Nurse Education Today 34 (2014) 906–911
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Congruency between educators' teaching beliefs and an electronic health record teaching strategy☆ Wegdan Bani-issa a,⁎, Veronica F. Rempusheski b,1 a b
University of Sharjah, College of Health Sciences, Department of Nursing, P.O. Box No. 27272, Sharjah, United Arab Emirates University of Delaware School of Nursing, 207 McDowell Hall, 25 N. College Avenue, Newark, DE 19716, USA
a r t i c l e
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Article history: Accepted 14 January 2014 Keywords: Nurse educators Electronic health records Constructivist and objectivist teaching beliefs Teaching practices
s u m m a r y Background: Technology has changed healthcare institutions into automated settings with the potential to greatly enhance the quality of healthcare. Implementation of electronic health records (EHRs) to replace paper charting is one example of the influence of technology on healthcare worldwide. In the past decade nursing higher education has attempted to keep pace with technological changes by integrating EHRs into learning experiences. Little is known about educators' teaching beliefs and the use of EHRs as a teaching strategy. Aim: This study explores the composition of core teaching beliefs of nurse educators and their related teaching practices within the context of teaching with EHRs in the classroom. Methods: A collective case study and qualitative research approach was used to explore and describe teaching beliefs of seven nurse educators teaching with EHRs. Data collection included open-ended, audio-taped interviews and non-participant observation. Content analysis of transcribed interviews and observational field notes focused on identification of teaching belief themes and associated practices. Findings: Two contrasting collective case studies of teaching beliefs emerged. Constructivist beliefs were dominant, focused on experiential, student-centered, contextual and collaborative learning, and associated with expanded and a futuristic view of EHRs use. Objectivist beliefs focused on educators' control of the context of learning and were associated with a constrained, limited view of EHRs. Constructivist educators embrace technological change, an essential ingredient of educational reform. Conclusions: We encourage nurse educators to adopt a constructivist view to using technology in teaching in order to prepare nurses for a rapidly changing, technologically sophisticated practice. © 2014 Elsevier Ltd. All rights reserved.
Introduction Teaching beliefs determine, inform, and justify teaching practices of educators (Devine et al., 2013; Pajares, 1992; Taylor et al., 2007). Understanding core teaching beliefs is critical to educators' professional development and their ability to achieve successful educational outcomes (Kuzborska, 2011). Teaching beliefs, advances in technology, and the accompanying knowledge explosion are important elements that inform teaching practices and influence nursing higher education (Fetter, 2009; Gardner and Jones, 2012). Health information technology (HIT) has transformed healthcare; therefore, nurse educators must integrate HIT into curricula as learning experiences to remain on the cutting edge of change, educational reform, innovation and preparation of a knowledgeable workforce (Gardner and Jones, 2012). ☆ Researchers would like to acknowledge the contributions of Dr. Judith Warren, the director of the SEEDS project, for her advice and consultation in informatics during the conduct of the study. Also, researchers are thankful to nurse educators who gave freely of their time to participate in our study. ⁎ Corresponding author. Tel.: +971 505 7522; fax: +971 505 7501. E-mail addresses: [email protected] (W. Bani-issa), [email protected] (V.F. Rempusheski). 1 Tel.: +1 302 831 8502; fax: +1 302 831 2382. 0260-6917/$ – see front matter © 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2014.01.006
The American Association of Colleges of Nursing AACN (2008) and the National League for Nursing (NLN, 2008) identified informatics as an essential competency of nurse educators to prepare them for effective integration of informatics into nursing curricula. Therefore, integrating EHRs as a learning experience in nursing education is one example of an essential component of informatics integration (Gardner and Jones, 2012). One program's attempt to integrate EHRs into nursing education in the United States (US) is the education/business partnership between the School of Nursing (SON) at the University of Kansas (KU) and an IT vendor. The project was called the Simulated Electronic hEalth Delivery System (SEEDS) and aimed to teach students nursing course content using EHRs (Kennedy et al., 2009; Warren et al., 2002). Regardless of the persistent demand that nurse educators use technology in education, teaching with EHRs was a new context for educators teaching in the SEEDS project. While educators were required to teach students course content using EHRs, very little was known about the composition of the teaching beliefs that guided their instructional approach while using this technology. Use of EHRs was a new teaching-learning modality for nurse educators; therefore, making known their underlying teaching beliefs may assist other educators in evaluating their own teaching beliefs when using EHRs (Taylor et al., 2007). Current research asserted the link between educators' teaching
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beliefs and technology integration in the classroom (Kala et al., 2010; Lawrence, and Lentle-Keenan, 2013). Explicating educators' teaching beliefs is essential to understand the congruency between teaching beliefs and practices within the context of teaching with EHRs. The current study aims to explore the concepts, themes and patterns that comprise the teaching beliefs and practices of educators teaching with EHRs in the SEEDS project. Background Teaching Beliefs and Practices Teaching beliefs is a complex concept; multiple terms have been used to identify the concept. Initially defined by Pajares (1992) as teaching philosophy or paradigm that guides teachers' practices, other educational researchers expanded the definition of teaching beliefs to include personal convictions or opinions about teaching (Tarman, 2012). Irez (2007) provided a comprehensive definition of teaching beliefs and stated that: “Beliefs are psychological constructs that (a) includes understandings, assumptions, images or propositions considered to be true, (b) drive a person's actions and support decisions and judgments, (c) have highly variable and uncertain linkages to personal, episodic and emotional experiences, (d) although undeniably related to knowledge, differs from knowledge in that beliefs do not require a condition of truth” (p. 17). Evidence supports the significance of beliefs associated with understanding educators' teaching practices (Ertmer and Ottenbreit-Leftwich, 2010) and are known to influence teaching goals, materials and decisionmaking processes in the classroom (Kuzborska, 2011; Potter, 2013). Two main contrasting beliefs in education are evident in the literature: objectivism and constructivism (Taylor et al., 2007). Traditional teaching beliefs emerged from early Greek philosophies, focused on a positivistic way of thinking, and controlled the field of education for decades (Pajares, 1992). The assumptions relevant to the context of teaching include, a) knowledge is objective and decontextualized; b) learning is knowledge transmission, a reflection of what teachers know, wellstructured; c) reality is objective and external to the knowing subjects, and d) instructions should be designed to transfer the knowledge to the learners through abstract rules, lectures, and prediction (Ertmer and Ottenbreit-Leftwich, 2010). The practices of objectivist educators focus on what to think, emphasis on the content, use of predetermined instruction, and limited interactions (Ottenbreit-Leftwich et al., 2010). Objectivism seems to lend itself to values of conformity, uniformity, and passivity—a “one-sizefits-all” approach to teaching. This philosophy assumes that everyone can learn the same content in the same way at the same pace (Potter, 2013). Within this perspective, objectivist beliefs can be described as teacher-focused wherein an educator controls the context of learning. Potter (2013) called objectivism a “dead philosophy” and made a plea for the alternative teaching philosophy of constructivism. Constructivism emerged from cognitive, social, and psychological research, and arguably begins with Kant, to challenge objectivism (Glasersfeld, 1996). This belief structure considers knowledge as viable in the experiential world of individuals (Taylor et al., 2007). Assumptions of constructivism include, a) knowledge is constructed and situated in experiences; b) reality is a product of the mind; the structure of the world is created in the mind through interaction with the world; c) learning is the construction of knowledge and meaning, interpretation of the world, experiential, articulation–reflection, and process oriented; and d) instructions are reflections of multiple perspectives, inductive, modeling, and learner-generated (Ertmer and OttenbreitLeftwich, 2010). Within this context, education should focus on providing learners with the means and facilitation necessary to assist them to construct their own knowledge (Potter, 2013). Unlike objectivism, education in a constructivist view is an active and experiential learning pedagogy in which students learn by applying latent knowledge alike to the present situation; through this application and later reflection on the
