SUPPORTING COLLABORATION THROUGH A NURSING INFORMATICS CURRICULUM STAGE 11 Lucill L Travis, PhD, RN, CNA Case Western Reserve Universty, Cleveland, OH
Barbara Hoehn, RN, MBA Ernst & Young, New York, NY
Celest Spees, RN, MSN Cas Wetern Resrve University, Cleveland, OH Kathisn Hribar, RN, MSN Case Wstern Reserve University, Cleveland, OH JoAnne Youngblut, RN, PhD Cas Wetern Resrve Univesity, Cleveland, OH
ABSTRACT Collaboraion is at the center of the process used to design, implement and evaluate an integrated informatcs curriculum in a baccalaureate nursing program. This paper describes the second stage of a process to design the informatics nursing courses. The challanges to foster faculty collaborative relationships as well as to enhance the course content of all nursing informacs curriculum. A number of stategies were used to develop the collaborave efforts between the faculty and nursing staff in the clinical agencies. Information technology was incorporated into the didactic and clinical portions of courses through the use of creatv teaching strategies. Therefore, the faculty have ensured a blend of informaion, technology, and the clinical care process throughout the curriculum. PURPOSE Prepaation o nusmes for the 21st century requires educonal prgram well grounded in the traditional physical, biolgical, and social sciences as well as the evolving infoLrmAtn sciences. Therefore this paper wil describe the collaboration process used to design, mpl and evaluate a new integrated informatics curriculum currently in place in a baccalaureate nursing program. First time mplatn of the second course of a required four couse sequence is occurring as well as the ongong evaluation Of the first and secord year of the curriculum. 0195-4210/92/$5.00 (©1993 AMIA, Inc.
BACKGROUND AND REVIEW Recently the School Of Nursing and three area hospials formed a consortium to launch a lareate program in nursing. In the Fall new of 1990, 101 students were admitted into the inaugural class. Presety there are two classes with 202 students in the program. Key aspects of the program Include (1) focus on acute and critical care nursin, (2) bedside nursing emphasis, (3) strong clinical experence throughout all four years beginning In the firs semeer of the curriculum, (4) innovative inclusion of nursing informatics throughout the four years of curriculum, (5) development of kienty with professional nursing through pnal link-up with nurses in clinical settings, and (6) well defined linkages to the three hospitals Increase in the use of computer technology and ironation science in nursing prtice, education, and administration demands a new aprach to the application of information tehoy However, technical competence inckxdes not only equipmert competence but skill in the efficient ppan of information. We are continually chalnged to produce a baccalaureate graduate who utilizes information technologies in their clinical praice. CHALLENGE The ImIplmeIon Of the second course provided the folowing challenges: 1) To foster faculty collaborative relationships necessary to. continue the of a realistic, develpment and impna
future-oriented cuniculm.
419
2) To enhance the course content of all nursing informatics curricula based on faculty and student suggestos. Collaboration among faculty is ongoing and occurring at various levels. The School of Nursing has worked closely with the management information faculty to implement nursing informatics software on the fiberoptic university network. There is a relationship with the consortium hospitals which encourages exchange of new ideas through the linkages wkh staff nurses as clinical teaching associates who work directly with the nursing students. Staff nurses also act as mentors who also work directly wkh the nursing students. And finally, there is an ongoing collaborative relationship between the nursing science faculty and the nursing irm consultants who are assisting the school in curriculum development. DESIGN Informaics courses are designed to articulate wkh the clinical experence and comprehensive course progressin followed bythe BSN students. The three basic components of the model identified to provide a framework are information, technology and cinical care pr A model was developed to illustrate the three aspects of nursing informatics in the undergraduate curriculum. See Figure 1. Each course addresses the three components, however, the emphasis regarding each component varies with each course. During the first course introduced in 1991, the emphasis was on informa on and technoogy with an overlap in the clinical care proc In Nursing Informatc lI, the primary emphasis i on information and the clinical care process with secondary emphasis on technology. (See figure 1). In order to succesully focus the curriculum in this direction, the nursing iformatics and nursi science faculy c worked to develop a
collaborative relatonship whereby nursing informatics and nursing scence theories would be integrated into both curricula We accomplIshed this through sveral approaches. Argyrs and Schon [11 sgest that the clinical field experiene in a pressnal nursing program should not be desined merely to give students experence in the real clinical setting to learnaccepted practices, but should also provide the student with the opportunity of trying out new approaches and modalkies of care. To e v accomplish this, a plan of action was developed to assist informatics as well as to incoate
FRANCES PAYNE BOLTON SCHOOL OF NURSINO CASE WESTERN RESERVE UNIVLRSITY umi. laOmsseo" strs" l wSm"a* .raw"
(Yea 1)
(Year 2)
Flrst Coure
Second Course
(Year 3)
Thir and Fowth Course.
