Students Nurses’ Knowledge toward ED Training

by Giannis Polychronis, PhD candidate, MSN, RN,
Anti-Cancer Society Cyprus, Nicosia, Cyprus 

Maria Noula, PhD, MSc, BS,
Department of Life and Health Sciences,
University of Nicosia, Cyprus

Maria Pitsilidou, PhD, RN,
Evangelistria Medical Centre, Nicosia, Cyprus 

Zoe Roupa, PhD, MD, RN,
Department of Life and Health Sciences,
University of Nicosia, Cyprus

Citation: Polychronis, G., Noula, M., Pitsilidou, M., & Roupa, Z. (2020). Students Nurses’ Knowledge and Attitude toward their Training in Electronic Documentation: A Cross-Sectional Study. Canadian Journal of Nursing Informatics, 15(3). https://cjni.net/journal/?p=8106

ABSTRACT 

Background: Printed nursing documentation has been identified as an insufficient method and consequently Electronic Nursing Documentation (END) is becoming more widespread in the clinical working place. The training of nursing students in using END should become a requirement as they will be exposed to a working environment that becomes more dependent on technology.

Purpose: To investigate the training level of nursing students regarding END.

Methods: A cross-sectional survey using both paper and web-based delivery methods was used. A modified version of a previously developed questionnaire was used to survey participants. Convenience sampling was performed with a total of 102 nursing students (October – November 2019). Through the website of a professional nursing organization in Cyprus, an online advertised – invitation was sent, to approach nursing students to participate in the survey. Most data were collected online, with some collected manually using paper-based questionnaires from one University. Data were analyzed using IBM SPSS 24.0.

Results: In the present study, 52 % of the students stated that they have not been trained at all in the use of  Electronic Health Records (EHR) applications with a significant statistical difference p<0.042 in undergraduate nursing students as compared to the postgraduate nursing students which reported that they are more trained in the EHR systems. In the quantitative results of this study, 62.5% of the students believed that END reinforces the ability of problem-solving as well as critical thinking, with the students trained in EHR supporting this view to the greatest extent (p<0.001).  

Conclusions: To date, minimum attention has been given to END in undergraduate nursing programs which leaves nursing students disappointed since they believe that technology improves communication and strengthens their critical thinking. The findings of this study highlight the importance of the development and implementation of electronic documentation in undergraduate nursing programs to allow nursing students to apply current and future technology. 

Keywords: Electronic Nursing Documentation, Computerized Nursing Documentation, Students Nurse Perception of Electronic Health Records, Cross-sectional 

INTRODUCTION

Nursing Documentation (ND) has been one of the most significant nursing functions since the time of Florence Nightingale in the 19^th century because it serves extremely important purposes. ND is generally, and internationally, recognised as one of the most important nursing duties that promote professional autonomy and constitute the core of the functions of nurses (Jenkins & Davis, 2019). Nursing care provision has changed due to the introduction of information systems, and ND is the most important aspect of that change (Mountain et al., 2015). According to the World Health Organization (2012), an END is any system that records, stores, manages or transmits information regarding the health of persons, or the activities of healthcare organisations. 

According to the available literature there are three ND methods: a) paper based b) electronic c) and a combination of both these methods (Bose et al., 2019). ?ND, which is part of a wider END, is a type of clinical technology which focuses on the collection of information regarding the health of patients (Fareed et al., 2015). Paper based ND has proven to be ineffective based on the findings of several studies conducted both in EU and non-EU countries. Therefore, all competent bodies must support the transition to ?ND since it enhances effective documentation, quality of communication and, consequently, improves the quality of care provided (Ramukumba & Amouri 2019; Choi et al., 2016; Fareed et al., 2015; Kahouei et al., 2014; Aktan et al., 2011).  

The implementation of END and electronic documentation in the clinical area are becoming more and more widespread due to their advantages (Zhang et al., 2012), but very little attention has been paid to the study of this subject within nursing education programs (Tubaishat, 2018). Misuse of END could lead to adverse reactions/events, medical errors and other unintended negative consequences (Metzger et al., 2010). Therefore, preparing students for END is deemed to be essential, since they will increasingly be faced with an environment which is becoming more and more dependent on technology (Baillie et al., 2013; Choi et al., 2015). 

