Presentation
A Needs Assessment for Improving EHR Training in Nursing School
DescriptionIntroduction
The electronic health record (EHR) is a central tool in nurses’ work, with up to 27% of their time spent working in the EHR1. EHRs are complex, with numerous features, multifaceted interfaces, nuances inherent to various EHR vendors, and several EHR-based tasks required to be completed in any given nursing shift. As a result, training is needed for nurses to effectively use the EHR. EHR training provided during nursing programs (before clinical practice) promotes patient safety by avoiding the cognitive overload of learning a complex system in the context of a fast-paced, high-stakes job environment.2 While some formal training programs exist (e.g., EHR Go, Shadow Health), it is unclear how often they are implemented and how they can best meet the needs of nursing students; prior work suggests that few nursing programs provide formal training to students on the EHR.3 This ultimately leaves new nurses with a steep learning curve to adjust to using an EHR on the job, exacerbating high cognitive load in the context of a work setting that is already associated with heavy cognitive burdens. To this end, we sought to conduct a needs assessment to better understand the greatest areas of need for EHR training in nursing school.
Toward the goal of educating nursing students in skills to be used in their future jobs, we followed the Transfer of Training framework by Baldwin and Ford.4,5 This framework posits that in order to apply knowledge, skills, and attitudes learned in a training context to a job, learning must be generalized to the job context and retained over a period of time. The framework further suggests that three categories of inputs can influence learning, retention, and ultimately training transfer: (1) characteristics of the trainees (e.g., cognitive ability, motivation); (2) design of the training (spaced practice, using multiple learning strategies, testing during training); and (3) the work environment (e.g., supervisor support, opportunity to use trained skills). Given our goal, we emphasize the training design category in this study.
Methods
Study Design
This is a qualitative study leveraging semi-structured interviews, approved by the IRB.
Participants and Recruitment
We are recruiting two groups: (1) new nurses (licensed for 6 months-2 years) who work in the inpatient setting, (2) nursing faculty members who teach EHR-related content. We are recruiting 10 nurses and 5 faculty via flyers in inpatient settings, email listservs, and word-of-mouth. Participants receive a $50 gift card after the interview.
Procedure
Potential participants complete an eligibility questionnaire. If eligible, a study team member schedules a virtual, 45-minute semi-structured interview. A verbal informed consent process is conducted at the beginning, and interviews are conducted by members of the study team who do not work with or supervise nurses, nursing faculty, or nursing students. Interviews are audio recorded and transcribed, then de-identified. Topics on the nurse interview guide include perceptions of adequacy of EHR training during nursing school, challenges faced with using the EHR during their first months and years on the job, and recommendations to improve EHR training in nursing school. Topics on the faculty guide include how EHR content is integrated into curricula, teaching strategies to address EHR competencies, perceived gaps in EHR training, student readiness to use the EHR, and recommendations for improving EHR preparation in nursing school.
Analysis
Two study team members will independently code the transcripts using a combined inductive-deductive approach based on the frameworks, and the coded data will be analyzed using thematic analysis to identify common themes related to EHR training gaps and challenges.
Results
Thus far, we have interviewed four nurses and three nursing faculty members, with several other interviews scheduled. The nurses in our sample work in an ICU (n=1) and medical-surgical units (n=3). The nursing faculty members have taught undergraduate (BSN) nursing courses, including skills and clinical classes.
Experiences with Training in Nursing School and Perceived Job Readiness to Use the EHR
Three nurses (75%) indicated that they received no formal training on the EHR during nursing school. For example, Nurse Participant 1 said “We literally opened [the EHR] just to see what it looks like, and that's the extent of our training.” Instead, their EHR experience prior to their first nursing job was limited to quick views of the EHR during clinical rotations. They indicated feeling ill-prepared to use the EHR in their roles as nurses. Nurse Participant 2 stated that their lack of knowledge on the EHR “was definitely slowing [my practice] down… It was slowing me down a lot.” Nurse Participant 1 conveyed a similar experience, indicating that “initially, it's very overwhelming, because it's a lot to grasp.”
The nurse participants indicated they wished for more EHR training during nursing school, e.g., “Before going in, um, I wish they would have showed us how to, like, navigate [the EHR], even if taking just… you know, a class, or just, you know, a one-hour lecture of just showing us, like, a general one… Because that's the main part of my job, is documenting, you know?”- Nurse Participant 1.
