Nurse Educator
Nurse Educator Vol. 39, No. 6, pp. 298-301 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Electronic Medical Records in Clinical Teaching Ina Warboys, MS, RN & Wai Yin Mok, PhD & Karen H. Frith, PhD, RN, NEA-BC The purpose of the project was to provide students with experiences to develop their technology competency and examine student perceptions about an academic electronic medical record (EMR) as a learning tool. Nurse educators need to integrate EMRs into their curricula to give students practice in the use of electronic documentation and retrieval of clinical information. The findings of this study indicated that students’ use of EMRs at least 5 times resulted in the development of positive perceptions about their EMR experience.
Keywords: academic electronic medical record; documentation; health information technologies; nursing students; technology
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ational efforts to convert medical records to electronic medical records (EMRs) are moving forward at a rapid pace.1 Healthcare providers and hospitals are required by federal law to demonstrate meaningful use of certified EMR technology2; thus, students currently in nursing programs will be practicing in an environment with EMRs. In 2008, the American Association of Colleges of Nurses revised its Essentials of Baccalaureate Education for Professional Nursing Practice to include technology competency in Baccalaureate Essential IV.3 The purpose of our project was to provide students with experiences to meet Baccalaureate Essential IV and to examine student perceptions of EMR as a learning tool focusing on prioritization, safety, client needs, and documentation for fundamental concepts. Nursing education programs should include electronic documentation and other health technologies to prepare their graduates for future employment.4 Students should emerge from their educational programs prepared to engage in the use of EMRs because employers expect new graduates to be competent in technology-based patient documentation.5-9 Students and nurse educators may have difficulty accessing EMRs in some clinical settings because of an insufficient number of computers or because of restricted access to all parts of the EMR.6,10 In addition, the feedback about charting from nurses or nurse educators to students during clinical may be so limited that students cannot learn about best practices Author Affiliations: Clinical Associate Professor of Nursing (Ms Warboys) and Professor of Nursing (Dr Frith), College of Nursing, and Associate Professor of Information Systems, College of Business Administration (Dr Mok), University of Alabama in Huntsville. The authors declare no conflicts of interest. Correspondence: Ms Warboys, College of Nursing, The University of Alabama in Huntsville, 301 Sparkman Dr, Huntsville, AL 35899 (warboysi@ uah.edu). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: June 14, 2014 Published ahead of print: July 25, 2014 DOI: 10.1097/NNE.0000000000000072
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in electronic documentation.10 An academic EMR can be a solution because it gives students practice and feedback in a lower-stress environment.11 Practice with retrieval and documentation of clinical information in an academic setting can improve student performance in clinical settings.6 Electronic medical records can be added to simulations to replicate selected clinical experiences.11 When EMRs are added to clinical simulations, students learn to navigate EMRs to find clinically relevant information and document patient assessments, treatments, and nursing decisions.11 Similar to the use of patient care simulators, practice with EMRs in educational settings can improve the transfer of knowledge from classrooms or laboratories to EMRs in clinical settings.6 Several researchers have reported on student outcomes using academic EMRs.6,12,13 First, Lucas6 collaborated with a medical center to give undergraduate students access to the training EMR before the first clinical. In Lucas’ study, 4 learning activities with a training EMR were implemented with students in the learning resource center and the simulation laboratory. Students also were given access to the training EMR from home to gain more practice before their first clinical experiences. Students felt more confident with their documentation and retrieval skills in clinical practice and reported that having EMR skills prior to clinical experience allowed them to focus on patient care and prioritization.6 Jones and Richards reported on the use of an academic EMR by students who were enrolled in a community health class.14 Students took laptops with Internet access to clients’ homes during the course. When asked about their perceptions about the EMR, students reported that use of the EMR improved their physical examinations and their ability to answer clients’ medical questions. Students had mixed perceptions about how the EMR affected their interaction with clients: 45% agreed that using a computer enhanced their interaction, whereas 50% disagreed with that statement. About half of the students believed that the EMR enhanced patient safety, but the remainder of students was undecided. However, all students agreed with the statement that learning how to use an EMR was important.12 Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Johnson and Bushey13 described the desired outcomes of an academic EMR across sophomore, junior, and senior levels in 3 dimensions: collaboration, critical thinking, and application. Combined with simulation cases, students first learned how to use the simple navigation and documentation functions in the EMR and then progressed to complex simulation cases that required critical thinking in the higher levels of the undergraduate program. However, at the time of publication, measurement of outcomes had been planned but not reported. Only 1% of nursing programs have academic EMRs.12 With so few nursing programs using academic EMRs, there is little known about student perceptions on academic EMRs as a learning tool.15,16 This study contributes to the nursing literature about the use of academic EMRs as learning tools.
