Citation: Miller, L., Stimely, M., Matheny, P., Pope, M., McAtee, R. & Miller, K. Novice Nurse Preparedness to Effectively Use Electronic Health Records in Acute Care Settings: Critical Informatics Knowledge and Skill Gaps. Available in the Online Journal of Nursing Informatics (OJNI),18 (2).
The ability of nurses to use an Electronic Health Record (EHR) effectively is critical to patient safety, decreased facility expenditures for training, and reduced healthcare costs. To use EHRs effectively, nurses must have the required knowledge and skills. The purpose of a quantitative descriptive study conducted in 2012 was to identify what, if any, gaps exist between the informatics knowledge and skills self-reported by new/novice nurses and the informatics knowledge and skills demonstrated in acute-care settings by new/novice nurses as reported by nurse managers. Survey responses from 222 new/novice nurses and 326 nurse managers revealed gaps in 13 of 28 knowledge and skills areas thought to be critical to effective EHR use.
For more than 25 years, U.S. healthcare organizations have been moving from paper-based medical records to electronic health records (EHR). With EHRs, healthcare organizations can enter, retrieve, and update individual patient records. EHRs provide healthcare organizations with tools, such as reminders and alarms, to help automate processes for improved clinical accuracy and outcomes.
The Institute of Medicine published the landmark document, To Err is Human (2000), reinforcing the importance of such a movement by addressing the high rate of medical errors occurring in the U.S. healthcare system. The Institute of Medicine identified EHRs as tools for increasing patient safety and decreasing the cost of healthcare.
Recognizing the high costs of implementing an EHR system and properly training the stakeholders who will be using it, Congress passed and President Obama signed into law the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was enacted under the American Recovery and Reinvestment Act of 2009 (Obama, 2009). The law incentivized the adoption and meaningful use of electronic health records and other health IT systems.
Despite healthcare expenditures comprising 17.6 % of the gross national product (GNP) in 2009 (U.S. Department of Health and Human Services [HHS], 2011), healthcare industry use of electronic records lags behind other GNP industries. The GNP is anticipated to increase by 6.1 percent each year through 2019 (HHS, 2011). The move to EHRs is placing a greater burden on the resources of an already struggling U.S. healthcare system (Bhattacherjee, Hikmet, Menachemi, Kayhan, & Brooks, 2007; Murphy, 2014; Porter & Lee, 2013).
The HITECH Act provides $19 billion for reimbursement to healthcare facilities for the costs of implementing an EHR and training healthcare providers to use it. The Centers for Medicare & Medicaid Services (CMS) allocates reimbursement to healthcare facilities if the EHR software system obtains and calculates specified percentages of each core and menu objective identified by Meaningful Use criteria (Centers for Medicare & Medicaid Services, 2014). Nurses can influence reimbursement received by healthcare facilities through their documentation of patient care. The ability of healthcare providers, such as new/novice nurses, to access and use an EHR system quickly and efficiently is believed to decrease facility expenditures for training, improve patient safety, decrease healthcare costs, and support meaningful-use reimbursement (for example, see Evall, Ren, Tuite, Reynolds, & Hravnak, 2014; HealthIT.gov, 2014; Kallem, 2011; King, Patel, Jamoom, & Furukawa, 2014).
The current healthcare system, both system-wide and at the facility level, is experiencing changes related to EHR usage. Changes while transitioning to EHRs impact the entire healthcare organization and directly affect patient care (Bhattacherjee et al., 2007). Nurses are the largest number of employees in acute-care settings (Furukawa, Raghu, & Shao, 2010) and how effectively nurses are able to use EHRs has the greatest potential impact on patient care.
As healthcare organizations operationalize EHR use, the transition to using EHRs influences nursing documentation, care delivery, and staffing (Robles, 2009). Nurses have long heard “if it wasn’t charted, it wasn’t done.” As well known in the healthcare profession, computer documentation can help decrease documentation deficiencies because an EHR system’s prompts remind a nurse to chart important care aspects, creating a complete clinical record of a patient’s condition. Nursing program education provides the nurse with the fundamental and specific professional nursing knowledge for using the clinical decision support systems incorporated in EHRs. Nurses can also be educated to utilize EHRs to complete complex clinical calculations, identify potential drug interactions, and quickly scan large amounts of information if the appropriate electronic reports are accessible (Robles, 2009).
Historically, academic institutions offering nursing degrees did not include EHR use in curricula (Borycki, Joe, Armstrong, Bellwood, & Campbell, 2010; Curry, 2011; Mahon, Nickitas, & Nokes, 2010) and nurses reported they were not prepared to use EHRs (Candela & Bowles, 2008). However, today practitioners and educational institutions are recognizing the need for meaningful and quality learning opportunities related to EHR use (for example, see Gonzalez, 2013).
Not surprisingly, in the past, academia has struggled with what is important to include in each level of nursing education because the industry lacked awareness of the skills required for nurses to effectively use EHRs (Mahon et al., 2010; Simpson, 2007). Today, nursing program faculty are working to develop curricula that includes current information technology, such as adding simulated EHRs to the assignments for the assessments and care plans completed during clinical rotations (Birz, 2014; Brostoff & Conwell, 2013). Nurses entering practice will need to complete electronic care plans, collect data needed for patient education, and complete discharge planning (Ackley & Ladwig, 2013; Rodak, 2013). Another important documentation aspect for the nursing student is learning how to effectively document in real-time rather than waiting until the end of the shift (Mahon et al., 2010).
