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Evolution of a Graduate-Level Informatics Course for the Noninformatics Specialist Nurse Roxanne Beckham, DNP, RN, and Kathy Riedford, PhD, RN

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ABSTRACT The design evolution of a novice-level informatics course for nurses in a nurse practitioner, educator, and leadership track graduate nursing program is described in this article. The support of nurse empowerment to recognize a personal role and develop skill competency in information management is the desired course outcome. The course evolution incorporates activities that encourage students to make connections between the concepts of informatics and the practice environment. Journal Entries Wk2&3 Assignment

Keywords: course design, informatics, information management, information needs, novice informatics � 2014 Elsevier, Inc. All rights reserved.

ince the publication of the revised The Essen- tials of Master’s Education in Nursing, which

Sdevoted an entire section to informatics and 

health care technology knowledge and skills, the inclusion of an informatics course in graduate cur- riculums has proliferated.1 Students who may have neither previous informatics experience nor infor- matics interest are now required to complete the informatics course. Some graduate students experi- ence apprehension about informatics course expec- tations, and some faculty may express reluctance to teach an informatics course.

The purpose of this article is to describe how a newly developed novice-level graduate informatics course evolved to pique students’ curiosity regarding informatics and meet the information management needs of students who are pursuing a nurse practi- tioner (NP)e, educator-, or leadership-focused graduate education.

BACKGROUND Clarity regarding specific goals of the informatics course is an initial and crucial step in preparing stu- dents and faculty for the integration of this type of course into the graduate curriculum. Confusion oftentimes exists that informatics is synonymous with

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computer class. Informatics has been defined more accurately as focused on information instead of technology.2,3 The management of information is certainly not a new concept in nursing. The chal- lenge for graduate faculty is to design an informatics course that prepares the professional nurse to perform the critical skill of information management while relegating technology to its position of merely being a tool for nurses to use. Technology is not the driver of nursing practice.

Courses for the informatics specialist role have been designed in many colleges of nursing, but these courses may exceed the learning needs and interest of the informatics novice. The 4 levels of informatics competency for nurses have been described as novice, advanced, specialist, and innovator2 (Table 1). The curriculum for the informatics specialist role has been well described, but there is a paucity of literature that describes how essential informatics concepts are in- tegrated into the curriculum for the novice. Although some level of informatics knowledge is an expecta- tion for all nurses, there is a lack of consistency re- garding the associated informatics competencies required for each level.2

Some graduate programs meet the American Association of Colleges of Nursing (AACN) informatics

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Table 1. Novice-Level Informatics Competencies

The nurse will have the ability to

� Access electronic resources and technology � Use information systems in an ethical manner � Use evidence-based practice knowledge to support care delivery

� Use computer-based patient records Data from the American Nurses Association.

2

standards by embedding informatics components into a current course. The development of informatics as a core curriculum course is another method to meet AACN expectations. A clearly understood connec- tion from informatics to the student’s area of practice is an imperative component of the novice informatics course regardless of design. Recognition that infor- mation management is a competency for all nursing roles and not simply a skill to be performed by the informatics specialist is significant to encourage stu- dent engagement in the course.

As with any course, it is important that updates occur based on evaluation and evolving content expectations. Course evaluations are based on clear connections among all components of the learning experience, including course objectives, teaching strategies, evaluation strategies, and student out- comes.4 Student learning needs have become more apparent to faculty with each semester of teaching the informatics course. Course revisions have been made based on student performance, feedback, and the evolving health care environment. Journal Entries Wk2&3 Assignment

INITIAL COURSE DESIGN AND EVALUATION In keeping with AACN standards, a 3-credit hour asynchronous online core curriculum informatics course was developed in a Midwestern university. AACN’s The Essentials of Master’s Education in Nursing was used as the developmental framework to ensure the informatics course design met the following necessary objectives: (1) analyze current and emerging technologies; (2) evaluate outcome data; (3) incorporate ethical principles for technology use; (4) develop strategies to document patient care and measure outcomes; and (5) use technology to educate patients, guide practice, and support lifelong learning.1

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In addition, the course was designed to facilitate student recognition and articulation of information needs in a manner that showed excellence in infor- mation management regardless of nursing track specialty. The student course evaluation strategy used was based on the completion of 11 group activities and peer discussions conducted through a Web-based delivery system. In addition, each student completed 2 assigned scholarly papers that showed personal use of informatics concepts and critical thinking. Each assignment was designed to meet a course objective and provide an informatics fundamental learning experience that students could link to their prac- tice settings.

