Foster, M. & Sethares, K. (Fall, 2017). Current Strategies to Implement Informatics into the Nursing Curriculum: An Integrative Review. Online Journal of Nursing Informatics (OJNI), 21(3).
Background: Informatics has rapidly developed over the last decade as an integral part of health care. Knowledge in informatics can improve both the safety and quality of care given to patients. While there is a significant body of literature related to informatics, many nursing schools have been slow to adopt informatics education into the curriculum.
Purpose: The purpose of this integrative review was to: (1) Describe the most current strategies used to implement informatics into the nursing curricula. (2) Describe facilitators and barriers to implementation of informatics into nursing curricula.
Methods: The integrative review of the literature was conducted using the Whittemore and Knafl five-stage methodology. The electronic databases CINAHL, Medline, ERIC and PsychINFO were searched using the terms “(nursing informatics AND curriculum AND education)”. Eighty-five articles were found.
Results: Twelve studies were included in this review. Strategies to implement informatics include (a) using a Learning Management System to support classroom-based courses, and (b) having students complete an electronic health record during a simulation experience. Factors that will facilitate adoption included: (a) focus on providing training on what and how to incorporate informatics and (b) hiring Master’s prepared informatics nurses to champion the integration of informatics. Barriers to adoption included: (a) lack of faculty competence in the use of technology and (b) lack of faculty awareness of informatics curricular guidelines.
Conclusions: Nursing schools must find ways to incorporate informatics into curricula to ensure that future graduates are prepared to function in a highly technological healthcare environment.
Informatics is an integration of basic computer skills, information literacy and information management which are essential components of current nursing practice (Technology Informatics Guiding Educational Reform (TIGER), 2009). With the constantly changing landscape of healthcare, nurse educators are faced with many challenges in preparing students for the increasing complexities of the work environment. The current expanded use of computers and information systems in healthcare means that all healthcare workers, especially nurses will need to interface with multiple technological sources to either enter or extract data to aid them in caring for patients (Gonen, Sharon, Offir & Lev-ari, 2014; Benner, Sutphen, Leonard and Day, 2010). This highly technological environment demands that nursing students are educated to think critically and exercise clinical decision- making while delivering safe quality care. This sentiment is echoed by an AACN (2008) report that noted that registered nurses need critical thinking skills, independent clinical judgment, management and organizational skills, leadership abilities, and technological understanding to practice in the varied healthcare settings that exist. It is therefore important to educate nursing students on how to use available technologies to access evidence-based data that supports decision-making as well as how to input and retrieve data pertinent to patient care.
Current research indicates that the use of healthcare information technology is expected to grow significantly and therefore, all prospective healthcare professionals must develop strategies for managing these continuing changes (De Gagne, Bisanar, Makowski & Neumann, 2012). The Institute of Medicine (IOM) (2003) proposed five core competencies that all health clinicians should have, regardless of their discipline, in order to meet the needs of the 21st- century health system. These five core competencies are provision of patient-centered care, interdisciplinary collaborative working teams, engagement in evidence-based practice, and application of quality improvement practices as well as the utilization of informatics.
Although informatics as a discipline has become ubiquitous in healthcare, nursing schools continue to struggle in their efforts to integrate it into their curricula (Hunter, McGonigle & Hebda, 2013; McBride, Tietze & Fenton, 2013). Educating nursing students about informatics is vital to provide them with evidence-based data so that patients can receive the best care.
Nurses who are experienced with using technology and databases are able to retrieve information to make sound decisions based on current research rather than opinion (O’Connor, 2011).
Ensuring that nursing graduates meet professional expectations for competence in informatics is an important baccalaureate nursing program outcome (Waters, Rochester & McMillan, 2012; Jones & Donelle, 2011; Williamson, Fineout-Overholt, Kent & Hutchinson, 2011).