Training students in a transitional electronic environment, should not be optional but compulsory and it should be implemented in all University nursing courses (Aktan et al., 2011). It is a fact that some nursing programs do not provide any opportunities for students to practise or learn about electronic documentation until they start their clinical practice (Meyer et al., 2011). During clinical practice, it is not easy for students to learn to use this technology correctly and appropriately (Baillie et al., 2013). The fact that END have been designed based on the needs of each area, clearly make the work of nursing educators difficult (Mahon et al., 2010). However, it is important for students to learn how to handle such systems during their studies, both on a theoretical and a practical level, and in laboratories equipped with training simulators (Gardner & Jones, 2012).

There are similar studies in the existing literature, which have attempted, mainly with improvised instruments, to evaluate and interpret nursing students’ level of training in END. The results of these studies have consistently shown that it is necessary for nursing students to come into contact with END systems during their training so that they are adequately prepared to enter their profession with strong technological skills (Choi et al., 2015; Chung & Cho, 2017; Meyer et al., 2011; Williamson & Muckle, 2018). Incorporating training programs devoted to END into nursing degrees would offer students a safe and supportive environment, improve communication and promote critical thinking (Polychronis et al., 2019).  Even though Cyprus is in the initial stages of incorporating END, they are already partly used in some clinical areas. However, the development of such systems, and therefore END, is extremely encouraging since more and more researchers have started to become involved with this issue (Ministry of Health, Republic of Cyprus, 2019). The main reason behind the decision to choose the specific research topic and to conduct this study is to investigate whether it is necessary to upgrade programs of study in Cyprus. It is a current and innovative issue and this document presents the first research conducted regarding Cypriot nursing students’ level of training as far as END is concerned.  

METHODS 

Design

This descriptive cross-sectional study investigated the attitudes and views of nursing students regarding their END training level between October – November 2019. The Chung & Cho (2017) questionnaire instrument, which was translated and adapted to the Greek language, was used for the quantitative results of the research.

Participants 

The convenience sample was drawn from the undergraduate and postgraduate student population of all the Universities in Cyprus, Greece. The final sample included 102 nursing students.  

Procedure

The students were recruited through the internet or through questionnaire distribution as is presented in more detail below.  

Online: The questionnaire was online for two months (October-November 2019) on the website esurvey.com and subsequently an online advertisement – invitation was sent through the website of a professional nursing organization in Cyprus. The questionnaire specified that the study concerned nursing students as well as the topic of the study.  Then, when the student clicked on the corresponding link there appeared a leaflet containing information regarding the purpose of the study, personal details of the researcher, in case further clarifications were required, thanks as well as reassurance that anonymity and confidentiality were guaranteed. 

Questionnaire distribution: The questionnaire was completed in writing by the students who wished to do so. Its distribution was conducted by the teaching staff of the Nursing Programme of the University of Nicosia. The questionnaires were given in sealed envelopes and, once completed, they were returned in the same manner. The first page contained information for the participants similar to the online questionnaire.   

Questionnaire Instrument

A review of the existing literature led to the conclusion that collection tools are limited since researchers attempt to evaluate and interpret the nursing students’ level of training in END mainly with improvised instruments. Therefore, the Chung & Cho (2017) questionnaire instrument was selected, which has been designed by the researchers themselves as a tool to measure the quantitative results of this study. The aforementioned questionnaire, consisted of 20 questions, which were divided into three subcategories: three questions related to demographic characteristics, 15 questions regarding ND, and two questions with Academic Content about END.

The questionnaire included a five-point Likert scale which ranged from “strongly disagree” (1) to “strongly agree” (5) or from “No understanding whatsoever” (1) to “Full understanding”. The questionnaire was translated from Greek to English through a two-way bilingual translation. 

Pilot implementation was deemed necessary for the weighting process of the questionnaire. To this end, the translated questionnaire of Chung & Cho (2017) was given to 15 nursing students. Following the analysis of the questionnaires, it was noted that the students lacked knowledge regarding the characteristics of an END. Therefore, a paragraph was added to the questionnaire, which included the definition of an END.  Apart from this, no other changes were made to the questionnaire. Finally, a reliability check was conducted using Cronbach’s alpha (0.74) coefficient.  

Ethical considerations 

Following an ethics approval request submission, the research study protocol obtained permission certificate from the Cyprus National Bioethics Committee. In addition, permission was requested from and granted by the University of Nicosia to participate in the study. The students who participated, were informed about the purpose of the study on the first page of the questionnaire, and they had been assured that complete confidentiality would be maintained regarding the personal data collected and that no mention of anything would be made during the analysis and publishing of the research results that could lead to the identification of any one person. Moreover, permission had been obtained, by the creators themselves, to use, translate and weight the questionnaire tool.

