Academic Electronic Health Records in Undergraduate Nursing

Original Paper

Education: Mixed Methods Pilot Study

Manal Kleib, MSc, MBA, PhD; Deirdre Jackman, MSc, PhD; Uirá Duarte Wisnesky, MSc, PhD; Shamsa Ali, BSc,

MSc

Faculty of Nursing, University of Alberta, Edmonton, AB, Canada

Corresponding Author:

Manal Kleib, MSc, MBA, PhD

Faculty of Nursing

University of Alberta

5-112 Edmonton Clinic Health Academy

Edmonton, AB, T6G1C9

Canada

Phone: 1 7802481422

Fax: 1 7804922551

Email: [email protected]

Abstract

Background: Teaching students about electronic health records presents challenges for most nursing programs, primarily

because of the limited training opportunities within clinical practice settings. A simulated electronic health record is an experiential,

learner-centered strategy that enables students to acquire and apply the informatics knowledge needed for working with electronic

records in a safe learning environment before the students have encounters with real patients.

Objective: The aim of this study is to provide a preliminary evaluation of the Lippincott DocuCare simulated electronic health

record and determine the feasibility issues associated with its implementation.

Methods: We used one-group pretest-posttest, surveys, and focus group interviews with students and instructors to pilot the

DocuCare simulated electronic health record within an undergraduate nursing program in Western Canada. Volunteering students

worked through 4 case scenarios during a 1-month pilot. Self-reported informatics knowledge and attitudes toward the electronic

health record, accuracy of computerized documentation, satisfaction, and students’ and educators’ experiences were examined.

Demographic and general information regarding informatics learning was also collected.

Results: Although 23 students participated in this study, only 13 completed surveys were included in the analysis. Almost

two-thirds of the students indicated their overall understanding of nursing informatics as being fair or inadequate. The two-tailed

paired samples t test used to evaluate the impact of DocuCare on students’ self-reported informatics knowledge and attitudes

toward the electronic health record revealed a statistically significant difference in the mean score of knowledge before and after

using DocuCare (before: mean 2.95, SD 0.58; after: mean 3.83, SD 0.39; t

=5.80, two-tailed; P<.001). There was no statistically

significant difference in the mean scores of attitudes toward the electronic health record before and after using DocuCare (before:

mean 3.75, SD 0.40; after: mean 3.70, SD 0.34; t

=0.39, two-tailed; P=.70). Students’documentation scores varied from somewhat

accurate to completely accurate; however, performance improved for the majority of students as they progressed from case

scenarios 1 to 4. Both the faculty and students were highly satisfied with DocuCare and highly recommended its integration.

Focus groups with 7 students and 3 educators revealed multiple themes. The participants shared suggestions regarding the

DocuCare product customization and strategies for potential integration in undergraduate nursing programs.

Conclusions: This study demonstrated the feasibility and suitability of the DocuCare program as a tool to enhance students’

learning about informatics and computerized documentation in electronic health records. Recommendations will be made to

academic leadership in undergraduate programs on the basis of this study. Furthermore, a controlled evaluation study will be

conducted in the future.

(JMIR Nursing 2021;4(2):e26944) doi: 10.2196/26944

KEYWORDS

academic electronic health record; Lippincott DocuCare; simulation; nursing informatics education

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Introduction

Background

Electronic health records (EHRs) are an essential component

of modern-day digitally connected health care. An EHR is a

secure and integrated digital health technology that houses

patients’ information and encounters with the health system.

EHRs help improve access to health services, enhance the

quality and safety of care, and increase the efficiency of the

health system [1]. As the largest group of care providers, nurses

are increasingly using digital health tools across practice settings

[2,3]. Therefore, nursing schools must provide theoretical and

technical knowledge related to these health information systems

for nursing students [4,5]. This is particularly important given

the growing concerns regarding the lack of preparedness in

using health information systems among graduating students

once they join the workplace [6-10]. However, teaching students

about EHRs presents challenges for most schools of nursing,

primarily because of the limited EHR training opportunities

within practice settings and the complexity of educating a large

number of students in busy and often complex clinical

environments [5,11-13].

Simulated EHRs for academic purposes have been proposed as

an innovative pedagogy to promote the acquisition of theoretical

knowledge of informatics and the skills needed to use EHRs in

a safe environment before encounters with real patients [14-25].

Incorporating these learning experiences within undergraduate

nursing education expands the realm of effective teaching and

learning practice, fulfills accreditation requirements, and ensures

graduates have the required entry-to-practice competencies in

nursing informatics upon exiting the program so that they are

better prepared for practice in today’s digitally rich health care

environment [3,26-28]. A simulated EHR is a learner-centered

pedagogy grounded in a constructivist approach of experiential

learning where learners are actively involved in the process of

knowledge construction and reflective learning as opposed to

passively receiving information [15,29,30]. Using case scenarios

that mimic real-world clinical practice enables the students to

learn how to use EHRs for care delivery, eg, identifying and

interpreting patient data such as verifying medication accuracy,

in a supervised environment before clinical encounters with real

patients; thus, it improves learning outcomes and can contribute

to promoting patient safety [20,30-36].