Figure 1 information technology into the clinical experience. Each of the mentors and clinical teaching assocites attend an all day conference on clinical decision making. It is our expectation that the outcome of the conference will be two fold: 1) to enhance the student's clinical experience and 2) to increase the understanding of nursing informatics of nurses interacting directly with the students regarding clinical practice. In order to apply classroom concepts to technology a computerized patient charting program, TLC-General Hospital 12) was selected to enhance the second level informatics course and placed in the campus fiberoptics network. As the hospital clinical sites currently lack many of the components of nursing Information systems, a broad based pInt charting program presents the studbnt with those pleces. The course focus Is on the process o accessing and documenting as wel as the development of critical analysis of the comipterized p care record. This 'hands onr introduction to Nursing Informics can nurture ato of and appreciation for the an computerized patient record. IMPLEMENTATION The second nursing informatics course was implemented in the second semester of the
420
second year of the BSN program. This is intended to allow students to practice handling the increased quantitative information encountered in the clinical area This occurred through the use of application software packages which were placed on the campus fiberoptic network. The student enters the second level of informatics with a basic understanding of the health care system as well as an introductory view of the information flow within that patient centered system. The focus now shifts to applying the developmernt of knowledge toward the technical aspects of the nursing informatics applications currently available. Concepts such as the lifetime electronic medical record, nursing minimum data set and clinical decision making are introduced. In order to help apply these concepts, a simulation program was selected which provided a broad source of patient data and easy accessibilky. In this second level informatics course the electronic patient record is used to expand upon the programs basic documentation functions with the help of instructor designed assignments allowing the program to be applied in more creative ways. For example, students are provided with only the computer data and forced to delegate tasks and make clinical care decisions based on the scenario presented. This reinforces the inherent analytical procss in critique of the information gathering utility of the computerized patient care record. Expioration of minimum data set, further brings to Ife the concept of prioritizing the most significant data in order to provide patient care. Within the TLC program, students revlew incomplete data and the students learn that some data are more significant than othes in planning and delivering the most effective and efficient patient care. This analysis of the 'value' of various data sets continues to build on crtical thinkhg as the students intemalize the concept of the minimum data set In additon to the specific course requirements other irformatics activities are For integrated throughout the curriculum. example, School Of Nursing facuity agreed that each student will be required to identify all sources of information obtained and utilized to deveiop the patient's nursing care plan. Students will indicate whether information was obtained through access to the manual chart, the automated computer systems, through inteniws with patientfamily or through inter/intradepartmental communcation. They will indicate the ease or difficulty of collecting
and analyzing patient information and also be required to identify opportunities where information technology could enhance the capture, processing and communication of their own nursing information. This approach not only reinforces the concepts of information capture and communication, but also gives the student an opportunity to analyze the voluminous data collected and maintained on patients and how to filter that data into clinically relevant information. EVALUATION NURSING INFORMATICS 11 In 'What Curriculum for the Information Age?' edited by Mary Alice White, Julie McGee proposes that the curriculum necessary to equip students for life in the Information Age should emphasize a new hierarchy of skills. [2] This skill set includes the a) abiliy to evaluate information, b) the ability to set priorities, and c) the ability to make decisons. These three skills are basic to the students understanding and application of information technology to support nursing care. During the freshman nursing informatics course, we evaluated the student's acquisition of knowledge through multiple choice examinations. This format Is useful in evaluating the student's knowledg, comprehension and application of material presented in cla and through the reading assignments. Since the second nursing inforatics course deals with the access, application and evaluation of information in relationship to the clinical care process, we have decided to evaluate the students' understanding of the principles of nursing informatics and their clinical applications through comprehensive essay examinatons The student is required apply information obtained through classwork and supp readings and that the supplemental reading be referenced in the answers. Each essay question also Includes an opinion or open-ended segment that encourages critical thinking on the part of the students understanding, acceptance and comfort with nursing information systems. While we do not grade the student's opinion, we do grade the iogic and presentation manner of the ratnale the student uses to defend his/her
opinion. UPDATE ON NURSING INFORMATICS I This course focuses on helping students identfy the conteit, flow, and processing of patient information within the hospltal. The course also buiids a basic understanding of information technologies and how these technologies can support nurss in delivering patient care.