Alternatively, Nursing Faculty 1 and 2 indicated that, in their program, nursing students do get the opportunity to learn and practice on the EHR using the Epic Playground, by assessing a simulated patient or task trainer, and documenting findings in the Playground. This is combined with a lecture component of Epic training to show nursing students the various components of the Epic EHR. This different experience may be due to different institutions, differences in training for Associate vs. Bachelor nursing programs, very recent changes in the curriculum, or some combination of these factors.
Most Used EHR Functions
We are also examining which functions in the EHR new nurses purport to use most frequently, to help target where to focus EHR training in nursing school. While participants indicated that this varies by clinical area, some functions are emerging as frequent tasks that are potentially generalizable between specialties, such as the medication administration record (MAR), assessments, reviewing history, documenting vitals and “ins and outs”, writing clinically-relevant notes, and reviewing orders.
Preliminary Recommendations for Training
The nurse participants indicated a desire for more EHR training during nursing school. All participants so far have stated a preference for demonstration- and practice-based training. Nurse Participant 2 indicated she would like to see “a little video, and then I perform the task… If you're just showing me slides… doing lectures, people won't pay attention after 10 minutes.” Another suggestion by Nurse Participant 1 was “but even just bringing, like a, practice patient, like a John Doe patient, just so that we can see the way [the EHR] looks. See what nurses are actually utilizing in the EHR system, and so that way it can, like, really prepare.”
In terms of timing, all nurses thus far have suggested that the training should be done closer to the end of a nursing program, to promote retention. Further, they suggested that integrating the training into other existing required learning experiences, such as simulation labs, would ensure students complete the training, as compared to setting it as an extra, optional opportunity. Nurse Faculty 1 suggested that “repetition might help them, because there's so many different ways in the EHR you can chart, and I think they get confused”.
These findings thus far align with recommendations proposed for training design by the transfer of training framework,4 in that more active instructional strategies (demonstration, practice), repetition, and feedback are key for learning, retention, and transfer.
The electronic health record (EHR) is a central tool in nurses’ work, with up to 27% of their time spent working in the EHR1. EHRs are complex, with numerous features, multifaceted interfaces, nuances inherent to various EHR vendors, and several EHR-based tasks required to be completed in any given nursing shift. As a result, training is needed for nurses to effectively use the EHR. EHR training provided during nursing programs (before clinical practice) promotes patient safety by avoiding the cognitive overload of learning a complex system in the context of a fast-paced, high-stakes job environment.2 While some formal training programs exist (e.g., EHR Go, Shadow Health), it is unclear how often they are implemented and how they can best meet the needs of nursing students; prior work suggests that few nursing programs provide formal training to students on the EHR.3 This ultimately leaves new nurses with a steep learning curve to adjust to using an EHR on the job, exacerbating high cognitive load in the context of a work setting that is already associated with heavy cognitive burdens. To this end, we sought to conduct a needs assessment to better understand the greatest areas of need for EHR training in nursing school.
Toward the goal of educating nursing students in skills to be used in their future jobs, we followed the Transfer of Training framework by Baldwin and Ford.4,5 This framework posits that in order to apply knowledge, skills, and attitudes learned in a training context to a job, learning must be generalized to the job context and retained over a period of time. The framework further suggests that three categories of inputs can influence learning, retention, and ultimately training transfer: (1) characteristics of the trainees (e.g., cognitive ability, motivation); (2) design of the training (spaced practice, using multiple learning strategies, testing during training); and (3) the work environment (e.g., supervisor support, opportunity to use trained skills). Given our goal, we emphasize the training design category in this study.
Methods
Study Design
This is a qualitative study leveraging semi-structured interviews, approved by the IRB.
Participants and Recruitment
We are recruiting two groups: (1) new nurses (licensed for 6 months-2 years) who work in the inpatient setting, (2) nursing faculty members who teach EHR-related content. We are recruiting 10 nurses and 5 faculty via flyers in inpatient settings, email listservs, and word-of-mouth. Participants receive a $50 gift card after the interview.