Simulated EHRs resemble electronic patient records used in

practice settings [22,37]. A number of products are available

for nurse educators to choose from including open-source EHR

or electronic medical record (EMR) and vendor-operated EHR

or EMR platforms [38]. Examples of open-source platforms

include OpenEMR, WorldVistA, and OSCAREMR.

Vendor-operated platforms are available through health

information system technology vendors such as Cerner. These

also are offered through publishing companies such as

Lippincott DocuCare by Wolters Kluwer, EHR Tutor by

Assessment Technologies Institute, SimChart by Elsevier, and

NEEHR Perfect, now known as ehr

, by Archetype Innovations.

Although these products have similar platforms, they vary in

cost and functionality [38].

Research suggests that integrating simulated EHRs in

prelicensure nursing education is beneficial to students’learning

and development of important educational outcomes [20,30,34].

Simulated EHRs help improve students’ critical thinking [18]

and their ability to navigate EHRs and understand informatics

concepts such as data management [19,39,40]. Other researchers

found that simulated EHRs help enhance students’ skills in

electronic documentation [24,41,42] and aid in the development

of positive attitudes and perspectives about electronic records

[43,44]. The integration of simulated EHRs also enhances

students’confidence and self-efficacy in using electronic records

[23,44-46] and increases informatics knowledge and competency

[16,40,47]. Despite these benefits, factors such as cost and

faculty expertise continue to be major challenges in integrating

simulated EHRs in nursing education [18,34,48,49].

At our university, curricular revisions presented an ideal

opportunity to explore the integration of a simulated EHR within

undergraduate nursing programs to expose students to health

information technologies used in practice and to acquire the

required entry-to-practice informatics competencies. This

direction was enforced further by the introduction of Connect

Care, a new EMR, in our health system. Although our students

will have the opportunity to complete a user-training program

before their clinical practicum in units that transitioned to

Connect Care, these students have no previous exposure to

hands-on practice with electronic records within their laboratory

or simulation education, which is a gap in our curriculum. To

support students’ learning and application of informatics

knowledge that is currently taught in theory courses and the

computerized documentation introduced in the new curriculum

across all clinical courses, we reviewed a number of simulated

EHR solutions considering the benefits and value in meeting

the students’ and program’s needs [16,18,37,38]. We opted for

the Lippincott DocuCare simulated EHR because it is user

friendly and is aligned with the V-Sim resources currently used

in our simulation laboratory. In addition, the cost of DocuCare

for an individual student’s web access at US $100 for 12 months

(negotiable when based on an institutional purchase plan)

provided additional support for choosing this product over

others. The next step of our evaluation was to obtain feedback

from students and faculty on the suitability of this product for

integration into our programs.

Research Questions

This pilot study aimed to provide a preliminary evaluation of

the Lippincott DocuCare program and to determine the

feasibility issues associated with its implementation. The

following research questions were examined:

Is there a significant difference in the mean scores of

self-reported informatics knowledge and attitudes toward

the EHR before and after using DocuCare?

What is the accuracy of students’electronic documentation?

Are students satisfied with using DocuCare as a learning

tool?

How do students and educators describe their experiences

using DocuCare as a learning tool to improve computerized

documentation and overall informatics competency?

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Methods

Design and Sample

In this mixed method pilot study, a quasi-experimental

one-group pretest-posttest design using short surveys was used

to answer research questions 1 to 3, which were relevant to

students’learning and satisfaction with DocuCare. Focus group

interviews with students and educators were used to answer

research question 4 [50]. A convenience sample from third- and

fourth-year nursing students enrolled in undergraduate nursing

programs in the Faculty of Nursing was invited to participate

in this study because, at this level of education, they would have

had some exposure to clinical practice and would have

accumulated sufficient theoretical knowledge. Nursing educators

involved in laboratory and clinical teaching within the

undergraduate programs were also invited to participate.

Study Procedures

Students were recruited through an announcement supplemented

with an information sheet on the e-class site, inviting students

registered in a number of third- and fourth-year courses to

express interest in participating by contacting the researchers.

A list of interested participants was then compiled, and the

volunteering students were enrolled in the study on a first-come

first-serve basis.

Interested student participants were contacted via email and

asked to complete a survey (pretest), as described later, and to

indicate their availability for attending an in-person orientation

session to have a practice demo, using a scavenger hunt exercise,

on how to use DocuCare. Two dates were provided with the

option for an evening and weekend meeting time to

accommodate students’ schedules. At the same time, a total of

50 access codes were requested from DocuCare for use by

students and educators in this study at no cost. Students who

completed the pretest survey were then contacted and given the

unique DocuCare access codes. As only a few students were

able to attend the in-person orientation, a supplementary written

guide with step-by-step directions and URL links to DocuCare

publisher training videos on how to use the program was

provided as a reference when they used DocuCare on their own.

The pretest-posttest survey included 18 items organized into 3

sections. This survey was administered to students at the

beginning of the pilot (pretest) and used again as a posttest at

the end of the pilot. Section 1 included 8 questions related to

demographic and general information: program, year of study,

opportunities for learning about informatics competencies in

theory and laboratory training, exposure to electronic

documentation in clinical sites, and support resources available

to students when learning about computerized documentation.