421
One of the most beneficial teaching strategies in this years Nursing Informatics 1, is a simulation program by Jackson and Milne. [31 This self-paced computer simulation demonstrates how advances in information technology can facilitate nursing practice. Further, k promotes comfort with use of computer systems in nursing practice. The program guides the student through several components and features of a Hospital Information System (HIS). In order to validate student participation, the computer simulation was placed on the university's fiberoptic computer network enabling students to access and complete the computer assignment from one of the university's libraries, computer labs, or individual dormitory rooms. Faculty designed a case study with pertinent patient information for the student to enter as they progressed through the simulation. The experience helped to fuffill the objectives of the course by demonstrating how a HIS facilkates departmental communication and integration while facilitating efcient patient care. Student response to the simulation was positive. Overall, students felt it was interesting and informative as well as a confidence buiider in computer usage. Students were also given a clinical assignment to promote collaboration between Introduction to Nursing Informatics and their clinical experience. The assignment was to identify and explain any aspect of patient care requiring information processing that would benefit from computer technology. Students were asked to outline/model the computerization process and explain the beefit of computerizing the identified aspect of the patient care process. Further, students were given the opportunity to apply informaton technology to improve an one specific aspect Of patient care. CURRICULUM AND PROGRAM EVALUATION This is the second stage of a longitudinal study to extend over a four year period. Evaluation of outcomes with respect to both students' atitudes and knowledge acquired will occur after each stage. In additon to following the first group of students through the four year period, a comparison between the first group of students and succeeding InfoLra ics student groups will occur. Here we report two aspecs of the ongoing evaluation. The first is to compare the students experience with computers. Second is to compare each cohort knowledge and attiude. At the end of the present course, the survey previous developed [4J to evaluate the students' knowledge and attiudes toward computers and Nursing Informatics will be 422
readministered
so
that an ongoing evaluation of
changes in knowledge and attitude will be captured. The current freshmen completed the
initial survey. Of the 84 completed surveys received, 68% had taken a computer course in grade school or high school. In comparison to the previous class, the number was 67%. Therefore same
there
minimal change from the previous to Additionally, 92% of the 2nd class had used a computer in school, predominately for word processing. This percentage was similar to the previous class which was 93%. Concurrently, the 54% of the new class owned computers compared to 52% from the previous freshman group. Therefore, the two cohorts are very similar in their experiences with was
current freshmen.
computers.
The instrument to be used for this study is 30 item questionnaire adapted from McConnel, O'Shea and Kirchhoff, to measure knowledge and attitudes toward computers. Factor analysis on the first sample supported a three factor structure and deletion of sax items. The three scales are scientific use of technology, common misconceptions associated with technological advances, and clinical care process. The scientific use scale is composed of four items regarding the advantages of computer technology in the health care setting. Higher scores indicate more positive knowledge and attitudes. Cronbach's alpha for the scale is .40. The common misconceptions scale has eight items which describe commonly held fears and concerns regarding advances in techrology in the workplace. Lower scores indicate les negative knowledge and attitudes. Cronbach's alpha was .75. The 12-item clinical care scale addresses the application of technology to support the nurse in providing patient care. a
Higher scores indicate
more
positive knowledge
and attkudes. Cronbach's alpha was .80. Each cohort was assigned in the freshman year on knowledge and attitude, this time, data from the first time poeriod are available for the current freshmen students and the previous freshmen students. Thus we are able to compare the two classes of beginning students regarding their prior knowledge and attitudes about computers in nursing informatics. Scores on the three scales for the two classes of students were compared with t-tests. Tests of homogeneity of varance do not suggest that the variances are significantly different, so t-tests based on pooled variance estimates are used. The two cohorts of students are not significantly different in their
scores for the scales measuring scientffic use of technology and common misconceptions. However, the second group of freshmen students scored significantly higher on the clinical care scale (t1l*=.3.70, p
Barbara Hoehn, RN, MBA Ernst & Young, New York, NY
