An Integrated Informatics Curculum in a Baccalaureate Nursing Program

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1 An Integrated Informatics Curculum in a Baccalaureate Nursing Program Lucille L. Travis, PhD, RN, CNA, Baccalaureate Program Director and Assistant Professor Cleveland, Ohio Adida Root, PhD, RN, Ernst & Young, Cleveland, Ohio Barbara Hoehn, MBA, RN Ernst & Young, New York, New York Patricia Brennan, PhD, RN Associate Professor Joyce J. Fitzpatrick, PhD, FAAN Dean of Nursing and Elizabeth Brooks Ford Professor of Nursing Mark Gross Ernst & Young, Cleveland, Ohio Joanne Youngblut, PhD, RN Assistant Professor As health care requirements change, nurses wiul not only have to process and communicate more information, but the nature and types of this information will dramatically change as well It is imperative that nurses understand the potential information technologies offer to assist the nurse in this expanded rol. This paper describes an innovative endeavor to incorporate information technology with its undergraduate nursing program. The challenge was to design a program that would help develop the students' skius to criticaly appraise their information needs and conceptually evaluate the utility ofgathering information in providing patient care. After completing the first nursing informatics course, there was an increase in the students'perception and understanding ofthe uses ofinformation technology to support the nursing process in providing patient care. Preparation of nurses to face the 21st century rests on educational programs well grounded in the sciences that support nursing. In addition to the traditional physical, biological, and social sciences, information sciences provides foundational support for nursing practice. Yet rarely is information science formally integrated into a baccalaureate curriculum in nursing. The purpose of this paper is to describe the design of a curriculum plan and first year implementation and evaluation of an integrated informatics curriculum currently in place in a unique baccalaureate program at Case Western Reserve University, Frances Payne Bolton School of Nursing. Background In Fall, 1987 the Frances Payne Bolton School of Nursing formed a consortium with three /91/$ AMIA, Inc. 278

2 area hospitals-cleveland Clinic Foundation, MetroHealth Medical Center, and University Hospitals of Cleveland-to launch a new BSN program in nursing. In the Fall of 1990, 101 students were admitted. Key aspects of the program include (1) focus on acute and critical care nursing, (2) bedside nursing emphasis, (3) strong clinical experience throughout all four years beginning in the first semester of the curriculum, (4) innovative inclusion of nursing informatics throughout the four years of the curriculum, (5) development of identity with professional nursing through personal link-up with nurses in clinical settings, and (6) well defined linkages to the three hospitals. Challenge The introduction to this program rests on our recognition of two challenges; the challenge of Acute Care Nursing in the 21st Century, the challenge to develop technical competence among students. Nurses in the 21st century will face demands for complex clinical practice characterized by escalating information management challenges. Not only will nurses have to handle more information than ever before, but the nature and types of information they must handle will change. Information technologies can help nurses meet these challenges, but only if nurses can effectively use these technologies. As Kathryn Hannah [1J noted, nursing education should encompass the requirements for entry into practice and, to the greatest extend possible, anticipated the requirements for the nursing practice in the future. As the use of computer technology and information science in nursing practice, education and administration increases, so does the nurse's need to be skilled and knowledgeable in the usage of information technology in nursing environments. Developing technical competence among students necessitates exposure and training in the psychomotor skills necessary to use computers in nursing. However, technical competence includes not only equipment competence but skill in the efficient use of information. Grier [2,3J noted the problems that inefficient information handling caused nurses. Incorrect diagnoses, cumbersome assessment strategies, and inappropriate problems required that nurses start from the beginning of their education to understand formal information theory as a supportive discipline to nursing. To prepare nurses to face the information challenges of the future required a sound grounding in information sciences; simply teaching computer applications in nursing would not provide nurses with the skills to critically appraise their information needs and conceptually evaluate the utility of gathering information in patient care. We faced a challenge to not only make nurses technologically competent, but to produce a new type of baccalaureate graduate destined for excellence in clinical practice in acute care through effective use of information technologies. Meeting these challenges demands that nurses understand computers as one of the many devices that support patient care. In preparing to design the Nursing Informatics curriculum, we canvased major university schools of nursing to determine what informatic coursework they encouraged or required of their students. What we discovered was that, while all the universities expected their students to be computer literate, the focus was more on keyboard and programming skills rather than the application of technology to the science of nursing. It is our opinion that an understanding of computers, or computer literacy, is not enough to insure that the practitioners of the future can reach the challenges of the future. It is essential that nurse educators incorporate the entire concept of informatics into the education of nurses. The challenges faced by educators here is to assure that nursing students view the integration of technology in the support of patient care as the appropriate focus of nursing. In an attempt to offer our students a unique experience in nursing informatic education, we are exploring, with clinical information system vendors, the possibility of implementing a patient care information system in a nursing laboratory setting at this University. It is our goal that the students be able to utilize advanced nursing applications in preparing assignments for both the nursing informatic coursework as well as other nursing science classes. Thus, we adopted a broad definition of informatics that permitted including specific topical material on computers and technologies, but placed as the initial foundational concept, nursing data. Design To insure both a realistic and future-oriented curriculum, faculty met with nursing information systems representatives from the three consortium hospitals and health care consultants from Ernst & Young. Additionally, faculty collaborated closely with Ernst & Young consultants to develop, implement and evaluate the curriculum in nursing informatics. The consultants were both nursing operations and nursing information system 279