Section 2 included 5 Likert-type scale items (strongly disagree

to strongly agree) that measured self-reported informatics

knowledge using the entry-to-practice informatics competency

indicators relevant to documentation and data management.

These indicators have been validated in another study (Cronbach

α=.93) [51]. Section 3 included 5 Likert-type scale items

(strongly disagree to strongly agree) that measured nurses’

attitudes and dispositions toward the EHRs (Cronbach α=.77)

[52]. A high score on this scale indicates a positive disposition,

and a low score indicates a negative disposition. Research

Electronic Data Capture (REDCap; Vanderbilt University)

software was used to administer the data collection tools [53].

During the pilot, which was conducted over approximately 1

month, the participating students were asked to work on 4 patient

case scenarios within the DocuCare platform, 1 scenario per

week, or as their schedule permitted. Each case scenario required

1 to 2 hours on average, during which time the students needed

to find information required for care planning, electronically

document the care provided, and submit their completed work

to the instructor for assessment. A standardized answer key for

each scenario and a marking rubric, developed for the purpose

of this study, were used to enhance objectivity and consistency

in marking students’ submissions in DocuCare. For each case

scenario, the students’ submissions were marked against the

rubric using a rating scale from 1 to 4 (1=inaccurate,

2=somewhat accurate, 3=fairly accurate, and 4=completely

accurate). A total score of 16 was tallied for the 4 case scenarios

for each student. Students’previous documentation skills were

not tested at baseline. Owing to their workload, laboratory

educators were not available to participate in marking students’

submissions. Instead, a master’s-level graduate student was

hired to assist with the project. The graduate student marked

the students’ submissions, provided feedback, tracked the

students’progress, and responded to questions they had during

the pilot. These marks were not included in academic grades.

The case scenarios used in this pilot were identified from the

Lippincott VR-Sim library and adapted slightly to balance the

difficulty level, that is, simple-to-complex concepts. Each

scenario was also mapped to relevant entry-to-practice

informatics competency indicators as they applied to the focus

of the scenario [27].

A few days after completion of the 1-month pilot, the students

were asked to complete the posttest survey and a satisfaction

survey and to express interest in participating in semistructured

focus group interviews to share their experiences. Two focus

groups were scheduled to accommodate students’ schedules.

The satisfaction survey included 15 items measured on a rating

scale from 1 to 5 (1 being very dissatisfied and 5 being very

satisfied). Some of these survey items were related to ease of

use and user experience that, with permission, were slightly

adapted from the DocuCare vendor product satisfaction survey.

The remaining items related to perceptions of the impact on

learning were added by the researchers. This survey was

integrated as a complementary measure in case students were

not able to participate in interviews because of their workload.

For nurse educators, a poster invitation was sent to recruit

interested participants. Those who expressed interest in

participating were offered a training webinar along with access

to DocuCare and the same scenarios that students used for them

to try out the product over a 2-week period and share their

perspectives. Educators were also asked to express interest in

participating in a focus group interview.

Each focus group interview lasted between 60 and 90 minutes.

The interviewers (second and third authors) facilitated all

discussions in English using an interview guide. Field notes

were taken and used, where required, to assist with reflecting

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on the data during analysis. The discussions were audio-recorded

and transcribed verbatim.

Data Analysis

Data from completed surveys were included in the analysis, and

incomplete surveys were excluded. Using IBM SPSS Statistics

version 25.0, descriptive statistics, including frequencies, means,

and SDs, were used to summarize and describe the data. A

two-tailed paired t test using a difference score (posttest and

pretest) was applied to test the null hypothesis: there was no

statistically significant difference in students’ self-reported

informatics knowledge and attitudes toward EHR mean scores

before and after using the DocuCare program for 1 month (H0:

M1−M2=0). For the qualitative interview data, the third author

(UDW) compared all transcriptions and audio recordings to

ensure the trustworthiness of the data. All transcripts were

imported into the NVivo 11 data management software (QSR

International Pty Ltd) and the data were coded and analyzed

inductively. All authors discussed and defined emergent codes

and themes to ensure intercoder reliability. The final codes and

themes were refined until a consensus about the interpretations

or coding frameworks was reached. Data were stored, managed,

accessed, and analyzed within a secure SharePoint drive.

Ethical Considerations

This study was approved by the institutional review and ethics

board. Participation was voluntary, and students were assured

that their participation had no impact on their academic

performance. Each participant received an information sheet

detailing the study procedures, benefits, and risks. Surveys were

completed by implied covert action (ie, completion and

submission of surveys). Written informed consent was obtained

from all participants before the focus group sessions. Each

interview began with an explanation of the purpose and

procedures of the interview and assurance that the discussion

would remain confidential.

Results

Characteristics of Participants and General

Information on Informatics Learning

Although 23 students participated in this pilot study, the results

are reported based on an analysis of 13 completed

pretest-posttest surveys. This decision was made because of

missing data between the pre- and posttest surveys. Most of

these respondents represented 2 large undergraduate nursing

programs: the Collaborative Program (n=7 students; 5 were

third-year and 2 were second-year students) and the

After-Degree Program (n=5; all were in their second year of

study). Only one third-year student was from the honors

program. There was no representation from first-year

After-Degree students or those in the bilingual program.