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results of the application, students are expected to create a new synthesis (Potter, 2013). For Potter (2013), the goal of constructivism is lifelong learning that places students in authentic contexts involving practice, reflection, and feedback. Constructivist teaching practices encourage multiple perspectives, enhance students' ownership of knowledge, reveal the “why” underlying teaching style (Potter, 2013; Taylor et al., 2007). Constructivist teachers use multiple strategies such as role-playing, simulation, project-based courses, problem-based learning, case-studies, and team-based learning (Potter, 2013). The educator is a facilitator in learning, considers students' experiences and enhances their interactions (Taylor et al., 2007) and use dialog, reflection, critical thinking and interaction (Ertmer and Ottenbreit-Leftwich, 2010). Constructivism allows for a deep, longlasting learning and is favored by many educators within different disciplines (Potter, 2013). Constructivism has demonstrated its utility in all levels within higher education. A growing body of nursing higher education literature indicated its applicability to nursing education with desirable learning outcomes (Brandon and All, 2010). Constructivist nurse educators are prepared to integrate multiple teaching strategies suitable for today's learners including teaching with technology (Kala et al., 2010). Using EHRs in the classroom is a new strategy for nurse educators; however, little is available about educators' teaching beliefs and practices and their relationship to the use of EHRs in the classroom. Therefore, this study attempted to expand the knowledge about teaching beliefs and practices of educators teaching with EHRs to evaluate the relationship between teaching beliefs and EHRs teaching strategy. Electronic Health Record and Its Application in the SEEDS Project Electronic Health Records (EHRs) EHRs is a “digital” version of patient's paper charts or an application of information technology (Gardner and Jones, 2012). It refers to “large computerized database management systems used by clinicians to access a wide range of patient care information systems, nursing information systems, medical information systems, and patient care management systems” (Axford and Carter, 1996, p. 156). The promising influence of the EHRs on the US healthcare system has prompted the Institute of Medicine (IOM) (2001) to recommend integration of EHRs into clinical settings. As frontline healthcare professionals, nurses are obliged to use EHRs in clinical practice and must evaluate the utility and clinical outcomes associated with their use. Eastaugh (2012) found that EHRs use was associated with a 1.6% increase in the productivity in 58 US hospitals during a 3-year period, 2008 to 2011. For example, EHRs use decreased the time for a medication order to be filled and administered, from 28 min in 2008 to 8 min in 2011 in same hospitals (Eastaugh, 2012). Waneka and Spetz (2010) reviewed existing nursing literature on EHRs use and found that adoption of EHRs have desirable clinical outcomes such as improvement in the quality of nursing documentation, workflow, the time to administer medication, and the time for patient discharges and transfers. Of particular clinical and economic significance, the use of EHRs was associated with a 13% decrease in the development of hospital acquired pressure ulcers in 29 US hospitals (Dowding et al., 2012). Kutney-Lee and Kelly (2011) found that the use of EHRs was associated with enhancing patient safety. Today, there is an accelerated use of EHRs with more than 80% of healthcare providers demonstrating meaningful use of EHRs compared to only 9% in 2008 (U.S. Department of Health and Human Services, 2013). Similar to nurses in practice settings, nurse educators have attempted to keep pace with technological changes and respond to the demands that nursing education prepare competent nurses for practice by integrating EHRs into teaching education. An example of such attempts is the experience of the University of Kansas (KU/SON) which integrated EHRs into their undergraduate nursing curriculum through the SEEDS project (Kennedy et al., 2009).
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Simulated Electronic hEalth Delivery System (SEEDS) Project
Results
The SEEDS Project was made possible by an academic business partnership between the school of nursing and an EHRs vendor. These EHRs were used as problem-based teaching strategies (Warren et al., 2004). The aim of SEEDS was to create a simulated environment to enable students to design nursing care plans for virtual cases and access databased references (Connors et al., 2002). The goal of SEEDS was to enhance students' critical thinking while providing an information infrastructure for evidence-based practice (Connors et al., 2002). Placed within the context of the SEEDS Project, the aim of this study was to explore and describe the core teaching beliefs and their accompanied teaching practices of nurse educators using EHRs teaching strategy. Teaching beliefs, teaching practices, and EHRs provided the conceptual orientation for this study.
Two collective case studies, one each of constructivist and objectivist educators, and the characteristics of participants are presented. The case studies are clustered by themes that reflect common teaching beliefs and associated practices emerged from participants' interviews. An attempt was made to use quotation efficiently to represent major themes and patterns that reflect the case study as suggested by Stake (2008).
Methods Study Design A qualitative, collective case study approach within an exploratory, descriptive research design was used to address the study aim. Case study can be used to “investigate contemporary phenomena within its real-life context” with the aim to explore, explain and describe the event or the issue to provide an in-depth understanding of that issue (Yin, 2014). Similarly, Stake (2008) indicated that case study can be used to provide full explanation and description that allow for a clearer view of the phenomena under study through “thick description.” The collective type of case study design involves studying multiple cases simultaneously or sequentially in an attempt to generate a broader appreciation of a particular issue (Crowe et al., 2011; Stake, 2008). In our research, we used a collective case study design to uncover collective or board concepts, themes and patterns that constitute teaching beliefs and practices of nurse educators teaching with EHRs as a new and nontraditional teaching tool. Researchers in this study followed Yin's (2014) steps in conducting the case studies including: preparing for data collection from multiple sources, collection of evidence, analysis of the evidence, and composition of the case study report. Within this context the use of collective case study seems to be justifiable. The unit of analysis was the collective of individual nurse educators in their natural environment. Setting and Procedure The study setting was a university-based school of nursing with an upper division baccalaureate program and average enrollment of 300 students in a Midwest city. The university's institutional review board approved the study. Nurse educators consented verbally, on audiotape, to participate in the study. Tape-recorded interviews, nonparticipant observations and video-taped observations of classroom teaching with EHRs were conducted over a period of six months. Data Analysis Data comprised of transcribed interviews, observation field notes and curriculum documents were content-analyzed iteratively to identify educators' teaching beliefs and practices. Using analytical induction and constant comparison, data were coded and organized into themes that represented teaching beliefs and practices of participants. Analysis was staged to examine individual and aggregated data into themes and then explained across individuals to derive collective results. Trustworthiness of data was established by data and investigator triangulation, reflection, member checks, and group debriefing (Lincoln and Guba, 1985; Stake, 2008; Yin, 2014).
Characteristics of Participants Teaching experiences of the seven participants ranged from 9 to 43 years (M = 24.7, SD = 22.5) at a university school of nursing. Participants' educational preparation ranged from Masters of Science in Nursing (MSN) to Doctorate in Philosophy of Science (PhD) in nursing degrees. None of the participants had taught using EHRs before the SEEDS project. All participants were familiar with and used in their role as educators computer applications such as word processing, spread sheets, course management systems, and the internet. All participants taught in the baccalaureate nursing program. Constructivist Educator Case Study Three main belief themes emerged that represented the constructivist educators and included beliefs about current students wherein learning is a primary focus, teaching is an interactive and shared experience, and nursing education is practical, future oriented, and focuses on solving real world problems. Belief about 21st Century Students: Learning is Primary Focus Constructivist nurse educators believe that many students today are “older than the traditional post high school age young adult”, “mature,” “self-directed learners,” with life experiences that enrich the learning process. One participant commented as follows: One of the big key things has to do with respecting what students bring to the classroom and not considering them blank sheets but they have already come with values, beliefs, experiences and we need to recognize that and build on it. They are not starting from scratch.....They do not have the knowledge base, but it does not mean that they cannot apply it once they learn it to that previous experience as a way to reflect on and to evaluate it. For constructivist educators, current students “come from the computer generation and [are] more comfortable with computers” than students in the past who “used typewriters.” Constructivist educators perceived current students as “computer savvy” because “they have been using them for most of their lives.” Corresponding Teaching Practices Results revealed that educators maintained consistent teaching practices in a traditional classroom, in courses delivered via the internet, and with use of EHRs. However, only examples of teaching practices of nurse educators teaching with EHRs are presented here. Their teaching practices reflected a belief in an experiential, contextual, learnercentered teaching approach. Constructivist nurse educators acknowledged that changes in teaching practices require advanced technology. The educators recognized the importance of integrating teaching strategies that are “current,” and suitable for “the computer generation.” They were optimistic about teaching with EHRs and attempted to increase students' awareness about EHRs to prepare them for computerized practice settings. Constructivist teachers believe that technology is the only way to improve practice and by familiarizing students with it, educators are “preparing them to be competent in automated healthcare settings.”