The purpose of a quantitative descriptive study conducted in 2012 was to identify what, if any, gaps exist between the informatics knowledge and skills self-reported by new/novice nurses and the informatics knowledge and skills that new/novice nurses demonstrate in acute-care settings, as reported by nurse managers. The focus was not on information technology knowledge and skills, as it was understood that the new/novice nurse would not have the skills of information technology, which include systems management, computer applications, and concern for the end-user interface. Identifying any existing informatics knowledge and skill gaps may help nursing educators and nursing directors in acute-care settings understand what can be done to improve nursing education and, therefore, better prepare nurses to use EHRs effectively in acute-care settings. The study was guided by three research questions:
- To what extent do new/novice nurses believe they demonstrate the informatics knowledge and skills required to use electronic health records effectively in acute-care settings?
- To what extent do nurse managers believe new/novice nurses demonstrate the informatics knowledge and skills critical to use electronic health records effectively when initially hired in acute-care settings?
- What gaps exist between new/novice nurses’ reported informatics knowledge and skills and the knowledge and skills reported by nurse managers in acute-care settings?
Because the current study was designed to describe gaps based on collected data, no hypotheses were tested. The study was not designed to test any relationships; rather, it was intended to provide a foundation for further research that could include hypothesis testing.
Study participants included 548 individuals: 222 new/novice nurses and 326 nurse managers. As shown in Table 1, most new/novice nurses (74 %) and nurse managers (72%) were females, and most new/novice nurses (57 %) and nurse managers (51 %) had bachelor’s degrees. Although most new/novice nurses were between 25 years and 45 years of age (71 %), most nurse managers were between 36 years and 56 years (71 %) old.
As shown in Table 2, most new/novice nurses had been registered nurses (RNs) less than two years (98 %), and most nurse managers had been RNs for six years or more (91 %). Most new/novice nurses had been working at the current facility less than two years (84 %), and most nurse managers had been at the current facility between three and 20 years (79 %).
Similarly, most new/novice nurses had been in their current position two years or less (94 %), and most nurse managers had been in their current position between one year and 10 years (76 %).
Figure 1 displays the setting of each nurse’s current position. Most new/novice nurses (59 %) and nurse managers (51 %) reported working in large, acute care hospitals (200 beds or more) in an urban area. The next greatest percentage was employed in small, acute-care hospitals in urban areas (16 % for new/novice nurses; 11 % for nurse managers).
After receiving institutional review board approval from the University of Phoenix, data were collected from two RN populations over a four-week period. Both populations were employed in acute-care settings, defined as any healthcare setting, excluding primary and long-term care (e.g., hospital, home healthcare, one-day surgery centers), that used EHRs. The first population—new/novice nurses—included individuals who graduated from nursing school and achieved their RN status less than two years prior to data collection. The second population was nurse managers, which included nurses who managed other RNs. Online surveys were sent to more than 70,000 non-manager nurses and 1,900 nurse managers; all were MarketTools ZoomPanel members. ZoomPanel is an online survey service provider (MarketTools, Inc. 2010) where researchers can easily access members of a population who meet specific criteria. All nurses and nurse managers were pre-identified based on research criteria and confirmed by MarketTools as real participants who provide quality data.
Because no existing instrument was found that would gather the data needed to answer the study research questions, a researcher-developed instrument (survey) was used as the primary means for collecting data. The survey was developed following best practices in survey design. The first step was to ensure the objectives of the survey (the guiding research questions) were clear and measurable (Fink, 2002; Miller, Lovler, & McIntire, 2013). Critical terms (such as knowledge and skills) were then operationally defined and the survey questions written to match the survey objectives. Best practices in survey question writing were followed (Converse & Presser, 1986; Fink, 2003; Miller et al., 2013) to facilitate respondents answering the questions easily and accurately. After programming the survey online, the survey was piloted tested with 10 individuals to ensure the questions were understandable and clear, the skip patterns were correctly programmed, and that the data collection process ran smoothly. The pilot test did not result in any survey question or data collection changes.
Upon completing the pilot test, members of both populations received an email with a hyperlink to the survey. Upon providing informed consent, potential participants answered several screening questions to verify they met the population criteria. Unqualified individuals were thanked for their time and exited from the survey, and qualified participants were asked to respond to a series of questions. New/novice nurses answered questions about their knowledge and skill levels in 28 areas anticipated to be critical to effective EHR use, and nurse managers answered questions about the extent to which new/novice nurses in their facility demonstrate each of 28 knowledge and skills anticipated to be critical to effective EHR use. The knowledge and skills were identified by reviewing existing literature discussing critical knowledge and skills in using an EHR. Both participant populations were asked to answer questions about EHR access as a nursing student, factors affecting EHR knowledge and skills, length of time to be comfortable using EHR, workload issues related to EHR, and type and hours of training received on EHR use.
Length of EHR use and training. Both new/novice nurses and nurse managers were asked to report how long their workplace had been using an EHR, type of EHR training received, and amount of training at their workplace. Table 3 includes response category options for all three questions and the percent selecting each response for both new/novice nurses and nurse managers. As shown in Table 3, a greater percentage of new/novice nurses (approximately 27 %) than nurse managers (approximately 15 %) reported their workplace had been using EHRs for less than one year. More than 50 % of new/novice nurses and nurse managers reported their workplace had been using EHRs for more than two years.