Students (n=13) described their overall understanding of the

concept of nursing informatics and its relevance to their future

practice as moderate (4/13, 31%), fair (6/13, 46%), or inadequate

(3/13, 23%). The majority indicated receiving specific learning

about informatics competencies expected of registered nurses

in Canada: information and knowledge management (12/13,

92%) and professional and regulatory accountability (13/13,

100%), but fewer reported on the competency pertinent to the

use of digital health technology in clinical practice (10/13, 77%).

With regard to learning about computerized documentation in

EHRs during undergraduate education, 54% (7/13) of

respondents indicated yes, whereas 46% (6/13) of them indicated

no. Regarding permissions for students in the clinical setting,

54% (7/13) indicated they were permitted to view patient

information with instructor or preceptor supervision. For

permissions related to electronic documentation, almost

two-third of the students (9/13, 69%) indicated that most clinical

placement sites they went to did not use electronic

documentation, whereas 23% (3/13) indicated yes and 8% (1/13)

indicated sometimes.

Self-reported Knowledge in Informatics and Attitudes

Toward EHRs

Table 1 provides an overview of the mean difference scores for

the pre- and posttest surveys. The two-tailed paired samples t

test to evaluate the impact of DocuCare on students’

self-reported informatics knowledge and attitudes toward the

EHR revealed a statistically significant difference in the mean

score of knowledge before (mean 2.95, SD 0.58) and after using

DocuCare (mean 3.83, SD 0.39; t

=5.80, two-tailed; P<.001).

The mean score was −0.88 (SD 0.54) with a 95% CI ranging

from −1.21 to −0.55. The eta-squared statistic (0.74) indicated

a large effect size. Therefore, the null hypothesis was rejected.

However, there was no statistically significant difference in the

mean scores of attitudes toward the EHR before (mean 3.75,

SD 0.40) and after using DocuCare (mean 3.70, SD 0.34;

=0.39, two-tailed; P=.70). The mean score was 0.05 (SD

0.43), with a 95% CI ranging from −0.21 to 0.30. Therefore,

we failed to reject the null hypothesis, that is, there was no

statistically significant difference in students’ self-reported

informatics attitudes toward the EHR mean scores before and

after using the DocuCare program.

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Table 1. Self-reported informatics knowledge and attitudes toward electronic health records before and after using DocuCare (N=13).

P valueDifference

score

Posttest,

mean (SD)

Pretest,

mean (SD)

Items

Informatics knowledge: I have...

.16−0.1544.15 (0.555)4 (0.577)A good knowledge to critically evaluate data and information from a variety of credible

sources (including experts, clinical applications, databases, practice guidelines, relevant

websites, etc) to inform the delivery of nursing care.

.003−1.1543.77 (0.439)2.62 (1.044)

A good knowledge of the various components of the EHR

such as results reporting,

clinical documentation, electronic medication administration, etc).

.08−0.6923.54 (0.877)2.85 (0.987)A good knowledge related to documenting important nursing and patient data using

standardized nursing languages, such as the International Classification for Nursing

Practice, ie, nursing diagnosis and interventions to support clinical decision-making

and nursing practice improvement.

.001−1.1543.92 (0.494)2.77 (1.092)A good knowledge related to gathering and retrieving relevant health care and patient

data from the EHR.

.004−1.2313.77 (0.439)2.54 (1.198)A good knowledge related to documenting health care and patient data into the EHR.

Attitudes toward EHRs

.680.2313.62 (1.121)3.85 (1.214)Use of EHRs are more of a help than a hindrance to patient care

.78−0.0774 (0.913)3.92 (0.760)Use of computerized charting has helped to improve documentation of the clinical

record

.440.1543.08 (0.954)3.23 (0.599)EHRs pose less threat to the patient’s privacy than do paper records.

.580.0773.54 (0.660)3.62 (0.768)Computerized charting has decreased the workload of nurses and other personnel.

.16−0.1544.31 (0.480)4.15 (0.376)In time, the use of EHRs will lead to improved patient care

EHR: electronic health record.

Accuracy of Students’ Electronic Documentation

For most students, their scores improved as they progressed

from case scenarios 1 to 4, with more practice and ongoing

feedback. Of the 13 students, 9 completed the 4 case scenarios.

The lowest total score obtained by these students was 11 of 16,

whereas the highest score was 15.

Students’ Satisfaction With the DocuCare Learning

Experience

Of the 13 student participants, 12 (92%) completed the

satisfaction survey at the end of the pilot. Only 42% (5/12) of

these students attended the in-person orientation. Of these 5

students, 3 (60%) were satisfied with this session. Regarding

the frequency of accessing DocuCare during the pilot, 58%

(7/12) of students indicated accessing the program once a week,

25% (3/12) accessed it multiple times each week, and 17%

(2/12) accessed it once a day or multiple times each day. Most

students (11/12, 92%) were satisfied to very satisfied with the

ability to access DocuCare at any time and from anywhere, the

ease of use when submitting completed learning activities for

assessment, and the ability to learn at their own pace. In

addition, students were satisfied to very satisfied with the

DocuCare layout (8/12, 67%) and reported that they encountered

no technical glitches when using DocuCare (7/12, 58%).