3 specialists, thereby bringing an integrated perspective to the course development. A core element of nursing course work at Frances Payne Bolton School of Nursing is based on the Nursing Process-the scientific method to systematically assess, plan, implement and evaluate quality, individualized nursing care. Since the nursing process begins with the search for data on which to base a nursing assessment and diagnosis and is completed only after the process has been evaluated for effectiveness, the flow of patient information is a key component in delivering quality patient care. Frances Payne Bolton School of Nursing has chosen to fully integrate Nursing Informatics courses throughout the four year program introducing the students to the management of information systems and the application of information technology to patient care. Courses are designed to articulate with the clinical experience and course progression followed by the BSN students. The three basic components of the model identified to provide a framework are information, technology and clinical care process. A model was developed to illustrate the three aspects of nursing informatics in the undergraduate curriculum. See Figure 1. FRANCES PAYNE SOLTON SCHOOL OF NURSING CASE WESTERN RESERVE UNIVERSITY 11ldIM a gelld FPaundatlaa in NwaImg learmalica (Year 1) First Coar s (Year 3) Third and Fourth Coursee Figure 1 (Year 2) aeoond Course Each course addresses the three components, however, the emphasis regarding each component varies with each course. The first course in the Nursing Informatics sequence is Introduction to Nursing Informatics. The emphasis is on information and technology with an overlap in clinical care process. It is scheduled in the second semester of the freshman year and was developed to coincide with the student's initial clinical experience. This course focuses on helping students identify the content, flow and processing of patient information within the hospital. It presents the hospital as an information processor and is based on the premise that the foundation of interdisciplinary communication and decision making is information generated by the patient and through caring for the patient. It is reviewed in the context of the Nursing Process examining the role of the nurse as the communication gateways for patient information. It provides an overview of the key players in the health care environment and how they impact the care delivery process. Furthermore, the course is designed to build a basic understanding of computer technologies and the ways the nurse can access computers to support her in delivering patient care. The primary objective is to give the student a basic understanding of the flow of information through the health care environment and how information technology can facilitate the collection, processing and communication of this information. The course addressed the following topics: 1) Hospital as an Information Processor; 2) Nurse as an Information Processor; 3) Nursing Delivery Models and Information Needs; 4) Role of Computers in the Health Care Environment; 5) Basic Data Processing Theory and Terminology; 6) Potential of Nursing Informatics Systems; 7) External Influences on Nursing Informatics. The second Nursing Informatics course prepares the student to handle the increased quantitative information encountered in the clinical area. The genesis and processing of clinical information and examination of data generated during care delivery will occur through discussion of conceptual topics such as set theory, matrix formulations, knowledge based systems and use of application packages which assimilate information to facilitate the decision process in delivering patient care. The third course will focus on giving the students an understanding of the unit relationships between nursing applications and hospital wide applications and the impact of nursing interventions on other departments' information processing. This 280

4 course is designed so students can develop a thorough understanding of the current and future state of nursing information systems, physiological monitoring systems and their potential in enhancing the nursing process. In addition, they will have an opportunity to examine the process of planning for, designing, developing and implementing and evaluating nursing information systems in a clinical environment. The fourth and final course will incorporate necessary knowledge learned in previous course work to build a perspective on the adaption and use of nursing information systems based on real-life case studies. The objective is to discuss industry needs that will impact the way nursing performance/care quality is measured, embodied and improved. In addition, the use of information technology to support health care policy decisions will be analyzed. Implementation Initially, a survey was developed to evaluate freshman Nursing students' attitudes toward computers and Nursing Informatics. The instrument addressed attitudes of freshman nursing students toward computers and computers in nursing as well as assessed the knowledge, usage and ownership of computers. Of the 98 students who completed the survey, 67% had taken a computer course in grade or high school while 33% had not taken a course. However, 93% had used a computer in school, predominately for word processing. Consequently, 52% owned computers; this involved at least 25 different brands. Based on the results of the survey, even though the class was relatively computer literate, they lacked an understanding of the potential benefits of information technology in assessing, planning, implementing and evaluating patient care. The first course was intended to be a didactic course. It was meant to increase students' awareness of how information is processed and managed within the health care setting. Actual and potential application of information technology to enhance the nurses ability to manage the data was examined Ṫo integrate the students' clinical experiences with course content, a number of activities were planned. Initially, students reviewed articles related to nursing informatics and utilized information obtained from the articles to identify appropriate nursing applications. To further link the didactic portion and the clinical care component, a field trip to the consortium hospitals was facilitated. Working in conjunction with the directors of the hospital information system, current status and future plans regarding the hospital information system with particular emphasis on nursing information systems was presented. Throughout the course, students were assisted in making the application of information and technology to their clinical practice. Curiulum and Program Evaluation This is the initiation of a longitudinal study to extend over a four year period. Evaluation of outcomes with respect to both students' attitudes and knowledge acquired will occur after each course. Total program evaluation will occur at the conclusion of the four nursing informatics courses. In addition, assessment of the graduates' ability to manage nursing data using information technology will occur after they have been in their first staff nurse position for six months. The following is the data from the first course in the informatics sequence. Freshman nursing students were asked to complete a questionnaire at the beginning and the end of the course. The instrument used to measure the students' attitudes and knowledge regarding computers and nursing informatics was adapted from a 22-item questionnaire used by McConnell, O'Shea, and Kirchhoff [41 in a study of registered nurses. Eight items were added to more fully address the use of computers by nurses in the clinical care process. The instrument consists of 30 items which students rated on a 5 point Likert scale. Factor analysis with principal components extraction and Varimax rotation suggested the existence of three factors: scientific use of technology, common misconceptions associated with technologic 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 attitudes. Cronbach's alpha for this scale is.61. The common misconceptions scale has eight items which describe commonly held fears and concern regarding advances in technology in the workplace. Lower scores indicate less negative attitudes. Cronbach's alpha was.80. The 12-item clinical care scale addresses the application of technology to support the nurse in providing patient care. Higher scores indicate more positive attitudes. Cronbach's alpha was.85. Six items either had weak factor loadings or loaded on more than one factor. These six items were dropped from further 281