Most new/novice nurses (90 %) and nurse managers (75 %) reported receiving EHR training at their current workplace. Few (20 %) new/novice nurses and very few (seven percent) nurse managers reported coursework on EHR use during nursing school. The greatest percentage (39 %) of new/novice nurses reported receiving between nine and 16 hours of training, and the greatest percentage of nurse managers (33 %) reported receiving greater than 24 hours of EHR use training at their current workplace. More than a quarter of new/novice nurses (30 %) and nurse managers (26 %) reported receiving less than eight hours of training.
Decreased patient load when learning EHR. To consider the changes from paper documentation to EHR, participants were asked to report if their facility decreased the patient- care load for the newly-hired nurse (less than six months) to allow time for learning how to use the EHR. As shown in Table 4, over half of new/novice nurses (58 %) and nurse managers (59 %) reported that workload was decreased only because the newly hired nurse was a new graduate.
Time to be comfortable using EHR. New/novice nurses and nurse managers were asked to report the time it took nurses to become comfortable using EHRs. As shown in Figure 2, new/novice nurses and nurse managers did not agree. While over 70 % of new/novice nurses reported they felt it took less than two months for them to feel comfortable using the EHR, more than 60 % of nurse managers reported it took new/novice nurses more than two months to be comfortable using EHRs.
Factors influencing EHR skill and knowledge level. New/novice nurses and nurse managers were asked to report the factors influencing their EHR skill and knowledge level. As shown in Figure 3, new/novice nurses and nurse managers agreed on the top four factors affecting EHR skill and knowledge level: age, previous clinical experience, hospital orientation, and department-specific orientation. New/novice nurses and nurse managers did not agree on the greatest factor influencing their EHR skill and knowledge level; the greatest number of nurse managers reported clinical experience, while the greatest percentage of new/novice nurses reported the factor of age.
Research Question Results
RQ 1. To answer the first research question (To what extent do new/novice nurses believe they demonstrate the informatics knowledge and skills critical to use electronic health records effectively in acute care settings), new/novice nurses were asked to rate how skilled they were in 28 areas anticipated to be critical to effective EHR use. The percent of new/novice nurses who rated themselves as highly or very highly skilled in each of the 28 areas is shown in Table 5. New/novice nurses reported being most highly skilled in five areas: email, Internet usage and search engines, word processing, lab results retrieval, keyboarding, and nursing-note documentation. New/novice nurses reported being least highly skilled in electronic publishing, graphic development, computer languages, webpage design, and coding for billing purposes. For only six of the 28 skill areas did 75 % for more new/novice nurses report being highly or very highly skilled: email, Internet usage and search engines, word processing, lab results retrieval, keyboarding, and nursing note documentation.
For eight of the 28 skill areas, fewer than 50 % of new/novice nurses report being highly or very highly skilled: order entry, electronic bill/payment, database use, electronic publishing, graphic development, computer languages, webpage design, and coding for billing purposes.
Table 5: Percent of New/Novice Nurse Reporting They are Highly of Very-Highly Skilled by Skill Area
|Skill area||Percent reporting highly skilled or very highly skilled|
|2. Internet usage and search engines||92%|
|3. Word processing||80%|
|4. Lab results retrieval||77%|
|6. Nursing note documentation||75%|
|7. Graphics documentation and tracking||74%|
|8. Online classrooms/education||72%|
|9. Medication administration documentation||72%|
|10. Treatment documentation||68%|
|11. Diagnostics results retrieval||68%|
|12. Accessing electronic charts contents||68%|
|13. Presentation development||67%|
|14. Patient education documentation||67%|
|15. Data entry||63%|
|16. Patient education material retrieval||62%|
|17. Care plan development and updates||59%|
|18. Accessing prior admission data||57%|
|19. Discharge planning documentation and updates||55%|
|20. Spreadsheet development||53%|
|21. Order entry||45%|
|22. Electronic bill/payment||41%|
|23. Database use||27%|
|24. Electronic publishing||19%|
|25. Graphic development||14%|
|26. Computer languages||13%|
|27. Webpage design||12%|
|28. Coding for billing purposes||11%|
RQ 2. To answer the second research question (to what extent do nurse managers believe new/novice nurses demonstrate the knowledge and skills critical to use electronic health records effectively in acute care settings when initially hired), nurse managers were asked to rate the extent to which new/novice registered nurses demonstrate 28 skill areas when they are initially hired. The percent of nurse managers who reported new/novice nurses demonstrate skill areas to a great or very great extent when first hired is shown in Table 6. Nurse managers reported new/novice nurses are most highly skilled in e-mail, Internet usage and search engines, word processing, lab results retrieval, keyboarding, and online classrooms/education when first hired. Nurse managers reported new/novice nurses are least highly skilled in electronic publishing, computer languages, graphic development, webpage design, and coding for billing purposes when first hired. For only four of the 28 skill areas did more than 75 % of the nurse managers agree that new/novice nurses demonstrated knowledge and skills to a great or very great extent when first hired. For 21 of the 28 skill areas, fewer than 50 % of nurse managers agreed that new/novice nurses demonstrated the skill area when first hired.