With regard to learning, two-thirds of the students (9/12, 75%)

were satisfied to very satisfied that DocuCare provided a realistic

learning experience about computerized charting in EHRs

because, in principle, it was similar to the electronic health or

patient records used in the clinical setting. It also helped increase

their confidence in gathering relevant patient information to

inform clinical judgment and nursing care planning for the

assigned case scenarios used in this pilot study and care planning

in general. The majority of the students (11/12, 92%) were also

satisfied to very satisfied that DocuCare increased their critical

thinking and clinical judgment abilities and their overall

confidence in applying computerized charting in a real clinical

setting (10/12, 83%). Overall, 92% (11/12) of students were

satisfied to very satisfied that using DocuCare enabled them to

progressively enhance their informatics competencies and

recommended using it for students’learning about computerized

charting in undergraduate nursing programs.

In their responses to an open-ended question at the end of the

satisfaction survey that asked what was helpful and what could

be improved, the students provided some insights. One student

indicated:

It could’ve been better if I attended the orientation

session prior to the study as the program was hard

to use in the beginning. However, the program

allowed me to find the areas which I need to improve

on such as critical thinking skills and judgement. I

think it will be helpful/beneficial to students if the

DocuCare program becomes part of the school

curriculum.

Another student asserted that DocuCare was user friendly:

it was nice and simple to follow through with the

steps, and the feedback was really helpful as well.

Another student added:

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definitely getting that feedback..., that did help me

increase my confidence in what I could do on this

system, so I thought that was helpful in that sense.

Focus Group Interviews With Students and Faculty

A total of 7 students participated in focus groups, one interview

had 4 students whereas the other had 3 students. A total of 7

educators attended the DocuCare webinar and tested the product;

however, only 3 educators expressed an interest and participated

in the focus group interview. Participants described their

experiences using DocuCare as a learning tool to improve

computerized documentation and overall informatics

competency. Overall, 5 themes emerged, which were as follows:

(1) current challenges related to documentation, (2) motivating

factors for embracing computerized charting as an educational

tool, (3) educators’ and students’ experiences with DocuCare,

(4) educators’ and students’ suggestions for improving

DocuCare, and (5) recommendations for integrating DocuCare

in undergraduate nursing curricula.

Theme 1: Current Challenges Related to Documentation

Reflecting on teaching and learning experiences in clinical

practicum sites and acknowledging that they may become more

complicated with the ongoing Connect Care implementation,

the participating educators and students agreed that a number

of challenges related to documentation currently exist in clinical

and laboratory learning. This first theme, current challenges

related to documentation, comprised 6 categories, 4 of which

were exclusively from educators’ perspectives: students’ level

of experience, stressful clinical settings, student-instructor ratios,

and limited laboratory training hours. The following excerpt

illustrates educators’ concerns about students’ level of

experience and student-instructor ratios:

For some of them, they’ve never been in the hospital,

so it’s a really, you know, unfamiliar environment,

and it is really high stakes. They’re real people

involved. You know, and so their stress levels are

already really high...I think...if you have eight students

and one instructor to do some of that stuff on the fly,

like with labs we have to do sometimes, is incredibly

stressful for the instructor and really stressful for the

students. [Educator 3]

A number of educators also underlined the limitations in

laboratory training hours and in teaching about documentation

and informatics as obstacles they currently encounter in clinical

practice:

we have two-hour labs now—we don’t always have

a lot of time for them to sit down and do a narrative

charting of what they just did [Educator 2]

In addition, educators felt that the stressful clinical setting

compounded the challenges faced by students when learning

about documentation:

you get in front of the computer...it is the time

factor...they get their two minutes on there, because

everybody else is lined up for them, right...and when

they get into a hurry, mistakes get made...they’re

charting on the wrong person and everything, getting

everybody stressed out...and I just find even with the

long paper charting, the entry “I received into care,

blah blah blah, found sitting, breathing

normally,”...they’ve got this whole thing memorized,

so they’re not even critically thinking about that.

[Educator 1]

Similarly, students shared their views on the challenges

encountered with learning about documentation, both in theory

and in a clinical setting. The limited teaching on documentation

and informatics was perceived as a substantial challenge:

I do remember having a couple classes maybe where

they taught us about charting in first year—which, I

mean, it felt really awkward to do it, but I think—they

did kind of tell us the basics. But yeah, I feel it’s just

kind of an awkward process of learning how to do it

properly [Student 1]

Students also mentioned their stressful experiences of learning

through trial and error in clinical sites:

...going through this program one of the biggest

struggles that I’ve had was documentation, period.

Whether it was on paper or in—that’s one thing that

I felt could ’ve been addressed a little bit more...my

very first clinical, I had no idea. Like, not a clue. So,

I’m just copying from what my nurse that was

buddying me, what they did—I mean, it may have

been right, it might’ve been wrong, but that’s the tool

that I had at that time. As time has gone on, I’ve kind

of figured out different ways to do things. [Student 2]

Theme 2: Motivating Factors for Embracing

Computerized Charting as an Educational Tool

Participants’ reflection on informatics and DocuCare as a

simulated record assisted in creating the second theme:

motivating factors for embracing computerized charting as an

educational tool. This theme included 3 categories: ideal timing,

fostering exposure, and learning opportunity.

