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Keywords:

  • Accuracy;
  • clinical reasoning;
  • educational electronic documentation system

Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. Purpose of the Study
  5. Context
  6. Research Questions
  7. Statement of the Problem
  8. Methodology
  9. Results
  10. Discussion of the Results
  11. Limitations
  12. Implication of the Results for Practice
  13. Conclusion
  14. References

Purpose

This quantitative research study used a pretest/posttest design and reviewed how an educational electronic documentation system helped nursing students to identify the accurate “related to” statement of the nursing diagnosis for the patient in the case study.

Methods

Students in the sample population were senior nursing students in a bachelor of science nursing program in the northeastern United States. Two distinct groups were used for a control and intervention group. The intervention group used the educational electronic documentation system for three class assignments. Both groups were given a pretest and posttest case study. The Accuracy Tool was used to score the students' responses to the related to statement of a nursing diagnosis given at the end of the case study. The scores of the Accuracy Tool were analyzed, and then the numeric scores were placed in SPSS, and the paired t test scores were analyzed for statistical significance. The intervention group's scores were statistically different from the pretest scores to posttest scores, while the control group's scores remained the same from pretest to posttest.

Implications

The recommendation to nursing education is to use the educational electronic documentation system as a teaching pedagogy to help nursing students prepare for nursing practice.

Nursing students care for patients in health care, and they have the responsibility of accurately indentifying nursing diagnoses (NDs) based on patient data. A nursing diagnosis is a clinical judgment about a patient, family, or community response to an actual or potential health issue according to NANDA-I (2003). This research study explored the impact of an educational electronic documentation system (EEDS) in a bachelor of science nursing education program and identified how this technology affects student-learning outcomes associated with accurately identifying NDs. An EEDS is a technology that mimics electronic health records used in health care. This technology allows students to document nursing care, create nursing care plans, enter care provider orders, and retrieve diagnostic exam results. This research topic is especially important because the federal government has mandated that all healthcare records be electronically stored by 2014.

The electronic documentation system (EDS) is a computer program that stores patient information related to health care. Gartee and Beal (2012) describe an EDS as a system that has the capabilities to store medical information, which can be accessed when needed. This program includes laboratory tests results, diagnostic tests, and pharmacy information for any medications the patient has ordered. Brokel and Odenbreit (2012) stated that the entered data should be accurate and complete to ensure that all providers have a true picture of the patient. EDS allows for communication between all care providers, with information being easily accessible to any member of the healthcare team. An EEDS was created by a nurse to help nursing students become familiar with the EDS used in health care settings. This system includes the same features as an EDS, as well as NDs definitions, Nursing Interventions Classification (NIC), and Nursing Outcome Classifications (NOC). Students can use this program during their education to prepare them for the systems they will use as practitioners in health care.

The components of the EEDS are important for nursing education to consider when advising students on best practices on entering and retrieving data. Brokel and Odenbreit (2012) noted the differences in EDS used in health care, and they discussed the importance of NDs being included in those systems. In the EEDS, students are able to develop a nursing care plan, this includes identifying NDs, interventions, and outcomes for patients. When nurses enter data into the nursing care plan, this information does not transfer over into a patient problem list, and this means that other providers have to view the care plan to find the nursing interventions and outcomes (Brokel & Odenbreit, 2012). Some EDS create a patient problem list, and the interdisciplinary team can find this information in the provider section (Brokel & Odenbreit, 2012). Nursing students should have an understanding of the differences of EEDS and EDS, as they will be responsible for communicating to the interdisciplinary team.

There is very little published evidence to support the use of the EEDS. Meyer, Sternberger, and Toscos (2011) reported that using an EEDS prepares students to use an EDS, as each system has many of the same components. In this research study, the results were favorable for using an EEDS. Therefore, nursing education can construct student learning activities and assignments in these systems to help students enhance their accuracy skills. Nursing students report that they are not comfortable using healthcare technology, and nurses in practice report that they are not comfortable using electronic healthcare records (Fetter, 2009; Kelley, Brandon, & Docherty, 2011). When students are able to use this technology in nursing education, they are prepared to enter the profession with strong technology skills.

In some nursing programs, students are not permitted to document in healthcare settings using EDS. As noted in Lucas's (2010) study, students only used the hospital's training system. The EEDS can be accessed as long as the Internet is available, so students can document in real time while caring for patients in healthcare settings. Students are able to gather preclinical data for patients, which include medical diagnoses, medications, laboratory values, and diagnostic exams. Then students can print this information and bring it with them, or access the system in the healthcare setting. Instructors can then review information, comment, and grade students' work in the EEDS. This will allow educators to track student progress throughout their education and serve as an indicator for benchmarking standards on this technology.