5 analyses. The sample consists of 98 students for the pretest and 99 for the posttest. Since the instrument was administered in a classroom setting, students were promised anonymity. Thus, paired analyses were not done. However, since the sample is almost exactly the same, the results of the analyses should not be adversely affected. Scores on the three scales obtained before the course were compared with scores obtained after the course with t-tests. Differences in means for the scientific use and the common misconceptions scale were not significantly different across time. However, the mean for the clinical care scale increased significantly from a mean of 42.8 (SD=5.87) before the course to a mean of (SD=6.45) after the course (t188=6.05, p<.ool). Evaluation of the first nursing informatics course addressed scientific uses of technology, common misconceptions regarding the implementation of computer technology in the workplace, and the application of nursing informatics in the clinical care process. Although attitudes regarding scientific uses and common misconceptions changed very little, understanding of the use of nursing informatics in the clinical setting improved dramatically. While we expected an effect in all three domains, the lack of significant change in scientific uses and common misconceptions most likely reflects a high level of sophistication of our students regarding computer usage at the beginning of the course in these two areas. Perhaps with a class of students who are less sophisticated in computer usage, the effects of the first nursing informatics course on attitudes regarding scientific uses and common misconceptions would be more apparent. However, despite this higher level of knowledge, students were relatively unsophisticated regarding the use of these technologies in the clinical care process. Thus, content presented in the course resulted in a significant increase in the students' attitudes and knowledge in this area. Summary As health care requirements change, nurses will not only have to process and communicate more information by the nature and types of this information will dramatically change as well. In response to this, the challenge was to design a program that would help develop the students' skill to critically appraise their information needs and conceptually evaluate the utility of gathering information in patient care. It is imperative that nurses understand the potential information technologies offer to assist the nurse in this expanded role. Traditionally, nursing assessment and data management courses have been developed to assist the student in learning how to collect and disseminate pertinent information that can be utilized in the delivery of health care by all members of the health care team. With the information provided within an informatics course, the nursing professional will be better prepared through practical applicability in the clinical setting to more efficiently manage patient care and ultimately the patient's course of treatment. Information technology provides the nurse with a tool which enhances the nurse's potential to more effectively assimilate and integrate information. The first course in this sequence is our initial innovative approach in utilizing the three basic components: information, technology and the nursing care process in developing a solid foundation in nursing informatics for students in nursing. Each successive course will add depth and breadth to the three (3) basic components. The graduates of the program will be prepared to manage the change in nature, type, and volume of information used in making decisions that facilitate delivering optimal patient care. They will be provided with the knowledge base, technical skills and applicable experiences to successfully utilize information technology. References 3Hannah, K Current trends in nursing informatics: implications for curriculum planning. In Nursing Uses of Computers and Information Science, K Hannah, E.J. Guillemin, and D.N. Conklin (Eds.). Elsevier Science Publishers, 1985, p IGrier, M. (1981). On the need for data in making nursing decisions. In Werley, H. and Grier, M. (Eds.). Nursing Information Systems. New York: Springer. 2Grier, M. (1984). Information processing in nursing. In J.J. Fitzpatrick (Ed.). Annual Review of Nursing Research. Philadelphia: Saunders. 4McConnell, E.A., O'Sheah, S.S., and Kirchhoff, K.T. (1989). RN attitudes toward computers. Nursing Management, 20(7),