Introduction of patient electronic medical records (EMR) into undergraduate nursing education: An integrated literature review

The impact of digital technology use on nurses' professional identity and relations of power: a literature review

AIM

This study seeks to review how the use of digital technologies in clinical nursing affects nurses' professional identity and the relations of power within clinical environments.

DESIGN

Literature review.

DATA SOURCES

PubMed and CINAHL databases were searched in April 2023.

METHODS

We screened 874 studies in English and German, of which 15 were included in our final synthesis reflecting the scientific discourse from 1992 until 2023.

RESULTS

Our review revealed relevant effects of digital technologies on nurses' professional identity and power relations. Few studies cover outcomes relating to identity, such as moral agency or nurses' autonomy. Most studies describe negative impacts of technology on professional identity, for example, creating a barrier between nurses and patients leading to decreased empathetic interaction. Regarding power relations, technologically skilled nurses can yield power over colleagues and patients, while depending on technology. The investigation of these effects is underrepresented.

CONCLUSION

Our review presents insights into the relation between technology and nurses' professional identity and prevalent power relations. For future studies, dedicated and critical investigations of digital technologies' impact on the formation of professional identity in nursing are required.

IMPLICATIONS FOR THE PROFESSION

Nurses' professional identity may be altered by digital technologies used in clinical care. Nurses, who are aware of the potential effects of digitized work environments, can reflect on the relationship of technology and the nursing profession.

IMPACT

The use of digital technology might lead to a decrease in nurses' moral agency and competence to shape patient-centred care. Digital technologies seem to become an essential measure for nurses to wield power over patients and colleagues, whilst being a control mechanism. Our work encourages nurses to actively shape digital care.

REPORTING METHOD

We adhere to the JBI Manual for Evidence Synthesis where applicable. EQUATOR reporting guidelines were not applicable for this type of review.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Academic Electronic Health Record in Mental Health Clinical: A Quality Review

Developing competency in the use of EHRs is essential for entry-level professional nurses. Although nursing education has been encouraged to integrate this technology into nursing curriculum, many students still graduate feeling unprepared in this area. As a result, nursing graduates lack the skills necessary to effectively use EHRs, which may have negative consequences for safe patient care. Use of academic EMRs provides students the opportunity to integrate informatics education, develop critical thinking, and incorporate problem-solving skills in the clinical area. An academic EMR was introduced to students in the second semester of a baccalaureate degree nursing program. Students completed documentation on one patient from the mental health clinical rotation. A retrospective chart review was conducted, using a rubric to determine charting efficacy. Data analysis indicated that students struggled with documentation of the mental health assessment, care plan development, and nursing notes. Student documentation was strongest in vital signs and basic information. Students need practice documenting on the critical aspects of nursing care. Utilization of an academic EMR for clinical charting provides an opportunity for students to practice documentation and develop necessary skills for clinical practice.

Nursing students' perspectives on being work-ready with electronic medical records: Intersections of rurality and health workforce capacity

AIM

To explore nursing students' views on being prepared for using electronic medical records during clinical placement.

BACKGROUND

The need for an undergraduate nursing curriculum to include electronic medical record training has been internationally recognised, however successful implementation has been inconsistent worldwide and limited in Australia. Many nursing students are unprepared to effectively provide care during clinical placement using electronic medical records and are therefore not work-ready as registered nurses.

DESIGN

Online survey.

METHODS

Third-year nursing students from two multi-campus universities were invited to complete the survey.

RESULTS

Most students believed that learning electronic medical records during simulations would be extremely or very useful. Student confidence levels correlate with the amount and type of exposure to electronic medical records prior to clinical placement. Four themes emerged from qualitative analysis: Don't throw out the baby with the bathwater; Prepare us for practice; Mistakes - hardly any; and Universities need to catch up and put out.

CONCLUSION

Students receiving hospital-based education on eMR and eObs can improve student confidence in preparation for clinical practice. First-year optional eMR university education had a limited impact on students' perception of preparedness for clinical practice. Shared responsibility between both the universities and health services on eMR education would provide improved student confidence and preparedness for clinical practice. This study supports the international research that eMR education needs to be scaffolded over the three years of study with increasing complexity of real-life scenarios.