Inconsistent infusion of informatics knowledge and skills into nursing education is commonly cited (Hunter, McGonigle & Hebda, 2013). Compounding the situation is the lack of consensus on how to integrate informatics content into nursing curriculum (Spencer, 2012). One factor that may be impacting this problem is the notion that millennials, the largest group of consumers of higher education, are not only skillful at using technology but are more adept at using it than faculty (Hwang & Park, 2011).
The notion that millennial students are skilled in technology use may be true; however, students entering nursing programs today are a mixed body of traditional and non-traditional students who are widely varied in their informatics competency and are most likely deficient in most aspects of informatics (Gonen, Sharon, Offir & Lev-ari, 2014). Also, mastery of technology does not necessarily suggest that one has a mastery of informatics or information technology (Byrne, 2012). In a study conducted by Choi (2012) it was noted that students are competent in basic computer knowledge (searching the internet, word processing, and multimedia presentation) but not in information literacy, which is a subset of informatics that includes the ability to recognize, efficiently access and determine the extent of information needed, critically evaluate information and its sources as well as incorporation of that information into their knowledge base (Button, Harrington & Belan, 2014; Flood, Gasiewicz, Delpier, 2010; Bundy, 2004).
There remains a major gap in informatics education in nursing programs that needs to be addressed in order to ensure that students are proficient in managing and using healthcare information (Button, Harrington & Belan, 2014; Hwang & Park, 2011). Attending to this gap will enable nurse educators to effectively integrate informatics into the curricula and to adequately prepare student nurses for future nursing roles. Therefore, the purpose of this article is to present the findings from an integrative review of current strategies to implement informatics into nursing curricula and to review facilitators and barriers to it’s’ implementation.
This integrative review used the Whittemore and Knafl (2005) integrative review methodology to address the following research questions: (1) what are current strategies employed by schools of nursing to implement informatics into the undergraduate and graduate nursing curricula? (2) What are the facilitators and barriers to implementation of informatics into undergraduate and graduate nursing curricula? Three databases were used for the literature search CINAHL, ERIC and Medline. The search terms were “nursing informatics” AND “curriculum AND “education.” Articles had to be published between 2011- 2016. The timeframe was chosen because it captured a time period where there was increased government support for the implementation of information technology in healthcare. The search generated 85 articles after the duplicates were removed and two articles were obtained from hand searching.
Article inclusion criteria were limited to those published in English. Exclusion criteria included articles discussing informatics strategies in a non-academic environment. All of the articles were screened and 12 met the inclusion criteria and were included in this review. Data analysis was accomplished with the utilization of a matrix of the articles based on the Hawker et al. (2002) review criteria (see Table 1).
A total of 11 out of the 12 studies included in this review described strategies to implement informatics into the nursing curriculum. Strategies focused on faculty, students and course development processes. Studies included four quantitative (descriptive surveys) and eight qualitative (two explorative qualitative studies and six retrospective analyses of data studies). A summary of results is listed in Table 1 and strategies to implement informatics into the curriculum are summarized below.
Strategies to Support Faculty to Implement Informatics. Judicious use of information from a range of sources and thoughtful consideration of current and future contexts of the role informatics will play in health care are necessary to employ when integrating informatics throughout the curriculum however this process needs to be undergirded with support for faculty (Waters, Rochester & McMillan, 2012). Six out of the 12 studies discussed varied supportive strategies for faculty. It is important to recognize that faculty need support from outside personnel and also from their peers. Peer support can help faculty understand and master informatics competencies and to integrate them into the nursing curricula (Madsen, Cummings & Borycki, 2015). If the peers are not able to provide support then consulting or contracting with another school or department within the educational institution to address integration of informatics into the curriculum may be another option (Fulton, Meek & Walker, 2014). In addition, to peer mentoring, and the use of a consultant, requiring faculty to have an informatics competency as part of their professional development is a strategy that can improve the faculty member’s ability to teach informatics (Kowitlawakul, Chan, Wang & Wang, 2014). Assessing the need for faculty training in informatics by administration prior to beginning training will inform the development of a targeted faculty training related to integrating informatics into the curriculum (Nguyen, Zierler & Nguyen, 2011). Providing faculty with an inventory of informatics resources and tools on how to teach students informatics can help to guide faculty (Madsen, Cummings & Borycki, 2015; Nagle et al., 2014). An inventory of resources can be housed on a learning management system to enable faculty to have easy access to credible website resources (Stephens-Lee, Lu & Wilson, 2013).
