October 1, 2008
Informatics in the Nursing Curriculum
By Thompson, Brent W Skiba, Diane J
Numerous forces in the last decade have converged to form a "tipping point" demanding that nurses have the necessary knowledge and skills to practice in a technology-rich health care environment. Several Institute of Medicine (IOM) reports have highlighted the importance of health information technologies in providing safe and quality care. In particular, Health Professions Education: A Bridge to Quality (A. C. Greiner and E. Knebel, National Academies Press, 2003) recommends informatics as a core competency for all health care professionals. Federal initiatives spearheaded by the Office of the National Coordinator of Health Information Technology also served as an impetus for preparing nurses to work with a variety of informatics tools. The TIGER Initiative and others advocate that a nurse's portfolio needs to include knowledge and skills in computer literacy, information literacy, and informatics. In 2005, the NLN Educational Technology and Information Management Advisory Council established the Task Group on Informatics Competencies to review the informatics literature and survey faculty and administrators on the extent of preparation in nursing informatics competencies in schools of nursing. The purpose of the survey was to measure the informaticsrelated requirements of nursing curricula and ascertain how those requirements are integrated into curricula.
Procedure An email with an invitation to participate in the survey was sent to all faculty and administrators in the NLN membership database, which includes LPN, all levels of RN, and graduate program faculty. Respondents answered anonymously online, but could choose to provide contact information if they wished to provide exemplars.
Faculty respondents were asked the technology requirements of the school; how the curriculum currently addressed informatics; how faculty members personally integrated informatics into their courses; and the informatics tools used in the clinical setting. They were also asked to self-rate their informatics knowledge.
Administrators were asked similar questions, but were also asked details about courses containing informatics content or practice. If they reported no such integration, administrators were asked to provide rationales for not including informatics in the curriculum.
Demographics Respondents included 1,557 faculty and 540 administrators. All faculty were asked to indicate the one program where they had the majority of their teaching, student advisement, and leadership responsibilities. Educational levels were recategorized for reporting purposes. The largest percentage was from associate degree programs (42 percent) followed by baccalaureate programs (31 percent). Table 1 depicts the breakdown by educational level.
Five hundred ninety-four respondents (38 percent) were from the South. Other regions represented were the Midwest, 404 (26 percent); North Atlantic, 377 (24 percent); and West, 167 (11 percent). Fifteen respondents (1 percent) were from US territories or did not reply.
Among faculty respondents, 1,048 (67 percent) had master's degrees, and 360 (23 percent) had doctorates. Thirty-seven percent had the rank of instructor; the others were assistant professors (25 percent), associate professors (18 percent), and professors (14 percent). The remaining respondents either did not reply or had no academic rank.
Ninety percent of faculty respondents were full-time employees; 79 percent had both classroom and clinical responsibilities. Fifteen percent had classroom responsibilities only; and 6 percent had clinical responsibilities only.
Administrators represented ADN (47 percent), BSN (38 percent), LPN (35 percent), graduate (26 percent), and diploma (6 percent) programs. The highest proportion were from the South (38 percent); at least 25 percent were from the North Atlantic and Midwest, and 13 percent were from the West.
Technology Requirements of Schools of Nursing Asked to report the technology requirements of their programs, a small percentage of faculty (15 percent) and administrators (11 percent) reported that their schools required students to own a desktop or laptop computer. A very small percentage (faculty, 3 percent; administrators, 6 percent) required students to have handheld computers. The majority of schools said computer literacy was a requirement by faculty (56 percent) and administrators (58 percent). Information literacy was less likely to be a requirement (faculty, 38 percent; administrators, 39 percent).
Definitions for all three concepts (computer and information literacy and informatics) were provided in pop-up boxes, but it is unknown if respondents accessed those definitions to guide their responses.
Integration of Informatics in the Curriculum Respondents were asked to identify all the ways their curricula integrated informatics; multiple answers were accepted. The most common methods reported by faculty were integration throughout several courses, clinical exposure, and content provided by the library. BSN and higher degree programs had higher percentages of integration.
In comparison with other educational levels, BSN and master's programs were more likely to have program outcomes or terminal objectives for informatics and to offer a separate nursing informatics course. Nearly a third of administrators (31 percent) reported using orientation to provide needed content. Only a small number of programs included informatics as a terminal or program objective; similar numbers offered a separate nursing informatics course or no content at all.