Promoting patient safety using electronic medical records in nursing/midwifery undergraduate curricula: Discussion paper

This discussion paper highlights the importance of Australian nursing and midwifery students' lack of exposure to electronic medical records during their undergraduate programs. There is pressure on universities offering nursing and midwifery programs to provide students with opportunities to learn to use patient electronic medical records. This will provide authentic rehearsal with the digital technology prior to clinical placements and increase graduate work readiness. Informed by contemporary literature, we describe the benefits of implementing electronic medical records (eMR) in health organisations and identify the challenges and barriers to implementing and integrating the education of electronic records into undergraduate nursing and midwifery programs. Undergraduate students who had not experienced eMR as part of on-campus learning felt unprepared and lacked confidence when commencing clinical practice. Some international nursing and midwifery programs have found that student's skills improve in decision-making and documenting patient observations when eMR is integrated into their university education program. Successful integration of an eMR program should consider academic/teaching staff skills and confidence in technology use, initial and ongoing costs and technical support required to deliver the program. In conclusion, Australian universities need to embed eMR learning experiences into the nursing and midwifery undergraduate curricula to increase students work-readiness with a focus on patient safety.

Challenges and opportunities in creating a deprescribing program in the emergency department: A qualitative study

BACKGROUND

As the population of older adults increases, appropriate deprescribing becomes increasingly important for emergency geriatric care. Older adults represent the sickest patients with chronic medical conditions, and they are often exposed to high-risk medications. We need to provide an evidence-based, standardized deprescribing program in the acute care setting, yet the evidence base is lacking and standardized medication programs are needed.

METHODS

We conducted a qualitative study with the goal to understand the perspective of healthcare workers, patients, and caregivers on deprescribing high-risk medications in the context of emergency care practices, provider preferences, and practice variability, along with the facilitators and barriers to an effective deprescribing program in the emergency department (ED). To ensure rich, contextual data, the study utilized two qualitative methods: (1) a focus group with physicians, advanced practice providers, nurses, pharmacists, and geriatricians involved in care of older adults and their prescriptions in the acute care setting; (2) semi-structured interviews with patients and caregivers involved in treatment and emergency care. Transcriptions were coded using thematic content analysis, and the principal investigator (S.L.) and trained research staff categorized each code into themes.

RESULTS

Data collection from a focus group with healthcare workers (n = 8) and semi-structured interviews with patients and caregivers (n = 20) provided evidence of a potentially promising ED medication program, aligned with the vision of comprehensive care of older adults, that can be used to evaluate practices and develop interventions. We identified four themes: (1) Challenges in medication history taking, (2) missed opportunities in identifying high-risk medications, (3) facilitators and barriers to deprescribing recommendations, and (4) how to coordinate deprescribing recommendations.

CONCLUSIONS

Our focus group and semi-structured interviews resulted in a framework for an ED medication program to screen, identify, and deprescribe high-risk medications for older adults and coordinate their care with primary care providers.

Factors in integrating academic electronic medical records in nursing curricula: A qualitative multiple case studies approach

BACKGROUND

Academic electronic medical records are useful simulation-based educational tools that assist health professional students develop their skill sets for digital health practice. Despite this, their utilisation in pre-registration nursing curricula is uncommon in Australia and New Zealand.

AIM

To explore factors surrounding integration of academic electronic medical records into pre-registration nursing curricula in Australia and New Zealand.

DESIGN

Exploratory qualitative multiple case studies approach with purposive sampling set within a larger research project.

METHODS

Semi-structured interviews conducted with course leaders from six nursing schools. Data were analysed in an iterative content-driven deductive and inductive process using open-coding and categories. Case analysis involved within case and cross-case analysis.

RESULTS

Findings revealed different factors that impacted the utilisation of academic electronic medical records in nursing curricula including factors influencing adoption, barriers and challenges with implementation, enablers for integration and perceived benefits for students' clinical practice preparation. Reasons for not using academic electronic medical records, barriers for implementation, and preparation of students for clinical practice in the absence of these simulation tools were also highlighted.

