Influencing Today's Nursing Students for Practice Tomorrow: Integrating Simulated Electronic Documentation

Statement of the Problem: Federal directives, nursing and nursing education associations, as well as accrediting bodies emphasize the importance of integrating health information technology and electronic health care record (EHR) into nursing practice. Additionally, information management and the application of technology in patient care is a required competency of baccalaureate nursing graduates. Content needed in the curriculum to meet this requirement includes the utilization of EHRs, decision support tools, and databases in the health care system. Key professional nursing associations, as well as a national nursing informatics coalition, have created policy statements that support competency in nursing informatics for all practicing nurses, as well as nursing students. Documentation and planning of patient care through an EHR is a relevant skill necessary in achieving this competency.

Unfortunately, in the clinical setting, students are rarely afforded the opportunity to document on patients electronically. Most facilities are equipped with computers at the nurse’s station or in patient care rooms. Some have computers on wheels (COWS). These computers are primarily for the nursing staff to use to deliver care to patients. Therefore, faculty and students have limited access on these computers. Furthermore, because of time restraints, faculty are not able to adequately review all students’ documentation daily in the clinical setting. In addition, students spend a limited amount of time in an assigned clinical agency; consequently, many organizations believe that the sensitivity of medical records and the resources needed for training outweigh the benefits of allowing students to utilize the EHR system. Therefore, students are often prevented from documenting in permanent EHRs.

Description of Innovation: As a part of the project, nursing faculty received an electronic tablet. Orientation to the resource and its use as a teaching tool occurred during a specified meeting time prior to the beginning of the clinical component of assigned courses; all faculty were oriented at the same time. Faculty who planned to use the electronic tablet as a teaching tool and were unfamiliar with the technology received additional orientation to the device by a Technology Services Manager prior to beginning clinical. All faculty accessed a Health Insurance Portability and Accountability Act (HIPPA) compliant, web-based EHR simulation software via his/her tablet. The students utilized the educational simulation EHR in the clinical setting as assigned. Students used the electronic tablets and EHR simulation software to demonstrate electronic documentation of patients cared for in the clinical setting. Documentation was submitted related to the patients as if they were making real-life decisions. The instructor evaluated student documentation and provided immediate feedback for each documentation activity. At the end of the semester, all students involved in the project completed a questionnaire of the teaching tool’s accessibility, practicality, and impact on performance and patient care.  

Change Brought About by Innovation: As a result of the project, nursing students were afforded the opportunity to practice real-time electronic documentation on patients at a clinical site in a safe environment. As the EHR simulated software utilized also provided students with peer-reviewed information on evidenced-based practice, medications, and applicable practice guidelines, they use this information to assist with clinical reasoning. Therefore, the students were better prepared to enhance patient comfort and prevent undesirable outcomes. By creating a simulated EHR in the clinical setting, nurse faculty were able to improve the documentation skills of pre-licensure students. Overall, students provided positive feedback related to the utilization of simulated electronic documentation and voiced the necessity of the technology in the nursing curricula. Students generally acknowledge the potential of electronic document to improve patient safety. In addition, faculty reported improvement in students’ point-of-care and real time charting.

Implications and Significance for Practice and Education: For the most part, a nursing student’s documentation is a hand-written account of the student’s fulfillment of the professional and legal duty of care. This documentation process provides an overview of the communication between health care professionals, a plan of patient care, an analysis of health care, a source for education and research, and the patient’s medical position. In the clinical setting, students are required to bring resources such as lab books, pathophysiology books, and course specific books as well as calculators, drug cards, and concept maps to assist in planning in documenting this care of patients in the health care setting. Access to an overview of patients’ current data, medication history, and alerts for drug incompatibility can dramatically increase the quality of nursing care. Often, documentation is not reviewed and graded until after the clinical experience; allowing the loss of great “teaching moments.” Clear, concise, instantly accessible information stimulates critical thinking, resulting in better clinical decisions grounded in evidence-based care. Access to technology via an electronic tablet affords students the opportunity to practice documentation electronically and learn simultaneously.

Recommendations: Resources to enhance students’ learning in the area of electronic documentation in an effort to prepare them for practice after graduation is essential in influencing nursing education. Simulated electronic documentation teaches students to think critically about documentation in a safe environment while enabling faculty to measure their progress. The knowledge acquired by integrating simulated electronic documentation into nursing curricula will provide students a valuable educational experience as well as real-world practice.