A small percentage of schools offered informatics courses. These were more likely to be requirements than electives (81 percent) and were usually taught by a nurse faculty member (77 percent). In some programs, librarians and liberal arts faculty taught the courses.
When a program offered no content, administrators were asked for the reasons for the exclusion. Reasons for not including content were "no room in the curriculum" (17 percent), "faculty not prepared to teach informatics" (17 percent), "not a teaching priority" (12 percent), "taught in general education courses" (7 percent), "budget restraints" (7 percent), and "information systems not used in our clinical sites" (2 percent).
Respondents were also offered an "other" category of informatics integration methods. Most striking was that nearly any type of computer-related activity was seen as informatics. Examples included "the use of computers,""using computer-based learning software,""searching databases," or "taking online courses." Some respondents commented that informatics was integrated through exposure at the library, orientation classes, or general education courses such as English or communications. A small number of respondents reported more direct integration of nursing informatics through activities such as electives, an informatics conference, student presentations, and use of a PDA or a clinical documentation system.
In summary, the majority of schools claimed that informatics is integrated throughout the courses in their curricula and in clinical exposure to informatics; another large percentage (40 percent) identified the library as the major source for addressing informatics. This finding indicates that many faculty and administrators are likely equating information literacy skills with knowledge of informatics.
Integration of Informatics into Courses by Faculty Faculty were asked to talk specifically about the integration of informatics in their own courses. A large majority of faculty (86 percent) integrated informatics content into some or all their courses. Within this group, 53 percent claimed to integrate informatics in all their courses. Faculty who taught at BSN and higher educational levels were more likely to integrate informatics throughout all their courses.
Faculty who reported that they integrated informatics into their courses were asked for examples from a long list of pedagogical integration methods. These examples can be classified as: teaching content about particular informatics tools or informatics issues; having students use the web to do assignments; using the computer to accomplish tasks like presentations, spreadsheets, or databases; using handheld computers or clinical information systems for information retrieval or documentation; and using web-based discussion groups. The intent was to examine if informatics was equated with computer or information literacy skills and/or online course skills.
For the first category, a surprising percentage of faculty (72 percent) incorporated into their courses on informatics issues such content as privacy, security, patient confidentiality, impact of technology on workflow, and patient outcomes. A larger percentage of LPN programs reported that they covered this content than higher degree programs. Over 60 percent taught content about informatics tools on topics such as electronic health records, clinical documentation systems, and bar code medication systems. Half of the faculty taught about informatics tools facilitating nurses' work, and a smaller percentage taught content about clinical decision support systems and informatics tools to promote patient safety. It is reassuring that some content on informatics is covered in various nursing courses across all levels of education. The highest proportion of faculty reported web assignments as a teaching method. The most common assignments were to ask students to search the web for a particular topic and to find evidence in the literature. Over 60 percent incorporated assignments to find webbased patient educational materials, and 35 percent asked students to evaluate websites, especially for consumers.
One half of the faculty reported using PowerPoint as a computer tool to do student-prepared presentations. Faculty in BSN programs (65 percent) and in graduate programs (81 percent) were more than twice as likely to use this method as faculty in LPN, diploma, or ADN programs. The use of spreadsheets and databases was taught in 41 percent of graduate programs and in no more than 11 percent of prelicensure programs. Relatively few courses (21 percent) had incorporated the use of software to create nursing care plans.
No more than 25 percent of courses used handheld computers, or PDAs, as tools to retrieve information, document clinical experiences, or retrieve evidence to support nursing practice. Graduate level classes were more likely to promote their use to find reference materials. Despite the increasing emphasis on evidenced- based practice, faculty have been resistant to using such tools. Clinical information systems were also rarely used (26 percent) as part of clinical simulation experiences.
Online discussions were used often (42 percent) and were most popular among BSN (53 percent) and graduate programs (70 percent). This finding may be due to a greater overall use of online education in these programs. Again, it appears that faculty were equating taking online courses with informatics competencies.
In summary, the findings suggest several things. 1) Information literacy exercises are the predominate example of informatics integration into courses. 2) Informatics content related to issues (e.g., privacy, confidentiality, security, and impact) are offered frequently in prelicensure course work. 3) The notion that online courses are the same things as informatics is ubiquitous. 4) The use of handheld computers, software for care plans, and clinical information systems was rarely integrated into courses. 5) Online learning and using computers for assignments (i.e., creating PowerPoint slides) are often cited as other methods of integrating informatics. 6) Graduate programs are far more likely to integrate content and other learning experiences than other programs.