The primary intent of the informatics course was that the patient, as the central focus of an interprofessional team, would benefit from each health care provider having clearly identified and implemented informatics skills. These commonly shared informatics skills support the assertion that the management of information will have a positive impact on health care quality and effectiveness.5

Clearly defined information needs recognized by the nurse were a faculty assumption in the infor- matics course. There was also an assumption of empowerment by the nurse to articulate the need for or revision of critical information not currently available for patient care. Journal Entries Wk2&3 Assignment

Student failure to recognize a personal role in information need determination and articulation became apparent through teaching the course. The practice gap was recognized through submitted scholarly papers, course discussions, and survey re- sponses. Although the ability to find pertinent data from within the volumes of data presented from all sources was discussed as a key information manage- ment role for nurses, the skill was not evident.6

Based on the evaluation of student online discussions, faculty identified the need for student experiential practice to explore current practice situations in relation to the identification of information needs and data use. Experiential learning is supported as a way to integrate course knowledge and skills into the practice environment.7

Nurses use data transformed into information to make clinical practice intervention decisions.2 It is essential that nurses have opportunities to develop

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recognition of crucial information needed to evaluate the quality of presented data before developing in- terventions. Accurate, timely, and up-to-date clinical information for 90% of clinical decisions by 2020 is a goal that reinforces the nursing role across settings.8

Therefore, the need for the NP, nurse educator, and nurse leader to acquire informatics role prepa- ration is obvious.

METHODS The Staggers Nursing Computer Experience Ques- tionnaire (SNCEQ) was offered to students before and after the informatics course during the first 3 semesters the course was offered.9 The SNCEQ survey was used to provide insight regarding students’ previous technology experiences and perceived data management skills. Students were given the option to anonymously complete the SNCEQ survey, which included 2 open-ended questions developed by the informatics faculty: (1) How do you identify your need for information/data? and (2) How do you identify your need for data revision?

Scoring the SNCEQ survey was based on subsets of computer use and knowledge as in- structed by the survey developer.9 The Cronbach alpha for the computer application and health information system of the survey is 0.89. The survey was formatted into Survey Monkey (Survey Monkey Inc., Portland, OR) for the purpose of this informatics course and was offered from the online informatics course at the beginning and again at the end of the semester. The total number of students completing the precourse survey over the 3 semesters was 175. Postcourse surveys were completed by 91 students over the 3 semesters.

Survey Findings Based on the review of student responses to the open-ended questions, the transfer of informatics course concepts to personal practice was not evident. The finding led to faculty concern because there had been an expectation of informatics competency diffusion to the work setting. The diffusion expec- tation is consistent with the progressive and successful introduction and transfer of an innovative idea into an organization.10

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The predominant method students reported to sort and place value on presented information was related to the availability of patient data. The method suggests nurse acceptance of data as presented by the current electronic system. The student re- sponses related to how the need for data revision is identified were variable, but 13.18% of postcourse survey respondents expressed a lack of perceived empowerment to communicate a data need or im- pact change. Based on survey findings, the faculty identified the need to update the informatics course to more clearly articulate the theory and nursing practice link in all course objectives, lectures, and assignments. Journal Entries Wk2&3 Assignment

The quantitative SNCEQ survey findings will be discussed in detail in a separate article. The quanti- tative findings indicated a self-reported student pre- to postcourse score improvement for computer application and knowledge. The improved SNCEQ scores did not correlate to the open-ended ques- tion responses.

COURSE REDESIGN Course Objectives The primary learning objective of an informatics course is nurse competency to efficiently and effec- tively manage information critical for health care delivery. The acknowledged link between infor- matics concepts and nursing practice is the outcome expectation for all students completing the graduate informatics course. Based on the evaluation of stu- dent performance and survey responses, a decision was made to revise the graduate-level informatics core course after it had been taught over the period of 3 semesters.

The redesigned informatics course objectives remain based on the AACN Essentials of Master’s Education in Nursing.1 Bloom’s taxonomy frame- work is used for measuring the cognitive levels of learning for the course.11 Course objectives were revised to reflect higher cognitive skill performance expectations. The use of terms such as synthesize and evaluate promote student focus on the development of a better understanding of concepts and critique of processes instead of regurgitation of textbook facts (Table 2). Journal Entries Wk2&3 Assignment

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Table 2. Informatics Course Foundation

Author Topical Content Course Design

American Association of Colleges

of Nursing 1

The Essentials of Master’s Education

in Nursing

Course objectives

American Nurses Association 2

Nursing informatics: scope &

standards of practice

Competency expectations

Oermann and Gaberson 11

Bloom’s taxonomy Cognitive level of learning

McBride 12

Nurse role (empowerment) Student recognition of personal role in

informatics engagement

McGonigle and Mastrian 13

Nurse as knowledge worker Student application of high-level cognitive

talents to show informatics competencies

Sternberg 14

and Sternberg et al 15

Balance theory of wisdom Decision-making model that allows student

to rehearse an informatics solution in a

balanced manner

Rogers 10

Diffusion of innovations Student recognition of need to diffuse

acquired informatics competency to

the work setting

A practice link for students in the NP, educator, or leadership tracks is incorporated into each com- ponent of the revised informatics course. Students are encouraged to examine the impact of informa- tion management on their practice role during the initial week of the course. Active and creative problem solving are communicated by the faculty to be ideal student behaviors in the course. Current workplace computer documentation screens, infor- mation availability challenges, and patient scenarios are submitted by students to be critiqued in a professional and innovative manner. A sense of em- powerment to actively engage in change processes in the health care environments is expressed by fac- ulty as an expected learning outcome. Journal Entries Wk2&3 Assignment