Table 6: Percent of Nurse Managers Reporting New/Novice Nurses Demonstrate Skill Areas to a Great or Very Great Extent by Skill Area
|Skill area||Percent reporting great extent or very great extent|
|2. Internet usage and search engines||93%|
|4. Word processing||73%|
|5. Online classrooms/education||57%|
|6. Presentation development||51%|
|7. Nursing note documentation||50%|
|8. Graphics documentation and tracking||47%|
|9. Lab results retrieval||47%|
|10. Diagnostics results retrieval||45%|
|11. Medication administration documentation||43%|
|12. Accessing electronic charts contents||42%|
|13. Care plan development and updates||42%|
|14. Treatment documentation||41%|
|15. patient education material retrieval||39%|
|16. Patient education documentation||39%|
|17. Data entry||37%|
|18. Discharge planning documentation and updates||37%|
|19. Spreadsheet development||32%|
|20. Accessing prior admission data||32%|
|21. Database use||27%|
|22. Order entry||27%|
|23. Electronic bill/payment||21%|
|24. Electronic publishing||16%|
|25. Computer languages||16%|
|26. Graphic development||14%|
|27. Webpage design||11%|
|28. Coding for billing purposes||11%|
RQ 3. To answer the third research question (What gaps exist between new/novice nurse graduates’ reported informatics knowledge and skills and the knowledge and skills reported by nurse managers’ in acute care setting) percentages were used to identify reported strengths and development areas. If 50 % or more of new/novice nurses reported being highly or very highly skilled, the skill area was considered a strength. If 50 % or more of nurse managers reported new/novice nurses demonstrate a skill area to a great or very great extent, the skill area was considered a strength. Table 7 includes a comparison of new/novice nurse and nurse manager skill strengths and development areas, based on percentages. Figure 4 displays agreed-upon strengths, development areas, and potential skill gaps.
Figure 4. Agreed Upon Strengths, Development Areas, and Potential Skill Gaps
|Agreed upon strengths||Word processing|
Internet usage and search engines
Nursing note documentation
|Agreed upon development areas||Database use|
Coding for billing purposes
|Areas new/novice nurses report as strengths, yet nurse manages report as development areas||Spreadsheet Development|
Medication administration documentation
Graphics documentation and tracking
Patient education material retrieval
Patient education documentation
Lab results retrieval
Diagnostics results retrieval
Accessing electronic charts contents
Accessing prior admission data
Care plan development and updates
Discharge planning documentation and updates
Results revealed agreement that seven of the 28 skill areas were strengths (word processing, email, online classrooms/education, presentation development, Internet usage and search engines, keyboarding, and nursing note documentation) and eight were development areas (database use, webpage design, electronic publishing, computer languages, coding for billing purposes, electronic billing/payment, graphic development, and order entry). However, while new/novice nurses data revealed 13 of the 28 skill areas were strengths, a greater percentage of nurse managers did not report new/novice nurses could demonstrate the skills to a great or very great extent. The 13 skill areas that may be potential skill gaps are spreadsheet development, data entry, medication administration, documentation, treatment documentation, graphics documentation and tracking, patient education material retrieval, patient education documentation, lab results retrieval, diagnostics results retrieval, accessing electronic charts contents, accessing prior admission data, care plan development and updates, and discharge planning documentation and updates. There were no instances where nurse managers reported a skill area as a strength and new/novice nurses reported the same skill area as a development area.
Analysis of survey data from 222 new/novice nurses and 326 nurse managers revealed the participants reporting on informatics knowledge and skills were indeed employed by facilities using EHRs. A significant percentage reported their workplace were using EHR for over 1 year, and most new/novice nurses (approximately 76 %) and nurse managers (approximately 90 %) reported being trained on how to use EHRs at their current workplace, with few (20 % new/novice nurses; seven percent nurse managers) reporting coursework on EHR use during nursing school. New/novice nurses and nurse managers did not agree on the amount of time it took for new/novice nurses to become comfortable using EHRs. More than 70 % of new/novice nurses reported it took less than two months, and over 60 % of nurse managers reported it taking more than two months for new/novice nurses to be comfortable using EHRs. New/novice nurses and nurse managers tended to agree on the factors influencing EHR skill and knowledge level, reporting age, previous clinical experience, hospital orientation, and department-specific orientation; however, although the greatest percentage of new/novice nurses reported the factor of age, the greatest number of nurse managers reported clinical experience.
New/novice nurses reported being highly or very highly skilled in 20 of 28 knowledge and skill areas. New/novice nurses reported being most skilled in email, Internet usage and search engines, word process, lab results retrieval, keyboarding, and nursing note documentation; they reported being least skilled in electronic publishing, graphic development, computer languages, webpage design, and coding for billing purposes. Nurse managers reported new/novice nurses are most highly skilled in e-mail, Internet usage and search engines, word processing, lab results retrieval, keyboarding, and online classrooms/education; they reported new/novice nurses being least skilled in electronic publishing, computer languages, graphic development, webpage design, and coding for billing purposes. A gap analysis indicated that for 13 of the 28 knowledge and skill areas, new/novice nurses reported an area as a strength, and a greater percentage of nurse managers did not report new/novice nurses could demonstrate the knowledge or skill to a great or very great extent.
Current study results have significant implications for both nursing education programs and employers. First, if nursing education programs are not providing future nurses with the informatics knowledge and skills necessary to use EHRs effectively, employers must be prepared to provide not only on-the-job training for critical skills but also must have the infrastructure to educate new nurses. The infrastructure should likely consist of RNs who have been trained in informatics and in the particular EHR used by the facility. The infrastructure should likely also allow for classroom time for new employees and 24/7 support on the nursing units. Information technology (IT) help, available supervisors, and more paid time or less workload while the new nurse becomes proficient with the HER should also be included.