Statistical Analysis 

All the data were analysed with The Statistical Package for Social Science (SPSS 24.0). Descriptive statistics were used to describe frequency and percentage.  The decision to conduct the Independent Samples Test was made due to the independence and quantity of the variables tested (Table 1). It was found that our sample follows normal distribution and a 95% confidence interval was selected. 

Table 1: Significant Differences Between Variables

RESULTS

Demographic Characteristics of Participants

The final sample included 102 (100%) nursing students. The majority of the participants were female (71%). The answer to the question “Which programme are you registered in?” revealed that 61 (60%) were undergraduate nursing students and 36 (40%) were postgraduate nursing students. (Table 2). 

Table 2: Students demographic characteristics

Student perceptions of ND 

Most students (55%) evaluated their educational experience pertaining to ND as being of reasonable standards. More specifically, students were asked how they evaluated their knowledge regarding specific ND procedures, such as documentation during drug administration through common routes (PO, SC, IM, IV): most students (51%) replied that they fully understood how to do this. Moreover, as far as documentation while making decisions about patient care is concerned, 47% expressed full understanding whereas 39% reported little understanding of the subject. As for documentation during patient evaluation, most students (48%) stated that they fully understood it in contrast to nursing progress notes which was little understood by 43% of the students. 

Finally, most students appeared to express full understanding of documentation of instances of nursing interventions, but little understanding (46%) during documentation for purposes pertaining to nursing training.  The views of most students seemed to range between neutral opinion (37.5%) and agreement (33.5%) about whether the university provided the latest ND information during clinical practice. Finally, most students evaluated the level of their ND educational experience as average, which would mean that they would be able to handle END (Table 3). 

Table 3: Student perceptions of their knowledge in ND

Students’ perceptions of END 

It is evident that only 48% of the students have been trained/educated in relation to END. Most of them expressed neither agreement nor disagreement (55%), while several (34.5%) agreed that they find END in clinical settings easy to use during clinical practice. A similar conclusion has been drawn regarding another question since most expressed neither agreement nor disagreement (44%) whereas others disagreed (34.5%) with the statement: “It is difficult to interact with END in the clinical setting”. The following finding appears to be encouraging since 18.5% declared that they strongly agree that during clinical practice in a hospital setting END enhance a) the ability to solve problems and b) critical thinking.

Most students (42%) agreed that, in general, the Academic programs related to END have prepared them for the future of ND technology with applications that support and provide practical training. Moreover, it appears to be necessary to conduct Academic END before as well as during clinical practice since 45% agreed and 36.5%. strongly agreed with this point of view (Table 4).

Table 4: Student perceptions of EHRs

DISCUSSION

The study has indicated that almost half the students are trained regarding END, while the rest are not. As far as the variable related to the study program is concerned, a statistically significant difference was found (p<0.042), since postgraduate students stated that they were better trained/educated regarding END than undergraduate students. That is due to the fact that postgraduate students were found to receive more training related to ND and END.  A descriptive study by Jones & Donelle (2011)^, which researched a relevant issue, agreed with the previous finding and adds that students have had no experience with END at University before participating in clinical practice at local institutions. At this point, it could be suggested that it is of utmost necessity that such educational programs are introduced at the undergraduate level, Baillie et al., (2013) added that if nursing students have positive experiences regarding END systems during their studies, and they have the opportunity to use them during clinical practice, they are more likely to support the implementation of such systems as they will then enter the workforce as specialised personnel.

The findings of this study have also illustrated that a large number of students believe that END enhances problem solving abilities and critical thinking. A similar finding, which was the result of a descriptive study by Whitt et al. (2017) indicated that the majority of the students think that END have a positive impact on patient care, offer more satisfaction in the workplace and result in increased productivity. 

Additionally, most of the students agreed that the Academic programs related to END have caused them to be better prepared for the future of technology in ND with applications that support and offer practical training in this area. A similar point of view was shared by the Academic staff, according to the study by Chung & Cho (2017), whose questionnaire was adopted for this study. Moreover, most students agreed that, as far as ND is concerned, Academic programs related to END must be offered before as well as during clinical practice. A statistically significant difference was also found (p<0.015) in students trained in END, who appeared to hold the belief that the University provided the latest ND information. However, it is necessary for END Academic programs to be adopted during ND teaching, since the qualitative results showed that one in six students felt that it is difficult for them to interact with END in the clinical area. Besides, 1/3 of students disagreed that the University provided the latest information regarding ND by using educational applications/programmes related to END. As far as this point is concerned, there is a significant statistical difference, since undergraduate students appear to disagree more about this issue (p<0.044).