Research Questions Two research questions guided the project: (1) What are nursing student perceptions of EMR as a learning tool for fundamental concepts? and (2) what is the level of EMR use needed for positive perceptions of EMR software? Application of this new skill, electronic documentation, was integrated into the simulations and clinical experiences of the students in the first semester. We also assessed students’ perceptions of the need for additional training because it could indicate whether use of the academic EMR provided sufficient learning experiences for developing technology competencies (Essential IV).
Methods Research Design We used a nonexperimental, correlational design for the study. The design included education on the use of the EMR, integration of the EMR in simulations and clinical experiences, and measurement of students’ perceptions of EMR as a learning tool. Setting and Sample This study was conducted at a research university in the southeastern part of the United States. The nursing program has a large annual enrollment of more than 1000 students in the BSN (prelicensure and RN), MSN, and DNP programs. The sample consisted of 267 baccalaureate junior-level nursing students from different cohorts of students enrolled in the nursing program, with 220 students (82.4%) participating in the study. The institutional review board of the University approved the study. Researchers could not differentiate between students who did and did not participate. Participation had no impact on course completion or course grade. Educational Intervention The project team selected an open-source EMR software, called OpenEMR.17 An open-source software consists of source code available and with a right provided for the users to study, change, and distribute the software for any purpose.18 OpenEMR has 2 main advantages. First, because the software is open source, there was no cost for installing or running the software. Second, both OpenEMR versions 4.1.0 (released on September 23, 2011) and 4.1.1 (released on August 31, 2012) have Complete Ambulatory EMR Certification as recognized by the Office of the National Coordinator for Health Information Technology. Nurse Educator
At the beginning of the fundamentals course, we provided a 50-minute training session to students. This session consisted of behaviors such as logging into the secure server and learning which tabs were used to chart different clinical information such as vital signs, medications, and assessment findings. The students practiced with instructors during the training session. If students needed more direction, a PDF file of instructions was available in the online course management system. During the fundamentals course, we provided students with education about standard nursing documentation principles. The principles included items such as legal requirements under nursing licensure and ethical reporting of assessment findings. In an effort to increase student comfort level with electronic charting and with nursing documentation skills, we selected open-source software to place on a password-protected server. We instructed students to chart on client care without revealing any personal client identity information after simulations and their clinical experiences in a long-term-care facility.
Instrument At the conclusion of a 15-week semester, students completed an anonymous EMR-use perception survey. The survey consisted of 12 questions/statements (see Table, Supplemental Digital Content 1, http://links.lww.com/NE/A159). The first question asked students if they used the EMR in their clinical groups. Another question was used to determine the number of EMR uses. An EMR use was counted as 1 use for each client assigned during an entire clinical shift or simulation episode. The possible number of EMR uses in the semester was 0 to 7. There were 2 questions about the realism of the EMR and the value of the EMR as a learning object. In addition, there were 8 statements about the students’ perceptions after using the EMR. These statements were developed to measure fundamental nursing concepts including safety, documentation, goals, client needs, prioritization, nursing process, training needs, and recommendations for continued use of an academic EMR. The statements were measured with a Likert scale for rating agreement/disagreement. The rating options were 0 through 5, with higher numbers indicating greater agreement with the statements. We used the Statistical Package for Social Sciences (SPSS) (version 22; IBM, Armonk, New York) to perform a factor analysis to examine the construct validity of the survey. Using eigenvalues greater than 1.0 as a cutoff, we conducted a principal component analysis with varimax rotation. Two factors had an eigenvalue greater than 1; they cumulatively explained 79.05% of the total variance, which was a satisfactory indication of construct validity. Factor 1 consisted of 7 items measuring perceptions of fundamental concepts: safety, documentation, goals, client needs, prioritization, nursing process, and recommendations. Factor 2 consisted of 1 item: training needs. Data Analysis We conducted data analysis with Microsoft Excel (version 2010; Microsoft, Redmond, Washington) and with SPSS. We ran descriptive statistics including frequencies and percentages for demographic data. For research question 1, we used minimums, maximums, means, and SDs. When analyzing data for research question 2, we calculated proportions, Pearson correlation, t tests, and z tests. Volume 39 & Number 6 & November/December 2014
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Results Demographic Information Participants in the study were third-year baccalaureate nursing students completing their first clinical course. The age of students was 20 to 49 years. The majority of students were enrolled full-time; only 2% were enrolled part-time. Twelve percent had worked as a nursing aide or technician prior to entering the collegiate program.