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Furthermore, constructivist educators believe that students are mature learners, have experiences and “life stories” that enhance their knowledge formation. For example, when documenting an obstetric and newborn case study using the EHRs, a constructivist educator identified several students who had breastfed their own children. These students were asked to share their experiences so as to introduce practical ideas that may provide insights to nurses. For constructivist educators, experiential learning enriches students' learning because, it brings “meaning to their lives.” Additionally, constructivist educators treat students with less guidance because they are self-directed learners and let them discover by themselves different aspects of the online documentation process. Class activities were less structured and mainly planned by students which indicate constructivist belief in students' acquisition of knowledge. Constructivist teachers are only guiding students and give them the time to navigate the system to complete the documentation process. Teaching is an Interactive and Shared Experience The second major belief theme that characterized constructivist educators is that teaching is an interactive and “shared experience” that can be achieved through students' involvement. Constructivist educators believe that “learning increases when people, the students, are active participants in their classroom experience.” Therefore, these educators viewed themselves as “facilitators more than sitting up in the front of the class and teaching.” Constructivist educators see their role as “resource” and “coach” who “help them learn skills that they need” while encouraging “multiple perspectives.” A constructivist educator is not the “sage on the stage” or “a giver of information who disseminate knowledge” only. Corresponding Teaching Practices Constructivist educators apply teaching practices that match their belief by enhancing dialog, argument, and discussion among students when teaching with the EHRs, thereby exhibiting a liberating teaching style through. For example, during the online documentation process, constructivist educators tried to engage students in a dialog to “get them to think” and reach a conclusion. They asked “Socratic questions” about the case study, such as: “How did you get to this point? How do you know what you are saying is right? What evidence can you provide to support your statement that you just made?” Constructivist educators allowed students to interact with each other during the online documentation process without interrupting. Observation revealed that constructivist educators tried to maximize interactions between students by allowing them to move from their own computer work station to other students' computer stations. Nursing Education is Practical; Future Oriented and Solves Real World Problems Constructivist educators believe that teaching is “to be able to apply what they're learning, what they're seeing to the real world of nursing.” Constructivist educators believe that nursing education should be “more application learning and educators should make sure that the students who graduate are really safe and capable nurses.” They believe that the role of the educator is to “make [students] better care takers.” Constructivist educators' main concern is to provide good quality nursing graduates for practice. For constructivist educators, this can be accomplished only “through the use of technology or EHRs.” Corresponding Teaching Practices Teaching practices that are consistent with this belief theme is the futuristic look of constructivist educators about the use of the EHRs in teaching. Constructivist educators act as “a role model” for students and perceive the EHRs as “the future and students need to be exposed to it because it makes them a good product for healthcare systems.”
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Constructivist educators use a “real case study” approach that illustrates their belief in contextual learning. For them, the EHRs facilitates students' learning through real clinical contexts. They believe that case studies “get students to think” about real needs for patients. Objectivist Educator Case Study Most of the teaching beliefs and practices within the context of teaching with EHRs represented a constructivist orientation; however, there was one theme that characterized the objectivist case study: belief about students wherein learning is a secondary focus. Belief about Students Today: Learning is a Secondary Focus Objectivist educators perceive students as “immature learners;” that they do not have the adequate “experience and practice of nursing.” Objectivist educators believe that students learn best with “direction and guidance” because “they are so novice [and] do not know enough yet to decide this is important and this is not. [Educators] have a better view of what they need to do.” One objectivist educator said: “[Students] are unable to articulate their learning needs. Do not know what it is they want to learn. Do not know what their learning needs are.” Objectivist educators' vision is limited because they believe that “the students care more about the grades and what jobs should be done to get the grade.” Students, for objectivist educators, are “willing to take short cuts that will still give them the grades but not necessarily the learning.” Objectivist educators believe that “grades are a major standard [italics added]” that they “really look at” because they are the first priority for students. The goal of objectivist educators is to help students be “successful in their testing arena.” To achieve that goal, objectivist educators believe their role is to deliver the “material,” and “disseminating information” in “lectures.” The focus of the objectivist educator is the content that comes directly from the “course objectives” and should match “what students are going to be tested on.” One objectivist educator said: “I'm really a giver of information. I'm a mother-like type. I want to tell them everything they need to know for their exams.” Corresponding Teaching Practices Observation of seminars of objectivist educators using EHRs revealed that they follow “a mothering approach” with students, and offer little space for interactions and dialog. They supervised students closely on a one-to- one basis, did not extrapolate from students' personal experiences, used a didactic instructional approach, and demonstrated negative attitudes toward using EHRs. For objectivist educators, “students do not see the future utility of it” and it is “just a data entry mechanism” and should not be integrated in their teaching practices because, as one educator noted: The goal or the objective is to get them to be able to be professional in nursing process and the activities that I designed for them were designed around that end…so that they can be successful in their testing arena, then they can get good grades [italics added]…Now, I do not know how [EHRs] fits in that.
Discussion This study provided valuable information on a topic that is less represented in nursing educational research which is teaching beliefs and their corresponding teaching practices of educators using EHRs in the classroom. Our study emphasized the link between educators' teaching beliefs and practices in the classroom, as proposed in education research (Devine et al., 2013; Lawrence and Lentle-Keenan, 2013; Taylor et al., 2007). More importantly, it provided evidence for the significance of
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nurse educators' adoption of constructivist beliefs for the effective integration of technology to prepare the future generation of nurses (Legg et al., 2009). Examining types of beliefs that emerged from our study indicated that nurse educators are in favor of constructivist over objectivist beliefs as most authors of educational literature have asserted (Legg et al., 2009; Potter, 2013). Educators with constructivist beliefs demonstrated enthusiasm toward using EHRs to prepare students for the practice world while using a liberal teaching approach. They envisioned the future utility of EHRs for clinical practice as indicated in education research (Dowding et al., 2012; Eastaugh, 2012; Kutney-Lee, and Kelly, 2011; Waneka and Spetz, 2010). Therefore, constructivism seems to be essential for leveraging high-technology learning, a relationship that is proposed in the literature (Legg et al., 2009). In our study, constructivist educators used the EHRs efficiently to assist students constructing their own knowledge by learning from real clinical cases through dialog, reflection, team-work and interaction to create a dynamic and meaningful learning environment; all of which are consistent with constructivist beliefs (Etmer and Ottenbreit-Leftwich, 2010; Potter, 2013). Although constructivist teaching seems to be essential to adopt technology, it is worth mentioning that EHRs could be an efficient teaching tool that fostered constructivism's principles such as enhancing problem-based, student-centered, contextual and interactive learning. In two studies that evaluated the use of EHRs in the classroom, Kennedy et al. (2009) and Johnson and Bushey (2011) reported that nursing students perceived EHRs as a learning tool that equipped them with skills essential to function effectively in automated health care settings such as navigation of technology, decision making, nursing process and documentation. In our study, similar statements were asserted by nurse educators. The EHRs contributed to the