Nursing education must prepare nursing students to easily transition into healthcare settings to care for patients with health deficiencies. As De Clercq, Moor, Bellon, Foulon, and van der Lei (2008) stated, nurses in practice have negative attitudes about using an EDS; therefore, nursing education has the potential to impact this pessimistic stance. With electronic records being used in most healthcare settings, nurses must understand how and where to document data. Blair and Smith (2012) reported “poor documentation potentially negatively affects patient care, professional accountability, and organizational risk” (p. 161). In a study done by Keenan, Yakel, Dunn-Lopez, Tschannen, and Ford (2013), they found that nurses in practice have many variations of verbal and written communication techniques when reporting patient information. Knowing where to document and retrieve information is critical to the patients' recovery process. All EDS gather general patient information but may have different screens and steps to enter and find data.

Multidisciplinary healthcare teams are critical to a patient's recovery process, and these individuals collaborate to enhance the recovery process of patients in health care. An EDS can help the communication between these individuals as Green and Thomas (2008) noted. Many times, these members of the team rely on information in the patients' record to plan care, anticipate discharge needs, plan and encourage physical activity, and nutritional aspects of patient care. A concerning discovery was made by Keenan et al. (2013) that the multidisciplinary team members do not regularly communicate with nurses who are caring for patients in the hospital setting, and this includes using the EDS to find nursing documentation. When these care providers are able to locate information, they need in an EDS, then no delay in care will occur.

Background

  1. Top of page
  2. Abstract
  3. Background
  4. Purpose of the Study
  5. Context
  6. Research Questions
  7. Statement of the Problem
  8. Methodology
  9. Results
  10. Discussion of the Results
  11. Limitations
  12. Implication of the Results for Practice
  13. Conclusion
  14. References

Nursing students must learn to interpret patient data in order to accurately identify NDs. Lunney's (2008) research suggested that nurses in practice do not accurately translate patient information, which can lead to an increase in patient length of stay in the acute care setting. When student nurses received education and training on the nursing process, they had higher NDs accuracy than those who did not have the training (Lunney, 2008). Keenan et al. (2012) reported that hospital nurses who completed an educational program on standardized language using NANDA-I, NIC, and NOC, as well as imbedded clinical decision support, identified these elements and consistently documented them in patient care. Nurses are accountable for documenting and monitoring nursing interventions and outcomes related to patient care (Paans & Muller-Staub, 2012). The Institute of Medicine (2010) identified safety as an area that must be addressed in nursing education. Hospitals are accountable for medical errors occurring in their facilities, and Gartee and Beal (2012) noted that as many as 98,000 patients die in acute care settings each year from medical mistakes. Therefore, nursing education must prepare students to recognize important cues in patients' subjective and objective assessments. When nursing students understand a patient's medical diagnoses, they are able to enhance their ability to appropriately identify NDs, and this would include the most important data from patients.

Nurses in clinical settings use technology in all aspects of patient care. Whittaker, Aufdenkamp, and Tinley (2009) reported usage of electronic documentation in 68% of hospitals nationwide. Students generally perceive that they have attained high levels of competency when using computer technology (Fetter, 2009); however, actual assessment of performance indicates that students do not have proficiency in these skills needed for optimal college coursework (Elder & Koehn, 2009). In terms of healthcare technology, students perceive that they possess low levels of competency in using applications such as electronic care documentation and creating a nursing care plan (Fetter, 2009). Therefore, nursing education must prepare student nurses to easily transition into their first employment settings. This study hypothesized that using an EEDS during the students' education is crucial for this role transition.

Theoretical Framework

This study employed both education and nursing philosophies, which support each other in forming the framework of the research. Analyzing both the constructivist education theory and the novice to expert practice development model provides nursing education valuable insights on using an EEDS. Each philosophy challenges the student to use critical thinking skills when dissecting a situation. When completing the unfolding case studies, students integrate past learning with new knowledge to evaluate the situation in the unfolding case study. This helps the student to expand their thinking on a situation and connects important concepts into a new context. Benner, Sutphen, and Leonard (2009) noted that “excellent practice required interaction and an imaginative grasp of the possibilities inherent in the particular situation as well as appropriate relevant knowledge for the particular demands of a situation” (p. 30). Students use what they have previously learned and apply that knowledge to the new situations presented in the case studies (Hunter & Krantz, 2010). The educator can act as a facilitator by answering questions or redirecting the questions so students can develop clinical reasoning skills during the educational process. Students then build on basic information and then question and clarify the data gathered when performing an assessment on a patient.

The constructivist educational theory provides a perspective of how students use the theory in the learning process. In the constructivist learning theory, students apply their learning to the educational experience. This means that students learn by actually performing a skill. Hunter and Krantz (2010) reported that developing an awareness of different ways of knowing can help students to internalize their learning. When students use the EEDS, they are applying their knowledge by actually creating nursing care plans. Students can also assess their own learning, and as Conceicao and Taylor (2007) noted, this is a vital aspect of the constructivist educational theory.

Other aspects of the constructivist theory include reflection, emotions, examining others' views, and developing multifaceted analysis of a situation. When students consider each one of the previous concepts, they start to develop thinking habits that are complex. Brooks and Brooks (1993) reported that asking students' open-ended questions helped to encourage communication and develop collaboration between other students and the educator. This is an important skill for students to develop when interpreting patient data and can help nursing students accurately identify NDs for patients. Nursing students are novice learners. Therefore, the practice development model was chosen for this research study, as all nursing students are novice learners.