‘‘yes’’ to realism and ‘‘no’’ to realism. There were 146 students who answered yes to realism; their mean EMR use was 4.36 times. There were 47 students answered no to realism, with a mean EMR use of 3.64 times. A 1-tailed t test confirmed that the means were different (t79 = 2.77, P = .0035). We also ran a t test to examine differences in the number of EMR uses between students who answered yes to helpfulness of the learning object. There were 166 students who answered yes to learning object; their mean EMR use was 4.37 times. There were 43 students who answered no to learning object, and the mean EMR use was 3.37 times. A 1-tailed t test confirmed that the mean EMR use was statistically different (t72 = 3.97, P = .00008). The t test found differences in mean EMR uses, but we wanted to know if there was a number of EMR uses that could be established as a minimum for positive perceptions. We found that 66 of the 78 respondents (84.6%) who used the EMR 5 or more times answered yes to realism, whereas only 80 of the 115 respondents (69.6%) who used the EMR less than 5 times answered yes to realism. A 2-proportion z test confirmed that the proportions were statistically different (z = 2.39, P = .0084). For the learning object question, we ran the same analysis. We found that 69 of the 78 respondents who used the EMR 5 or more times (88.5%) answered yes, but only 84 of the 118 respondents who used the EMR less than 5 times (71.2%) answered yes. A similar 2-proportion z test also confirmed that the proportions were significantly different (z = 2.86, P = .0021).
Student Perceptions of EMR as a Learning Tool for Fundamental Concepts A large percentage of students (94.5%) reported that they used the EMR for documentation during their first semester in the nursing program. On average, students used the EMR 4.10 (SD 1.63) times during the semester. Of the students who used the EMR, 72% (n = 159) had positive perceptions of the EMR as being realistic, and 75% (n = 166) had a positive perception of its being helpful in learning to document nursing care. We also measured perceptions of the EMR using 8 statements on the survey, which we reduced into 2 factors. Factor 1 contained statements about fundamental concepts including safety, documentation, goals, client needs, prioritization, nursing process, and recommendations for continued use of an academic EMR. The mean student perception about EMR on factor 1 was 2.88 (SD 1.46). The mean was slightly over the possible mean of 2.5, which indicated positive perceptions. Factor 2, training needs, had a mean of 2.73 (SD 1.63). This mean was above the possible mean of 2.5, but in this case, the results indicated that students perceived the need for more training.
Discussion
Level of EMR Use Needed for Positive Perceptions of EMR Software Of the 220 respondents, 203 recorded the number of times they used the EMR. We divided responses into subgroups based on the number of times the EMR was used, ranging from 0 to 7 times. We calculated the mean scores for 8 perception statements on the survey (Table). We observed that the mean scores for safety, learning documentation, student goals, client needs, prioritization, nursing process, and recommendation increased with the number of times the EMR was used. The only exception was training needs. We ran Pearson correlation coefficients between the number of times the EMR was used and the mean scores on 8 perception statements. The results were as follows: (1) the correlation coefficients between EMR use and each of the first 6 perceptions statements were all greater than 0.90, (2) the correlation coefficient between EMR use and training was j0.64, and (3) the correlation coefficient between EMR use and recommendation had a modest positive correlation coefficient of 0.72. These strong positive relationships indicated that the more students used the EMR, the more positive their perceptions were about the EMR. The negative correlation coefficient between EMR use and training needs was expected because as students used the EMR more often, they felt less training was needed. Next, we examined responses to 2 items we believed were important to understand EMR: realism and helpfulness as a learning object. We ran a t test to examine differences in the number of EMR uses between students who answered
Results from this study show that students can develop positive perceptions about EMR as a learning tool in their first semester of a nursing program. Lucas6 found that students who practiced with an EMR before the first day of clinical felt more confident with their EMR skills during clinical. Likewise, Melo and Carlton18 reported that use of academic EMRs helped students to feel confident in their ability to navigate an EMR and document their nursing care. Similar to other fundamental skills, students in this study needed to use the EMR numerous times to gain experience and develop positive perceptions about electronic documentation. On average, students in this study used the EMR slightly over 4 times, but with a large SD (1.63), we know students had variation in EMR use. Findings from the study indicate that students perceived the need for more training with the EMR. Moreover, the greater number of instances students used the EMR, the better their perceptions of EMR tools. Students who used the EMR 5 or more times had more positive perceptions than did the students who used the EMR less than 5 times. The findings also suggested a stronger perception of realism of the academic EMR with greater use. The participants felt they learned more about safety, client needs, and documentation as the number of uses reached 5 or greater. Lucas6 reported EMR activities in 4 weeks prior to students’ first clinical experiences. Hanson19 reported that EMR use over time, typically a semester, is needed for student competency. Our findings are consistent with those of Lucas6,19 and Hanson.6,19 Technology and information competencies need to be integrated throughout nursing curricula.20 While academic EMRs are useful as an adjunct to simulation experiences,
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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
students need practice with EMRs in clinical settings to be workforce ready.21 In addition, EMR experiences in simulation laboratories and in clinical practice help to meet Baccalaureate Essential IV.