creation of a positive learning atmosphere wherein students engaged in meaningful and “enjoyable” activities such as constructing knowledge, learning by analyzing clinical problems, browsing the Internet, reviewing and critiquing resources, and learning in a collaborative and interactive manner. It is possible that the harmony between teaching beliefs and technology itself, similar to our study, could facilitate students' learning (Ottenbreit-Leftwich et al., 2010; Sabzian et al., 2013). Such findings could encourage educators to consider using EHRs as a viable and practical teaching strategy in the classroom. Although educational research asserted that constructivism is an alternative and desirable philosophy in nursing education (Brandon and All, 2010; Legg et al., 2009) results from our study revealed that an objectivist orientation still exists in nursing education (Whall and Hicks, 2002). Objectivist teachers in our study did not see the future utility of EHRs and perceived it as “a data entry mechanism” only. Therefore, it is not surprising that objectivist participants in this study indicated that they were not ready to embrace technological changes in education. Their present-oriented vision and lack of interest in using EHRs as a teaching strategy appears to be an obstacle drawn from their belief structure (Legg et al., 2009). Hughes (2005) indicated that objectivist educators with traditional teaching beliefs are focused mainly on the use of technology itself without making connections to expected learning outcomes which hinder the educational process. Objectivist educators are more likely to implement “low level” teaching compared to “high level” teaching associates with constructivist beliefs (Chen and Chen, 2009). Still, our study did not account for other factors that could influence teaching practices of educators that are identified in educational research such as current practice, interaction with learners, the challenges of the day-to-day learning context (Jenkins, 2011), individual characteristics, preparation, and background of educators (Lawrence and LentleKeenan, 2013). Lawrence and Lentle-Keenan (2013) added that institutional factors, organizational priorities and expectation play a major role in determining practices of educators' uptake of technology and vary greatly within each country and school. In our study, educators were
selected from one nursing school without accounting for individual or institutional factors that may be related to their teaching beliefs and practices. Therefore, it is important to take into account the broader contextual and sociocultural factors that influence educators' use of technology (Devine et al., 2013). More importantly, the evolution and integration of teaching beliefs within an educational system that has used technology like EHRs, and the variables that contribute to their evolution and integration are still unknown. Also, unknown are the evolutionary variables that influence and shape teaching belief structure of educators teach with other types of technology that has been introduced into education, such as distance learning with online and video technology, and hybrid teaching formats. Recommendations for Nurse Educators Embracing the change in nursing education through technological change can be achieved when educators have constructivist teaching beliefs (Legg et al., 2009). Because of the rapid advancement, change and spread of EHRs worldwide, educators need to be aware of the importance of technological changes that influence patients' care by effective integration of EHRs in education (Meyer et al., 2011). This integration will be facilitated only with a constructivist–futuristic orientation that is based on teaching strategies that assist learners to apply their knowledge toward patient care (Ottenbreit-Leftwich et al., 2010). Involvement of educators in evaluating EHRs software could encourage objectivist educators toward utilizing it more efficiently and modifying their teaching beliefs. Some practical strategies are recommended to encourage educators to adopt constructivist teaching. Integrating teaching beliefs into professional preparation of educators is recommended (Ottenbreit-Leftwich et al., 2010; Sabzian et al., 2013). Also, using mentoring and selfmonitoring techniques like reflection and integrating “application activities” are strategies to help educators foster constructivist teaching. Creating academic cultures that nurture good teaching practices through a shared vision that involves adopting constructivist beliefs remains a key element for technological integration in curricula. Recommendations for Future Research The study of teaching beliefs is an essential topic of inquiry in educational research. Since little is known about educators' belief systems, clear conceptualization of key attributes of the term teaching beliefs is needed in future nursing research. As stated before, variables that could influence technology use in education need to be explored in future research. The cohort effect will be an important variable in future research as EHRs become the norm for communicating health information by health care providers worldwide and the vehicles for transmitting health information become increasingly sophisticated. Qualitative research and mixed methods with triangulated approaches are suggested to gain both an understanding of the contextual aspects of the belief systems of educators and a measurement of the effectiveness and outcomes for educators and students. Additional nursing research needs to examine the nature and trajectory of teaching beliefs throughout educators' careers to better understand the relationship of beliefs to teaching experience and changes in healthcare, technology and learners' abilities. Limitations The small number of educators teaching with EHRs at the study setting provided a rich context; however, the results are specific to one Midwest US school of nursing and one group of educators at one point in time. No longitudinal indices were addressed. It is possible that there are other belief systems that influence the use of EHRs and were not depicted in these results.
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Conclusions An attempt was made in this exploratory, descriptive study to expand knowledge about educators' teaching beliefs and practices within the context of teaching with EHRs. Constructivist educators are prepared to shape the future by embracing full use of HIT. Higher education institutions need to be cognizant of the teaching beliefs that underlie the teaching practices of educators in order to ensure full use of HIT for educating future nurses. Identifying best teaching practices of constructivist educators is essential for ensuring nursing education is preparing nurses for the rapidly changing HIT environment. Future collaborative research is needed between HIT vendors, schools of nursing and healthcare provider users of HIT. References American Association of Colleges of Nurses (AACN), 2008. The Essentials of Baccalaureate Education for Professional Nursing Practice. (Retrieved May 28, 2013, from) http://www.aacn.nche.edu/media-relations/fact-sheets/impact-of-education (accessed 20 December 2012). Axford, R.L., Carter, B., 1996. Impact of clinical information systems on nursing practice: nurse's perspectives. Comput. Nurs. 14, 156–163. Brandon, A.F., All, A.C., 2010. Constructivism theory analysis and application to curricula. Nurs. Educ. Perspect. 31 (2), 89–92. Chen, F.H., Chen, L.W., 2009. Integrating technology in the classroom: a visual conceptualization of teachers' knowledge, goals and beliefs. J. Comput. Assist. Learn. 25, 470–488. Committee on Quality of Health Care in America, Institute of Medicine, 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academic Press, Washington DC. Connors, H.R., Weaver, Ch., Warren, J., Miller, K.L., 2002. An academic–business partnership for advancing clinical informatics. Nurs. Educ. Perspect. 23, 228–233. Crowe, S., Cresswell, K., Robertson, A., Huby, G., Avery, A., Sheikh, A., 2011. The case study approach. BMC Med. Res. Methodol. 11 (1), 100–108. http://dx.doi.org/10.1186/ 1471-2288-11-100. Devine, D., Fahie, D., McGillicuddy, D., 2013. What is “good” teaching? teacher beliefs and practices about their teaching. Ir. Educ. Stud. 32 (1), 83–108. Dowding, D.W., Turley, M., Garrido, T., 2012. The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis. J. Am. Med. Inform. Assoc. 19 (4), 615–620. http://dx.doi.org/10.1136/amiajnl-2011-000504. Eastaugh, S., 2012. Health information technology impact on productivity. J. Health Care Finance 39 (2), 64–81. Ertmer, P.A., Ottenbreit-Leftwich, A., 2010. Teacher technology change: how knowledge, confidence, beliefs, and culture intersect. J. Res. Technol. Educ. 42 (3), 255–284. Fetter, M.S., 2009. Curriculum strategies to improve baccalaureate nursing information technology outcomes. J. Nurs. Educ. 48 (2), 78–85. Gardner, C., Jones, S., 2012. Utilization of academic electronic medical records in undergraduate nursing education. Online Nurs. J. Inform. 16 (2) ((Retrieved May 13, 2013 from) http://ojni.org/issues/?p=1702). Glasersfeld, E., 1996. Introduction: aspects of constructivism. In: Fosnot, C.T. (Ed.), Constructivism: Theory, Perspectives, and Practice. Teachers College Press, New York, NY, pp. 3–7. Hughes, J., 2005. The role of teacher knowledge and learning experiences in forming technology-integrated pedagogy. J. Technol. Teach. Educ. 13, 277–302. Irez, S., 2007. Reflection oriented qualitative approach in beliefs research. Eurasia J. Math. Sci. Technol. Educ. 3 (1), 17–27.