Because this study looked at the development of new nursing knowledge, Patricia Benner's (1984) practice development model was chosen. This nursing practice model focuses on how a student moves from being a novice nursing student to an advanced beginner student by the time they graduate. Benner's philosophy originated in nursing practice; the model describes how the nurse is able to use practical knowledge to discover complex issues (Altmann, 2007). Nurses move through different levels of knowledge and knowing, not only during their education, but also in their nursing career. There are five stages of the novice to expert learning model. These include novice, advanced beginner, competent, proficient, and expert. A student nurse does not become an expert by the time they graduate; however, they should be moving from a novice student nurse to an advanced beginner. When nursing students complete their education, they should have the knowledge and skills to proficiently care for patients in health care.

In Benner et al.'s (2009) most recent literature on the novice to expert practice model, students were asked to give feedback on situations, set priorities, reflect on practice, develop rationale, and answer the “when” questions of nursing practice. This information is critical to nursing education, as students must become comfortable with feedback not only from educators but also from peers. Students can develop nursing priorities for their patients, and finding the rationale for those priorities is important to the educational process. They can reflect on the choices they have made in planning patient care and consider the patients' responses to those nursing interventions. For example, in caring for surgical patients, students should consider when potential postoperative complications might develop. Nurse educators can use the unfolding case studies embedded in the EEDS for students to develop a nursing care plan with NDs, rationale, and interventions for patients.

Literature Review

As nursing education continues to change with new advancements in health care, there is a call for educators to change their teaching pedagogy. One area that demands more attention in nursing curricula is the use of healthcare technology. EEDS are now available for nursing schools to help provide students the skills in using these types of systems that will be required in all healthcare settings. Imbedded in the EEDS is the function of creating a nursing care plan. Nursing students develop care plans using a standardized language that includes assessment, diagnosis, implementation, outcomes, and evaluation. Accurately identifying patient needs and preferences are part of nurses' responsibilities. When nurses are able to accurately identify patient cues, they can assist patients to meet their goals and return to their highest level of functioning (Institute of Medicine, 2003, 2010). Thus, it is important for nursing students to gain competency in accurately identifying NDs and the “related to” statement of each nursing diagnosis. This topic is critical to study as EEDS are becoming available as a teaching pedagogy in nursing education.

Healthcare facilities require providers of care to record and retrieve records using EDSs. Wolf and Nellis (2011) reported that nurses who have poor computer skills may inaccurately report patient data. Additionally, if the nurse is not able to locate vital patient information in the electronic record, this could lead to serious adverse patient events (Wolf & Nellis, 2011). Keenan et al. (2013) found that nurses in acute care settings use variations of documentation in the electronic health record, which can jeopardize the quality of patient care. Nursing students must become knowledgeable on using EDS when caring for patients, and this can lead to a successful transition into the nursing profession (Horning, 2011). Kelley et al. (2011) noted that nurses with prior experience using EDS reported positive attitudes on using technology. The components of these systems include nursing assessments, care provider order entry, data retrieval, medication administration, patient kardex information, patient teaching, and nursing care plans. Learning the components of these systems is critical to documenting accurate patient data that are readily available to all healthcare professionals.

Purpose of the Study

  1. Top of page
  2. Abstract
  3. Background
  4. Purpose of the Study
  5. Context
  6. Research Questions
  7. Statement of the Problem
  8. Methodology
  9. Results
  10. Discussion of the Results
  11. Limitations
  12. Implication of the Results for Practice
  13. Conclusion
  14. References

The intent of the study was to analyze the accuracy of identifying critical information when using unfolding case studies in an EEDS. Students in the intervention and control groups were given a pretest case study to analyze and identify the “related to” statement of the nursing diagnosis given for the case study. Then the students in the intervention group used the EEDS in the medical surgical course and were assigned three unfolding case studies provided in the EEDS. The students in both the intervention and the control groups took the posttest case study to identify the “related to” statement of the nursing diagnosis provided at the end of the posttest case study. This study provided valuable information on how an EEDS prepares nursing students to accurately recognize critical elements of patients needs. Lunney's (2008) research reported that when nurses did not accurately identify the patient's responses, the patients had poorer outcomes. Students must understand the importance of identifying patients' information, and this must start during their education.