Strategies to Enhance Undergraduate and Graduate Students Readiness for Informatics Teaching. Students also need support to enable them to be prepared to incorporate higher-level informatics principles into their knowledge repertoire. Students should pursue basic knowledge of informatics (e.g. be able to use a computer or a word processing program) prior to entering a higher educational institution (Borycki & Foster, 2014).
Strategies to Use When Designing Courses for Undergraduate Students. Develop baseline informatics competencies of students upon entry into the program by utilizing computer- generated, computer-graded assessment tools that allow for immediate feedback upon completion of the assessment and using the results to prioritize what informatics strategies should be included in the curriculum (Choi & Zucker, 2013) and/or direct students to resources to help them develop those competencies. Using four major content areas typically found in curricula, professional responsibility, care delivery, community nursing/care of populations and leadership/management faculty can design and level more specific informatics content as students move from freshman to senior year (Frisch & Borycki, 2013). Another strategy is to introduce case scenarios in the student’s freshman year that increase in difficulty over the course of the student’s education (Stephens-Lee, Lu & Wilson, 2013). Faculty should also consider using the Knowledge Skills and Attitudes (KSAs) framework that was developed by Quality and Safety Education for Nurses (QSEN) to organize informatics specific content. Guided by the KSAs, the content can then be embedded into didactic, clinical or laboratory courses across the curriculum and linked to a learning activity (Spencer, 2012).
Strategies to Use When Designing Courses for Graduate Students. Only two articles discussed strategies to use specifically with graduate students. One strategy is to emphasize accessing or extracting information from clinical data sets (e.g. minimum data set) and seeking available resources to help in ethical decision making in computing or using educational materials (e.g. e-learning) (Choi & De Martinis, 2013). This strategy mirrors data used in practice. Finally, incorporating language specific to informatics into course outcomes to make it more explicit can ensure that activities related to the outcomes are implemented (Stephens-Lee, Lu & Wilson, 2013).
Facilitators to implementation of informatics into nursing curricula. A total of 12 studies described facilitators to implementation of informatics into the nursing curriculum. Strategies that are helpful to faculty enable them to feel supported by administrators and their peers.
Establishing a network of peers who can help share knowledge within a college department or across the university can help maintain faculty engagement with incorporating informatics into their teaching (Madsen, Cummings & Borycki, 2015). While support is necessary there are things that faculty can do to improve their understanding of informatics and therefore enable them to incorporate informatics with their students at different levels. Faculty can attend workshops and complete individual training along with negotiating with administration to obtain adequate time to integrate innovative new technologies into curriculum (Kowitlawakul, Chan, Wang & Wang, 2014; Nagle et al., 2014; Frisch & Borycki, 2013; Nguyen, Zierler & Nguyen, 2011). Training should focus on what to use and how to incorporate informatics into existing content areas (Frisch & Borycki, 2013). Another strategy is the use of an informatics champion who is informatics-certified or has a master’s degree or higher in informatics (Fulton, Meek & Walker, 2014). This person has specialized training and can assist the faculty to implement informatics across the curriculum.