CONCLUSION

Our findings suggest that use of academic electronic medical records in nursing curricula is still evolving and that their adoption and application within programs is not straightforward. While there are many factors unique to the schools using such resources, factors including decisions around curriculum incorporation, optimising available resources to support students' learning, and developing faculty capability to teach with academic electronic medical records were common considerations. Lack of funding and access to local educational tools were ongoing barriers for adoption. Further research examining curriculum timing and preparation, possibilities of partnerships to share resources, and evaluation in meeting students' needs is necessary.

Nurses’ Experiences After Implementation of an Organization-Wide Electronic Medical Record: Qualitative Descriptive Study

Background

Reports on the impact of electronic medical record (EMR) systems on clinicians are mixed. Currently, nurses’ experiences of adopting a large-scale, multisite EMR system have not been investigated. Nurses are the largest health care workforce; therefore, the impact of EMR implementation must be investigated and understood to ensure that patient care quality, changes to nurses’ work, and nurses themselves are not negatively impacted.

Objective

This study aims to explore Australian nurses’ postimplementation experiences of an organization-wide EMR system.

Methods

This qualitative descriptive study used focus group and individual interviews and an open-ended survey question to collect data between 12 and 18 months after the implementation of an EMR across 6 hospital sites of a large health care organization in Victoria, Australia. Data were collected between November 2020 and June 2021, coinciding with the COVID-19 pandemic. Analysis comprised complementary inductive and deductive approaches. Specifically, reflexive thematic analysis was followed by framework analysis by the coding of data as barriers or facilitators to nurses’ use of the EMR using the Theoretical Domains Framework.

Results

A total of 158 nurses participated in this study. The EMR implementation dramatically changed nurses’ work and how they viewed their profession, and nurses were still adapting to the EMR implementation 18 months after implementation. Reflexive thematic analysis led to the development of 2 themes: An unintentional divide captured nurses’ feelings of division related to how using the EMR affected nurses, patient care, and the broader nursing profession. This time, it’s personal detailed nurses’ beliefs about the EMR implementation leading to bigger changes to nurses as individuals and nursing as a profession than other changes that nurses have experienced within the health care organization. The most frequent barriers to EMR use by nurses were related to the Theoretical Domains Framework domain of environmental context and resources. Facilitators of EMR use were most often related to memory, attention, and decision processes. Most barriers and facilitators were related to motivation.

Conclusions

Nurses perceived EMR implementation to have a mixed impact on the provision of quality patient care and on their colleagues. Implementing technology in a health care setting was perceived as a complex endeavor that impacted nurses’ perceptions of their autonomy, ways of working, and professional roles. Potential negative consequences were related to nursing workforce retention and patient care delivery. Motivation was the main behavioral driver for nurses’ adoption of EMR systems and hence a key consideration for implementing interventions or organizational changes directed at nurses.

An Exploratory Study of Allied Health Students' Experiences of Electronic Medical Records During Placements

BACKGROUND

 Allowing students to access and document in electronic medical records (eMRs) during clinical placements is viewed as critical for ensuring that graduates have a high level of digital proficiency prior to entering the workforce. Limited studies have explored student access to eMRs in health disciplines outside of medicine and nursing.

OBJECTIVE

 Our main objective was to examine allied health students' experiences and perceptions of the opportunity to develop eMR competencies during their placement, across a range of allied health disciplines and placement settings.

METHODS

 An explanatory sequential design was used, comprising a quantitative survey (n = 102) followed by qualitative semi-structured interviews (n = 6) with senior allied health students to explore their experiences and perceptions of eMR access during placements.

RESULTS

 Of the 93 students who responded to the question about their placement eMR, nine (10%) reported their placement site did not use an eMR and four students reported that they were not allowed to access the eMR during their placement. Most students (64%, 54 out of 84) accessed the system using their own credentials, but 31% (26 out of 84) used someone else's log-in and password. Students were satisfied with the eMR training and support received while on placement, but there was significant variability across sites on the level of training and support provided. All students believed that eMR access was beneficial for learning and preparation for work, improved delivery of care, taking ownership of work, and feeling responsible for patient care.