Celest Spees, RN, MSN Cas Wetern Resrve University, Cleveland, OH Kathisn Hribar, RN, MSN Case Wstern Reserve University, Cleveland, OH JoAnne Youngblut, RN, PhD Cas Wetern Resrve Univesity, Cleveland, OH
ABSTRACT Collaboraion is at the center of the process used to design, implement and evaluate an integrated informatcs curriculum in a baccalaureate nursing program. This paper describes the second stage of a process to design the informatics nursing courses. The challanges to foster faculty collaborative relationships as well as to enhance the course content of all nursing informacs curriculum. A number of stategies were used to develop the collaborave efforts between the faculty and nursing staff in the clinical agencies. Information technology was incorporated into the didactic and clinical portions of courses through the use of creatv teaching strategies. Therefore, the faculty have ensured a blend of informaion, technology, and the clinical care process throughout the curriculum. PURPOSE Prepaation o nusmes for the 21st century requires educonal prgram well grounded in the traditional physical, biolgical, and social sciences as well as the evolving infoLrmAtn sciences. Therefore this paper wil describe the collaboration process used to design, mpl and evaluate a new integrated informatics curriculum currently in place in a baccalaureate nursing program. First time mplatn of the second course of a required four couse sequence is occurring as well as the ongong evaluation Of the first and secord year of the curriculum. 0195-4210/92/$5.00 (©1993 AMIA, Inc.
BACKGROUND AND REVIEW Recently the School Of Nursing and three area hospials formed a consortium to launch a lareate program in nursing. In the Fall new of 1990, 101 students were admitted into the inaugural class. Presety there are two classes with 202 students in the program. Key aspects of the program Include (1) focus on acute and critical care nursin, (2) bedside nursing emphasis, (3) strong clinical experence throughout all four years beginning In the firs semeer of the curriculum, (4) innovative inclusion of nursing informatics throughout the four years of curriculum, (5) development of kienty with professional nursing through pnal link-up with nurses in clinical settings, and (6) well defined linkages to the three hospitals Increase in the use of computer technology and ironation science in nursing prtice, education, and administration demands a new aprach to the application of information tehoy However, technical competence inckxdes not only equipmert competence but skill in the efficient ppan of information. We are continually chalnged to produce a baccalaureate graduate who utilizes information technologies in their clinical praice. CHALLENGE The ImIplmeIon Of the second course provided the folowing challenges: 1) To foster faculty collaborative relationships necessary to. continue the of a realistic, develpment and impna
future-oriented cuniculm.
419
2) To enhance the course content of all nursing informatics curricula based on faculty and student suggestos. Collaboration among faculty is ongoing and occurring at various levels. The School of Nursing has worked closely with the management information faculty to implement nursing informatics software on the fiberoptic university network. There is a relationship with the consortium hospitals which encourages exchange of new ideas through the linkages wkh staff nurses as clinical teaching associates who work directly with the nursing students. Staff nurses also act as mentors who also work directly wkh the nursing students. And finally, there is an ongoing collaborative relationship between the nursing science faculty and the nursing irm consultants who are assisting the school in curriculum development. DESIGN Informaics courses are designed to articulate wkh the clinical experence and comprehensive course progressin followed bythe BSN students. The three basic components of the model identified to provide a framework are information, technology and cinical care pr A model was developed to illustrate the three aspects of nursing informatics in the undergraduate curriculum. See Figure 1. Each course addresses the three components, however, the emphasis regarding each component varies with each course. During the first course introduced in 1991, the emphasis was on informa on and technoogy with an overlap in the clinical care proc In Nursing Informatc lI, the primary emphasis i on information and the clinical care process with secondary emphasis on technology. (See figure 1). In order to succesully focus the curriculum in this direction, the nursing iformatics and nursi science faculy c worked to develop a
collaborative relatonship whereby nursing informatics and nursing scence theories would be integrated into both curricula We accomplIshed this through sveral approaches. Argyrs and Schon [11 sgest that the clinical field experiene in a pressnal nursing program should not be desined merely to give students experence in the real clinical setting to learnaccepted practices, but should also provide the student with the opportunity of trying out new approaches and modalkies of care. To e v accomplish this, a plan of action was developed to assist informatics as well as to incoate
FRANCES PAYNE BOLTON SCHOOL OF NURSINO CASE WESTERN RESERVE UNIVLRSITY umi. laOmsseo" strs" l wSm"a* .raw"
(Yea 1)
(Year 2)
Flrst Coure
Second Course
(Year 3)
Thir and Fowth Course.