Clinical Experiences Clinical exposure to informatics tools is very common (71 percent). Faculty cited tools such as clinical information systems, decision support tools, and handheld computers during clinical experiences. Diploma schools reported the greatest number of such experiences (85 percent) followed by graduate, BSN, and ADN programs (70 to 74 percent). LPN programs had the least amount of experience with informatics tools in their clinical areas (56 percent).
Exposure to informatics tools is highly dependent on the resources and cooperation of the clinical facility. Most responses stated that hospitals and nursing homes had computerized patient records in some form. Where available, students' clinical uses included medication administration, progress documentation, viewing lab results, patient history and physician orders, retrieving patient teaching materials, and researching topics of interest. Internet access was often available. It would be interesting to follow up with schools to examine if students had access to these tools as part of their clinical or merely observed others using the informatics tools.
Clinical use of handheld computers ranged from 14 percent in LPN programs to 47 percent in graduate programs. Handheld computers were sometimes shared with the instructor. While only 3 percent required student use of handheld computers, some programs indicated future plans to require their use.
Faculty Knowledge of Informatics Faculty were asked to rate their level of informatics knowledge on a scale from novice to expert and to indicate they acquired that knowledge. The largest percentage (37 percent) rated themselves as competent, followed by advanced beginner (26 percent). More faculty considered themselves novices (13 percent) than experts (4 percent). Higher self-ratings of proficiency and competence were associated with BSN and higher degree programs.
Faculty were largely self-taught (82 percent) or acquired knowledge through continuing education offerings (42 percent). Relatively few (3 percent) attended the Weekend Immersion in Nursing Informatics Program or participated in certificate programs (3 percent). Some (15 percent) reported taking courses for credit. There were also at least 14 faculty who had received graduate degrees in informatics.
An analysis of open-ended responses to the courses or types of certificate program taken was revealing. Certificate programs named were often related to webbased or online teaching, such as courses offered through the NLN-Indiana University School of Nursing strategic alliance, WebCT training, educational technology certificates, and certificates in distance education. One respondent received a certificate in informatics from Excelsior College, and another worked as a nursing informatics director.
Several common themes were noted. First, relatively few faculty respondents indicated that they had degrees, course work, or certificate degrees in the field of nursing informatics. second, it was unclear if the courses mentioned by faculty were actually informatics courses; some may have focused on computer literacy or information literacy rather than informatics. Third, there were repeated instances where faculty equated distance learning, online learning, and web-based instruction as being prepared in informatics.
Conclusions Although there has been some progress across educational levels, nursing education has not fully integrated informatics into the curriculum. Major gaps remain in preparing nurses with the necessary knowledge and skills to use informatics tools to communicate with patients and health care professionals, manage knowledge, mitigate error, promote quality, and support clinical decision-making. To reach this goal, informatics must not be viewed as "extra" content to be crammed into the curriculum but as an integral component of modern nursing practice.
There is clearly work to do in preparing faculty to teach nursing informatics and to facilitate administrators' understanding of the distinctions among computer literacy, information literacy, and informatics competencies. The greatest impediment to reform is the incongruity between what nursing informatics is and the perceptions nurse educators have of what it is. A common theme in the survey was that exposure to a computer constituted education in informatics. This incongruity is analogous to believing you are a musician because you know how to play the radio.
In 2008, the NLN Board of Governors issued the position statement Preparing the Next Generation of Nurses to Practice in a Technology- Rich Environment: An Informatics Agenda (see www .nln.org/aboutnln/ PositionStatements/ informatics _052808.pdf). The need for this agenda was partially informed by the results of the NLN-sponsored nationwide survey of faculty and administrators on the nursing informatics requirements in their courses and curricula. The time to begin the dialogue necessary to ensure that future nurses have computer and information literacy knowledge and skills and can demonstrate informatics competencies is now.
Contributed by Brent W. Thompson, DNSc, RN, and Diane J. Skiba, PhD, FAAN, FACMI. Dr. Thompson, associate professor, West Chester University of Pennsylvania Department of Nursing, is acting chair of the NLN Educational Technology and Information Management Advisory Council. Dr. Skiba, chair of the Task Group on Informatics Competencies, is professor and project director, I-Collaboratory: Partnerships in Learning, University of Colorado Denver College of Nursing. She is the Emerging Technologies Center editor for Nursing Education Perspectives.
Copyright National League for Nursing, Inc. Sep/Oct 2008
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