Jun 22, 2020
Electronic documentation: gateway to nursing informatics?
Take away messages:
- Nurses need to master technological tools and information management systems to provide high-quality care.
- Training with electronic documentation and the electronic health record could provide a gateway to nursing informatics.
- Electronic documentation and health record practice help nurses develop a whole subset of information and computer technology skills.
Today’s health care is becoming increasingly complex as hospitals incorporate technology to assist nurses and other providers to deliver high-quality patient care. Citing a joint statement from the Canadian Nurses Association (CNA) and Canadian Nursing Informatics Association (CNIA), Anderberg, Björling, Stjernberg, & Bohman (2019) claim that “digitally connected health services environments are essential tools to empower the nurses in their caregiving.” The Institute of Medicine (2010), a major health-care think tank, noted as far back as 10 years ago that as nurses’ roles expand, it will be essential for them to master technological tools and information management systems.
Furthermore, in their joint position statement, CNA and CNIA (2017) noted that “[n]urses must develop their nursing informatics knowledge to ensure they can practice and think critically in complex environments that rely on ICT [information and communication technology]” (pg. 4).
What is informatics?
Informatics is an umbrella term that includes computer skills, information literacy, and information management. It includes basic computer skills as well as the ability to navigate systems, search, retrieve and evaluate information, document nursing interventions and patient outcomes, and numerous other skills.
Integrating ICTs into nursing practice affects nurses’ communication and relationships with their patients, as well as their working conditions and professional identities.
With ICTs having such a major impact on our practice, what is being done in education to prepare nurses for that work world, given that 10 years have passed since the Institute of Medicine called for nurses to engage in informatics?
While progress has been made, there is still an unfortunate gap between the needs of the current health-care environment and nursing education: informatics skills are not formally taught in many nursing programs despite recommendations from various nursing organizations (CNIA, 2002; CNA, 2006).
Bridging the gap
To date, some, but far from all Canadian-accredited nursing schools have successfully wrestled with the challenge of integrating informatics formally into their nursing program structure. In 2007, Dr. Lynn Nagle, a Canadian nurse informatics specialist, in a study of 79 nursing schools found that fewer than 40% had integrated informatics into their curriculum (Nagle, 2007). In 2018, when Dr. Nagle revisited the topic in Canadian nursing schools, she found that there was still a gap “in desired level of digital health/informatics awareness and education amongst both educators and administrators who develop nursing curriculum” (Nagle, Kleib, & Furlong, 2018).
In addition, Anderberg et al. (2019) “identified the need for both general and specific digital competence and digital literacy in the nursing profession and education,” which suggests that changes in nursing curricula are needed if we are to develop job-ready nurses for tomorrow.
While we are lagging in implementing nursing informatics in the curriculum, many groups are actively trying to move informatics forward. In the United States, Technology Informatics Guiding Education Reform (TIGER) is a group that since 2004 has been driving the advancement of nursing informatics competencies in the curriculum. TIGER shares specific actions for improving nursing education using health information technology.
While progress has been made, there is still an unfortunate gap between the needs of the current health-care environment and nursing education.
In Canada, the relatively new Digital Health Interest Group has formed through the Canadian Association of Schools of Nursing (CASN). CASN also nationally endorsed a set of entry-to-practice competencies for nursing informatics in 2012. The Registered Nurses’ Association of Ontario (2016) issued a statement that all “[n]ursing faculty designated as practice education teachers need to be prepared for the use of learning technologies, such as simulation” (p. 30).
With so many organizations calling for informatics in the curriculum, why aren’t we making more progress in education? One reason might be the “overcrowded” curriculum. How do faculty fit informatics into an already tight program?
Another reason is that the informatics “umbrella” is broad, so it is difficult for faculty to know where to start. Yet another reason might be that integrating the entire body of informatics competencies might seem overwhelming to faculty who may not have used informatics in their own practice.
This is where change theory might help us: we can start small. One approach might be to start with a key informatics skill, for example, electronic documentation, and achieve success with that first.
Electronic documentation or charting is the norm in an increasing number of health-care facilities and is becoming an essential tool for providing safe and high-quality care (Agency for Healthcare Research and Quality, 2018). Electronic documentation includes such skills as electronic data entry and data extraction for preparing care plans, planning patient care and education, and discharge planning; it is rapidly becoming a major practice competency.
When students practise electronic documentation, they develop a whole subset of ICT skills. They are exposed to the electronic health record (EHR), which helps nurses, and therefore patients, in multiple ways (Hoover, 2016; Kelley, Brandon, & Docherty, 2011). One major advantage is that nurses can find up-to-date information at the point of care rapidly; some authors suggest that the data accessed through the EHR is equivalent to what nurses get when they attend clinical rounds.
Nurses can coordinate care among team members more easily, reduce medication errors, be alerted to life-threatening allergies, and quickly spot abnormal lab values. Through electronic documentation and the EHR, nurses benefit by learning a standardized nursing terminology so that the fundamental elements of nursing can be captured in the electronic record.
How might educators integrate electronic documentation into the curriculum? One approach is to embed it across the curriculum. Principles and practices of documentation and the function and role of the EHR and its relationship to patient assessment and care planning are first examined in nursing theory.
Next, students are oriented to the system and electronic documentation is included as routine hands-on practice during simulation exercises, building student familiarity with the EHR. Finally, students apply and adapt that learning when they receive orientation and practise in the clinical setting.
