THE DOCTOR OF Nursing Practice (DNP) was SELF-ASSESSMENT OF NURSING INFORMATICS COMPETENCIES PRACTICE STUDENTS FOR DOCTOR OF NURSING

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1 SELF-ASSESSMENT OF NURSING INFORMATICS COMPETENCIES FOR DOCTOR OF NURSING PRACTICE STUDENTS JEUNGOK CHOI, RN, PHD AND DONNA M. ZUCKER, RN, PHD This study examined the informatics competencies of doctor of nursing practice (DNP) students and whether these competencies differed between DNP students in the post-baccalaureate (BS) and post-master's (MS) tracks. Self-reported informatics competencies were collected from 132 DNP students (68 post-bs and 64 post-ms students) in their first year in the program (2007 to 2010). Students were assessed in 18 areas of 3 competency categories: computer skills, informatics knowledge, and informatics skills. Post-BS students were competent in 4 areas (computer skills in communication, systems, documentation, and informatics knowledge about impact of information management), whereas post-ms students were competent in only 1 area (computer skills in communication). Students in both tracks reported computer skills in decision support as their least competent area. Overall, post-bs students reported slightly higher than or similar competency scores as post-ms students, but scores were statistically significant in only 3 of 18 areas. The assessment indicated that knowledge and skills on informatics competencies need to be improved, especially in computer skills for data access and use of decision support systems. Strategies are suggested to integrate competencies into existing informatics course and DNP curricula. Further studies are recommended using an objective measure of informatics competencies. (Index words: Informatics competencies; Nursing informatics; Doctor of nursing practice; DNP; Self report) J Prof Nurs 29: , Elsevier Inc. All rights reserved. THE DOCTOR OF Nursing Practice (DNP) was announced in 2006 as a new kind of doctoral degree for nurses by the American Association of Colleges of Nursing (AACN, 2006). For new DNP programs, the curriculum should contain eight essential areas of curricular content, one of which is information systems/technology and patient care technology for the improvement and transformation of health care (AACN, 2006). Integrating informatics into the DNP curriculum requires, as a first step, accurately assessing current level of informatics competencies in DNP students outlined by the AACN and the National Organization of Nurse Assistant Professor, School of Nursing, University of Massachusetts, Amherst, MA. Associate Professor, School of Nursing, University of Massachusetts, Amherst, MA. Address correspondence to Dr. Choi: School of Nursing, University of Massachusetts, Amherst, 120 Skinner Hall, 651 North Pleasant Street, Amherst, MA jeungokc@nursing.umass.edu /12/$ - see front matter Practitioner Faculties (NONPF, 2011). Incorporating assessment of informatics competency into the curriculum is essential for adjusting the teaching method or content of the informatics curriculum to the students' various needs (Jenkins, Wilson, & Ozbolt, 2007). Despite the importance of assessing informatics competencies in the DNP curriculum, no study to date has reported informatics competencies of DNP students. A review of the literature revealed that a few studies addressed informatics in advanced practice programs including the DNP, and most of these studies defined areas of competency (Cronenwett et al., 2009; Curran, 2003) or the extent to which graduate program has incorporated information technology skills and knowledge into nursing curricula (McNeil et al., 2003). Several reported strategies to integrate informatics competencies in a DNP or master's (MS) curricula (Grant & Brettle, 2006; Jenkins et al., 2007; Manning & Frisby, 2011). The purpose of this article is to report the informatics competencies of DNP students from 2007 through 2010 and to suggest competency areas that will strengthen the informatics Journal of Professional Nursing, Vol 29, No. 6 (November/December), 2013: pp Elsevier Inc. All rights reserved.