These findings make the adoption of an Academic END program during undergraduate nursing training imperative. At this point, it should be noted that no differentiation was found between the study regarding the students’ opinion about whether the END of the clinical setting were easy to use (P > 0.643), which could be attributed to the current generation’s flexibility with handling technology. This comment is also supported by a descriptive study conducted by Williamson & Muckle (2018), since their findings illustrated that almost all students (99.7%) owned a smartphone and were able to use various kinds of technology with ease. Nevertheless, the same study reached the conclusion that integrating ?ND in a study program is necessary in order for the students to be able to cope with future challenges. Zhang & Walji (2011), encouraged END system designers to take into serious consideration the views and beliefs of nurses while designing such systems, since such a user-friendly tool, which facilitates the nursing profession, is necessary. 

Finally, this study has found that if a student had previously been trained/educated in END, then they believed that they would in fact be able to use these devices in a real setting later on (p<0.001) and, what is more, they actually evaluated their educational experience regarding ND more positively (p<0.001). Other studies added that patient security may be attributed to nursing competency and that if a student lacks self-confidence with electronic documentation then they are in danger of non-secure ND (McBride, 2005; Raymond et al., 2019). This has been confirmed by the findings of this study which indicated that if a student had been previously trained/educated regarding END then they held the belief that END enhances problem-solving abilities and critical thinking (p<0.001).

LIMITATIONS 

This study has several limitations. Due to the low sample number (n=102), the present study is not representative of the population. Furthermore, nursing students do not receive extended END training/education and their evaluations are likely to reflect lack of knowledge regarding END characteristics. The Greek language is also likely to be a limiting factor, since it excludes foreign-speaking nursing students who were attending a University in Cyprus during the data collection period. 

However, the findings of this study might provide a descriptive instance of student attitudes towards END and may therefore be considered useful for training  nursing students as well as when designing END.  

CONCLUSIONS 

The application of ?ND in the clinical setting is constantly increasing. The findings of this study indicated the importance of the development and integration of END in nursing undergraduate programs, so that the students’ ability to use current and future technology will be enhanced. Therefore, this is considered to be of utmost importance since it will lead to the improvement of ND. So far, little attention has been paid to END in nursing degree programs, a fact which displeases students, who hold the view that END improves communication and critical thinking.  

It is imperative that more studies are conducted which describe the need to integrate END educational programs into nursing degree studies. Therefore, researchers must evaluate the effectiveness and functionality of educational programs for future implementation.

It is extremely important that the researchers’ results are communicated to the relevant bodies of the State of Cyprus so that this may contribute to the adoption of practices which will improve quality of patient care and safety through nurses and student nurses trained in END.  

REFERENCES 

Aktan, N. M., Tracy, J., & Bareford, C. (2011). Computerized documentation and community health nursing students. Journal of Nursing Education and Practice, 1(1). https://doi.org/10.5430/jnep.v1n1p25

Baillie, L., Chadwick, S., Mann, R., & Brooke-Read, M. (2013). A survey of student nurses’ and midwives’ experiences of learning to use electronic health record systems in practice. Nurse Education in Practice, 13(5), 437–441. https://doi.org/10.1016/j.nepr.2012.10.003

Bose, E., Maganti, S., Bowles, K. H., Brueshoff, B. L., & Monsen, K. A. (2019). Machine Learning Methods for Identifying Critical Data Elements in Nursing Documentation. Nursing Research, 68(1), 65–72. https://doi.org/10.1097/NNR.0000000000000315

Choi, M., Lee, H. S., & Park, J. H. (2015). Usability of academic electronic medical record application for nursing students’ clinical practicum. Healthcare Informatics Research, 21(3), 191–195. https://doi.org/10.4258/hir.2015.21.3.191

Choi, M., Park, J. H., & Lee, H. S. (2016). Assessment of the Need to Integrate Academic Electronic Medical Records into the Undergraduate Clinical Practicum. CIN: Computers, Informatics, Nursing, 34(6), 259–265. https://doi.org/10.1097/CIN.0000000000000244

Chung, J., & Cho, I. (2017). The need for academic electronic health record systems in nurse education. Nurse Education Today, 54, 83–88. https://doi.org/10.1016/j.nedt.2017.04.018 

Fareed, N., Bazzoli, G. J., Farnsworth Mick, S. S., & Harless, D. W. (2015). The influence of institutional pressures on hospital electronic health record presence. Social Science and Medicine, 133, 28–35. https://doi.org/10.1016/j.socscimed.2015.03.047 

Gardner, C. and Jones, S. (June 2012). Utilization of academic electronic medical records in undergraduate nursing education. Online Journal of Nursing Informatics (OJNI), 16(2), http://ojni.org/issues/? p=1702