Context

  1. Top of page
  2. Abstract
  3. Background
  4. Purpose of the Study
  5. Context
  6. Research Questions
  7. Statement of the Problem
  8. Methodology
  9. Results
  10. Discussion of the Results
  11. Limitations
  12. Implication of the Results for Practice
  13. Conclusion
  14. References

This research study focused on using unfolding case studies in an EEDS to help students accurately identify important patient cues. The nursing profession uses a standardized language known as the nursing process, and an EEDS can help students learn this process. Keenan et al. (2012) found that nurses who used an electronic health record using a standardized language were able to consistently include all the aspects of the NDs, NIC, and NOC when documenting. The nursing process has five steps that include assessment, diagnosis, planning, implementation, and evaluation (ANA, 2014). Nursing schools must prepare students to accurately incorporate the nursing process into caring for patients. It is not well documented or understood how students are evaluated on the accuracy of NDs they develop for patients. This study provides nursing programs information on how students develop NDs in relation to information from unfolding case studies, and how the EEDS can promote accuracy to refine this competency by investigating the learning outcomes of 37 fourth-year students enrolled in a traditional bachelor of science nursing program. Nursing faculty has not previously used this in any nursing courses.

Senior nursing students were chosen for the study over sophomores and juniors because they are exposed to most disease processes. Therefore, the students can use pathophysiology of disease processes and diagnostic exam values they previously learned in their nursing studies. Because prior research conducted by Lunney (2008) used nurses working in the hospital setting, this was another consideration for using senior nursing students. The EEDS has unfolding case studies designed for students at the senior level. These case studies have complex patient scenarios for students to put information into a clinical context.

Research Questions

  1. Top of page
  2. Abstract
  3. Background
  4. Purpose of the Study
  5. Context
  6. Research Questions
  7. Statement of the Problem
  8. Methodology
  9. Results
  10. Discussion of the Results
  11. Limitations
  12. Implication of the Results for Practice
  13. Conclusion
  14. References

The following research questions were formulated after investigating how EDSs are used in nursing education.

Research Question 1

What is the effect of using an EEDS on the nursing students' ability to identify accurate NDs?

  • Hypothesis. The EEDS will have an effect on the nursing students' ability to identify accurate NDs.

Research Question 2

What effect does an EEDS have on the students' confidence level?

  • Hypothesis. The EEDS will have an effect on the nursing students' confidence level.

Research Question 3

What effect does the student grade point average (GPA) have on the accuracy of NDs created by nursing students? The GPA is based on a 4.0 scale.

  • Hypothesis. A nursing student's GPA does effect the accuracy of NDs created by the students.

Statement of the Problem

  1. Top of page
  2. Abstract
  3. Background
  4. Purpose of the Study
  5. Context
  6. Research Questions
  7. Statement of the Problem
  8. Methodology
  9. Results
  10. Discussion of the Results
  11. Limitations
  12. Implication of the Results for Practice
  13. Conclusion
  14. References

The research problem is that many nursing students are unable to accurately identify NDs. This is evidenced by Lunney's (2008) research, which suggests that nurses in practice do not always accurately interpret patient information. In terms of healthcare technology, nursing students perceive that they possess low levels of competency in nursing application technology such as electronic care documentation and creating a nursing care plan (Fetter, 2009). Therefore, nursing education must better prepare students to recognize the important cues in patient data and assessments. When students recognize accurate cues from patients, the patient can have a decreased length of stay in the healthcare setting (Muller-Staub, Needham, Odenbreit, Lavin, & van Achterberg, 2007). When patients spend less time in healthcare settings, they decrease the risk of developing complications and hospital-acquired infections, which can lead to death.

Methodology

  1. Top of page
  2. Abstract
  3. Background
  4. Purpose of the Study
  5. Context
  6. Research Questions
  7. Statement of the Problem
  8. Methodology
  9. Results
  10. Discussion of the Results
  11. Limitations
  12. Implication of the Results for Practice
  13. Conclusion
  14. References

Research Design

A quasi-experimental pretest/posttest design was use for this research study. Students in the intervention and control groups took both the pretest and the posttest, using two different case studies. The mean scores from the intervention and control groups were analyzed with SPSS. Therefore, collecting actual responses of students' “related to” statement of a nursing diagnosis has not previously been done in any study to date.

Intervention

The intervention used in this study was three unfolding case studies in an EEDS. The intervention took place over three consecutive weeks in the spring semester. The chosen unfolding case studies were related to course content. This alignment assisted students to understand new theory content, as well as build on past learning of nursing theory. The content in the unfolding case studies included pneumonia, diabetic foot ulcer, and femur fracture. Components of the unfolding case studies included documenting assessments, entering vital signs, intake/output, teaching, and developing a nursing care plan. Students completed the unfolding case studies in the EEDS and then submitted it for grading.

Sampling Method/Data Collection

The university's institutional review board approved the study. The chair of the nursing program granted permission, as did faculty in both nursing courses. For the research study, a convenience sample of students in the medical surgical and nursing leadership courses was used. Students were given information on the study, and a consent form was signed and collected. The students in the medical surgical course did not have extra assignments or attend additional classes. The instructor of the course assigned three unfolding case studies in the EEDS as student assignments in the course.

The study took place over the students' regular semester. After the pretest, the intervention group was assigned three unfolding case studies in the EEDS; this assignment was part of the course and explained in the syllabus. After the completion of the three unfolding case studies, students in both the control and the intervention group completed the posttest.