In the first online peer discussion of the course, students are introduced to an opinion that was expressed in 2005 and asked to compare and syn- thesize how the current environment is different. The opinion voiced was that “nurses are the primary users yet their voices and opinions are frequently omitted from procurement, design, and imple- mentation phases of IT [information technology] adoption.”12 Nurse recognition of a personal impact on the overall health care system through active engagement in informatics is an expected student course outcome. The design of the informatics course in a manner that piques student interest and connects

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concepts to practice is proposed to achieve course outcomes.

Teaching Strategies The asynchronous online course is presented using the Blackboard learning system (Blackboard Inc., Washington, DC). Lectures are presented using the collaboration tool VoiceThread (VoiceThread LLC, Boca Raton, FL), and students are assigned readings from the course textbook.13 Although readings from various scholarly journals are assigned, the informatics education foundation is provided by the course textbook. Recorded lectures by faculty reinforce key concepts from the text. All course assignments are designed to complement, not replace, activities in the textbook. The nurse is identified in the textbook as a knowledge worker who must apply high-level cognitive talents, such as ingenuity, creativity, and initiative, to show utilization of informatics skills to their fullest potential.13 The designation as a knowledge worker implies the nurse is an active participant in information management versus a passive recipient. The knowledge worker is empowered to identify information needs and artic- ulate the need for information revisions. Journal Entries Wk2&3 Assignment

Students are assigned 5 activities and 2 scholarly papers during the semester, but the unique charac- teristic of the revised course is that students are given

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choices of assignments that match their interests and practice settings. Each assignment is designed to foster active problem solving based on the synthesis of readings and the evaluation of practice alternatives.

An example of a completed group activity was the creative design of a telehealth opportunity for a person with a specific health issue. The student group developed a telehealth solution proposal to positively impact quality and safety for the patient. The activ- ity included a discussion regarding the effect of financial and legal issues on the proposed telehealth solution and how the choice would impact the nurse’s role.

The ability to research and present an unbiased report on a controversial informatics issue was the focus of another course activity. The student findings were posted as a Voice Thread presentation, and classmates contributed responses. Informatics issues reviewed included the role of personal electronic devices, technology disaster readiness, system inter- operability, and patient record privacy. Journal Entries Wk2&3 Assignment

In the first scholarly paper, the student delves deeply into an informatics topic of personal interest. A rubric is offered to guide the student regarding key topical headings. Major categories addressed in the paper include a literature review, relationship of topic to health care quality and safety, anticipated changes attributed to the topic, and impact on nursing and interprofessional practice.

The second scholarly paper is focused on work- flow analysis of a current information management practice and how it could be redesigned to increase efficiency and effectiveness. The purpose is to pro- vide an opportunity to examine the procedural steps of technology designed for information gathering or sharing and offer recommendations. Students eval- uate planning and actions required to implement a successful change. Awareness of the impact of the proposed change on the health care team is critical to successfully introduce the redesign into the workplace.

Before beginning the analysis for the second paper, lectures and assigned reading are provided to articulate Sternberg’s balance theory of wisdom.14

The theory serves as a model for the decision-making process of the change proposal that will impact the

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interprofessional health care team. Sternberg’s theory is the framework for balanced decision making that considers choices to meet the shared needs of pa- tients, the health care team, and the organization to achieve desired goals. Sternberg’s theory evolved from the constructivist viewpoint and is useful to guide students in the development of critical thinking skills and decision making that moves beyond an egocentric view.15 The graduate student has an op- portunity to rehearse an informatics solution that considers the information needs of the interprofes- sional team.

Evaluation Strategies The expected student utilization of the higher-level cognitive skills of analysis, synthesis, and evaluation were identified in the course objectives. The achievement of objectives and the acquisition of classroom knowledge are not synonymous with the ability to transfer knowledge to practice. The re- quirements of the course link to the practice setting to provide an opportunity for skill rehearsal. Sup- portive and constructive timely individual feedback from faculty is given throughout the semester re- garding each assignment.16 The faculty objective is to support the development of students’ confidence with informatics through constructive feedback. Journal Entries Wk2&3 Assignment

An advisory council, composed of nursing leaders, has been queried regarding current informatics practices in the region. These stakeholders have been informed of the course revisions, and their feed- back has been requested regarding any nurse infor- mation management practice changes observed. In addition, anonymous student formative and sum- mative course evaluations are solicited by faculty to gain awareness of perceived student learning needs and course design suggestions. The SNCEQ survey and open-ended questions will be offered to students of the revised course.