Implementing the EHR in a community college simulation centre
An increasing number of hospitals in our area were implementing EHR, and this acted as a driver to our nursing faculty to adopt an EHR in our simulation centre. By doing so, we could prepare students for clinical practice without having to wait for the larger, more challenging curriculum revision required to integrate nursing informatics into our multi-site program.
- We used an open-source electronic health record in our simulation centre. OpenEMR is one such open-source EHR and medical practice management solution that can be downloaded and modified for free. (https://www.open-emr.org)
- After modifying the product to meet our needs, we uploaded it to the Internet for student and faculty use. We created a user manual and provided in-person orientation sessions for users.
- We loaded a laptop with simulated client charts. We ran a simulation lab where students were assigned a patient (a human patient simulator). The students were asked to document vital signs, sign off medications on the medication administration record, and input their nursing notes based on the care they gave to the simulated client.
- Results: Students and faculty could see the benefits of the EHR, but we ran into several challenges and learned several lessons.
Students were keen to use the EHR in the classroom and in simulated practice.
- The system must be user-friendly. This means that sufficient funding is needed to modify the software as necessary to make it user-friendly; this is an essential step.
- You need a good rapport with your vendor to help with modifications and third-party technical support.
- Students and faculty need a solid orientation to the theory behind the EHR and ample time for hands-on practice with the EHR prior to simulation practice.
- Expectations need to be managed: students and clinical faculty need to be advised that each clinical setting uses a different system. The sim centre EHR will not be identical to the EHR they use when they get to clinical practice.
This integration experience with electronic documentation, and the subsequent exposure to the electronic health record, helped to develop student nurses’ ICT skills (despite the lack of a formal nursing informatics course) and provided a gateway to further ICT competency. This finding is supported by Chung and Cho (2017), who conducted a study to understand the impact and value of documentation and other uses of the EHR. Their findings suggest that electronic documentation with the EHR helps prepare students in information technology and improves their problem-solving and critical thinking skills.
Students value electronic documentation; Mountain, Redd, O’Leary-Kelly, and Giles (2015) noted that students were keen to use the EHR in the classroom and in simulated practice.
While electronic documentation may be a practical way to introduce informatics in the curriculum, in our experience, success rests on several factors:
- Adequate financial support for this initiative is essential; introducing this technology is not an inexpensive undertaking.
- The adopted EHR needs to be user-friendly, and vendor support needs to be readily available and ongoing.
- Nursing faculty need to be competent with electronic documentation and comfortable navigating the EHR. This means strong support will be needed from administrators for faculty professional development and curriculum development release time.
- Finally, all too often students and faculty are faced with using a different EHR in the clinical setting compared with the system they learned in school. Students should be prepared for this eventuality. They will also need a solid orientation and regular, ongoing evaluation of the learning–practice cycle.
Numerous studies have shown that informatics competencies and associated skills are very important for a nurse to be successful in today’s nursing environment. Currently, a gap exists between practice competencies and education outcomes.
Practice with electronic documentation in the context of the EHR embedded as teaching and learning activities in various courses will help nurses gain ICT skills and competencies. With adequate funding to ensure a user-friendly experience and orientation for faculty and students, the EHR can be a useful gateway to informatics in the nursing curriculum.
Agency for Healthcare Research and Quality. (2018). Use of electronic health records. Rockville, MD.
Anderberg, P., Björling, G., Stjernberg, L., & Bohman, D. (2019). Analyzing nursing students’ relation to electronic health and technology as individuals and students and in their future career (the eNursEd Study): Protocol for a longitudinal study. JMIR Research Protocols, 8(10), e14643. doi:10.2196/14643
Canadian Nurses Association (CNA). (2006). Position statement: Nursing information and knowledge management.
Canadian Nurses Association (CNA). (2017). Joint position statement: Nursing informatics.
Canadian Nursing Informatics Association (CNIA). (2002). Educating tomorrow’s nurses: Where’s nursing informatics? Ottawa: Author.
Chung, J., & Cho, I. (2017). The need for academic electronic health record systems in nurse education. Nurse Education Today, 54, 83–88. doi:10.1016/j.nedt.2017.04.018
Hoover, R. (2016). Benefits of using an electronic health record. Nursing, 46(7), 21–22. doi:10.1097/01.nurse.0000484036.85939.06
Institute of Medicine. (October 2010). Future of nursing: Leading Change, Advancing Health Report Brief.
Kelley, T.F., D.H. Brandon, & S.L. Docherty. (2011). Electronic nursing documentation as a strategy to improve quality of patient care. Journal of Nursing Scholarship, 43(2), 154-62. doi:10.111/j.1547-5069.2011.01397.x
Mountain, C., Redd, R., O’Leary-Kelly, C., & Giles, K. (2015). Electronic medical record in the simulation hospital: Does it improve accuracy in charting vital signs, intake, and output? Computers, Informatics, Nursing, 33(4), 166–171.
Nagle, L. M. (2007). Everything I know about informatics, I didn’t learn in nursing school. Nursing Leadership, 20(3), 22–25. doi: 10.12927/cjnl.2007.19285
Nagle, L., Kleib, M., & Furlong, K. (2018). Study of digital health in Canadian schools of nursing: Curricular content and nurse educator capacity. Canadian Association of Schools of Nursing.
Registered Nurses’ Association of Ontario (RNAO). (2016). Practice Education in Nursing. Toronto, ON: Registered Nurses’ Association of Ontario.