CONCLUSION

 Providing students with access to eMRs during placements is fundamental to the development of a student's professional identity and to recognizing their role in the delivery of interprofessional patient care. For graduates to be equipped to effectively contribute to multi-disciplinary care in a digital health environment, universities need to work with practice partners to standardize and formalize eMR access, registration, training, and support, and to provide students with early exposure and training on eMRs in university courses.

Core Competency-Related Professional Behaviors During Patient Encounters: A Report From the Association for Athletic Training Education Research Network

CONTEXT

To enhance the quality of patient care, it is important that athletic trainers integrate the components of the core competencies (CCs; evidence-based practice [EBP], patient-centered care [PCC], health information technology [HIT], interprofessional education and collaborative practice [IPECP], quality improvement [QI], professionalism) as a part of routine clinical practice. In what ways, if any, athletic training students (ATSs) are currently integrating CCs into patient encounters (PEs) during clinical experiences is unclear.

OBJECTIVE

To describe which professional behaviors associated with the CCs were implemented by ATSs during PEs that occurred during clinical experiences.

DESIGN

Multisite panel design.

SETTING

A total of 12 professional athletic training programs (5 bachelor's, 7 master's level).

PATIENTS OR OTHER PARTICIPANTS

A total of 363 ATSs from the athletic training programs that used E*Value software to document PEs during clinical experiences participated.

MAIN OUTCOME MEASURE(S)

During each PE, ATSs were asked to report whether professional behaviors reflecting 5 of the CCs occurred (the professionalism CC was excluded). Summary statistics, including means ± SDs, counts, and percentages were tabulated for the professional behaviors of each CC.

RESULTS

Data from 30 630 PEs were collected during the study period. Professional behaviors related to EBP were the most frequently incorporated during PEs (74.3%, n = 22 773), followed by QI (72.3%, n = 22 147), PCC (56.6%, n = 17 326), HIT (35.4%, n = 10 857), and IPECP (18.4%, n = 5627).

CONCLUSIONS

It is unsurprising that EBP and PCC behaviors were 2 of the most frequently incorporated CCs during PEs due to the emphasis on these competencies during the past several years. However, it is surprising that ATSs did not incorporate behaviors related to either HIT (in 65% of PEs) or IPECP (in 82% of PEs). These findings suggest that directed efforts are needed to ensure that ATSs are provided opportunities to incorporate professional behaviors related to the CCs during clinical experiences.

The critical need for advanced training of electronic records use: implications for clinical practice, education, and the advancement of athletic training

CONTEXT

The effective use of electronic records (ie, electronic health/medical records) is essential to professional initiatives and the overall advancement of the athletic training profession. However, evidence suggests comprehensive patient care documentation and wide-spread use of electronic records is still limited in athletic training. The lack of formal training and education for clinicians and students are often cited as primary barriers to electronic records use. Other healthcare disciplines have used academic electronic health records (AEHR) systems to address these barriers with promising results.

OBJECTIVES

To identify common challenges associated with the effective use of electronic records in clinical practice, discuss how an AEHR can address these challenges and encourage more effective use of electronic records, and describe strategies for deploying AEHRs within the athletic training profession.

DESCRIPTION

The AEHR is an electronic records system specifically designed for educational use to support simulation learning among all types of learners (eg, practicing clinicians, students). Mimicking the form and function of an EHR, the AEHR offers various educational tasks including patient care documentation projects, critical reviews of standardized patient cases, and assessments of patient care data for quality improvement efforts. Clinical and Research Advantages: Recent evidence suggests the use of an AEHR can improve knowledge and enhance skills. Specifically, AEHR use has been associated with enhanced attitudes toward EHR technology, enhanced informatics competencies, and improved documentation skills. Also, the use of an AEHR has been associated with improved critical thinking and decision-making skills. AEHRs appear to be valuable tools for health professions education and athletic training stands to benefit from AEHR use to better train and upskill clinicians and students alike for clinical practice. Although the implementation of an AEHR will require much time and large-scale coordinated efforts, it will be a worthy investment to address current challenges and advance the athletic training profession.