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Jenkins, C., 2011. Authenticity through reflexivity: connecting teaching philosophy and practice. Aust. J. Adult Learn. 5172–5189. Johnson, D.M., Bushey, T.I., 2011. Integrating the academic electronic health record into nursing curriculum: preparing student nurses for practice. Comput. Inform. Nurs. 29 (3), 133–137. Kala, S., Isaramalai, S., Pohthong, A., 2010. Electronic learning and constructivism: a model for nursing education. Nurse Educ. Today 30 (1), 61–66. http://dx.doi.org/10.1016/ j.nedt.2009.06.002. Kennedy, D., Pallikkathayil, L., Warren, J.J., 2009. Using a modified electronic health record to develop nursing process skills. J. Nurs. Educ. 48 (2), 96–100. Kutney-Lee, A., Kelly, D., 2011. The effect of hospital electronic health record adoption on nurse-assessed quality of care and patient safety. J. Nurs. Adm. 41 (11), 466–472. http://dx.doi.org/10.1097/NNA.0b013e3182346e4b. Kuzborska, I., 2011. Links between teachers' beliefs and practices and research on reading. Read. Foreign Lang. 23 (1), 102–128. Lawrence, B., Lentle-Keenan, S., 2013. Teaching beliefs and practice, institutional context, and the uptake of Web-based technology. Dist. Educ. 34 (1), 4–20. http://dx.doi.org/ 10.1080/01587919.2013.770432. Legg, T.J., Adelman, D., Mueller, D., Levitt, Ch., 2009. Constructivist strategies in online distance education in nursing. J. Nurs. Educ. 48 (2), 64–69. Lincoln, Y.S., Guba, E.G., 1985. Naturalistic Inquiry. Sage, Beverly Hills, CA. Meyer, L., Sternberger, C., Toscos, T., 2011. How to implement the electronic health record in undergraduate nursing education: learn how one university integrated this technology into its interdisciplinary healthcare curricula. Am. Nurse Today 6 (5), 40–44. National League for Nursing (NLN), 2008. Preparing the next generation of nurses to practice in a techno log-rich environment. An informatics Agenda (Retrieved May 25, 2013 from http://www.nln.org/aboutnln/positionstatements/informatics_052808. pdf). Ottenbreit-Leftwich, A., Glazewski, A., Newby, T., Ertmer, B., 2010. Teacher value beliefs associated with using technology: addressing professional and student needs. Comput. Educ. 55, 1321–1335. Pajares, M.F., 1992. Teacher' beliefs and educational research: cleaning up a messy construct. Rev. Educ. Res. 62, 307–332. Potter, M., 2013. Constructivism in the shadow of a dead God. Int. J. Sch. Teach. Learn. 7 (1), 1–12 (Available from: Education Research Complete, Ipswich, MA. Accessed November 2, 2013). Sabzian, F., Gilakjani, P.A., Sodouri, S., 2013. Use of technology in classroom for professional development. J. Lang. Teach. Res. 4 (4), 684–692. Stake, R.E., 2008. Qualitative case studies. In: Denzin, N.K., Lincoln, Y.S. (Eds.), Strategies of Qualitative Inquiry. Sage, Los Angeles, pp. 119–149. Tarman, B., 2012. Prospective teachers' beliefs and perceptions about teaching as a profession. Educ. Sci. Theory Pract. 12 (3), 1964–1973. Taylor, E., Tisdell, E., Gusic, M., 2007. Teaching beliefs of medical educators: perspectives on clinical teaching in pediatrics. Med. Teach. 29, 371–379. U. S. Department of Health and Humans Services, 2013. Doctors and Hospitals' Use of Health IT More Than Doubles Since 2012. ((Retrieved May 25, 2013 from) http://www.hhs.gov/news/press/2013pres/05/20130522a.html). Waneka, R., Spetz, J., 2010. Hospital information technology systems' impact on nurses and nursing care. J. Nurs. Adm. 40 (12), 509–514. Warren, J.I., Connors, H.R., Weaver, C., 2002. Clinical information systems and critical thinking: outcomes of an innovative education strategy. HR Pulse 19, 21–24. Warren, J.J., Fletcher, K.A., Connors, H.R., Ground, A., Weaver, C., 2004. The SEEDS Project: from health care information system to innovative educational strategy. In: Whitten, P., Cook, D. (Eds.), Understanding Health Communication Technologies. Jossey-Bass, San Francisco, CA, pp. 225–231. Whall, A.L., Hicks, F.D., 2002. The unrecognized paradigm shift in nursing: implications, problems, and possibilities. Nurs. Outlook 50, 72–75. Yin, R.K., 2014. Case Study Research: Design and Methods, 5th ed. Sage Publications, Inc., Los Angeles.
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Congruency between educators' teaching beliefs and an electronic health record teaching strategy☆ Wegdan Bani-issa a,⁎, Veronica F. Rempusheski b,1 a b
University of Sharjah, College of Health Sciences, Department of Nursing, P.O. Box No. 27272, Sharjah, United Arab Emirates University of Delaware School of Nursing, 207 McDowell Hall, 25 N. College Avenue, Newark, DE 19716, USA
a r t i c l e
i n f o
Article history: Accepted 14 January 2014 Keywords: Nurse educators Electronic health records Constructivist and objectivist teaching beliefs Teaching practices
s u m m a r y Background: Technology has changed healthcare institutions into automated settings with the potential to greatly enhance the quality of healthcare. Implementation of electronic health records (EHRs) to replace paper charting is one example of the influence of technology on healthcare worldwide. In the past decade nursing higher education has attempted to keep pace with technological changes by integrating EHRs into learning experiences. Little is known about educators' teaching beliefs and the use of EHRs as a teaching strategy. Aim: This study explores the composition of core teaching beliefs of nurse educators and their related teaching practices within the context of teaching with EHRs in the classroom. Methods: A collective case study and qualitative research approach was used to explore and describe teaching beliefs of seven nurse educators teaching with EHRs. Data collection included open-ended, audio-taped interviews and non-participant observation. Content analysis of transcribed interviews and observational field notes focused on identification of teaching belief themes and associated practices. Findings: Two contrasting collective case studies of teaching beliefs emerged. Constructivist beliefs were dominant, focused on experiential, student-centered, contextual and collaborative learning, and associated with expanded and a futuristic view of EHRs use. Objectivist beliefs focused on educators' control of the context of learning and were associated with a constrained, limited view of EHRs. Constructivist educators embrace technological change, an essential ingredient of educational reform. Conclusions: We encourage nurse educators to adopt a constructivist view to using technology in teaching in order to prepare nurses for a rapidly changing, technologically sophisticated practice. © 2014 Elsevier Ltd. All rights reserved.