2 382 CHOI AND ZUCKER curriculum. Strategies are also suggested for integrating competencies into existing DNP curricula, with a specific example of how competency findings were integrated into a nursing informatics course. Because DNP students in the post-baccalaureate (BS) and post-ms tracks have different educational backgrounds and might have different preparation levels in informatics, we also examined whether informatics competencies differed between DNP students in these two tracks. Informatics Competencies in BS Nursing Education BS nursing students' information technology abilities have been well studied, along with recommended interventions to improve these competencies. In general, BS nursing students have been evaluated as having competent (Desjardins, Cook, Jenkins, & Bakken, 2005) or moderate informatics and technology knowledge, attitudes, and skills (Fetter, 2009; McDowell & Ma, 2007). Desjardins et al. examined the effect of informatics for evidence-based practice courses on nursing informatics competencies in students at the end of the BS year of a combined BS/MS program. They found that students were competent in four areas: computer skills: communication; computer skills: basic desktop software; computer skills: systems; and informatics knowledge: impact (Desjardins et al., 2005). More recently, graduating BS nurses were found to have moderate information technology skills (Fetter, 2009). These students were most confident in their Internet, word processing, and systems operations skills and rated themselves lowest on care documentation and planning, valuing informatics knowledge, skills development, and data entry competencies (Fetter, 2009). Following formal training and hardware provision, modest improvements were found in basic informatics knowledge and skills but fewer gains in advanced skills and information literacy for nurses at the BS (McDowell & Ma, 2007) andpost-bs(cole & Kelsey, 2004) levels. Improved skills have been associated with specific educational approaches, such as distance learning (Cole & Kelsey, 2004; Kenny, 2002), the Nightingale Tracker system and personal digital assistants (Miller et al., 2005; Ndiwane, 2005), and clinical simulation methods (Rhodes & Curran, 2005). The informatics content of curricula for BS nursing students was found to be limited, largely because of nursing faculty's lack of familiarity with computerized systems and knowledge of informatics competencies (Ornes & Gassert, 2007). To address informatics shortcomings in a BS nursing curriculum, the authors designed five assignments to incrementally increase students' abilities to recognize the need for information (i.e., knowledge); advance their abilities to locate, evaluate, and use information (i.e., skills); and foster a positive appreciation for information literacy (i.e., attitudes) when planning safe and effective patient care (Flood, Gasiewicz, & Delpier, 2010). The informatics and technology competencies of BS nursing graduates were issues of concern in two surveys of nurse executives and deans and directors of undergraduate and graduate programs (McCannon & O'Neal, 2003; McNeil et al., 2003). The nursing executives reported that new graduate nurses needed to be familiar with nursing-specific software such as computerized medication administration systems (McCannon & O'Neal, 2003). The executives recommended improving incorporation of these skills into nursing curricula, but the deans and directors of nursing programs reported no formal evaluation of student informatics competencies and rated faculty who were teaching informatics content at the novice or advanced beginner level (McNeil et al., 2003). Informatics Competencies in Graduate Education, Including DNP Education The few studies that have addressed informatics competencies in graduate students have defined the areas of competency for nurse practitioners (Cronenwett et al., 2009; Curran, 2003), or the extent to which graduate programs have incorporated information technology skills and knowledge into MS nursing curricula (McNeil et al., 2003), or suggested strategies to integrate informatics competencies in a DNP or a MS curriculum (Grant & Brettle, 2006; Jenkins et al., 2007; Manning & Frisby, 2011). For example, the deans and directors of nursing programs in one study reported that the lowest informatics technology content areas taught in the graduate program were standard languages or terminologies or data standards for information systems (McNeil et al., 2003). In addition, a foundational course was proposed for all DNP students with strategies for integrating informatics throughout the curriculum, for example, requiring students to use informatics tools to search for and evaluate population-based health knowledge in epidemiology, research, and statistics courses (Jenkins et al., 2007). Informatics competencies were one of several competencies, along with their related knowledge, skills, and attitudes, integrated into an existing online DNP patient safety course (Manning & Frisby, 2011). The students formed teams to produce educational videos on hand hygiene, which provided the vehicle for experiential learning, interpretative thinking, reflective practice, and peer review to facilitate DNP student achievement of advanced competencies in teamwork and collaboration, evidence-based practice, and informatics into their existing course (Manning & Frisby, 2011). The literature searching skills of MS- and doctoral-level students (n = 13) improved after taking a Web-based tutorial developed as part of a 12-week evidence-based practice module on health and social care (Grant & Brettle, 2006). In summary, this review of the literature reveals a lack of studies on informatics competency assessment of DNP students. Existing literature has focused solely on defining the areas of competency (Cronenwett et al., 2009; Curran, 2003; McNeil et al., 2003) or strategies to

