). This fact drives faculty members to adopt HIT software and integrate it into teaching and learning methods. The findings suggest that, when integrating the use of EHRNE software into the curriculum, objectives should be included in each lesson. They also suggest that adequate time needs to be allocated to learn these new electronic documentation skills. Similarly, Nickitas et al. (2010) found that the integration of innovative new technology into curricula requires significant time from the users and support from the administrators. If the faculty members have allocated sufficient time to learn these new documentation skills and have strong adminis-
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trative support, the integration of EHRNE software in the curriculum can optimize the learning outcomes of students. In this study, the participants found that the current EHRNE software program needs to be enhanced to become accessible using mobile phones or smart phones. They also found that its functionality needs to be increased. These results are similar to those observed in another study (Kowitlawakul et al. 2013) that suggests EHRNE software applications should be transformed into web-based applications to increase their functionality and accessibility. Therefore, the development of a newer version of the EHRNE software with web-based applications is highly recommended in the future.
Limitations The EHRNE software application had only been implemented for 2–3 months at the time of the interviews. Consequently, the participants might have lacked the necessary skill and competence and confidence to implement it successfully. A similar study should be conducted 12 months after implementation of the EHRNE program and that educator’ specific needs for in-service and continuing education should be identified and addressed at regular intervals. In addition, one participant used the EHRNE software application for only one session in her teaching and learning activities, while the other faculty members used it for more than four sessions. The unequal exposure to the EHRNE software might have had an impact on participants’ perceptions.
Conclusions Our findings show that the integration of HIT programs, such as the EHRNE software application, is highly dependent on the faculty members’ experiences with the new technology, as well as their perceptions of it. Even though some participants perceived this new technology as a challenge and doubted its capacity to impact on the learning outcomes of students, they also valued it as a new innovation that had a strong potential to train and prepare undergraduate nursing students to be aware of and competent in documenting clinical data electronically. The development of web-based EHRNE applications that can be accessed using mobile phones and smart phones is highly recommended for the new generation of nursing students. More investigation into the potential benefits of HIT on students’ learning outcomes and, eventually, an evaluation of faculty competency of HIT in assisting students with learning is highly recommended for future research studies. Implications for nursing and health policy
The importance of information and communication technologies has been recognized internationally (International
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Council of Nurses 2012). Cultivating positive attitudes and competencies among the faculty using HIT to enhance teaching and learning is important. Nursing departments and schools can include health informatics as a required competency in the faculty’s professional development programme and policy. Participation in international HIT conferences to share and exchange knowledge might be another platform to enhance health informatics knowledge. More investigation into the relationship between the faculty’s health informatics competency and students’ acceptance of the technology and learning outcomes is also recommended for future studies. A series of workshops should be conducted to develop faculty members’ knowledge and health informatics skills. The content of each workshop should include evidence on the usefulness of the technology, how it can enhance faculty members’ teaching and how it can change the learning outcomes of students. Nursing administrators can develop content objectives and guidelines with the faculty members to standardize student competencies throughout the curriculum. It is also highly recommended that sufficient time is allocated in each course for faculty members to learn the new informatics contents and skills. In addition, strong administrative support must be provided to faculty members during the integration of HIT into the nursing curriculum.
Acknowledgements This study was funded by the Alice Lee Centre for Nursing Studies (ALCNS), Start-Up Grant at the National University of Singapore (NUS). The authors would like to thank the participants and faculty members at ALCNS/NUS for their great support. Special thanks to the NUHS Medical Publications Support Unit (PSU) and Associate Professor Cathy Kopac, Marymount University, VA, USA, for editing the manuscript.
Author contributions YK: Study conception/design, data analysis, drafting manuscript, revising manuscript. SW-CC: Study conception/design, critical revision of important intellectual content, supervision. LW: Data collection and analysis, administrative/technical/ material support. WW: Study conception/design, data analysis, critical revision of important intellectual content.
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