Procedure
Potential participants complete an eligibility questionnaire. If eligible, a study team member schedules a virtual, 45-minute semi-structured interview. A verbal informed consent process is conducted at the beginning, and interviews are conducted by members of the study team who do not work with or supervise nurses, nursing faculty, or nursing students. Interviews are audio recorded and transcribed, then de-identified. Topics on the nurse interview guide include perceptions of adequacy of EHR training during nursing school, challenges faced with using the EHR during their first months and years on the job, and recommendations to improve EHR training in nursing school. Topics on the faculty guide include how EHR content is integrated into curricula, teaching strategies to address EHR competencies, perceived gaps in EHR training, student readiness to use the EHR, and recommendations for improving EHR preparation in nursing school.
Analysis
Two study team members will independently code the transcripts using a combined inductive-deductive approach based on the frameworks, and the coded data will be analyzed using thematic analysis to identify common themes related to EHR training gaps and challenges.
Results
Thus far, we have interviewed four nurses and three nursing faculty members, with several other interviews scheduled. The nurses in our sample work in an ICU (n=1) and medical-surgical units (n=3). The nursing faculty members have taught undergraduate (BSN) nursing courses, including skills and clinical classes.
Experiences with Training in Nursing School and Perceived Job Readiness to Use the EHR
Three nurses (75%) indicated that they received no formal training on the EHR during nursing school. For example, Nurse Participant 1 said “We literally opened [the EHR] just to see what it looks like, and that's the extent of our training.” Instead, their EHR experience prior to their first nursing job was limited to quick views of the EHR during clinical rotations. They indicated feeling ill-prepared to use the EHR in their roles as nurses. Nurse Participant 2 stated that their lack of knowledge on the EHR “was definitely slowing [my practice] down… It was slowing me down a lot.” Nurse Participant 1 conveyed a similar experience, indicating that “initially, it's very overwhelming, because it's a lot to grasp.”
The nurse participants indicated they wished for more EHR training during nursing school, e.g., “Before going in, um, I wish they would have showed us how to, like, navigate [the EHR], even if taking just… you know, a class, or just, you know, a one-hour lecture of just showing us, like, a general one… Because that's the main part of my job, is documenting, you know?”- Nurse Participant 1.
Alternatively, Nursing Faculty 1 and 2 indicated that, in their program, nursing students do get the opportunity to learn and practice on the EHR using the Epic Playground, by assessing a simulated patient or task trainer, and documenting findings in the Playground. This is combined with a lecture component of Epic training to show nursing students the various components of the Epic EHR. This different experience may be due to different institutions, differences in training for Associate vs. Bachelor nursing programs, very recent changes in the curriculum, or some combination of these factors.
Most Used EHR Functions
We are also examining which functions in the EHR new nurses purport to use most frequently, to help target where to focus EHR training in nursing school. While participants indicated that this varies by clinical area, some functions are emerging as frequent tasks that are potentially generalizable between specialties, such as the medication administration record (MAR), assessments, reviewing history, documenting vitals and “ins and outs”, writing clinically-relevant notes, and reviewing orders.
Preliminary Recommendations for Training
The nurse participants indicated a desire for more EHR training during nursing school. All participants so far have stated a preference for demonstration- and practice-based training. Nurse Participant 2 indicated she would like to see “a little video, and then I perform the task… If you're just showing me slides… doing lectures, people won't pay attention after 10 minutes.” Another suggestion by Nurse Participant 1 was “but even just bringing, like a, practice patient, like a John Doe patient, just so that we can see the way [the EHR] looks. See what nurses are actually utilizing in the EHR system, and so that way it can, like, really prepare.”
In terms of timing, all nurses thus far have suggested that the training should be done closer to the end of a nursing program, to promote retention. Further, they suggested that integrating the training into other existing required learning experiences, such as simulation labs, would ensure students complete the training, as compared to setting it as an extra, optional opportunity. Nurse Faculty 1 suggested that “repetition might help them, because there's so many different ways in the EHR you can chart, and I think they get confused”.
These findings thus far align with recommendations proposed for training design by the transfer of training framework,4 in that more active instructional strategies (demonstration, practice), repetition, and feedback are key for learning, retention, and transfer.
Event Type
Oral Presentations
TimeTuesday, March 248:30am - 8:52am EDT
LocationMorgan
Simulation and Education