Results of the current study revealed that more than half of the new/novice nurses and the nurse managers reported workloads were only decreased when the new nurse was also a new graduate. Employing facilities should consider reducing workloads for nurses new to the facility because of the differences in EHRs from facility to facility. Nurses who are not new graduates, but who are new to the facility, also need time to learn the EHR. Carayon and Gurses (2008) indicated the heavy workload for nurses is a challenge for the nursing profession. Nursing workloads are increased by higher demand for nurses, insufficient nurse supply, and nurse- staffing reductions with increased overtime (Carayon & Gurses, 2008). Reducing nursing workloads for a period of time for all nurses new to a facility is necessary to ensure proper use of the facility’s EHR.
Research consistently reveals that nursing students learn best when studying a topic or theory and then applying the learning in the clinical setting (Benner, Sutphen, Leonard, & Day, 2010). The art and science of nursing requires developing a specific skill set alongside the critical thinking that transforms theory into practice. Documentation skills have consistently been a part of nursing curriculum, and collaboration between nurse educators and hospital administrators will promote a smooth transition from paper to electronic charting. In 2008, the American Association of Colleges of Nursing identified “information management and application of patient care technology” as a core competency (p. 17). Nursing programs across the country are currently developing curricula to incorporate educational strategies that will facilitate mastery of informatics, including health information technology (Johnson & Bushey, 2011; Taylor, Hudson, Vazzano, Naumann, & Neal, 2010).
Nursing programs have increased students’ exposure to EHRs, with new/novice nurses reporting a 20 % exposure and nurse managers reporting only a seven percent exposure. Increased exposure to using an EHR may assist students in successfully mastering the knowledge and skill required to use EHRs effectively. Classroom hours at their workplace or on-the-job training account for 76.08% of the training for new/novice nurses and 90 % of the training of nurse managers. The endeavor to develop EHR software for nursing educators to incorporate into the didactic phase of student education is gaining momentum (Wyatt, Li, Indranoi, & Bell, 2012).
Regardless of the format, the patient’s health record is a communication tool. Therefore, it requires skills in basic communication, concise writing, and computer use. Classroom teaching must be reinforced and contextualized in the clinical setting (Benner et al., 2010). Since the EHR is a legal document and access follows stringent security, nursing students must be able to practice the skills essential for the effective use of EHRs in the classroom. The foundational skills used for EHR documentation are skills as essential to future success in nursing as the hands-on skills of bedside care. Incorporating EHRs into nursing curriculum will assist schools of nursing in providing competent nurses with the skills needed to excel in the current practice environment.
Nursing programs may encounter several challenges when implementing EHR curriculum. Results of the current study indicate that age and level of clinical experience may influence the ability of a new/novice nurse to become comfortable using the EHR. Non-traditional nursing students are common, and student comfort with e-mail, Internet, word processing, keyboarding, and search engines should not be assumed. Word processing, email, keyboarding, and using search engines may be considered basic computer skills; but, poor keyboarding could increase the time a nurse needs to chart patient care. One benefit of an EHR is to allow the nurse to use specified search engines to retrieve patient-education handouts. A nurse who has not been exposed to using search engines could have difficulty retrieving important patient information. The purpose of the EHR is to increase patient safety, decrease cost, and increase efficiency. If nurses spend too much time charting because of a deficiency in basic computer skills, these goals will not be reached. Assuming nursing students will receive the necessary training for electronic charting at the clinical site decreases the opportunity for the nursing profession to determine how nursing students will be trained to chart important nursing documentation. Nursing documentation is a foundation of nursing practice and helps determine if standards of care have been followed, possible areas of nursing research, and guidance for ways to decrease errors.
Nurse educators are challenged with the task of incorporating evidenced-based nursing informatics curriculum into nursing education. The nursing profession is only beginning to develop an understanding of the needed knowledge and skills for the novice nurse entering practice (Johnson & Bushey, 2011). The lack of knowledge or experience using informatics and EHRs for nursing faculty can be a barrier for developing entry-level informatics courses for nursing programs (Mahon et al., 2010). The knowledge and skills gap identified in this study can assist nursing educators in analyzing informatics courses and open dialogue between the nursing program and the clinical site. The changes taking place in nursing practice require collaboration between nurse educators and nurse managers (Sherwood & Drenkard, 2007). A partnership between nursing programs and the facilities used for clinical education of the nursing students could assist nursing educators in identifying gaps in knowledge that need to be addressed in the curriculum (Taylor et al., 2010). A partnership could also provide a dialogue for determining what areas can be addressed most effectively in a didactic setting and what principles are best taught in the clinical setting. Including nursing faculty, informatics nurses, and nursing administrators in sessions to develop new curricula may be helpful (Johnson & Bushey, 2011; Taylor et al., 2010). Including members from each group of shareholders may increase buy-in of each group by facilitating understanding of everyone’s perspectives.
A second consideration for nursing programs is students who are receiving clinical training at clinical sites without an EHR. Students who are not receiving EHR training from a clinical site or the nursing program are missing valuable skills when they enter the workforce. Mahon et al. (2010) identified a primary barrier to incorporating information technology into the curriculum is lack of experience using EHRs among nursing faculty. Nursing faculty and nurses working at sites without electronic records may not be able to provide the student nurse with the required skills for using the electronic health records (Taylor et al., 2010).