Jenkins, M. L., & Davis, A. (2019). Transforming nursing documentation. Studies in Health Technology and Informatics, 264, 625–628. https://doi.org/10.3233/SHTI190298

Jones, S., & Donelle, L. (2011). Assessment of electronic health record usability with undergraduate nursing students. International Journal of Nursing Education Scholarship, 8(1). https://doi.org/10.2202/1548-923X.2123

Kahouei, M., Mohammadi, H., Majdabadi, H., Solhi, M., Parsania, Z., Roghani, P., & Firozeh, M. (2014). Nurses’ Perceptions of Usefulness of Nursing Information System: a Module of Electronic Medical Record for Patient Care in Two University Hospitals of Iran. Materia Socio Medica, 26(1), 30. https://doi.org/10.5455/msm.2014.26.30-34

Mahon, P. Y., Nickitas, D. M., & Nokes, K. M. (2010). Faculty perceptions of student documentation skills during the transition from paper-based to electronic health records systems. Journal of Nursing Education, 49(11), 615–621. https://doi.org/10.3928/01484834-20100524-06 

McBride, A. B. (2005). Nursing and the informatics revolution. Nursing Outlook, 53(4), 183–191. https://doi.org/10.1016/j.outlook.2005.02.006 

Metzger, J., Welebob, E., Bates, D. W., Lipsitz, S., & Classen, D. C. (2010). Mixed results in the safety performance of computerized physician order entry. Health Affairs, 29(4), 655–663. https://doi.org/10.1377/hlthaff.2010.0160

Meyer, L., Sternberger, C., & Toscos, T. (2011). How to implement the electronic health record in undergraduate nursing education. American Nurse Today, 6, 40–44. 

Ministry of Health, Republic of Cyprus. (2019). National Contact Point for  (Original work published in Greek).

Mountain, C., Redd, R., O’Leary-Kelly, C., & Giles, K. (2015). Electronic Medical Record in the Simulation Hospital: Does It Improve Accuracy in Charting Vital Signs, Intake, and Output? CIN – Computers Informatics Nursing, 33(4), 166–171. https://doi.org/10.1097/CIN.0000000000000144

Polychronis, G., Pitsillidou, M., & Noula, M. (2019). The implementation of electronic documentation in the clinical hospital and nursing education: a research on attitudes and views. Rostrum of Asclepius / Vima Tou Asklipiou, 18(2), 103–124. https://doi.org/10.5281/zenodo.2619536 (Original work published in Greek).

Ramukumba, M. M., & El Amouri, S. (2019). Nurses’ perspectives of the nursing documentation audit process. Health SA Gesondheid, 24, 1–7.  https://doi.org/10.4102/hsag.v24i0.1121

Raymond, L., Paré, G., & Marchand, M. (2019). Extended use of electronic health records by primary care physicians: Does the electronic health record artefact matter? Health Informatics Journal, 25(1), 71–82. https://doi.org/10.1177/1460458217704244

Tubaishat, A. (2018). Perceived usefulness and perceived ease of use of electronic health records among nurses: Application of Technology Acceptance Model. Informatics for Health and Social Care, 43(4), 379–389. https://doi.org/10.1080/17538157.2017.1363761 

Whitt, K. J., Eden, L., Merrill, K. C., & Hughes, M. (2017). Nursing student experiences regarding safe use of electronic health records a pilot study of the safety and assurance factors for EHR resilience guides. CIN – Computers Informatics Nursing, 35(1), 45–53. https://doi.org/10.1097/CIN.0000000000000291

World Health Organization (2012) Management of patient information: trends and challenges in member states: based on the findings of the second global survey on e-Health.World Health Organization WHO Global Observatory for eHealth, In World Health Organization WHO Global Observatory for eHealth (p. 80). 

Williamson, K. M., & Muckle, J. (2018). Students’ Perception of Technology Use in Nursing Education. CIN – Computers Informatics Nursing, 36(2), 70–76. https://doi.org/10.1097/CIN.0000000000000396 

Zhang, J., & Walji, M. F. (2011). TURF: Toward a unified framework of EHR usability. Journal of Biomedical Informatics, 44(6), 1056–1067. https://doi.org/10.1016/j.jbi.2011.08.005 

Zhang, Y., Yu, P., & Shen, J. (2012). The benefits of introducing electronic health records in residential aged care facilities: A multiple case study. International Journal of Medical Informatics, 81(10), 690–704. https://doi.org/10.1016/j.ijmedinf.2012.05.013