Instrumentation

The senior nursing students were given the demographic questionnaire that was completed at the time of the pretest case study. The information that was self-reported included gender, age, ethnicity, GPA, and a question asking their confidence on identifying accurate NDs. The case study was given to students to complete once they were finished filling out the demographic questionnaire. Students were instructed to read the case study itself and identify the “related to” statement of the nursing diagnosis given at the end of the case study. For the final part, they were asked to return to the case study, without changing their answer, and write the number(s) of the three most important sentences for the second part of the diagnosis, i.e., the three sentences that contain the most relevant information. Then the “related to” statement of the nursing diagnosis was scored using the Accuracy Tool. For the posttest, the same procedure was used to administer and score the case study. The Accuracy Tool was developed in conjunction with the case studies that were used for the pretest and posttest. The Accuracy Tool allowed the cues to be ranked from the student responses chosen for the “related to” statement of the nursing diagnosis at the end of the case study (Lunney, 1992). The Accuracy Tool has numeric numbers ranging from +5 to −1. There are explanations for expected responses with each numeric score. The predetermined responses on the Accuracy Tool ranged from the nursing diagnosis was highly relevant and consistent with all the cues of the situation presented in the case study to the cues were completely missed and should be discarded or rejected. Lunney (1992) validated the two case studies, by having four experts identify the most accurate responses. The content validity index was 91.7. The experts also validated the case study responses identifying high to low accuracy of the responses. The Pearson product–moment correlations are as follows: case study 1 = .96 and case study 2 = .97.

Description of the Sample

The sample for the study included 37 senior nursing students in a traditional bachelor of science nursing program at a university in the northeastern United States. The intervention group included 19 participants, and the control group included 18 participants. Students in the intervention group were enrolled in the medical surgical course. They were assigned to the intervention group because the unfolding case studies aligned with the content in this nursing course, and the sample consisted of the entire senior class (Table 1). Ninety-four percent of the students in the study were between the ages of 21 and 28 (Table 1). Seventy-eight percent of the participants were White (Table 1). The GPAs of 67% of the students were 3.0–3.4 (Table 1). This is consistent with all of the students in the nursing program at this university.

Table 1. Description of the Sample
 InterventionControl
Gender  
● Female1714
● Male24
Age  
● 21–281916
● 29–35 1
● >35 1
Ethnicity  
● African American21
● Asian21
● Hispanic//Latino11
● White1415
Grade point average  
● 3.5–4.046
● 3.0–3.41411
● 2.9–2.511

Results

  1. Top of page
  2. Abstract
  3. Background
  4. Purpose of the Study
  5. Context
  6. Research Questions
  7. Statement of the Problem
  8. Methodology
  9. Results
  10. Discussion of the Results
  11. Limitations
  12. Implication of the Results for Practice
  13. Conclusion
  14. References

The intervention group's mean scores on the Accuracy Tool for both the pretest and the posttest were analyzed using a paired t test using SPSS (IBM Corporation, Armonk, NY, USA). A p value of .05 was set, and a two-tailed test was set for determining statistical significance. The mean, standard deviation, paired t test, and confidence intervals were determined (Table 2). The p value of the paired t test was .019, which is statistically significant. The p value of the control group was .842; the paired t test analysis is presented in Table 3. The confidence level was set at 95% of the mean score, indicating that the population would fall between −1.8 and −.18. To identify the significance of the tests, the hypothesis, null hypothesis, and the absolute values were determined. Another consideration was to analyze if the control group's scores changed over the time. Therefore, an independent t test was analyzed on the pretest and posttest scores on the Accuracy Tool for the control group, and the mean scores remained the same over the time of the intervention. Therefore, the hypothesis was accepted for the primary research question that EEDS had an effect on the nursing students' ability to identify accurate NDs.

Table 2. Intervention Group's Paired t Test
 Paired differencestdfSig. (two-tailed)
MeanSDSECI
LowerUpper
  1. Note: SPSS paired t test intervention group. A p value of .05 was set, and a two-tailed test. .019 statistically significant. CI, confidence interval; df, degrees of freedom; SD, standard deviation; SE, standard error.

Pre/post accuracy1.01.699.3899−1.82−.181−2.56518.019
Table 3. Control Group's Accuracy Paired t Test
 Paired differencestdfSig. (two-tailed)
MeanSDSECI
LowerUpper
  1. Note: SPSS paired t-test control group. The p value of the control group was .842, therefore not statistically significant. CI, confidence interval; df, degrees of freedom; SD, standard deviation; SE, standard error.

Pre/post accuracy.1112.32.546−1.041.27.20317.842

The second research question stated that the EEDS will have an effect on the nursing students' confidence levels. The pretest and posttest ordinal scores were analyzed using a paired t test. A p value was set at .05 using a two-tailed test of significance. For the research question, students were asked to rate their confidence level on developing accurate NDs. The mean scores of the intervention group's pretest were 3.8 and posttest 3.3 (Table 4). A two-tailed test was used for statistical significance with a p value of .058 on the paired t test analysis. Therefore, the hypothesis was rejected because there was no effect on the nursing students confidence levels after using the EEDS.