3 SELF-ASSESSMENT OF NURSING INFORMATICS COMPETENCIES 383 integrate informatics competencies into DNP or MS curricula (Grant & Brettle, 2006; Jenkins et al., 2007; Manning & Frisby, 2011). Measuring DNP students' perceived informatics competencies is one of the elements for successfully designing informatics curricula and in meeting the DNP informatics competencies outlined by the AACN (2006) and the NONPF (2011) by identifying areas of deficits and strengthening those areas. Thus, this study was undertaken to assess perceived informatics competencies of DNP students. Methods Our school of nursing began offering the DNP for both post-bs and poststudents in 2006 using on-line distance education. This program was accredited in 2010 by the Commission on Collegiate Nursing Education. Since 2007, the informatics for nursing practice course is offered in the first semester of the program. The informatics course and informatics concepts threaded through courses in our DNP program have been designed and implemented according to the AACN DNP Essentials IV: Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care and the NONPF's Technology and Information Literacy Competencies. During the first week of the course, students were asked to take an informatics competency assessment embedded in the Blackboard Vista learning management system. Students were told that the information was being collected for course evaluation and improvement purposes, and responses to the survey would have no effect on their current or future success in the course or program. Competency Assessment Tool The 86-item informatics competency assessment was based on a published set of 43 informatics competency statements for beginning and experienced nurses (Staggers, Gassert, & Curran, 2001; Staggers, Gassert, & Curran, 2002), with additional items related specifically to evidence-based practice and information literacy (Bakken et al., 2004; Curran, 2003). Each item is rated on a 5-point Likert scale (1 = not competent to 5 = expert). Items are arranged using the 18 competency areas in three competency categories: computer skills, informatics knowledge, and informatics skills. Means were calculated for each of the 18 competency areas. Table 1 shows sample competency statements. These 86 competency statements measure skills and knowledge of 18 competency areas, which are decision support system, basic desktop software, health care information system, data access and monitoring, computerized information management system, ethical and legal issues related to use of health care information system, and consumer health information resources. These areas are consistent with the informatics competencies outlined by AACN DNP Essentials IV and NONPF's Technology and Information Literacy Competencies. This assessment measures students' perceived competencies by self-report. Measuring students' perceptions of informatics skills and knowledge is an important step in assessing informatics competencies because direct measures of competencies are time consuming and may not be feasible with large numbers of students. Students' self-report of perceived competencies has been used by many researchers as a measure of informatics competencies (Desjardins et al., 2005; Fetter, 2009; Garde, Harrison, & Hovenga, 2005; Hwang & Park, 2011; McDowell & Ma, 2007; Ornes & Gassert, 2007; Yoon, Yen, & Bakken, 2009). Data Analysis Data were analyzed using SPSS, Version 19 (Chicago, IL). Students' informatics competencies were summarized using descriptive statistics (frequencies, percentages, means, and standard deviations). Differences in informatics competencies by student track (post-bs vs. post- Table 1. Examples of Informatics Competency Statements Informatics competency category Competency statement Computer skills: documentation Use applications for structured data entry Use application to document patient care Computer skills: decision support Uses decision support systems, expert systems, and aids for clinical decision making or differential diagnosis Computer skills: communication Use telecommunication devices (e.g., modems or other devices) to communicate with other systems (e.g., access data, upload, and download) Use Use interactive communication devices with patients and other health care providers Informatics knowledge: privacy/security Discuss the principles of data integrity, professional ethics, and legal requirements for patient confidentiality and data security Describe patients' rights as they pertain to computerized information management Informatics knowledge: impact of Explain use of networks for electronic communication (e.g., Internet) computerized information management Identify the basic components of the computer system (e.g., features of a personal computer and workstation) Discuss the impact of computerized information management systems on the role of the nurse Informatics skills: data Convert information needs into answerable questions Evaluate health information on the Internet using a structured critique format

4 384 CHOI AND ZUCKER MS) in the DNP program were analyzed using independent t tests. The internal consistencies of the entire instrument and for each of three competency categories were assessed using Cronbach's alpha. Results Demographics of Student Sample Informatics competency scores were based on 132 DNP students in the post-bs or post-ms track in 2007 (n = 31), 2008 (n = 18), 2009 (n = 44), and 2010 (n = 39). The sample was predominantly female (76.8%), with slightly more in the post-bs track (54.6%, n = 72) than in the post-ms track (45.4%, n = 60). Informatics Competencies Informatics competency scores in computer skills, informatics knowledge, and informatics skills did not differ significantly across years in the post-bs and post- MS tracks, F(3, 64) =.93 to 1.22, P =.31 to 0.43 in the post-bs track; F(3, 60) = 1.85 to 2.09, P =.11 to.15 in the post-ms track. Therefore, the data from 2007 through 2010 were aggregated for analysis. The internal consistency reliabilities of the instrument were high; Cronbach's alpha for all items was.98, for computer skills was.97, for informatics knowledge was.95, and for informatics skills was.93. Competency scores are summarized by track in Table 2. With competence indicated by a minimum score of 3, overall post-bs and post-ms students were not competent in any of the three categories of informatics competencies. Post-BS