Application to Practice Early in nursing programs, students need instruction in electronic documentation. Educators often struggle with the questions of how much practice is needed to learn this new skill. Our study demonstrated that positive student perceptions with an academic EMR required at least 5 times of documenting use. The study also provided empirical data on which to base teaching decisions when determining how many times to require students to perform technology assignments. Limitations and Future Research The study has several limitations that affect its generalizability. We conducted the study at a single university with a convenience sample from several cohorts of first-semester nursing students. We developed an instrument to measure student perceptions about an academic EMR as a learning tool focusing on topics appropriate to first-semester students. Therefore, we have several suggestions for future research. First, a multicenter study of academic EMRs with common instruments could be conducted. Such a study could include measurements to determine the optimal number of uses for positive student perceptions of academic EMRs. Second, studies could include student outcomes beyond student perceptions including self-efficacy, competency with academic EMR, and competency with EMRs in healthcare settings. Third, studies could be designed to examine student outcomes with academic EMRs across curricula to see if maturation of technology competencies occurs. Acknowledgment The authors thank Mary M. Hays, DSN, RN, for her support of this project.
References 1. Health Information and Management Systems Society (HIMSS). EMR Adoption Model. 2013. Available at http://www.himssanalytics .org/home/index.aspx. Accessed May 20, 2013. 2. Centers for Medicare and Medicaid Services (CMS). EMR Incentive Programs. 2014. Available at http://www.cms.gov/Regulationsand-Guidance/Legislation/EMRIncentivePrograms/index.html? redirect=/EMRIncentivePrograms. Accessed March 23, 2014. 3. American Association of Colleges of Nursing (AACN). The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington, DC: AACN; 2008.
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4. Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine (IOM). The Future of Nursing: Leading Change, Advancing Health. Washington DC: The National Academies Press; 2010. 5. Billings D. Guest editorial. Quality care, patient safety, and the focus on technology. J Nurs Educ. 2008;47(2):51-52. 6. Lucas L. Partnering to enhance the nursing curriculum: electronic medical record accessibility. Clin Simulat Nurs. 2010;6(3): e97-e102. 7. Anest R. Teaching Patient Safety with a Functional Electronic Medication Record. J Nurs Educ. 2013;52(5):30. 8. Vestal V, Krautwurst N, Hack R. CIN Plus. A model for incorporating technology into student nurse clinical. Comput Inform Nurs. 2008;26(1):2-49. 9. FauchaldS. CIN Plus. An academic-industry partnership for advancing technology in health science education. Comput Inform Nurs.2008;26(1):4-8. 10. Baillie L, Chadwick S, Mann R, Brooke-Read M. A survey of student nurses’ and midwives’ experiences of learning to use electronic health record systems in practice. Nurse Educ Pract. 2013;13(5):437-441. 11. Gardner CL, Jones SJ. Utilization of academic electronic medical records in undergraduate nursing education. Online J Nurs Inform. 2012;16(2):31-37. 12. Brooks CL, Erickson LK. What is the solution for clinical nurse educators and the electronic medical record?. Teach Learn Nurs. 2012;7(4):129-132. 13. Johnson DM, Bushey TI. Integrating the academic electronic health record into nursing curriculum: preparing student nurses for practice. Comput Inform Nurs. 2011;29(3):133-137. 14. Jones CA, Richards E. The impact of nursing students’ use of electronic health records in the home setting. Home Healthc Nurse. 2013;31(9):474-481. 15. Jones S, Donelle L. Assessment of electronic health record usability with undergraduate nursing students. Int J Nurs Educ Scholarsh. 2011;8(1):1-18. 16. Kuiper R. Metacognitive factors that impact student nurse use of point of care technology in clinical settings. Int J Nurs Educ Scholarsh. 2010;7(1):1-15. 17. OpenEMR. Available at http://www.open-emr.org/. Accessed August 2010. 18. Melo D, Carlton K. CIN Plus. A collaborative model to ensure graduating nurses are ready to use electronic health records. Comput Inform Nurs. 2008;26(1):8-12. 19. Hanson DS. Nurse Educators’ Consensus Opinion on Using an Academic Electronic Health Record: A Delphi Study. [dissertation]. Grand Forks, ND: University of North Dakota; 2013. 20. Mahon P, Nickitas D, Nokes K. Faculty perceptions of student documentation skills during the transition from paper-based to electronic health records systems. J Nurs Educ. 2010;49(11): 615-621. 21. McGonigle D, Mastrian K. Nursing Informatics and the Foundation of Knowledge. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2015.