Introduction Teaching beliefs determine, inform, and justify teaching practices of educators (Devine et al., 2013; Pajares, 1992; Taylor et al., 2007). Understanding core teaching beliefs is critical to educators' professional development and their ability to achieve successful educational outcomes (Kuzborska, 2011). Teaching beliefs, advances in technology, and the accompanying knowledge explosion are important elements that inform teaching practices and influence nursing higher education (Fetter, 2009; Gardner and Jones, 2012). Health information technology (HIT) has transformed healthcare; therefore, nurse educators must integrate HIT into curricula as learning experiences to remain on the cutting edge of change, educational reform, innovation and preparation of a knowledgeable workforce (Gardner and Jones, 2012). ☆ Researchers would like to acknowledge the contributions of Dr. Judith Warren, the director of the SEEDS project, for her advice and consultation in informatics during the conduct of the study. Also, researchers are thankful to nurse educators who gave freely of their time to participate in our study. ⁎ Corresponding author. Tel.: +971 505 7522; fax: +971 505 7501. E-mail addresses: [email protected] (W. Bani-issa), [email protected] (V.F. Rempusheski). 1 Tel.: +1 302 831 8502; fax: +1 302 831 2382. 0260-6917/$ – see front matter © 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2014.01.006
The American Association of Colleges of Nursing AACN (2008) and the National League for Nursing (NLN, 2008) identified informatics as an essential competency of nurse educators to prepare them for effective integration of informatics into nursing curricula. Therefore, integrating EHRs as a learning experience in nursing education is one example of an essential component of informatics integration (Gardner and Jones, 2012). One program's attempt to integrate EHRs into nursing education in the United States (US) is the education/business partnership between the School of Nursing (SON) at the University of Kansas (KU) and an IT vendor. The project was called the Simulated Electronic hEalth Delivery System (SEEDS) and aimed to teach students nursing course content using EHRs (Kennedy et al., 2009; Warren et al., 2002). Regardless of the persistent demand that nurse educators use technology in education, teaching with EHRs was a new context for educators teaching in the SEEDS project. While educators were required to teach students course content using EHRs, very little was known about the composition of the teaching beliefs that guided their instructional approach while using this technology. Use of EHRs was a new teaching-learning modality for nurse educators; therefore, making known their underlying teaching beliefs may assist other educators in evaluating their own teaching beliefs when using EHRs (Taylor et al., 2007). Current research asserted the link between educators' teaching
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beliefs and technology integration in the classroom (Kala et al., 2010; Lawrence, and Lentle-Keenan, 2013). Explicating educators' teaching beliefs is essential to understand the congruency between teaching beliefs and practices within the context of teaching with EHRs. The current study aims to explore the concepts, themes and patterns that comprise the teaching beliefs and practices of educators teaching with EHRs in the SEEDS project. Background Teaching Beliefs and Practices Teaching beliefs is a complex concept; multiple terms have been used to identify the concept. Initially defined by Pajares (1992) as teaching philosophy or paradigm that guides teachers' practices, other educational researchers expanded the definition of teaching beliefs to include personal convictions or opinions about teaching (Tarman, 2012). Irez (2007) provided a comprehensive definition of teaching beliefs and stated that: “Beliefs are psychological constructs that (a) includes understandings, assumptions, images or propositions considered to be true, (b) drive a person's actions and support decisions and judgments, (c) have highly variable and uncertain linkages to personal, episodic and emotional experiences, (d) although undeniably related to knowledge, differs from knowledge in that beliefs do not require a condition of truth” (p. 17). Evidence supports the significance of beliefs associated with understanding educators' teaching practices (Ertmer and Ottenbreit-Leftwich, 2010) and are known to influence teaching goals, materials and decisionmaking processes in the classroom (Kuzborska, 2011; Potter, 2013). Two main contrasting beliefs in education are evident in the literature: objectivism and constructivism (Taylor et al., 2007). Traditional teaching beliefs emerged from early Greek philosophies, focused on a positivistic way of thinking, and controlled the field of education for decades (Pajares, 1992). The assumptions relevant to the context of teaching include, a) knowledge is objective and decontextualized; b) learning is knowledge transmission, a reflection of what teachers know, wellstructured; c) reality is objective and external to the knowing subjects, and d) instructions should be designed to transfer the knowledge to the learners through abstract rules, lectures, and prediction (Ertmer and Ottenbreit-Leftwich, 2010). The practices of objectivist educators focus on what to think, emphasis on the content, use of predetermined instruction, and limited interactions (Ottenbreit-Leftwich et al., 2010). Objectivism seems to lend itself to values of conformity, uniformity, and passivity—a “one-sizefits-all” approach to teaching. This philosophy assumes that everyone can learn the same content in the same way at the same pace (Potter, 2013). Within this perspective, objectivist beliefs can be described as teacher-focused wherein an educator controls the context of learning. Potter (2013) called objectivism a “dead philosophy” and made a plea for the alternative teaching philosophy of constructivism. Constructivism emerged from cognitive, social, and psychological research, and arguably begins with Kant, to challenge objectivism (Glasersfeld, 1996). This belief structure considers knowledge as viable in the experiential world of individuals (Taylor et al., 2007). Assumptions of constructivism include, a) knowledge is constructed and situated in experiences; b) reality is a product of the mind; the structure of the world is created in the mind through interaction with the world; c) learning is the construction of knowledge and meaning, interpretation of the world, experiential, articulation–reflection, and process oriented; and d) instructions are reflections of multiple perspectives, inductive, modeling, and learner-generated (Ertmer and OttenbreitLeftwich, 2010). Within this context, education should focus on providing learners with the means and facilitation necessary to assist them to construct their own knowledge (Potter, 2013). Unlike objectivism, education in a constructivist view is an active and experiential learning pedagogy in which students learn by applying latent knowledge alike to the present situation; through this application and later reflection on the
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results of the application, students are expected to create a new synthesis (Potter, 2013). For Potter (2013), the goal of constructivism is lifelong learning that places students in authentic contexts involving practice, reflection, and feedback. Constructivist teaching practices encourage multiple perspectives, enhance students' ownership of knowledge, reveal the “why” underlying teaching style (Potter, 2013; Taylor et al., 2007). Constructivist teachers use multiple strategies such as role-playing, simulation, project-based courses, problem-based learning, case-studies, and team-based learning (Potter, 2013). The educator is a facilitator in learning, considers students' experiences and enhances their interactions (Taylor et al., 2007) and use dialog, reflection, critical thinking and interaction (Ertmer and Ottenbreit-Leftwich, 2010). Constructivism allows for a deep, longlasting learning and is favored by many educators within different disciplines (Potter, 2013). Constructivism has demonstrated its utility in all levels within higher education. A growing body of nursing higher education literature indicated its applicability to nursing education with desirable learning outcomes (Brandon and All, 2010). Constructivist nurse educators are prepared to integrate multiple teaching strategies suitable for today's learners including teaching with technology (Kala et al., 2010). Using EHRs in the classroom is a new strategy for nurse educators; however, little is available about educators' teaching beliefs and practices and their relationship to the use of EHRs in the classroom. Therefore, this study attempted to expand the knowledge about teaching beliefs and practices of educators teaching with EHRs to evaluate the relationship between teaching beliefs and EHRs teaching strategy. Electronic Health Record and Its Application in the SEEDS Project Electronic Health Records (EHRs) EHRs is a “digital” version of patient's paper charts or an application of information technology (Gardner and Jones, 2012). It refers to “large computerized database management systems used by clinicians to access a wide range of patient care information systems, nursing information systems, medical information systems, and patient care management systems” (Axford and Carter, 1996, p. 156). The promising influence of the EHRs on the US healthcare system has prompted the Institute of Medicine (IOM) (2001) to recommend integration of EHRs into clinical settings. As frontline healthcare professionals, nurses are obliged to use EHRs in clinical practice and must evaluate the utility and clinical outcomes associated with their use. Eastaugh (2012) found that EHRs use was associated with a 1.6% increase in the productivity in 58 US hospitals during a 3-year period, 2008 to 2011. For example, EHRs use decreased the time for a medication order to be filled and administered, from 28 min in 2008 to 8 min in 2011 in same hospitals (Eastaugh, 2012). Waneka and Spetz (2010) reviewed existing nursing literature on EHRs use and found that adoption of EHRs have desirable clinical outcomes such as improvement in the quality of nursing documentation, workflow, the time to administer medication, and the time for patient discharges and transfers. Of particular clinical and economic significance, the use of EHRs was associated with a 13% decrease in the development of hospital acquired pressure ulcers in 29 US hospitals (Dowding et al., 2012). Kutney-Lee and Kelly (2011) found that the use of EHRs was associated with enhancing patient safety. Today, there is an accelerated use of EHRs with more than 80% of healthcare providers demonstrating meaningful use of EHRs compared to only 9% in 2008 (U.S. Department of Health and Human Services, 2013). Similar to nurses in practice settings, nurse educators have attempted to keep pace with technological changes and respond to the demands that nursing education prepare competent nurses for practice by integrating EHRs into teaching education. An example of such attempts is the experience of the University of Kansas (KU/SON) which integrated EHRs into their undergraduate nursing curriculum through the SEEDS project (Kennedy et al., 2009).
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Simulated Electronic hEalth Delivery System (SEEDS) Project
Results
The SEEDS Project was made possible by an academic business partnership between the school of nursing and an EHRs vendor. These EHRs were used as problem-based teaching strategies (Warren et al., 2004). The aim of SEEDS was to create a simulated environment to enable students to design nursing care plans for virtual cases and access databased references (Connors et al., 2002). The goal of SEEDS was to enhance students' critical thinking while providing an information infrastructure for evidence-based practice (Connors et al., 2002). Placed within the context of the SEEDS Project, the aim of this study was to explore and describe the core teaching beliefs and their accompanied teaching practices of nurse educators using EHRs teaching strategy. Teaching beliefs, teaching practices, and EHRs provided the conceptual orientation for this study.