Participants acknowledged the need to prioritize the introduction

of EHRs during their nursing education. They felt that their

time in school was the ideal time to learn about EHRs because

of their availability and openness and the school’s propitious

learning environment. According to one student:

I think that informatics in general is like, a whole

concept, a language, a culture, a mindset—and you

have to learn how to use that...I think it’s very

important. If we’re using these kinds of systems, I

think this is the perfect time to teach that. It’s a time

when we’re not as worried about maybe—other job

or political ramifications—we’re here at school to

learn and to be educated, and to prepare for that

setting. So, I think this is a captive audience who

wants to learn, and that means it’s a perfect time.

And if we are here for two to four years, that’s enough

time that we can go and ask more questions about it,

and kind of say what we want to see better or worse,

whereas in—afterwards, time sometimes goes a little

bit faster. So, I think the fact that we’re here and

we’re learning about the job—this is in part—a huge

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aspect of the job, and it’s a perfect time to do it.

[Student 2]

Educators followed up by emphasizing that fostering hands-on

experience in simulated electronic records is vitally important

for the development of documentation competencies and for

building confidence in using clinical information systems in

clinical settings:

This will just open their eyes to a bit of what they can

expect...documentation...it’s so different than, you

know, they write essays. But charting is not like

that...it’s like a new language almost for them,

right...it’s such a looming thing you know at the

beginning for them that I think the more that they can

kind of get exposed to it and see it and get familiar

with in ways that sort of—you know, the more we can

kind of tie as many pieces together as we can early

on...you know, the better. [Educator 3]

Similarly, students shared important insights into how fostering

exposure with hands-on practice opportunities with simulated

records may help provide a standardized approach to refine

documentation skills, alleviate anxiety, and enhance overall

readiness for clinical practice:

So, I felt very disorganized going to clinical, even

though I was trying to follow that paper, and I know

it’s somewhat charting by exception, but—I think with

DocuCare it will definitely help me organize my

thoughts better—kind of understand the assessments

and questions they would ask, and to use that to

develop other like, nursing diagnoses. And how to

interpret other kind of orders that are put in place

better...I would say it [DocuCare] definitely gave me

a bit of perspective of what using digital health

resources means, like in terms of navigation, in terms

of like—all those little details and like, the potential

value of it. [Student 3]

Several of the participants highlighted that there were valuable

learning opportunities, especially those regarding the refinement

of documentation skills and enhancing their critical thinking.

One student stated the following:

The learning was multifaceted for me—it did bring

up that systems analysis part, like—what would be

the challenges of implementing this? What would be

the challenges of me using this as a clinician on the

floor? What are the challenges, how do they affect

the patient? I don’t understand why wouldn’t try to

teach the exact programs that we’re trying to

implement in the hospital so that there’s a lot more

confidence when you’re graduating nurses. I’d like

to know how to do it, like—have a computer that

you’ll have on a unit in the lab, so that you’ll have a

chance to see what it feels like to document. [Student

Furthermore, participants agreed that the learning opportunities

offered while using DocuCare would be transferable to different

EHR systems. This transferability would occur in a learning

juxtaposition of facts and theories being formed during school

with DocuCare and the new systems and processes they

encounter when they become clinicians, which may result in

augmenting or restructuring the former. One educator certified

the following:

I work on so many different units, and every chart is

set up a little bit differently, and things are found in

slightly different places...I guess going from

DocuCare to Connect Care, there might be a little

bit of an adjustment if they’re slightly different, but

really once they’re on Connect Care and familiar

with where everything is, it’ll be the same no matter

where they go, which’ll be great. [The systems] are

both different, but I think—it’s similar enough...we

teach our students critical thinking, that sort of

thing—like I actually was really impressed with how

easy I found this. And I think because—even though

they’re not exactly the same, they’re similar enough.

[Educator 3]

Students corroborated educators’ views regarding learning

opportunities and the transferability of knowledge, where

simulated learning with DocuCare may help address gaps and

inconsistencies relevant to the limited opportunities for learning

about clinical informatics systems. This was evident for students

who had opportunities to receive Connect Care training before

the pilot. They were able to compare similarities and differences

and think about how these systems can be used in a

complementary way to address gaps in students’ learning. As

a student explained:

I did start off with Connect Care before I started the

DocuCare so, in some sense, I could see where I’m

navigating, but likewise I’ve never done orders and

stuff on Connect Care—I just know the basic

assessments and stuff. And like, I do see

differences—Connect Care is more advanced with its

formatting, navigating through tabs and the

information they portray, but I think DocuCare is a

great kind of preliminary health record for students

to learn if they can’t have access to Connect Care

yet—because Connect Care is very limited in

locations, and as they slowly roll it out, whereas

DocuCare is a—kind of a good simulation to get

comfortable with, you know, the electronic health

record. [Student 2]

Theme 3: Educators’ and Students’ Experiences With

DocuCare

During the focus group interviews, participants described their

experiences with DocuCare. On the basis of the accounts that

emerged, we attempted to understand the experiences with

DocuCare for both students and educators. This third theme is

divided into 4 categories: ease of use, provision of feedback to

students, well-integrated layout, and tools to provide safer care.

