Embracing innovation in nursing education: Successful implementation of the electronic health record in nursing programs

Jan Cannon MSN, RN Professor of Nursing
DeeAnne Sisco MSN, RN, CNOR, CBN Nursing Instructor

Change is often difficult. Change is inevitable. Embracing change involves acceptance and a willingness to dive in when change is called for. It is important for nursing educators to choose to champion change rather than embracing resistance. This became our motto as we moved towards incorporating the electronic health record (EHR) across our curriculum. The evolution of the EHR and its effect on nursing and healthcare has been profound. Nursing faculty have the enormous challenge of preparing graduates for success in effectively utilizing the EHR while successfully integrating it into nursing curriculum.

Well-educated and experienced nurses are a great commodity to any health care institution. A competent nurse is skilled in practice, critical thinking, sound clinical judgement, communication, and collaboration with other health care disciplines. A nurse educator is a clinical expert whose primary role is to ensure new graduates possess these qualifications. Implementing the EHR into nursing curriculum must be considered to meet the ultimate goal of providing safe and effective care to patients. EHRs build upon each of these essential qualities. They improve patient care, improve coordination of care, improve patient outcomes, increase patient participation in care, streamlines providers” workflow, and promote cost savings.

Implementing the EHR into our curriculum

The bedrock for our decision for implementing the EHR into the curriculum was a first-year graduate nurse survey from our healthcare partners which indicated new graduates did not possess the knowledge and skills needed to utilize the EHR. Based on this survey, our program needed to make a change. We began with an assessment of our program needs in regards to bridging the gap in technology with the EHR. We also searched for data regarding what other nursing programs were doing in regards to the EHR. What we found was that many schools are implementing the academic EHR in only a few areas of the curriculum, particularly in simulated clinical experiences or documentation of the nurse's notes.

Effective strategies to address faculty buy-in and developmental needs have failed. Evidence indicates nursing faculty can be a significant barrier to implementing EHR technology. Faculty who have not worked at the bedside for a number of years may not have the experience with EHRs from practice, and this hinders necessary change.

Creating a comprehensive plan of change is challenging, and nurse educators must be prepared for unanticipated resistance. Nurse educators are required to be innovative, flexible, and knowledgeable to select and implement an effective strategy for curricular change. Implementing of the EHR across the curriculum with 100% faculty buy-in sets the stage for successful integration.

Getting started

We started by eliminating paper care plans and documentation. We wanted to utilize a resource that was already available through our current required course materials to ensure we did not add additional expense to the students. We adopted Course Point Plus which incorporates an EHR called DocuCare. We offset the expense of this new software by eliminating the need for a hard copy of the textbook, separate drug guide, lab manual, and care plan book. This resulted in a savings to our students as compared to a book bundle.

Developing a partnership with our clinical facilities to allow students access to the hospitals EHR during clinical rotations was paramount to our success. DocuCare met the guidelines for the requirements for private healthcare information (PHI), and this allowed us to utilize the program within the clinical facilities, as it is HIPAA compliant. Clear communication between the clinical facilities and the nursing faculty helped facilitate this implementation.

Establishing a timeline and sticking with it kept us on track for successful and timely implementation. A pilot group was formed using first level clinical students to begin implementation. The pilot of the program extended over one semester and one summer term before integrating across the curriculum. This provided the opportunity to work through any issues with the EHR.

Guidelines for data collection, screenshots of each component of DocuCare, and a comprehensive orientation to Docucare were developed as part of the pilot project. The guidelines for data collection provided a framework for what would eventually go to curriculum for implementation across the program.

Identify super users

We utilized super users to orient students and faculty to the product. Identifying two or three faculty experts to lead faculty development and student training will ensure a more seamless implementation process. An intensive Faculty Development Program was provided to all faculty, in addition to regular lunch and learn training sessions during the go live semester.

Super users were available to all faculty during the first year of the implementation process. This helped to ease the anxiety among faculty and helped to ensure a smoother transition.

Get your team on board

It is critical to get your team on board from the very beginning. By decreasing faculty anxieties first, we were able to reduce the stress among students who were only familiar with the paper care planning and documenting process. It's important to note that this required a 100% participation from the faculty. As with any major curriculum change, we started with the Curriculum Committee. At the completion of the pilot term, the EHR went through the Curriculum Committee to determine how to comprehensively and successfully integrate it into our nursing curriculum. A task force was established which included representatives from each program level and the Clinical Coordinators.

The goal of the task force was to develop comprehensive guidelines for implementation through each of the four levels within our program. Each level was given a timeline to complete level and specialty course specific instructions for each clinical course. Each level developed daily and weekly clinical assignments using the EHR for planning and carrying out the plan of care. It was important for each clinical course to develop meaningful learning assignments to promote clinical judgement, prioritization, communication, teamwork and collaboration among health science disciplines, quality improvement, safety and evidence based practice.

Additionally, it was important for our program to show progression from novice to advanced clinical practice. Our assignment timelines were tailored to start basic with the first level clinical students and then progress to full utilization of the EHR for students who are preparing for graduation and entering the profession of nursing.

Implementation

The implementation of the EHR for our program has been relatively seamless due to communication, collaboration, faculty and student buy-in, and extensive orientation for both faculty and students. We developed a mandatory half-day, hands-on Docucare training for our first level nursing students the week before clinical begins. We train the students on the use of Docucare and accompanying resources to help them build a comprehensive plan of care. This training is a collaborative effort between a Lippincott representative and the designated super users.

It has helped us bridge the gap in students learning and ability to skillfully use the EHR upon entering practice.

Troubleshooting

As with any software program, there were a few technical glitches in the beginning. We discovered most were related to the students” own hardware (i.e. laptop, tablet) and/or network issues like weak Wi-Fi signals. This was easily resolved by training faculty on how to instruct students when these issues arise and including troubleshooting guidelines in every course for students to refer to for assistance. A responsive technology assistance/customer service is also invaluable when integrating this type of program.

Strategies for continued success

Challenges and success strategies must continue to be addressed. The DocuCare Task Force has developed a plan to meet once yearly to evaluate strategies to continue to improve use of the EHR, discuss any new assignments to build clinical decision making skills, update assignment timelines and guidelines, and incorporate any updates that continue to be made with the program. Evaluation is a critical step in ensuring continued success with the implementation of the EHR in nursing education.