Reliance on the clinical site to provide the needed training for EHR usage can play a role in the knowledge gaps identified by the current study. Many of the items identified are documentation or material-retrieval areas that are EHR specific. Numerous EHR software systems are available, and location of material and how information must be added to the EHR software system can differ from facility to facility. Whenever a nurse is exposed to a new EHR system, a period of acclimation should be anticipated. Healthcare facilities are going to train nurses to meet the specific needs of the EHR system being used, and facilities should adjust staffing needs while the nurse is learning the new system, regardless of the nurse’s age or years of experience.
Nursing programs will not be able to provide the complete training needed for proficient use of all EHR systems being used in clinical settings. Nursing programs are developing curricula that provides evidence-based education on important components of the EHR (Johnson & Bushey, 2011). Lectures that address ethical usage of an EHR, the Health Information Portability and Accountability Act (HIPAA) guidelines for EHR use, and requirements of meaningful use can provide a strong foundation for the knowledge and skill gained in the clinical setting. An important component of successful EHR implementation is user education. The foundation for that education can begin in schools of nursing.
Results indicated that although new/novice nurses may have a small subset of the knowledge and skills required to use EHRs effectively in acute-care settings, they need help developing a larger base of critical knowledge and skills. It is clear that a wide difference exists in the perceptions of the nurse managers and the new/novice nurse; maybe the confidence with EHRs of the new nurses exceed their actual skill level. Perception bias may help explain why new/novice nurses overestimate their EHR knowledge and skills. Perception bias occurs when people make self-judgments about their abilities and overvalue their abilities when self-reporting (John & Robins, 1994; Moore & Small, 2007). Another reason for differences in perception is nurses may overestimate their actual skill level because of a lack of knowledge about the functionality of the EHR. A lack of understanding about how the EHR interfaces within the reimbursement systems and across facilities (or levels of care) may help explain why nurses believe they are using the system more effectively. Educating nurses about the core and menu objectives of meaningful use may help nurses understand what they need to document and why documenting the information may improve patient safety and decrease healthcare costs.
The current study may have some limitations related to the study sample and the methodology. One potential limitation is that the study sample of new/novice nurses and nurse managers may not be representative of the entire population of nurses in acute care settings. A second potential limitation is related to the informatics knowledge and skills evaluated. The knowledge and skills evaluated were based on a review of existing literature, not on a thorough job analysis. A third potential limitation is that data were collected based on self-report data. Self-report data may not always be completely accurate; for example, survey participants may not have been able to accurately remember information or they may have responded in a socially desirable way.
Recommendations for Future Research
Based on the study sample, methodology, and results three studies are recommended for future research. First, researchers might consider conducting a similar studying using knowledge and skill areas identified through a thorough job analysis. A job analysis can help to fully understand the nature of a job, including the duties and tasks that must be performed and the qualifications (including knowledge, skills, and abilities) needed to successfully perform the duties and tasks (Meglich, 2009).
Second, researchers might consider conducting a similar study using a more stringent sampling technique, such as stratified sampling. With stratified sampling, it may be possible to gather data from a group of new/novice nurses and nurse managers who are more representative of the population within acute care settings. While more complex and time-consuming, a stratified sampling technique can ensure that specific groups are represented in the sample (e.g., by gender or age group). Additionally, since the legislation has been more fully implemented since this study was completed, there would be added value in using the more stringent sampling as there are now more facilities that have implemented the use of EHRs.
Third, researchers might consider conducting a similar study in a setting other than an acute care setting. The long-term care, clinic, and home healthcare settings stand to benefit from increased training for new/novice nurses since they also use EHRs.
Nurses’ ability to use an EHR effectively, by demonstrating critical knowledge and skills, is critical to patient safety, decreased facility expenditures for training, and decreased healthcare costs. The current study identified what gaps exist between the informatics knowledge and skills self-reported by new/novice nurses and the informatics knowledge and skills demonstrated in acute care settings by new/novice nurses as reported by nurse managers. Data gathered from 222 new/novice nurses and 326 nurse managers revealed skill gaps in 13 of 28 knowledge and skills areas thought to be critical to effective EHR use.
Nursing program administrators and healthcare administrators in acute care settings can use the final results of the study to determine which knowledge areas and skills must be better addressed in nursing programs or on-the-job training. Collaboration between clinical facilities and nursing programs can provide trained nurses able to deliver safe and efficient patient care and meet documentation requirements for meaningful-use reimbursement easing the financial burdens of the healthcare facility.
Ackley, B. J., & Ladwig, G. B. (2013). Nursing diagnosis handbook: An evidence-based guide to planning care (10th ed.). Maryland Heights, MO: Mosbey Elsevier.