Figure 1 information technology into the clinical experience. Each of the mentors and clinical teaching assocites attend an all day conference on clinical decision making. It is our expectation that the outcome of the conference will be two fold: 1) to enhance the student's clinical experience and 2) to increase the understanding of nursing informatics of nurses interacting directly with the students regarding clinical practice. In order to apply classroom concepts to technology a computerized patient charting program, TLC-General Hospital 12) was selected to enhance the second level informatics course and placed in the campus fiberoptics network. As the hospital clinical sites currently lack many of the components of nursing Information systems, a broad based pInt charting program presents the studbnt with those pleces. The course focus Is on the process o accessing and documenting as wel as the development of critical analysis of the comipterized p care record. This 'hands onr introduction to Nursing Informics can nurture ato of and appreciation for the an computerized patient record. IMPLEMENTATION The second nursing informatics course was implemented in the second semester of the
420
second year of the BSN program. This is intended to allow students to practice handling the increased quantitative information encountered in the clinical area This occurred through the use of application software packages which were placed on the campus fiberoptic network. The student enters the second level of informatics with a basic understanding of the health care system as well as an introductory view of the information flow within that patient centered system. The focus now shifts to applying the developmernt of knowledge toward the technical aspects of the nursing informatics applications currently available. Concepts such as the lifetime electronic medical record, nursing minimum data set and clinical decision making are introduced. In order to help apply these concepts, a simulation program was selected which provided a broad source of patient data and easy accessibilky. In this second level informatics course the electronic patient record is used to expand upon the programs basic documentation functions with the help of instructor designed assignments allowing the program to be applied in more creative ways. For example, students are provided with only the computer data and forced to delegate tasks and make clinical care decisions based on the scenario presented. This reinforces the inherent analytical procss in critique of the information gathering utility of the computerized patient care record. Expioration of minimum data set, further brings to Ife the concept of prioritizing the most significant data in order to provide patient care. Within the TLC program, students revlew incomplete data and the students learn that some data are more significant than othes in planning and delivering the most effective and efficient patient care. This analysis of the 'value' of various data sets continues to build on crtical thinkhg as the students intemalize the concept of the minimum data set In additon to the specific course requirements other irformatics activities are For integrated throughout the curriculum. example, School Of Nursing facuity agreed that each student will be required to identify all sources of information obtained and utilized to deveiop the patient's nursing care plan. Students will indicate whether information was obtained through access to the manual chart, the automated computer systems, through inteniws with patientfamily or through inter/intradepartmental communcation. They will indicate the ease or difficulty of collecting
and analyzing patient information and also be required to identify opportunities where information technology could enhance the capture, processing and communication of their own nursing information. This approach not only reinforces the concepts of information capture and communication, but also gives the student an opportunity to analyze the voluminous data collected and maintained on patients and how to filter that data into clinically relevant information. EVALUATION NURSING INFORMATICS 11 In 'What Curriculum for the Information Age?' edited by Mary Alice White, Julie McGee proposes that the curriculum necessary to equip students for life in the Information Age should emphasize a new hierarchy of skills. [2] This skill set includes the a) abiliy to evaluate information, b) the ability to set priorities, and c) the ability to make decisons. These three skills are basic to the students understanding and application of information technology to support nursing care. During the freshman nursing informatics course, we evaluated the student's acquisition of knowledge through multiple choice examinations. This format Is useful in evaluating the student's knowledg, comprehension and application of material presented in cla and through the reading assignments. Since the second nursing inforatics course deals with the access, application and evaluation of information in relationship to the clinical care process, we have decided to evaluate the students' understanding of the principles of nursing informatics and their clinical applications through comprehensive essay examinatons The student is required apply information obtained through classwork and supp readings and that the supplemental reading be referenced in the answers. Each essay question also Includes an opinion or open-ended segment that encourages critical thinking on the part of the students understanding, acceptance and comfort with nursing information systems. While we do not grade the student's opinion, we do grade the iogic and presentation manner of the ratnale the student uses to defend his/her
opinion. UPDATE ON NURSING INFORMATICS I This course focuses on helping students identfy the conteit, flow, and processing of patient information within the hospltal. The course also buiids a basic understanding of information technologies and how these technologies can support nurss in delivering patient care.