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Nurse Educator Vol. 39, No. 6, pp. 298-301 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Electronic Medical Records in Clinical Teaching Ina Warboys, MS, RN & Wai Yin Mok, PhD & Karen H. Frith, PhD, RN, NEA-BC The purpose of the project was to provide students with experiences to develop their technology competency and examine student perceptions about an academic electronic medical record (EMR) as a learning tool. Nurse educators need to integrate EMRs into their curricula to give students practice in the use of electronic documentation and retrieval of clinical information. The findings of this study indicated that students’ use of EMRs at least 5 times resulted in the development of positive perceptions about their EMR experience.
Keywords: academic electronic medical record; documentation; health information technologies; nursing students; technology
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ational efforts to convert medical records to electronic medical records (EMRs) are moving forward at a rapid pace.1 Healthcare providers and hospitals are required by federal law to demonstrate meaningful use of certified EMR technology2; thus, students currently in nursing programs will be practicing in an environment with EMRs. In 2008, the American Association of Colleges of Nurses revised its Essentials of Baccalaureate Education for Professional Nursing Practice to include technology competency in Baccalaureate Essential IV.3 The purpose of our project was to provide students with experiences to meet Baccalaureate Essential IV and to examine student perceptions of EMR as a learning tool focusing on prioritization, safety, client needs, and documentation for fundamental concepts. Nursing education programs should include electronic documentation and other health technologies to prepare their graduates for future employment.4 Students should emerge from their educational programs prepared to engage in the use of EMRs because employers expect new graduates to be competent in technology-based patient documentation.5-9 Students and nurse educators may have difficulty accessing EMRs in some clinical settings because of an insufficient number of computers or because of restricted access to all parts of the EMR.6,10 In addition, the feedback about charting from nurses or nurse educators to students during clinical may be so limited that students cannot learn about best practices Author Affiliations: Clinical Associate Professor of Nursing (Ms Warboys) and Professor of Nursing (Dr Frith), College of Nursing, and Associate Professor of Information Systems, College of Business Administration (Dr Mok), University of Alabama in Huntsville. The authors declare no conflicts of interest. Correspondence: Ms Warboys, College of Nursing, The University of Alabama in Huntsville, 301 Sparkman Dr, Huntsville, AL 35899 (warboysi@ uah.edu). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: June 14, 2014 Published ahead of print: July 25, 2014 DOI: 10.1097/NNE.0000000000000072
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in electronic documentation.10 An academic EMR can be a solution because it gives students practice and feedback in a lower-stress environment.11 Practice with retrieval and documentation of clinical information in an academic setting can improve student performance in clinical settings.6 Electronic medical records can be added to simulations to replicate selected clinical experiences.11 When EMRs are added to clinical simulations, students learn to navigate EMRs to find clinically relevant information and document patient assessments, treatments, and nursing decisions.11 Similar to the use of patient care simulators, practice with EMRs in educational settings can improve the transfer of knowledge from classrooms or laboratories to EMRs in clinical settings.6 Several researchers have reported on student outcomes using academic EMRs.6,12,13 First, Lucas6 collaborated with a medical center to give undergraduate students access to the training EMR before the first clinical. In Lucas’ study, 4 learning activities with a training EMR were implemented with students in the learning resource center and the simulation laboratory. Students also were given access to the training EMR from home to gain more practice before their first clinical experiences. Students felt more confident with their documentation and retrieval skills in clinical practice and reported that having EMR skills prior to clinical experience allowed them to focus on patient care and prioritization.6 Jones and Richards reported on the use of an academic EMR by students who were enrolled in a community health class.14 Students took laptops with Internet access to clients’ homes during the course. When asked about their perceptions about the EMR, students reported that use of the EMR improved their physical examinations and their ability to answer clients’ medical questions. Students had mixed perceptions about how the EMR affected their interaction with clients: 45% agreed that using a computer enhanced their interaction, whereas 50% disagreed with that statement. About half of the students believed that the EMR enhanced patient safety, but the remainder of students was undecided. However, all students agreed with the statement that learning how to use an EMR was important.12 Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Johnson and Bushey13 described the desired outcomes of an academic EMR across sophomore, junior, and senior levels in 3 dimensions: collaboration, critical thinking, and application. Combined with simulation cases, students first learned how to use the simple navigation and documentation functions in the EMR and then progressed to complex simulation cases that required critical thinking in the higher levels of the undergraduate program. However, at the time of publication, measurement of outcomes had been planned but not reported. Only 1% of nursing programs have academic EMRs.12 With so few nursing programs using academic EMRs, there is little known about student perceptions on academic EMRs as a learning tool.15,16 This study contributes to the nursing literature about the use of academic EMRs as learning tools.