American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche.edu/education-resources/baccessentials08.pdf
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
Bhattacherjee, A., Hikmet, N., Menachemi, N., Kayhan, V. O., & Brooks, R. G. (2007). The differential performance effects of healthcare information technology adoption. Information Systems Management, 24, 5-14. doi:10.1080/10580530601036778
Birz, S. (2014). Lessons learned: Information technology meets nursing education. Retrieved from http://www.nursezone.com/nursing-news-events/devices-and-technology/Lessons-Learned-Information-Technology-Meets-Nursing-Education_23998.aspx
Borycki, E., Joe, R. S., Armstrong, B., Bellwood, P., & Campbell, R. (2010). Educating health professionals about the electronic health record (EHR): Removing the barriers to adoption. Knowledge Management & E-Learning: An International Journal, 3(1). 51-62. Retrieved from file:///Users/drlesliemiller/Downloads/94-286-2-PB.pdf
Brostoff, M., & Conwell, K. (2013). Introducing EHR through simulation for the newly licensed nurse. Retrieved from http://blog.himss.org/2013/06/13/introducing-the-ehr-through-simulation-for-the-newly-licensed-nurse/
Candela, L., & Bowles, C. (2008). Recent RN graduate perceptions of educational preparation. Nursing Education Perspectives, 29(5), 266-272-1. Retrieved from http://www.nln.org/nlnjournal/
Carayon, P., & Gurses, A. P. (2008). Nursing workload and patient safety—a human factors engineering perspective. In R. G Huges (ed.). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (203-216). Rockville, MD: Agency for Healthcare Research and Quality.
Centers for Medicare & Medicaid Services. (2014). Medicare and Medicaid EHR incentive program basics. Retrieved from http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Basics.html
Converse, J. M., and Presser, S. (1986). Survey questions: Handcrafting the standardized questionnaire. Thousand Oaks, CA: Sage.
Curry, D. G. (2011). Selection and Implementation of a simulated electronic medical record (EMR) in a nursing skills lab. Journal of Educational Technology Systems, 39(2), 213-218.
Evatt, M., Ren, D., Tuite, P., Reynolds, C., & Hravnak, M. (2014). Development and implementation of an educational support process for electronic nursing admission assessment documentation, MEDSURG Nursing, 23(2), 89-100.
Fink, A. (2002). How to design survey studies (2nd ed.). Thousand Oaks, CA: Sage.
Fink, A. (2003). How to ask survey questions (2nd ed.). Thousand Oaks, CA: Sage.
Furukawa, M. F., Raghu, T. S., & Shao, B. B. M. (2010). Electronic medical records, nurse staffing, and nurse-sensitive patient outcomes: Evidence from California hospitals, 1998-2007. Hsr: Health Services Research, 45(4), 941-962. doi:10.1111/j.1475-6773.2010.01110.x
Gonzalaz, L. (2013). EHR in the nursing curriculum: Is it necessary? Where to begin? Retrieved from http://toadn.org/presentations/EHRpresentation_TOADN.pdf?PHPSESSID=c38f94e477ad5746e2a0982c7f1820a2
HealthIT.gov. (2014). Medical practice efficiencies and cost savings. Retrieved from http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, D.C.: National Academy Press.
John, O. P., & Robins, R. W. (1994). Accuracy and bias in self-perception: Individual differences in self-enhancement and the role of narcissism. Journal of Personality and Social Psychology, 66(1), 206-219. doi:10.1037/0022-35184.108.40.206
Johnson, D. M., & Bushey, T. I. (2011). Integrating the academic electronic health record into nursing curriculum: Preparing student nurses for practice. CIN: Computers, Informatics, Nursing, 29(3), 133-137. doi:10.1097/NCN.06013e3182121ed8
Kallem, C. (2011). Transforming clinical quality measures for HER use: NQF refines emeasures for use in EHRs and meaningful use program. Journal of AHIMA, 82(11), 52-53.
King, J., Patel, V., Jamoom, E. W., & Furukawa, M. F. (2014). Clinical benefits of electronic health record use: National findings. Health Services Research, 49(1pt2), 392-404. doi:10.1111/1475-6773.12135
Latham & Watkins. (2010, August 11). "Meaningful use" regulations finalized to implement incentives for electronic health records. Venulex Legal Summaries, 1072, 1-7. Retrieved from http://cufts2.lib.sfu.ca/CJDB4/BLTW/journal/419650
Mahon, P. Y., Nickitas, D. M., & Nokes, K. (2010). Faculty perceptions of student documentation skills during the transition from paper-based to electronic health records systems. Journal of Nursing Education, 49(11), 615-621. doi. 10.3928/01484834-20100524-06
MarketTools. Inc. (2010). Online survey panels for market research. Retrieved from http://www.markettools.com/products/zoompanel Meglich, P. (2009). Essentials of job analysis. Retrieved from www.shrm.org/education/hreducation/.../job%20analysis_final.pptx
Miller, L.A., Lovler, R., & McIntire, S. A. (2013). Foundations of psychological testing: A practical approach (4th ed.). Thousand Oaks, CA: Sage.
Moore, D. A., & Small, D. A. (2007). Error and bias in comparative judgment: on being both better and worse than we think we are. Journal of Personality and Social Psychology, 92(6), 972-989. doi:10.1037/0022-35220.127.116.112
Murphy, M. (2014). Medical scribes in the hospitalist setting, are they work the investment? Retrieved from https://scribeamerica.com/newblog/future-of-healthcare/page/2/
Obama, B. (2009, February 24). Remarks of President Barack Obama - As prepared for delivery address to Joint Session of Congress [Delivery address]. Retrieved from The White House Web site: http://www.whitehouse.gov/the_press_office/Remarks-of-President-Barack-Obama-Address-to-Joint-Session-of-Congress/
Porter, M. E., & Thomas, H. L. (2013). The strategy that will fix health care. Harvard Business Review. Retrieved from http://hbr.org/2013/10/the-strategy-that-will-fix-health-care/ar/1
Robles, J. (2009). The effect of the electronic medical record on nurses' work. Creative Nursing, 15(1), 31-35. Retrieved from http://www.springerpub.com/product/10784535#.UYKBsStARX8
Rodak, S. (2013). 11 best practices for discharge planning from CMS. Retrieved from http://www.beckershospitalreview.com/quality/11-best-practices-for-discharge-planning-from-cms.html
Sherwood, G., & Drenkard, K. (2007). Quality and safety curricula in nursing education: Matching practice realities. Nursing Outlook, 55(May/June), 151-155.