421
One of the most beneficial teaching strategies in this years Nursing Informatics 1, is a simulation program by Jackson and Milne. [31 This self-paced computer simulation demonstrates how advances in information technology can facilitate nursing practice. Further, k promotes comfort with use of computer systems in nursing practice. The program guides the student through several components and features of a Hospital Information System (HIS). In order to validate student participation, the computer simulation was placed on the university's fiberoptic computer network enabling students to access and complete the computer assignment from one of the university's libraries, computer labs, or individual dormitory rooms. Faculty designed a case study with pertinent patient information for the student to enter as they progressed through the simulation. The experience helped to fuffill the objectives of the course by demonstrating how a HIS facilkates departmental communication and integration while facilitating efcient patient care. Student response to the simulation was positive. Overall, students felt it was interesting and informative as well as a confidence buiider in computer usage. Students were also given a clinical assignment to promote collaboration between Introduction to Nursing Informatics and their clinical experience. The assignment was to identify and explain any aspect of patient care requiring information processing that would benefit from computer technology. Students were asked to outline/model the computerization process and explain the beefit of computerizing the identified aspect of the patient care process. Further, students were given the opportunity to apply informaton technology to improve an one specific aspect Of patient care. CURRICULUM AND PROGRAM EVALUATION This is the second stage of a longitudinal study to extend over a four year period. Evaluation of outcomes with respect to both students' atitudes and knowledge acquired will occur after each stage. In additon to following the first group of students through the four year period, a comparison between the first group of students and succeeding InfoLra ics student groups will occur. Here we report two aspecs of the ongoing evaluation. The first is to compare the students experience with computers. Second is to compare each cohort knowledge and attiude. At the end of the present course, the survey previous developed [4J to evaluate the students' knowledge and attiudes toward computers and Nursing Informatics will be 422
readministered
so
that an ongoing evaluation of
changes in knowledge and attitude will be captured. The current freshmen completed the
initial survey. Of the 84 completed surveys received, 68% had taken a computer course in grade school or high school. In comparison to the previous class, the number was 67%. Therefore same
there
minimal change from the previous to Additionally, 92% of the 2nd class had used a computer in school, predominately for word processing. This percentage was similar to the previous class which was 93%. Concurrently, the 54% of the new class owned computers compared to 52% from the previous freshman group. Therefore, the two cohorts are very similar in their experiences with was
current freshmen.
computers.
The instrument to be used for this study is 30 item questionnaire adapted from McConnel, O'Shea and Kirchhoff, to measure knowledge and attitudes toward computers. Factor analysis on the first sample supported a three factor structure and deletion of sax items. The three scales are scientific use of technology, common misconceptions associated with technological advances, and clinical care process. The scientific use scale is composed of four items regarding the advantages of computer technology in the health care setting. Higher scores indicate more positive knowledge and attitudes. Cronbach's alpha for the scale is .40. The common misconceptions scale has eight items which describe commonly held fears and concerns regarding advances in techrology in the workplace. Lower scores indicate les negative knowledge and attitudes. Cronbach's alpha was .75. The 12-item clinical care scale addresses the application of technology to support the nurse in providing patient care. a
Higher scores indicate
more
positive knowledge
and attkudes. Cronbach's alpha was .80. Each cohort was assigned in the freshman year on knowledge and attitude, this time, data from the first time poeriod are available for the current freshmen students and the previous freshmen students. Thus we are able to compare the two classes of beginning students regarding their prior knowledge and attitudes about computers in nursing informatics. Scores on the three scales for the two classes of students were compared with t-tests. Tests of homogeneity of varance do not suggest that the variances are significantly different, so t-tests based on pooled variance estimates are used. The two cohorts of students are not significantly different in their
scores for the scales measuring scientffic use of technology and common misconceptions. However, the second group of freshmen students scored significantly higher on the clinical care scale (t1l*=.3.70, p