The financial impact of failed technology imple- mentation has increased the motivation of health care organizations to increase the involvement of direct care providers in technology design.17 Student motivation to implement information management skills after the informatics course will be the final determinant of successful informatics knowledge and

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skill diffusion to practice. The sense of urgency for change may be enhanced by an informatics course that challenges students to recognize the value in informatics management skills and seize the oppor- tunity to engage.18

CONCLUSION The Institute of Medicine’s Future of Nursing report suggested that a variety of teaching strategies will be needed for nurses to achieve information manage- ment competencies.19 The design of the novice-level informatics course is an example of an innovative strategy to promote nurse development of informa- tion management confidence and skill. The primary goal is that students acquire and show excellence in information management competencies that are diffused into practice. The goal can best be achieved through active student engagement in an informatics course that piques interest, fosters empowerment, and provides an opportunity to rehearse skills in a supportive environment. Journal Entries Wk2&3 Assignment

References

1. American Association of Colleges of Nursing (AACN). The Essentials of

Master’s Education in Nursing. http://www.aacn.nche.edu/education-

resources/MastersEssentials11.pdf. Updated March 21, 2011. Accessed

January 25, 2014.

2. American Nurses Association. Nursing Informatics: Scope & Standards of

Practice. Silver Spring, MA: Nurses Books Org; 2008.

3. Hersh W. A stimulus to define informatics and health information technology.

BMC Med Inform Decis Mak. 2009;9(24):1-6.

4. Billings DM, Halstead JA. Teaching in Nursing: A Guide for Faculty. St. Louis,

MO: Saunders Elsevier; 2009:369-385.

5. Tierney WM. Safe and effective health care systems. Paper presented at:

Summer Institute on Nursing Informatics; July 18, 2012; Baltimore, MD.

6. Staggers N. The April 2011 Hearing on EHR usability: crucial conversations

about optimal design column. Online J Nurs Inform. 2011; 15(2):section 3.

http://ojni.org/issues/?p¼542. Accessed January 25, 2014.

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7. Dillard N, Siktberg L. Curriculum development: an overview. In: Billings DM,

Halstead JA, eds. Teaching in Nursing: A Guide for Faculty. St. Louis, MO:

Saunders Elsevier; 2009:75-91.

8. Institute of Medicine. Clinical Data as the Basic Staple of Health Learning:

Creating and Protecting a Public Good: Workshop Summary. Washington,

DC: The National Academies Press; 2010.

9. Staggers N. The Staggers Nursing Computer Experience Questionnaire. Appl

Nurs Res. 1994;7(2):97-106.

10. Rogers EM. Diffusion of Innovations. 3rd ed. New York, NY: The Free Press;

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11. Oermann MH, Gaberson KB. Evaluation and Testing in Nursing Education.

4th ed. New York, NY: Springer Publishing Company; 2014.

12. McBride AB. Nursing and the informatics revolution. Nurs Outlook.

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13. McGonigle D, Mastrian KG. Nursing Informatics and the Foundation of

Knowledge. Burlington, MA: Jones & Bartlett; 2012:282.

14. Sternberg RJ. A balance theory of wisdom. Rev Gen Psychol.

1998;2(4):347-365.

15. Sternberg RJ, Reznitskaya A, Jarvin L. Teaching for wisdom: what matters is

not just what students know, but how they use it. London Rev Educ.

2007;5(2):143-158.

16. Vioral AN, Gaberson KB. Online testing and assessment of learning. In:

Oermann MH, Gaberson KB, eds. Evaluation and Testing in Nursing

Education. 4th ed. New York, NY: Springer Publishing Company;

2014:205-214.

17. Lorenzi NM, Novak LL, Weiss JB, Gadd CS, Unerti KM. Crossing the

implementation chasm: a proposal for bold action. J Am Med Inform Assoc.

2008;15(3):290-296.

18. Kotter J. A Sense of Urgency. Boston, MA: Harvard Business Review Press;

2008:60.

19. Institute of Medicine. Committee on the Robert Wood Foundation Initiative on

the Future of Nursing. The Future of Nursing: Leading Change, Advancing

Health. Washington, DC: The National Academies Press; 2011.

All authors are affiliated with the University of Southern Indiana in Evansville. Roxanne Beckham, DNP, RN, CNE, NE-BC, is the course coordinator for graduate nursing informatics and can be reached at Rbeckham@usi.edu. Kathy Riedford, PhD, RN, PMHNP-BC, is an associate professor of nursing. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.

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