Two collective case studies, one each of constructivist and objectivist educators, and the characteristics of participants are presented. The case studies are clustered by themes that reflect common teaching beliefs and associated practices emerged from participants' interviews. An attempt was made to use quotation efficiently to represent major themes and patterns that reflect the case study as suggested by Stake (2008).
Methods Study Design A qualitative, collective case study approach within an exploratory, descriptive research design was used to address the study aim. Case study can be used to “investigate contemporary phenomena within its real-life context” with the aim to explore, explain and describe the event or the issue to provide an in-depth understanding of that issue (Yin, 2014). Similarly, Stake (2008) indicated that case study can be used to provide full explanation and description that allow for a clearer view of the phenomena under study through “thick description.” The collective type of case study design involves studying multiple cases simultaneously or sequentially in an attempt to generate a broader appreciation of a particular issue (Crowe et al., 2011; Stake, 2008). In our research, we used a collective case study design to uncover collective or board concepts, themes and patterns that constitute teaching beliefs and practices of nurse educators teaching with EHRs as a new and nontraditional teaching tool. Researchers in this study followed Yin's (2014) steps in conducting the case studies including: preparing for data collection from multiple sources, collection of evidence, analysis of the evidence, and composition of the case study report. Within this context the use of collective case study seems to be justifiable. The unit of analysis was the collective of individual nurse educators in their natural environment. Setting and Procedure The study setting was a university-based school of nursing with an upper division baccalaureate program and average enrollment of 300 students in a Midwest city. The university's institutional review board approved the study. Nurse educators consented verbally, on audiotape, to participate in the study. Tape-recorded interviews, nonparticipant observations and video-taped observations of classroom teaching with EHRs were conducted over a period of six months. Data Analysis Data comprised of transcribed interviews, observation field notes and curriculum documents were content-analyzed iteratively to identify educators' teaching beliefs and practices. Using analytical induction and constant comparison, data were coded and organized into themes that represented teaching beliefs and practices of participants. Analysis was staged to examine individual and aggregated data into themes and then explained across individuals to derive collective results. Trustworthiness of data was established by data and investigator triangulation, reflection, member checks, and group debriefing (Lincoln and Guba, 1985; Stake, 2008; Yin, 2014).
Characteristics of Participants Teaching experiences of the seven participants ranged from 9 to 43 years (M = 24.7, SD = 22.5) at a university school of nursing. Participants' educational preparation ranged from Masters of Science in Nursing (MSN) to Doctorate in Philosophy of Science (PhD) in nursing degrees. None of the participants had taught using EHRs before the SEEDS project. All participants were familiar with and used in their role as educators computer applications such as word processing, spread sheets, course management systems, and the internet. All participants taught in the baccalaureate nursing program. Constructivist Educator Case Study Three main belief themes emerged that represented the constructivist educators and included beliefs about current students wherein learning is a primary focus, teaching is an interactive and shared experience, and nursing education is practical, future oriented, and focuses on solving real world problems. Belief about 21st Century Students: Learning is Primary Focus Constructivist nurse educators believe that many students today are “older than the traditional post high school age young adult”, “mature,” “self-directed learners,” with life experiences that enrich the learning process. One participant commented as follows: One of the big key things has to do with respecting what students bring to the classroom and not considering them blank sheets but they have already come with values, beliefs, experiences and we need to recognize that and build on it. They are not starting from scratch.....They do not have the knowledge base, but it does not mean that they cannot apply it once they learn it to that previous experience as a way to reflect on and to evaluate it. For constructivist educators, current students “come from the computer generation and [are] more comfortable with computers” than students in the past who “used typewriters.” Constructivist educators perceived current students as “computer savvy” because “they have been using them for most of their lives.” Corresponding Teaching Practices Results revealed that educators maintained consistent teaching practices in a traditional classroom, in courses delivered via the internet, and with use of EHRs. However, only examples of teaching practices of nurse educators teaching with EHRs are presented here. Their teaching practices reflected a belief in an experiential, contextual, learnercentered teaching approach. Constructivist nurse educators acknowledged that changes in teaching practices require advanced technology. The educators recognized the importance of integrating teaching strategies that are “current,” and suitable for “the computer generation.” They were optimistic about teaching with EHRs and attempted to increase students' awareness about EHRs to prepare them for computerized practice settings. Constructivist teachers believe that technology is the only way to improve practice and by familiarizing students with it, educators are “preparing them to be competent in automated healthcare settings.”
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Furthermore, constructivist educators believe that students are mature learners, have experiences and “life stories” that enhance their knowledge formation. For example, when documenting an obstetric and newborn case study using the EHRs, a constructivist educator identified several students who had breastfed their own children. These students were asked to share their experiences so as to introduce practical ideas that may provide insights to nurses. For constructivist educators, experiential learning enriches students' learning because, it brings “meaning to their lives.” Additionally, constructivist educators treat students with less guidance because they are self-directed learners and let them discover by themselves different aspects of the online documentation process. Class activities were less structured and mainly planned by students which indicate constructivist belief in students' acquisition of knowledge. Constructivist teachers are only guiding students and give them the time to navigate the system to complete the documentation process. Teaching is an Interactive and Shared Experience The second major belief theme that characterized constructivist educators is that teaching is an interactive and “shared experience” that can be achieved through students' involvement. Constructivist educators believe that “learning increases when people, the students, are active participants in their classroom experience.” Therefore, these educators viewed themselves as “facilitators more than sitting up in the front of the class and teaching.” Constructivist educators see their role as “resource” and “coach” who “help them learn skills that they need” while encouraging “multiple perspectives.” A constructivist educator is not the “sage on the stage” or “a giver of information who disseminate knowledge” only. Corresponding Teaching Practices Constructivist educators apply teaching practices that match their belief by enhancing dialog, argument, and discussion among students when teaching with the EHRs, thereby exhibiting a liberating teaching style through. For example, during the online documentation process, constructivist educators tried to engage students in a dialog to “get them to think” and reach a conclusion. They asked “Socratic questions” about the case study, such as: “How did you get to this point? How do you know what you are saying is right? What evidence can you provide to support your statement that you just made?” Constructivist educators allowed students to interact with each other during the online documentation process without interrupting. Observation revealed that constructivist educators tried to maximize interactions between students by allowing them to move from their own computer work station to other students' computer stations. Nursing Education is Practical; Future Oriented and Solves Real World Problems Constructivist educators believe that teaching is “to be able to apply what they're learning, what they're seeing to the real world of nursing.” Constructivist educators believe that nursing education should be “more application learning and educators should make sure that the students who graduate are really safe and capable nurses.” They believe that the role of the educator is to “make [students] better care takers.” Constructivist educators' main concern is to provide good quality nursing graduates for practice. For constructivist educators, this can be accomplished only “through the use of technology or EHRs.” Corresponding Teaching Practices Teaching practices that are consistent with this belief theme is the futuristic look of constructivist educators about the use of the EHRs in teaching. Constructivist educators act as “a role model” for students and perceive the EHRs as “the future and students need to be exposed to it because it makes them a good product for healthcare systems.”