Research Questions Two research questions guided the project: (1) What are nursing student perceptions of EMR as a learning tool for fundamental concepts? and (2) what is the level of EMR use needed for positive perceptions of EMR software? Application of this new skill, electronic documentation, was integrated into the simulations and clinical experiences of the students in the first semester. We also assessed students’ perceptions of the need for additional training because it could indicate whether use of the academic EMR provided sufficient learning experiences for developing technology competencies (Essential IV).
Methods Research Design We used a nonexperimental, correlational design for the study. The design included education on the use of the EMR, integration of the EMR in simulations and clinical experiences, and measurement of students’ perceptions of EMR as a learning tool. Setting and Sample This study was conducted at a research university in the southeastern part of the United States. The nursing program has a large annual enrollment of more than 1000 students in the BSN (prelicensure and RN), MSN, and DNP programs. The sample consisted of 267 baccalaureate junior-level nursing students from different cohorts of students enrolled in the nursing program, with 220 students (82.4%) participating in the study. The institutional review board of the University approved the study. Researchers could not differentiate between students who did and did not participate. Participation had no impact on course completion or course grade. Educational Intervention The project team selected an open-source EMR software, called OpenEMR.17 An open-source software consists of source code available and with a right provided for the users to study, change, and distribute the software for any purpose.18 OpenEMR has 2 main advantages. First, because the software is open source, there was no cost for installing or running the software. Second, both OpenEMR versions 4.1.0 (released on September 23, 2011) and 4.1.1 (released on August 31, 2012) have Complete Ambulatory EMR Certification as recognized by the Office of the National Coordinator for Health Information Technology. Nurse Educator
At the beginning of the fundamentals course, we provided a 50-minute training session to students. This session consisted of behaviors such as logging into the secure server and learning which tabs were used to chart different clinical information such as vital signs, medications, and assessment findings. The students practiced with instructors during the training session. If students needed more direction, a PDF file of instructions was available in the online course management system. During the fundamentals course, we provided students with education about standard nursing documentation principles. The principles included items such as legal requirements under nursing licensure and ethical reporting of assessment findings. In an effort to increase student comfort level with electronic charting and with nursing documentation skills, we selected open-source software to place on a password-protected server. We instructed students to chart on client care without revealing any personal client identity information after simulations and their clinical experiences in a long-term-care facility.
Instrument At the conclusion of a 15-week semester, students completed an anonymous EMR-use perception survey. The survey consisted of 12 questions/statements (see Table, Supplemental Digital Content 1, http://links.lww.com/NE/A159). The first question asked students if they used the EMR in their clinical groups. Another question was used to determine the number of EMR uses. An EMR use was counted as 1 use for each client assigned during an entire clinical shift or simulation episode. The possible number of EMR uses in the semester was 0 to 7. There were 2 questions about the realism of the EMR and the value of the EMR as a learning object. In addition, there were 8 statements about the students’ perceptions after using the EMR. These statements were developed to measure fundamental nursing concepts including safety, documentation, goals, client needs, prioritization, nursing process, training needs, and recommendations for continued use of an academic EMR. The statements were measured with a Likert scale for rating agreement/disagreement. The rating options were 0 through 5, with higher numbers indicating greater agreement with the statements. We used the Statistical Package for Social Sciences (SPSS) (version 22; IBM, Armonk, New York) to perform a factor analysis to examine the construct validity of the survey. Using eigenvalues greater than 1.0 as a cutoff, we conducted a principal component analysis with varimax rotation. Two factors had an eigenvalue greater than 1; they cumulatively explained 79.05% of the total variance, which was a satisfactory indication of construct validity. Factor 1 consisted of 7 items measuring perceptions of fundamental concepts: safety, documentation, goals, client needs, prioritization, nursing process, and recommendations. Factor 2 consisted of 1 item: training needs. Data Analysis We conducted data analysis with Microsoft Excel (version 2010; Microsoft, Redmond, Washington) and with SPSS. We ran descriptive statistics including frequencies and percentages for demographic data. For research question 1, we used minimums, maximums, means, and SDs. When analyzing data for research question 2, we calculated proportions, Pearson correlation, t tests, and z tests. Volume 39 & Number 6 & November/December 2014
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Results Demographic Information Participants in the study were third-year baccalaureate nursing students completing their first clinical course. The age of students was 20 to 49 years. The majority of students were enrolled full-time; only 2% were enrolled part-time. Twelve percent had worked as a nursing aide or technician prior to entering the collegiate program.