students' mean (SD) competency scores in computer skills, informatics knowledge, and informatics skills were 2.55 (.64), 2.61 (.64), and 2.46 (.77), respectively. Post-MS students' mean (SD) competency scores in computer skills, informatics knowledge, and informatics skills were 2.39 (.67), 2.42 (.68), and 2.36 (.78), respectively. More specifically, post-bs students were competent in four areas: computer skills: communication (M = 3.33, SD =.61); computer skills: systems (M = 3.14, SD =.83); computer skills: documentation (M = 3.10, SD =.91); and informatics knowledge: impact of computerized information management (M = 3.15, SD =.69). Post-BS students reported their least competent informatics area as computer skills: decision support (M = 1.62, SD =.86) followed by computer skills: data access (M = 1.98, SD =.63). In contrast, post-ms students were competent in only one area, computer skills: communication (M = 3.15, SD =.68), and did not achieve competence in the other informatics areas. However, post-ms students reported their least competent area as computer skills: decision support (M = 1.78, SD =.98), followed by computer skills: data access (M = 1.91, SD =.66), the same as the post-bs students. Differences in Competency Scores Between Post-BS and Post-MS DNP Students Post-BS students reported slightly higher than or similar competency scores as post-ms students in most areas except two (computer skills: decision support and informatics skills: data). However, these differences Table 2. Summary of Competency Scores Post-BS, (n = 72) Post-MS, (n = 60) Post-BS vs. post-ms Competency scale No. of items M SD M SD Independent t P Computer skills Decision support Communication Basic desktop software Systems Documentation Data access Monitoring Education Administration Informatics knowledge Impact Privacy Security Systems Data Informatics skills Data Systems Clinical Administration Privacy Security Post-BS: post-bs track. Post-MS: post-ms track.

5 SELF-ASSESSMENT OF NURSING INFORMATICS COMPETENCIES 385 were statistically significant in only three areas: computer skills: documentation (t = 3.01, P =.003), computer skills: monitoring (t = 2.51, P =.01), and informatics knowledge: systems (t = 2.24, P =.03). For the other areas, no significant differences were identified (Table 2). Discussion Low Competence Across Informatics Competency Areas Overall, DNP students in the post-bs and post-ms tracks at the beginning of their first semester were not competent in any of the three categories of informatics competency: computer skills, informatics knowledge, and informatics skills. This assessment indicates that DNP students' knowledge and skills on overall informatics competencies need to be improved through the informatics curriculum. In particular, students in both tracks scored the lowest (from not competent to somewhat competent) on computer skills: decision support, followed by computer skills: data access. These results show that students perceived that they were not competent in using decision support systems, aids for clinical decision making or differential diagnosis, accessing or extracting information from clinical data sets (e.g., minimum data set), searching for and retrieving literature resources and integrating them into a personally usable file (e.g., RefWorks, an online tool for managing references and citations), using data and statistical analyses to describe and evaluate practice, and using computer applications for statistical analysis (e.g., SPSS) and nursing research. Our findings indicate that these areas need to be prioritized when designing an informatics course in DNP curricula. Integrating Competencies Into Existing DNP Curricula The results of this study reveal ample room for improvement across almost all surveyed informatics competencies, except three competency areas for post- BS students and one for post-ms students. To efficiently and effectively address the deficiencies in informatics curricula, we recommend that educators prioritize students' most pressing improvement needs and then strategize how to include content in the informatics curriculum leading to informatics competencies. However, preparing DNP students to be competent in all the areas of informatics competencies during one informatics course does not seem practical or efficient. Instead, informatics competencies need to be incorporated into the DNP curriculum in collaboration with other DNP instructors (Flood et al., 2010; Jenkins et al., 2007). For example, activities or exercises using spreadsheets, databases, and statistical software could be included in DNP courses such as nursing research or intermediate biostatistics, leadership, or health quality. Familiarizing students with statistical software for quality improvement projects can be incorporated into leadership or health quality courses. Another example would be to use informatics tools such as retrieving data, information, and knowledge to investigate population health (in an epidemiology course) and to evaluate knowledge for evidence-based practice (in a research methods course). Informatics skills could be incorporated into clinical practicum courses in the DNP curriculum by applying point-of-care technologies for decision support and documentation. Administrative, clinical, and educational databases could be utilized in the planning and execution of the capstone project (Jenkins et al., 2007). Integrating Competencies Into an Informatics Course After the final survey of students' perceived informatics competencies in 2010, the findings were incorporated into our school of nursing's current informatics course. This 14-week on-line informatics course provides an overview of current information systems/technologyenabled health care environment, functions of the informatics nurse specialist, and cutting-edge issues in health care informatics that impact the role of the DNPprepared nurse in various health care settings. The course content emphasized decision support systems and information access and retrieval from large data sets. These two content areas were also strengthened using course assignments. Throughout the semester, students