Table 4. Paired t Test on Confidence Levels
Confidence levelPaired differencestdfSig. (two-tailed)
MeanSDSECI
LowerUpper
  1. Note: Paired t test of confidence levels of the intervention group on creating accurate nursing diagnoses. CI, confidence interval; df, degrees of freedom; SD, standard deviation; SE, standard error.

Pre/post intervention.4741.020.2341−.0180.9652.02418.058

The hypothesis of the final research question stated that a nursing student's GPA does effect the accuracy of NDs created by the students. To answer the third research question, a Pearson product–moment correlation (Table 5) was analyzed; this provided information on the two variables of Accuracy and GPA. The Pearsons r value is a linear value between −1 and +1, and a score of zero is no relationship. This value for the correlation of GPA and Accuracy Tool score for this research question the r = of −.051, this is a weak negative correlation. The hypotheses was rejected because after an analysis of the inferential statistic, this showed no statistical significance.

Table 5. Correlations of Pearsons r on GPA and Accuracy
 GPAAccuracy
  1. Note: Correlation of self reported GPA and Accuracy Tool score of the intervention group.

Grade point averager1−.128
Sig. (two-tailed) .449
N3737
Accuracyr−.1281
Sig. (two-tailed).449 
N3737

Discussion of the Results

  1. Top of page
  2. Abstract
  3. Background
  4. Purpose of the Study
  5. Context
  6. Research Questions
  7. Statement of the Problem
  8. Methodology
  9. Results
  10. Discussion of the Results
  11. Limitations
  12. Implication of the Results for Practice
  13. Conclusion
  14. References

This study supported using an EEDS in nursing education. With this type of technology becoming widely used in health care, new nurses are expected to have a working knowledge of an EDS. This technology can help students learn to use and refine these skills needed for nursing practice. Guhde (2010) noted that an online activity using a case study increased nursing students' clinical decision-making skills, helped them recognized the importance of a patient's assessment, and they reported this activity as a valuable learning exercise. The results of this study using an EEDS showed that students who used the unfolding case studies identified critical cues in patient data. As a result, those students developed more accurate nursing diagnosis for the patients in the two case studies used for this research.

During their education, nursing students need to have realistic patient data and pragmatic nursing situations. Guhde (2010) noted that students who used case studies were able to analyze their own thinking patterns, and this helped them increase their awareness of identified misconceptions of real nursing expectations. Bruylands, Paans, Hediger, and Müller-Staub (2013) noted that the practice of guided clinical reasoning helped nurses with accuracy of patient information. Guided clinical reasoning is described as critical thinking and reflection technique to help nurses identify accurate NANDA-I NDs, interventions, and outcomes (Bruylands et al., 2013). The unfolding case studies embedded in the EEDS provides students with the opportunity to evaluate information, provide realistic assessments, develop nursing interventions, and create teaching plans. Using the unfolding case studies in an EEDS can help students prepare for real patient situations.

The EEDS allows the student to consider all the aspects of a patient's assessment, teaching, and nursing care plans. The EEDS has NANDA-I NDs, NIC, and NOC information embedded in the nursing care plan section of the EEDS. In addition, the system has teaching information that is appropriate for the nursing and medical diagnoses, medication information, and areas that should be assessed during a physical examination. In Brokel's (2009) information on clinical decision support, she noted that this support in an EEDS helped to prevent errors, promote safety, enhance communication, and provide evidence-based practice decisions. This means that students can see all areas of the assessment data and can then determine what is appropriate for the assessments of individual patients.

Limitations

  1. Top of page
  2. Abstract
  3. Background
  4. Purpose of the Study
  5. Context
  6. Research Questions
  7. Statement of the Problem
  8. Methodology
  9. Results
  10. Discussion of the Results
  11. Limitations
  12. Implication of the Results for Practice
  13. Conclusion
  14. References

The unfolding case studies that were used for this research were developed by the EEDS company. The nursing faculty teaching the Care of Adults III course selected the unfolding case studies, and the content taught in the course is instructor dependent. Groups for the quantitative study were small, and a larger population would give stronger support for using an EDDS. Using other populations of nursing students in different educational settings would provide for expanded use of this pedagogy. For this study, the EEDS was only used for three weeks in one nursing course. Using this system for the entire semester might provide different results. If this technology were used across the nursing curriculum, the results could be different. When developing a study in the future, a researcher might use two different nursing programs, one school who has this technology and one who has not adopted the use of an EEDS in the curriculum.

Implication of the Results for Practice

  1. Top of page
  2. Abstract
  3. Background
  4. Purpose of the Study
  5. Context
  6. Research Questions
  7. Statement of the Problem
  8. Methodology
  9. Results
  10. Discussion of the Results
  11. Limitations
  12. Implication of the Results for Practice
  13. Conclusion
  14. References

Because the findings support the research hypothesis that students who use this system identify more accurate NDs after using an EEDS, nursing programs should strongly consider using this learning tool across the nursing curriculum. Using this as a teaching pedagogy in every nursing course can expose students to situations they may not encounter in a clinical setting. When students have exposure to different situations, this will help them develop clinical reasoning skills needed for nursing practice. Every nurse in the profession will be expected to document in electronic format at some time in the near future. Candela and Bowles (2008) noted that 76% of new nursing graduates were not prepared to assess and use electronic medical records. Preparing students to use this technology should be an expectation in nursing education.