‘‘yes’’ to realism and ‘‘no’’ to realism. There were 146 students who answered yes to realism; their mean EMR use was 4.36 times. There were 47 students answered no to realism, with a mean EMR use of 3.64 times. A 1-tailed t test confirmed that the means were different (t79 = 2.77, P = .0035). We also ran a t test to examine differences in the number of EMR uses between students who answered yes to helpfulness of the learning object. There were 166 students who answered yes to learning object; their mean EMR use was 4.37 times. There were 43 students who answered no to learning object, and the mean EMR use was 3.37 times. A 1-tailed t test confirmed that the mean EMR use was statistically different (t72 = 3.97, P = .00008). The t test found differences in mean EMR uses, but we wanted to know if there was a number of EMR uses that could be established as a minimum for positive perceptions. We found that 66 of the 78 respondents (84.6%) who used the EMR 5 or more times answered yes to realism, whereas only 80 of the 115 respondents (69.6%) who used the EMR less than 5 times answered yes to realism. A 2-proportion z test confirmed that the proportions were statistically different (z = 2.39, P = .0084). For the learning object question, we ran the same analysis. We found that 69 of the 78 respondents who used the EMR 5 or more times (88.5%) answered yes, but only 84 of the 118 respondents who used the EMR less than 5 times (71.2%) answered yes. A similar 2-proportion z test also confirmed that the proportions were significantly different (z = 2.86, P = .0021).
Student Perceptions of EMR as a Learning Tool for Fundamental Concepts A large percentage of students (94.5%) reported that they used the EMR for documentation during their first semester in the nursing program. On average, students used the EMR 4.10 (SD 1.63) times during the semester. Of the students who used the EMR, 72% (n = 159) had positive perceptions of the EMR as being realistic, and 75% (n = 166) had a positive perception of its being helpful in learning to document nursing care. We also measured perceptions of the EMR using 8 statements on the survey, which we reduced into 2 factors. Factor 1 contained statements about fundamental concepts including safety, documentation, goals, client needs, prioritization, nursing process, and recommendations for continued use of an academic EMR. The mean student perception about EMR on factor 1 was 2.88 (SD 1.46). The mean was slightly over the possible mean of 2.5, which indicated positive perceptions. Factor 2, training needs, had a mean of 2.73 (SD 1.63). This mean was above the possible mean of 2.5, but in this case, the results indicated that students perceived the need for more training.
Discussion
Level of EMR Use Needed for Positive Perceptions of EMR Software Of the 220 respondents, 203 recorded the number of times they used the EMR. We divided responses into subgroups based on the number of times the EMR was used, ranging from 0 to 7 times. We calculated the mean scores for 8 perception statements on the survey (Table). We observed that the mean scores for safety, learning documentation, student goals, client needs, prioritization, nursing process, and recommendation increased with the number of times the EMR was used. The only exception was training needs. We ran Pearson correlation coefficients between the number of times the EMR was used and the mean scores on 8 perception statements. The results were as follows: (1) the correlation coefficients between EMR use and each of the first 6 perceptions statements were all greater than 0.90, (2) the correlation coefficient between EMR use and training was j0.64, and (3) the correlation coefficient between EMR use and recommendation had a modest positive correlation coefficient of 0.72. These strong positive relationships indicated that the more students used the EMR, the more positive their perceptions were about the EMR. The negative correlation coefficient between EMR use and training needs was expected because as students used the EMR more often, they felt less training was needed. Next, we examined responses to 2 items we believed were important to understand EMR: realism and helpfulness as a learning object. We ran a t test to examine differences in the number of EMR uses between students who answered
Results from this study show that students can develop positive perceptions about EMR as a learning tool in their first semester of a nursing program. Lucas6 found that students who practiced with an EMR before the first day of clinical felt more confident with their EMR skills during clinical. Likewise, Melo and Carlton18 reported that use of academic EMRs helped students to feel confident in their ability to navigate an EMR and document their nursing care. Similar to other fundamental skills, students in this study needed to use the EMR numerous times to gain experience and develop positive perceptions about electronic documentation. On average, students in this study used the EMR slightly over 4 times, but with a large SD (1.63), we know students had variation in EMR use. Findings from the study indicate that students perceived the need for more training with the EMR. Moreover, the greater number of instances students used the EMR, the better their perceptions of EMR tools. Students who used the EMR 5 or more times had more positive perceptions than did the students who used the EMR less than 5 times. The findings also suggested a stronger perception of realism of the academic EMR with greater use. The participants felt they learned more about safety, client needs, and documentation as the number of uses reached 5 or greater. Lucas6 reported EMR activities in 4 weeks prior to students’ first clinical experiences. Hanson19 reported that EMR use over time, typically a semester, is needed for student competency. Our findings are consistent with those of Lucas6,19 and Hanson.6,19 Technology and information competencies need to be integrated throughout nursing curricula.20 While academic EMRs are useful as an adjunct to simulation experiences,
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students need practice with EMRs in clinical settings to be workforce ready.21 In addition, EMR experiences in simulation laboratories and in clinical practice help to meet Baccalaureate Essential IV.