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Constructivist educators use a “real case study” approach that illustrates their belief in contextual learning. For them, the EHRs facilitates students' learning through real clinical contexts. They believe that case studies “get students to think” about real needs for patients. Objectivist Educator Case Study Most of the teaching beliefs and practices within the context of teaching with EHRs represented a constructivist orientation; however, there was one theme that characterized the objectivist case study: belief about students wherein learning is a secondary focus. Belief about Students Today: Learning is a Secondary Focus Objectivist educators perceive students as “immature learners;” that they do not have the adequate “experience and practice of nursing.” Objectivist educators believe that students learn best with “direction and guidance” because “they are so novice [and] do not know enough yet to decide this is important and this is not. [Educators] have a better view of what they need to do.” One objectivist educator said: “[Students] are unable to articulate their learning needs. Do not know what it is they want to learn. Do not know what their learning needs are.” Objectivist educators' vision is limited because they believe that “the students care more about the grades and what jobs should be done to get the grade.” Students, for objectivist educators, are “willing to take short cuts that will still give them the grades but not necessarily the learning.” Objectivist educators believe that “grades are a major standard [italics added]” that they “really look at” because they are the first priority for students. The goal of objectivist educators is to help students be “successful in their testing arena.” To achieve that goal, objectivist educators believe their role is to deliver the “material,” and “disseminating information” in “lectures.” The focus of the objectivist educator is the content that comes directly from the “course objectives” and should match “what students are going to be tested on.” One objectivist educator said: “I'm really a giver of information. I'm a mother-like type. I want to tell them everything they need to know for their exams.” Corresponding Teaching Practices Observation of seminars of objectivist educators using EHRs revealed that they follow “a mothering approach” with students, and offer little space for interactions and dialog. They supervised students closely on a one-to- one basis, did not extrapolate from students' personal experiences, used a didactic instructional approach, and demonstrated negative attitudes toward using EHRs. For objectivist educators, “students do not see the future utility of it” and it is “just a data entry mechanism” and should not be integrated in their teaching practices because, as one educator noted: The goal or the objective is to get them to be able to be professional in nursing process and the activities that I designed for them were designed around that end…so that they can be successful in their testing arena, then they can get good grades [italics added]…Now, I do not know how [EHRs] fits in that.
Discussion This study provided valuable information on a topic that is less represented in nursing educational research which is teaching beliefs and their corresponding teaching practices of educators using EHRs in the classroom. Our study emphasized the link between educators' teaching beliefs and practices in the classroom, as proposed in education research (Devine et al., 2013; Lawrence and Lentle-Keenan, 2013; Taylor et al., 2007). More importantly, it provided evidence for the significance of
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nurse educators' adoption of constructivist beliefs for the effective integration of technology to prepare the future generation of nurses (Legg et al., 2009). Examining types of beliefs that emerged from our study indicated that nurse educators are in favor of constructivist over objectivist beliefs as most authors of educational literature have asserted (Legg et al., 2009; Potter, 2013). Educators with constructivist beliefs demonstrated enthusiasm toward using EHRs to prepare students for the practice world while using a liberal teaching approach. They envisioned the future utility of EHRs for clinical practice as indicated in education research (Dowding et al., 2012; Eastaugh, 2012; Kutney-Lee, and Kelly, 2011; Waneka and Spetz, 2010). Therefore, constructivism seems to be essential for leveraging high-technology learning, a relationship that is proposed in the literature (Legg et al., 2009). In our study, constructivist educators used the EHRs efficiently to assist students constructing their own knowledge by learning from real clinical cases through dialog, reflection, team-work and interaction to create a dynamic and meaningful learning environment; all of which are consistent with constructivist beliefs (Etmer and Ottenbreit-Leftwich, 2010; Potter, 2013). Although constructivist teaching seems to be essential to adopt technology, it is worth mentioning that EHRs could be an efficient teaching tool that fostered constructivism's principles such as enhancing problem-based, student-centered, contextual and interactive learning. In two studies that evaluated the use of EHRs in the classroom, Kennedy et al. (2009) and Johnson and Bushey (2011) reported that nursing students perceived EHRs as a learning tool that equipped them with skills essential to function effectively in automated health care settings such as navigation of technology, decision making, nursing process and documentation. In our study, similar statements were asserted by nurse educators. The EHRs contributed to the creation of a positive learning atmosphere wherein students engaged in meaningful and “enjoyable” activities such as constructing knowledge, learning by analyzing clinical problems, browsing the Internet, reviewing and critiquing resources, and learning in a collaborative and interactive manner. It is possible that the harmony between teaching beliefs and technology itself, similar to our study, could facilitate students' learning (Ottenbreit-Leftwich et al., 2010; Sabzian et al., 2013). Such findings could encourage educators to consider using EHRs as a viable and practical teaching strategy in the classroom. Although educational research asserted that constructivism is an alternative and desirable philosophy in nursing education (Brandon and All, 2010; Legg et al., 2009) results from our study revealed that an objectivist orientation still exists in nursing education (Whall and Hicks, 2002). Objectivist teachers in our study did not see the future utility of EHRs and perceived it as “a data entry mechanism” only. Therefore, it is not surprising that objectivist participants in this study indicated that they were not ready to embrace technological changes in education. Their present-oriented vision and lack of interest in using EHRs as a teaching strategy appears to be an obstacle drawn from their belief structure (Legg et al., 2009). Hughes (2005) indicated that objectivist educators with traditional teaching beliefs are focused mainly on the use of technology itself without making connections to expected learning outcomes which hinder the educational process. Objectivist educators are more likely to implement “low level” teaching compared to “high level” teaching associates with constructivist beliefs (Chen and Chen, 2009). Still, our study did not account for other factors that could influence teaching practices of educators that are identified in educational research such as current practice, interaction with learners, the challenges of the day-to-day learning context (Jenkins, 2011), individual characteristics, preparation, and background of educators (Lawrence and LentleKeenan, 2013). Lawrence and Lentle-Keenan (2013) added that institutional factors, organizational priorities and expectation play a major role in determining practices of educators' uptake of technology and vary greatly within each country and school. In our study, educators were
selected from one nursing school without accounting for individual or institutional factors that may be related to their teaching beliefs and practices. Therefore, it is important to take into account the broader contextual and sociocultural factors that influence educators' use of technology (Devine et al., 2013). More importantly, the evolution and integration of teaching beliefs within an educational system that has used technology like EHRs, and the variables that contribute to their evolution and integration are still unknown. Also, unknown are the evolutionary variables that influence and shape teaching belief structure of educators teach with other types of technology that has been introduced into education, such as distance learning with online and video technology, and hybrid teaching formats. Recommendations for Nurse Educators Embracing the change in nursing education through technological change can be achieved when educators have constructivist teaching beliefs (Legg et al., 2009). Because of the rapid advancement, change and spread of EHRs worldwide, educators need to be aware of the importance of technological changes that influence patients' care by effective integration of EHRs in education (Meyer et al., 2011). This integration will be facilitated only with a constructivist–futuristic orientation that is based on teaching strategies that assist learners to apply their knowledge toward patient care (Ottenbreit-Leftwich et al., 2010). Involvement of educators in evaluating EHRs software could encourage objectivist educators toward utilizing it more efficiently and modifying their teaching beliefs. Some practical strategies are recommended to encourage educators to adopt constructivist teaching. Integrating teaching beliefs into professional preparation of educators is recommended (Ottenbreit-Leftwich et al., 2010; Sabzian et al., 2013). Also, using mentoring and selfmonitoring techniques like reflection and integrating “application activities” are strategies to help educators foster constructivist teaching. Creating academic cultures that nurture good teaching practices through a shared vision that involves adopting constructivist beliefs remains a key element for technological integration in curricula. Recommendations for Future Research The study of teaching beliefs is an essential topic of inquiry in educational research. Since little is known about educators' belief systems, clear conceptualization of key attributes of the term teaching beliefs is needed in future nursing research. As stated before, variables that could influence technology use in education need to be explored in future research. The cohort effect will be an important variable in future research as EHRs become the norm for communicating health information by health care providers worldwide and the vehicles for transmitting health information become increasingly sophisticated. Qualitative research and mixed methods with triangulated approaches are suggested to gain both an understanding of the contextual aspects of the belief systems of educators and a measurement of the effectiveness and outcomes for educators and students. Additional nursing research needs to examine the nature and trajectory of teaching beliefs throughout educators' careers to better understand the relationship of beliefs to teaching experience and changes in healthcare, technology and learners' abilities. Limitations The small number of educators teaching with EHRs at the study setting provided a rich context; however, the results are specific to one Midwest US school of nursing and one group of educators at one point in time. No longitudinal indices were addressed. It is possible that there are other belief systems that influence the use of EHRs and were not depicted in these results.
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