When student nurses interpret patient data accurately, it increases the likelihood that they will ascertain appropriate NDs for each individual patient. Using the EEDS, technologic innovation presents numerous implications for the future of nursing education, specifically the technology students' use in the classroom, nursing resource center, and clinical setting. Therefore, nursing students' exposure to technology in their educational program prepares them for using systems in health care, as noted by Fetter (2009), Lucas (2010), Nickitas et al. (2010), and Warren and Connors (2007). Given nurses' responsibilities in interpreting and documenting data in health records, this topic is especially important to nursing education.

Technology is integrated into nursing care, and nurses must be comfortable using an EDS, as they will use this equipment in their first employment setting. Preparing students to use the EDS is critical to the success of electronic documentation. As systems become more advanced, all patient records will be connected so every provider can access any health information regardless of where the tests or care were performed (Horning, 2011). In the future with EDS, this information would be accessible to all providers. This technology has the potential to reduce the cost of health care by decreasing the amount of duplication of services.

Learning to develop strong clinical reasoning skills is vital to positive patient outcomes in health care. The concept of clinical reasoning was recently identified as a middle-range nursing theory. Nurses use clinical reasoning skills when interpreting patient data. Simmons (2010) reported that clinical reasoning is complex and uses formal and informal thinking strategies to analyze, evaluate, and weigh alternative actions. Nurses must employ critical thinking skills when developing cognitive skills; Lunney (2010) identified habits of the mind as a way to advance important critical thinking skills. These habits of the mind include the concepts of confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection (Lunney, 2010). Lunney also reported that when nurses do not use critical thinking skills, diagnostic errors can occur in patient care. Potentially, students learning on an EEDS with the unfolding case studies would have higher level thinking skills.

Conclusion

  1. Top of page
  2. Abstract
  3. Background
  4. Purpose of the Study
  5. Context
  6. Research Questions
  7. Statement of the Problem
  8. Methodology
  9. Results
  10. Discussion of the Results
  11. Limitations
  12. Implication of the Results for Practice
  13. Conclusion
  14. References

The results of this quantitative research study provided valuable information on using an EEDS as a teaching pedagogy in nursing education, as well as addressed a gap in the current literature base. EEDS are available for a cost to nursing students, just as other online educational programs used in higher education. Using an EEDS as part of the curriculum can help students accurately identify important patient data. When an EEDS is used, students can develop higher level thinking skills, as these skills are essential for nursing practice. With information in health care rapidly changing and new information being generated daily, this technology helps all health care providers' access vital patient information.