Application to Practice Early in nursing programs, students need instruction in electronic documentation. Educators often struggle with the questions of how much practice is needed to learn this new skill. Our study demonstrated that positive student perceptions with an academic EMR required at least 5 times of documenting use. The study also provided empirical data on which to base teaching decisions when determining how many times to require students to perform technology assignments. Limitations and Future Research The study has several limitations that affect its generalizability. We conducted the study at a single university with a convenience sample from several cohorts of first-semester nursing students. We developed an instrument to measure student perceptions about an academic EMR as a learning tool focusing on topics appropriate to first-semester students. Therefore, we have several suggestions for future research. First, a multicenter study of academic EMRs with common instruments could be conducted. Such a study could include measurements to determine the optimal number of uses for positive student perceptions of academic EMRs. Second, studies could include student outcomes beyond student perceptions including self-efficacy, competency with academic EMR, and competency with EMRs in healthcare settings. Third, studies could be designed to examine student outcomes with academic EMRs across curricula to see if maturation of technology competencies occurs. Acknowledgment The authors thank Mary M. Hays, DSN, RN, for her support of this project.
References 1. Health Information and Management Systems Society (HIMSS). EMR Adoption Model. 2013. Available at http://www.himssanalytics .org/home/index.aspx. Accessed May 20, 2013. 2. Centers for Medicare and Medicaid Services (CMS). EMR Incentive Programs. 2014. Available at http://www.cms.gov/Regulationsand-Guidance/Legislation/EMRIncentivePrograms/index.html? redirect=/EMRIncentivePrograms. Accessed March 23, 2014. 3. American Association of Colleges of Nursing (AACN). The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington, DC: AACN; 2008.
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4. Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine (IOM). The Future of Nursing: Leading Change, Advancing Health. Washington DC: The National Academies Press; 2010. 5. Billings D. Guest editorial. Quality care, patient safety, and the focus on technology. J Nurs Educ. 2008;47(2):51-52. 6. Lucas L. Partnering to enhance the nursing curriculum: electronic medical record accessibility. Clin Simulat Nurs. 2010;6(3): e97-e102. 7. Anest R. Teaching Patient Safety with a Functional Electronic Medication Record. J Nurs Educ. 2013;52(5):30. 8. Vestal V, Krautwurst N, Hack R. CIN Plus. A model for incorporating technology into student nurse clinical. Comput Inform Nurs. 2008;26(1):2-49. 9. FauchaldS. CIN Plus. An academic-industry partnership for advancing technology in health science education. Comput Inform Nurs.2008;26(1):4-8. 10. Baillie L, Chadwick S, Mann R, Brooke-Read M. A survey of student nurses’ and midwives’ experiences of learning to use electronic health record systems in practice. Nurse Educ Pract. 2013;13(5):437-441. 11. Gardner CL, Jones SJ. Utilization of academic electronic medical records in undergraduate nursing education. Online J Nurs Inform. 2012;16(2):31-37. 12. Brooks CL, Erickson LK. What is the solution for clinical nurse educators and the electronic medical record?. Teach Learn Nurs. 2012;7(4):129-132. 13. Johnson DM, Bushey TI. Integrating the academic electronic health record into nursing curriculum: preparing student nurses for practice. Comput Inform Nurs. 2011;29(3):133-137. 14. Jones CA, Richards E. The impact of nursing students’ use of electronic health records in the home setting. Home Healthc Nurse. 2013;31(9):474-481. 15. Jones S, Donelle L. Assessment of electronic health record usability with undergraduate nursing students. Int J Nurs Educ Scholarsh. 2011;8(1):1-18. 16. Kuiper R. Metacognitive factors that impact student nurse use of point of care technology in clinical settings. Int J Nurs Educ Scholarsh. 2010;7(1):1-15. 17. OpenEMR. Available at http://www.open-emr.org/. Accessed August 2010. 18. Melo D, Carlton K. CIN Plus. A collaborative model to ensure graduating nurses are ready to use electronic health records. Comput Inform Nurs. 2008;26(1):8-12. 19. Hanson DS. Nurse Educators’ Consensus Opinion on Using an Academic Electronic Health Record: A Delphi Study. [dissertation]. Grand Forks, ND: University of North Dakota; 2013. 20. Mahon P, Nickitas D, Nokes K. Faculty perceptions of student documentation skills during the transition from paper-based to electronic health records systems. J Nurs Educ. 2010;49(11): 615-621. 21. McGonigle D, Mastrian K. Nursing Informatics and the Foundation of Knowledge. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2015.
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