Simpson, R. L. (2007). Nursing informatics: The economics of education. Nursing Management, 38(6), 16-17. Retrieved from http://journals.lww.com/nursingmanagement/Pages/default.aspx
Taylor, L., Hudson, K., Vazzano, J., Naumann, P., & Neal, M. (2010). The electronic health record meets baccalaureate nursing curriculum: Stories from the Battlefield, June, 40-44. Retrieved from http://www.nurseleader.com. doi:10.1016/j.mnl/2010.03.008
U.S. Department of Health & Human Services. (2011, January 13). NHE Fact Sheet. In National Health Expenditure Data (Historical NHE, Including Sponsor Analysis, 2009). Retrieved March 31, 2011, from CMS Centers for Medicare & Medicaid Services Web site: https://www.cms.gov.NationalHealthExpendData/25_NHE_Fact_Sheet.asp#TopOfPage
Wyatt, T. H., Li, X., Indranoi, C., & Bell, M. (2012). Developing iCare v. 1.0 an academic electronic health record. CIN: Computers, Informatics, Nursing, 30(6), 321-329. doi. 10.1097/NXN.06013e31824af81f
The authors would like to thank the University of Phoenix and its parent company, Apollo Group, Inc., for supporting the research upon which this publication is based. Thank you also Zachary K. Miller for his assistance with the quantitative data analysis efforts.
Dr. Leslie A. Miller is a consultant with more than 20 years’ experience researching, teaching, and working directly with organizations to design measurement instruments and processes to help organizations select, develop and retain the talent they need to achieve desired business results and support business strategy. She also Chairs doctoral dissertations and teaches doctoral research courses for the University of Phoenix School of Advanced Studies and psychology courses at Rollins College. Dr. Miller is an active writer and contributor to journals and professional associations. Her most recent book is a 4th-edition psychological testing/measurement textbook published in 2013 by Sage.
Michelle E. Stimely, EdD, MSN, CRNA
Dr. Michelle E. Stimely has been a Certified Registered Nurse Anesthetist for 10 years. She is an assistant professor and has been educating nursing students in the clinical setting, classroom, and simulation lab for 7 years. She completed her Doctorate of Education at the University of Phoenix in 2013, focusing her doctoral research on the use of electronic records in nurse anesthesia. She has experience as a meaningful use coordinator for implementing electronic health records into nursing practice.
Pamela M. Matheny, MSIO, PMP, CMPE
Pamela M. Matheny, MSIO is employed by the University of Missouri School of Medicine where she is the department administrator and senior practice manager in the Department of Dermatology. As a member of the department leadership team, Pam’s responsibilities include supporting professional development for both clinical and departmental staff including nurses. Pam is active in professional management organizations where she currently serves on boards and leadership teams. She is often an invited speaker for professional development at national meetings. Pam is a PhD student in Industrial and Organizational Psychology at the University of Phoenix School of Advanced Studies.
Melody F. Pope, EdD, RN
Dr. Melody F. Pope has served as the lead Professor of Nursing and Health Occupations at the College of the Redwoods, Del Norte Campus since 2005. Before moving to northern California, she developed the first grant-funded program in Denver, Colorado to bring nursing education to the workplace, allowing for community college courses to be completed on site where the students work. She has worked in acute care, long term care, and as a nurse administrator. Having over 25 years of experience in nursing, in addition to serving as a professor, Dr. Pope works with the local Del Norte High School students, teaching and mentoring them in pursuing careers in health care. A graduate of University of Phoenix School of Graduate Studies in 2010 and nurse educator of just over 15 years, she has contributed to several textbooks and continues to pursue her research interests in bullying in nursing education, curriculum development in an ever-changing environment, and developing successful health care educational programs.
Robin E. McAtee, PhD, RN, FACHE
Dr. McAtee serves as the Associate Director for the Arkansas Aging Initiative, at the University of Arkansas for Medical Sciences and is the Primary Investigator for an $8 million Home Caregiver Training program Grant from the Donald W. Reynolds Foundation. She is also the nurse educator for the Arkansas Geriatric Education Center, a Health Resources and Services Administration grant that focuses on education for healthcare professionals. Dr. McAtee has over 30 years of healthcare experience including over 10 years in hospital administration and more than 15 years in the field of geriatrics. Dr. McAtee’s research interests include macro system development, community-based educational endeavors for older adults, health professionals’ education, and healthcare policy. She also teaches graduate nursing students and serves as chair and member on several dissertation committees at the University of Arkansas for Medical Sciences and the University of Phoenix School of Advanced Studies. She is a published author and a national presenter.
Kia A. Miller
Kia Miller is a graduate student at George Mason University working on her Master’s of Science in Health Informatics offered through the College of Health and Human Services’ Department of Health Administration and Policy in collaboration with the Volgenau School of Engineering’s Applied Information Technology Program. Ms. Miller desire is to gain the knowledge and skills needed to help organizations adopt and use health information systems and analytic applications for administrative, clinical, and research purposes.