References

  1. Top of page
  2. Abstract
  3. Background
  4. Purpose of the Study
  5. Context
  6. Research Questions
  7. Statement of the Problem
  8. Methodology
  9. Results
  10. Discussion of the Results
  11. Limitations
  12. Implication of the Results for Practice
  13. Conclusion
  14. References
  • Altmann, T. K. (2007). An evaluation of the seminal work of Patricia Benner: Theory or philosophy? Contemporary Nurse: A Journal for the Australian Nursing Profession, 25(1–2), 114123.
  • American Nurses Association. (2014). Nursing process. Retrieved from http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-You-Need/Thenursingprocess.html
  • Benner, P. (1984). From novice to expert excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.
  • Benner, P., Sutphen, M., & Leonard, V. (2009). Educating nurses: A call for radical transformation. Hoboken, NJ: Jossey-Bass.
  • Blair, W., & Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse: A Journal for the Australian Nursing Profession, 41(2), 160168.
  • Brokel, J. M. (2009). Infusing clinical decision support interventions into electronic health records. Urologic Nursing, 29(5), 345353.
  • Brokel, J. M., & Odenbreit, M. (2012). Nursing classifications: Criteria and evaluation. In T. H. Herdman (Ed.), NANDA International nursing diagnoses: Definitions and classification 2012–2014. Oxford, UK: Wiley-Blackwell.
  • Brooks, J. G., & Brooks, M. G. (1993). In search of understanding: The case for constructivist classrooms. Alexandria, VA: Association for Supervision and Curriculum.
  • Bruylands, M., Paans, W., Hediger, H., & Müller-Staub, M. (2013). Effects on the quality of the nursing care process through an educational program and the use of electronic nursing documentation. International Journal of Nursing Knowledge, 24(3), 163170. doi:10.1111/j.2047-3095.2013.01248.x
  • Candela, L., & Bowles, C. (2008). Recent RN graduate perceptions of educational preparation. Nursing Education Perspectives, 29(5), 266271.
  • Conceicao, S., & Taylor, L. D. (2007). Using a constructivist approach with online concept maps: Relationship between theory and nursing education. Nursing Education Perspectives, 28(5), 268275.
  • De Clercq, E., Moor, G., Bellon, J., Foulon, M., & van der Lei, J. (2008). Collaborative patient centered ehealth. Amsterdam, The Netherlands: IOS Press.
  • Elder, B. L., & Koehn, M. L. (2009). Assessment tool for nursing student computer competencies. Nursing Education Perspectives, 30(3), 148152.
  • Fetter, M. S. (2009). Graduating nurses' self-evaluation of information technology competencies. Journal of Nursing Education, 48(2), 8690.
  • Gartee, R., & Beal, S. (2012). Electronic health records and nursing. Boston, MA: Pearson.
  • Green, S. D., & Thomas, J. D. (2008). Interdisciplinary collaboration and the electronic medical record. Pediatric Nursing, 34(3), 225.
  • Guhde, J. (2010). Clinical decision-making: Using online exercises and patient simulation to improve students' clinical decision-making. Nursing Education Perspectives, 31(6), 387389. doi:10.1043/1536-5026-31.6.387
  • Horning, R. (2011). Implementing an electronic medical record with computerized prescriber order entry at a critical access hospital. American Journal of Health-System Pharmacy, 68(23), 22882292. doi:10.2146/ajhp110249
  • Hunter, J., & Krantz, S. (2010). Constructivism in cultural competence education. Journal of Nursing Education, 49(4), 207.
  • Institute of Medicine. (2003). Key capabilities of an electronic health record system. Washington, DC: National Academy Press.
  • Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academy Press.
  • Keenan, G., Yakel, E., Dunn-Lopez, K., Tschannen, D., & Ford, Y. (2013). Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information. Journal of the American Medical Informatics Association, 20(2), 245251. doi:10.1136/amiajnt-2012-000894
  • Keenan, G., Yakel, E., Yao, Y., Xu, D., Szalacha, L., Tschannen, D., & Wilkie, D. J. (2012). Maintaining a consistent big picture: Meaningful use of a web-based POC EHR system. International Journal of Nursing Knowledge, 23(3), 119133. doi:10.1111/j.2047-3095.2012.01215.x
  • Kelley, T. F., Brandon, D. H., & Docherty, S. L. (2011). Electronic nursing documentation as a strategy to improve quality of patient care. Journal of Nursing Scholarship, 43(2), 154162. doi:10.1111/j.1547-5069.2011.01397.x
  • Lucas, L. (2010). Partnering to enhance the nursing curriculum: Electronic medical record accessibility. Clinical Simulation in Nursing, 6(3), e97e102. doi:10.1016/j.ecns.2009.07.006
  • Lunney, M. (1992). Divergent productive thinking factors and accuracy of nursing diagnosis. Research in Nursing & Health, 15, 303311.
  • Lunney, M. (2008). Current knowledge related to intelligence and thinking with implications for the development and use of case studies. International Journal of Nursing Terminologies & Classifications, 19(4), 158162.
  • Lunney, M. (2010). Use of critical thinking in the diagnostic process. International Journal of Nursing Terminologies & Classifications, 21(2), 8288. doi:10.1111/j.1744-618X.2010.01150.x
  • Meyer, L., Sternberger, C., & Toscos, T. (2011). How to implement the electronic health record in undergraduate nursing education: Learn how one university integrated this technology into its interdisciplinary healthcare curricula. American Nurse Today, 6(5), 4044.
  • Muller-Staub, M., Needham, I., Odenbreit, M., Lavin, M. A., & van Achterberg, T. (2007). Improved quality of nursing documentation: Results of a nursing diagnoses, interventions, and outcomes implementation study. International Journal of Nursing Terminologies & Classifications, 18(1), 517.
  • NANDA-I. (2003). NANDA-nursing diagnoses: Definition and classification 2003–2004. Philadelphia: Author.
  • Nickitas, D., Nokes, K., Caroselli, C., Mahon, P., Colucci, D., & Lester, R. (2010). Increasing nursing student communication skills through electronic health record system documentation. Plastic Surgical Nursing, 30(2), 103106.
  • Paans, W., & Muller-Staub, M. (2012). Standards in multi-professional digital documentation. IT for Health, 14(14).
  • Simmons, B. (2010). Clinical reasoning: Concept analysis. Journal of Advanced Nursing, 66(5), 11511158. doi:10.1111/j.1365-2648.2010.05262.x
  • Warren, J., & Connors, H. R. (2007). Health information technology can and will transform nursing education. Nursing Outlook, 55(1), 5860. doi:10.1016/j.outlook.2006.11.003
  • Whittaker, A. A., Aufdenkamp, M., & Tinley, S. (2009). Barriers and facilitators to electronic documentation in a rural hospital. Journal of Nursing Scholarship, 41(3), 293300.
  • Wolf, D. M., & Nellis, D. L. (2011). Informatics: Helping the LNC adjust to electronic records … the second of a two part series. Journal of Legal Nurse Consulting, 22(2), 812.