participated in three projects: two individual projects (e.g., health literacy assessment of health-related Web pages and a literature review on the impact of decision support systems on health care practice) and one group project (e.g., development of a proposal to design a computerized evidence-based clinical practice guideline system). For a health literacy assessment project, students evaluated the readability of Web pages using three readability assessment tools Fry, Simplified Measure of Gobbledygook, and Flesch Kincaid. For a review paper, students searched research databases, Current Index to Nursing and Allied Health Literature and PubMed, retrieved full-text articles from electronic journals, wrote a paper, and formatted it according to the American Psychological Association Manual using Refworks, an on-line citation and reference management software. For a group project, students developed a proposal for a computerized decision support system to implement evidence-based practice guidelines into clinical practice. The project consisted of an on-line presentation and an accompanying written report. To facilitate group work, students were given three communication boards: (a) chat/whiteboard, (b) discussion board, and (c) Wimba Voice discussion board (Wimba, 2012). The chat/whiteboard is a synchronous system in which students communicate by typing comments and getting responses immediately from other group members. The second discussion board is an asynchronous system in which activities are self-directed and students have greater freedom to process information and pace their learning/understanding. The third Wimba Voice discussion board is a synchronous system to record, post, and share audio messages with others. To examine student improvement in perceived informatics competencies after taking the revised informatics

6 386 CHOI AND ZUCKER course, we selected and surveyed in the first and last weeks of the semester 31 DNP students registered in the nursing informatics course. The findings show a significant improvement in perceived informatics competencies in all three categories; students' mean competency scores improved from not competent to competent : 2.60 to 3.75 in computer skills, paired t test(30) = 12.04, P b.05; 2.64 to 3.87 in informatics knowledge, paired t test(30) = 10.94, P b.05; and 2.55 to 3.83 in informatics skills, paired t test(30) = 9.74, P b.05, respectively. Specifically, students in both the post-bs and post-ms tracks improved in the two areas of lowest perceived competencies; computer skills: decision support and computer skills: data access improved from a mean score of 1.97 (pre) to 3.52 (post), and 2.03 (pre) to 3.47 (post), respectively. These differences are significant; paired t(30) = 1.55, P b.05 for computer skills: decision support and paired t(30) =1.43,P b.05 for computer skills: data access. These findings indicate the revised course improved students' perceived informatics competencies. Differences in Competency Scores of Post-BS Versus Post-MS Tracks One interesting finding of this assessment is that post-bs students reported higher competency scores than post- MS students in 16 of 18 competency areas. This finding cannot be compared with the literature because no study was found to compare competencies between two tracks of DNP students. However, our findings may reflect the higher number of post-bs students who were recent graduates (within the last 3 to 5 years) and who had been more exposed to informatics in their undergraduate programs compared with post-ms students. Similarly, Maag (2006) reported that graduate nursing students were found to have less exposure than undergraduate students to formal information technology education during nursing school. However, the differences between post-bs and post-ms track DNP students in this study were statistically significant in only 3 of 18 competency areas; thus, further studies are needed to explore differences in competency scores in the two tracks. Limitations and Future Research Informatics competencies were measured using students' self-report, not their actual performance on informatics knowledge and skills. Therefore, students could underestimate or overestimate their competence (Elder & Koehn, 2009). However, the informatics competency assessment was not considered in academic performance, providing little motivation for students to overestimate. Nevertheless, this limitation could be addressed in further studies by combining students' self-report with direct measures of informatics competencies. Because most of the DNP programs are currently offered in on-line format, an efficient method may be to use computergenerated, computer-graded assessment tools already embedded in on-line learning systems, thus allowing immediate feedback upon completing the assessments. With these on-line assessment tools, questionnaires assessing actual performance on computer skills can be developed in a multiple-choice or true/false format. For example, a multiple-choice format question could be What is the correct sequence of steps when you insert citations from Refworks?, and a true/false format question could be To save a voice recording file in Wimba voice discussion board, the firststepistoclickon the new icon in the title bar. Conclusion Establishing a baseline of informatics competencies in DNP students is vital to planning an informatics curriculum and adequately preparing students to use information technologies to promote safe and evidencebased nursing care. Students' perceived informatics competencies need to be taken into consideration as part of competency assessments when developing the DNP curriculum. Our study findings indicate that students perceived that they were not competent in almost all areas of informatics and suggest that informatics knowledge and competency skills need to be improved through informatics curricula, especially in the areas of computer skills in data access and use of decision support systems. This study provides an example of how to incorporate competency assessment findings into a revised informatics course. 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