Use of academic electronic medical records in nurse education: A scoping review

BACKGROUND

Use of academic electronic medical records is internationally recognised as a means for preparing health professional students for the digital healthcare environment. Reported practice benefits include skills for electronic documentation, health informatics, point-of-care clinical decision support systems, as well as preparation for information technology-enabled clinical settings, while challenges include lack of access to simulation software, faculty-related barriers, limited finances and educational software costs. However, little is known about best practices related to its use within pre-licensure or entry-to-practice nursing curricula and impact on clinical practice outcomes.

OBJECTIVE

This review sought to explore how academic electronic medical records are used in entry-to-practice nursing curricula.

DESIGN

A scoping review guided by the Joanna Briggs Institute three-step search strategy, exploring existing publications and grey literature.

INCLUSION CRITERIA

Quantitative and qualitative studies related to use of academic electronic medical records in pre-licensure nurse education.

INFORMATION SOURCES

A range of databases were searched including CINAHL, Medline, Proquest Central, ERIC, ScienceDirect, PubMed, IOS Press, as well as grey literature, reference lists and handsearching.

REVIEW METHODS

The search yielded 580 articles, from which inductive thematic analysis of 34 included studies was conducted.

RESULTS

Included articles were nine qualitative, 21 quantitative and five mixed methods studies. Most originated from the USA. Academic electronic medical records are mainly used to teach documentation, safe use of health technology, and for clinical preparation. Most are used for fundamental or junior levels courses, with problem-based learning and simulation embedded. Institution's technology resources and faculty capability are essential to implementation.

CONCLUSIONS

There is a need for more research that examines optimal timing and duration of use of academic electronic medical records in curricula, and their impact on critical thinking and clinical performance. Finally, there is a need to explore greater academic-clinical partnerships in the education process.

Academic Electronic Health Records in Undergraduate Nursing Education: Mixed Methods Pilot Study

BACKGROUND

Teaching students about electronic health records presents challenges for most nursing programs, primarily because of the limited training opportunities within clinical practice settings. A simulated electronic health record is an experiential, learner-centered strategy that enables students to acquire and apply the informatics knowledge needed for working with electronic records in a safe learning environment before the students have encounters with real patients.

OBJECTIVE

The aim of this study is to provide a preliminary evaluation of the Lippincott DocuCare simulated electronic health record and determine the feasibility issues associated with its implementation.

METHODS

We used one-group pretest-posttest, surveys, and focus group interviews with students and instructors to pilot the DocuCare simulated electronic health record within an undergraduate nursing program in Western Canada. Volunteering students worked through 4 case scenarios during a 1-month pilot. Self-reported informatics knowledge and attitudes toward the electronic health record, accuracy of computerized documentation, satisfaction, and students' and educators' experiences were examined. Demographic and general information regarding informatics learning was also collected.

RESULTS

Although 23 students participated in this study, only 13 completed surveys were included in the analysis. Almost two-thirds of the students indicated their overall understanding of nursing informatics as being fair or inadequate. The two-tailed paired samples t test used to evaluate the impact of DocuCare on students' self-reported informatics knowledge and attitudes toward the electronic health record revealed a statistically significant difference in the mean score of knowledge before and after using DocuCare (before: mean 2.95, SD 0.58; after: mean 3.83, SD 0.39; t 12=5.80, two-tailed; P<.001). There was no statistically significant difference in the mean scores of attitudes toward the electronic health record before and after using DocuCare (before: mean 3.75, SD 0.40; after: mean 3.70, SD 0.34; t 12=0.39, two-tailed; P=.70). Students' documentation scores varied from somewhat accurate to completely accurate; however, performance improved for the majority of students as they progressed from case scenarios 1 to 4. Both the faculty and students were highly satisfied with DocuCare and highly recommended its integration. Focus groups with 7 students and 3 educators revealed multiple themes. The participants shared suggestions regarding the DocuCare product customization and strategies for potential integration in undergraduate nursing programs.

CONCLUSIONS

This study demonstrated the feasibility and suitability of the DocuCare program as a tool to enhance students' learning about informatics and computerized documentation in electronic health records. Recommendations will be made to academic leadership in undergraduate programs on the basis of this study. Furthermore, a controlled evaluation study will be conducted in the future.