All of the above-mentioned facilitators were effective because of training, financial and technical support from administration. Having Deans and program directors that were educated about the Technology Informatics Guiding Education Reform (TIGER) initiatives increased the likelihood that support would be given to faculty to enable them to integrate informatics into the curriculum (Fulton, Meek & Walker, 2014; Kowitlawakul, Chan, Wang & Wang, 2014). Lastly, collaboration and commitment between faculty and administrators to implement and thread informatics throughout the curriculum was a powerful facilitator (Choi & Zucker, 2013; Gardner & Jones, 2012)
Barriers to implementation of informatics into nursing curricula. To successfully integrate informatics into the curricula, barriers that hinder its integration must be addressed. Barriers include lack of training on how to integrate informatics, lack of support for gaining access to informatics knowledge and lack of collaboration within the organization. There remains a lack of clarity on how to integrate informatics competencies into the curricula (Borycki & Foster, 2014). One barrier that still exists is faculty’s unfamiliarity with the TIGER competencies framework and report (Fulton, Meek & Walker, 2014). Lack of support and training on how to implement informatics into the curriculum was cited as a barrier, in particular lack of concrete examples on how to or where to bring a wide range of informatics competencies into the curricula (Kowitlawakul, et al., 2014; Nagle et al., 2014; Frisch & Borycki, 2013: Stephens-Lee, Lu & Wilson, 2013; Gardner & Jones, 2012). Lack of collaboration with other nursing instructors to efficiently and effectively incorporate informatics served as a barrier in some instances due to faculty resistance and/or discomfort with technology (Choi & De Martinis, 2013; Gardner & Jones, 2012; Spencer, 2012).
The studies reviewed represented an attempt to extrapolate the most current strategies used to integrate informatics into the curriculum. However, there were insufficient strong conclusive studies. The number of studies that investigated the current use of strategies to implement informatics into nursing curricula were low given that informatics has become more ubiquitous in healthcare. Another limitation was that all of the studies meeting inclusion criteria were qualitative and used a variety of methods to collect data. A further limitation was that seven out of the 12 studies were conducted at a single site.
Many strategies have been identified to help nursing faculty integrate informatics into the nursing curriculum of undergraduate and graduate students. This review provides a current update on strategies to enable university-based educators to integrate informatics into curricula at both the graduate and undergraduate levels. The strategies guide faculty to the available resources for implementing informatics and offers ways for faculty to level informatics within the curriculum using case scenarios that range in complexity. The guidance is also coupled with encouragement to faculty to seek help within and outside of their schools. To be successful at implementing these strategies it is important that faculty recognize the barriers that may exist that will serve as roadblocks. These roadblocks must be addressed if the nursing profession is going to strengthen its informatics expertise as other healthcare professions are already doing at a rapid pace (Hussey & Kennedy, 2016).
A keen awareness of the importance and uniqueness of the nursing profession’s role in defining context for education and training with external stakeholders is also essential (Hussey & Kennedy, 2016). Therefore, nursing curricula needs to be responsive to innovations in practice, teaching and learning (Waters, Rochester & McMilan, 2012). In order for curriculum to be responsive, competing demands for other curriculum content along with a lack of faculty preparation in informatics has to be addressed (Button, Harrington & Belan, 2014).
Furthermore, there is a lack of specificity as to the precise informatics competencies expected of student nurses prior to graduation from undergraduate nursing programs (Borycki & Foster, 2014). Without faculty and administrators making a concerted effort to work together for the implementation of informatics into the curriculum nursing continues to run the risk of graduating students who are proficient in theoretical content but inept in how to function in a highly technological healthcare environment.
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Marva Foster, PhD(c), RN, CHSE, Interim Director of Simulation Lab/Lecturer, Adult Nursing College of Nursing NLN SimLEAD Cohort 2016
PhD in progress University of Massachusetts Dartmouth, MA
MSN University of Rhode Island, Kingston, RI
BSN Rhode Island College, Providence, RI
Kristen Sethares PhD, RN, CNE, FAHA, Professor of Nursing, PhD Graduate Program Director, Nursing Honors Coordinator
PhD, Boston College School of Nursing, Chestnut Hill, MA
MSN, University of Massachusetts Boston, School of Nursing, Boston, MA
BSN, Southeastern Massachusetts University, College of Nursing, Dartmouth, MA