Although educators did not complete a satisfaction survey, they

shared important insights through the focus group interviews.

Educators described DocuCare as easy to use and having many

features that can facilitate engagement with learners:

I think it was pretty easy to go in and find the tabs,

and then you’d find something else the next time you

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went in that you missed last time, so—it was just a

matter of spending that time doing it, right? [Educator

Educators also mentioned the DocuCare feature for providing

feedback to students on their submissions was seamless and

efficient, thus promoting learning and positive interactions with

students. As an educator indicated:

I thought it was kind of easy because you could just

go in there and say, Okay, incomplete assessment,

now please resubmit...It was non-offensive,

supportive, which is sort of what we do, and then

there’s a box to add your comments [Educator 1]

Educators also found that the layout of tabs within DocuCare

was well integrated and presented a comprehensive view of the

clinical information that students need to document, and it

included a review of the care provided. According to one

educator:

Well, definitely the tabs. I did like that you had your

flow sheets; you had your assessment...you look at

it...and it’s there. You don’t have to go fishing around,

it’s a click. The layout, the dropdown menus—I mean

everything about it is very familiar, I didn’t have a

hard time navigating it. [Educator 2]

Students also stated that DocuCare reinforced the provision of

safer care. According to them, safer care was linked to

improvements in communication, efficiency, evidence-based

practice, and humanization of care. One student noted:

The doctor’s writing is really confusing, and I think

if you were to consolidate all of that onto electronic

charting, it’d be a lot easier to follow, like, the story

of how they’ve been doing up until like the point that

you’re now taking over...In some situations, it

[DocuCare] does condense the information down and

get you more focused on what’s important, what’s

necessary—and as well for multiple people, it kind

of makes everybody on the same field. So, somebody

might write something or explain something in a

completely different way, but this way—it’s all

uniform almost. So, it’s harder for me to get like, a

full picture of the patient, whereas with the DocuCare

it was actually—once I figured out where to go—it

was pretty easy to see, Okay, this is how they were

on their last shift, because it’s just typing and

everything comes out really clear, because it’s

electronic. So that I actually found it really easy in

terms of finding like, past information. [Student 2]

Theme 4: Educators’ and Students’ Suggestions for

Improving DocuCare

Many responses were assigned to the theme suggestions for

improving DocuCare. This theme, which is concerned with

suggestions for improvement, is divided into 3 categories:

warning signs, search functions, and indexing patient

information. Educators suggested that it might be beneficial to

have a warning sign within DocuCare, allowing users to know

when the data chart is incomplete. Educators clarified that they

(students):

always forget something when they do an

assessment...it would be kind of nice if it glowed or

something—it wouldn’t let you carry on unless you

complete it [Educator 1]

Conversely, students felt that having a search function in

DocuCare would make it more user friendly and easier to

navigate. One student explained:

In this world we all know that there’s so much

information, it’s changing all the time, and it could

be found anywhere. If I would’ve had a search bar

where I could have typed in “urticaria,” that

would’ve brought up which sections are those in...it

was very inefficient for me to spend an hour trying to

look for something. So, if there’s a tool that allows

me to search for it quick, then—I think that would be

super helpful. [Student 1]

Other students suggested adding a sidebar indexing patients’

most important and recent information would enhance access

to the most relevant information needed when providing care

within DocuCare. This indexing function is actually similar to

what is typically seen in clinical sites. According to one student:

With Connect Care they have the patient’s

information consistently on the side. You can easily

access the main information that you’re reporting,

like, what’s their weight and diet, what’s coming up

for them...so you can view everything, and even vital

signs. So, where DocuCare is very fragmented in

different tabs, Connect Care has it in like an actual

flow sheet, so where you know, you just read, scroll,

and you can add it in at the same time. [Student 3]

Theme 5: Recommendations for Integrating DocuCare

in Undergraduate Curricula

This theme comprised recommendations for integrating

DocuCare in the undergraduate nursing curricula. Specifically,

it included 4 categories: better orientation and support, more

exposure and frequency, scheduling DocuCare in the curriculum

and integrating it within courses, and flexibility of delivery with

a focus on learning, not grading.

Both educators and students agreed that the introduction of

DocuCare in the undergraduate curricula should start with an

orientation for both educators and students on the system usage

coupled with ongoing technical and human support. According

to one student:

It’ll be even good to just have like, one video example

with like, the computer videos of a teacher or

instructor just going through one basic assessment,

or one case scenario, so students can visualize and

see—This is how it [kind of] should be done. [Student

Educators, conversely, found that the orientation session

provided to them was sufficient:

I found the webinar actually really helpful. After I

watched that I was like, “Ah, piece of cake!” You

know—It was not intimidating at all! [Educator 2]

However, educators felt that:

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a designated tech support person would be good

[Educator 2]

and:

having access, like—on [our] time, because setting

things up...so, if there’s a way that we could have sort

of continuous access to it, that would be—I think

better [Educator 3]

Educators and students also agreed that incorporating DocuCare

in the education of nursing students should be systematic, with

more frequent exposure. They suggested that exposing students

to it in the simulation laboratory and, where possible, in clinical

settings would allow adequate opportunities for students to

develop proficiency and integration with their overall repertoire

of clinical skills. One student pointed out:

Yeah, and I mean even still at the end of all the cases

that I did—I still think I wasn’t, I still would’ve

wanted a little bit more practice. If that was my

method of documentation on the floor, I would

definitely want more than what I got in the cases that

I did...I think that it would be beneficial to do it

throughout the program, not just a one-time thing,

and kind of starting it off slow or starting it off

smaller, and then growing the pieces bigger so that

you are constantly exposed to it and constantly

practicing through it. [Student 2]

Students and educators differed in their views about the timing

of introducing DocuCare in the curriculum and integration with

other courses. For students, starting early in their program would

be most useful; however, they believed that having some

foundational knowledge in nursing first would be more

appropriate. According to one student:

I think—maybe at the end of first year, but more in

second year, because I think for me, like figuring out

how to do the assessments first—instead of having

like—learning to do the assessments, and then

learning to use DocuCare—I think I want be more

comfortable with actually what I’m doing before I try

putting in...[Student 1]

Conversely, educators felt:

it would be really valuable, that first year in health

assessment, if we can give them time [Educator 2]

Finally, educators and students provided important insights on

how DocuCare learning could be incorporated despite challenges

with content-heavy curricula and busy students’ schedules.

Flexible delivery, with a focus on learning not grading, was

highlighted. Students highly supported the use of self-directed

learning via online modules that can be incorporated into the

laboratory or e-class platform without imposing a grading

system. According to a student:

I could even see it as an e-class module...and with

the no marks thing. I think it’d be good if simulation

lab had an opportunity to like—you go in, here’s your

patient, here’s your thing. But I think it’d be great if

there was an option—almost like a little certificate

kind of thing. You could come at your own time, here

are the times and dates, we have the operator here,

here’s a case scenario, we need you to come in maybe

with yourself or with a partner, or even as a clinical

group. [Student 3]

Conversely, educators felt the need to engage students in this

learning and to monitor their progress down the road:

You have to make them accountable in some way...you

just put pass or fail. [Educator 3]

Discussion

Principal Findings

The purpose of this pilot study was to determine feasibility

issues and evaluate the suitability of DocuCare from the

perspectives of students and educators, as a tool for supporting

students’acquisition of informatics competency and to enhance

their readiness for future practice in digital health environments.

The use of DocuCare in this study contributed to improving

students’ knowledge about informatics and accuracy of

electronic documentation, congruent with findings from previous

research [16,19,24,40-42,47]. There was no change in attitudes

toward EHRs. On the basis of the findings from focus group

interviews with students, this could be explained by the fact

that students already had positive attitudes toward this

technology, as demonstrated in their responses. In our study,

educators agreed that hands-on learning opportunities through

simulated electronic records were vitally important for the

application of knowledge, development of critical thinking and

documentation competencies, and building confidence in using

clinical information systems in practice settings. Similarly,

students were overwhelmingly satisfied to very satisfied with

DocuCare and highly recommended using it in undergraduate

nursing programs. They indicated that opportunities for

electronic documentation will not only strengthen their

communication skills but also enhance their critical thinking

skills and their understanding of informatics concepts. It could

ease their transition to using advanced technology in the work

setting, which is congruent with findings from previous research

[11,47].

The results of this study and other research confirm that students

recognize gaps in their informatics preparedness to meet

workplace requirements regarding the use of electronic tools to

support nurses’ work, particularly for data management and

electronic charting [5,6,11,16,42]. Uniquely, in our study,

students and educators provided suggestions for improving the

DocuCare platform. They also shared strategies and

recommendations on how DocuCare could be incorporated in

strategic ways to augment students’learning about digital health

and informatics without creating additional workload or

overwhelming the already content-heavy curricula. Students

were also quite passionate and willing to take on a self-directed

role in embracing this technology to support their education.

They recognize that the technological changes taking place in

the clinical environment warrant action, but their education was

not keeping pace. Although these findings reflect more

awareness among student nurses regarding the importance of

digital health and informatics in nursing practice, they also

assert the need for more work on the part of nursing schools

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and nurse educators in creating learning opportunities within

the curriculum to enhance students’preparedness for their future

nursing roles. Unfortunately, within Canadian prelicensure

education, significant gaps still need to be addressed.

In a recent survey of Canadian schools of nursing, fewer than

20% of 360 nurse educators surveyed reported using EHR

simulation in conjunction with teaching clinical skills in a

simulation laboratory [5]. Congruent with these findings, in

another survey conducted by Canada Health Infoway, only 35%

of the nurse educators surveyed reported using a training version

of an electronic record or clinical information system to support

the teaching of nursing skills [2]. In addition, despite the

increased utilization of digital health tools in practice, only 6

of 10 nurses surveyed about the use of virtual care reported

having adequate knowledge and skills to use these systems [2].

Nagle et al [5] identified that teaching students about the use

of EHRs is challenging in practice settings because there are

few opportunities for students to access or use fully functional

EHR systems in health care facilities. These findings are

congruent with our findings and those in the general literature

[11,34]. Nagle et al [5] also highlighted the need for an

affordable EHR sandbox that could be used in simulation

laboratories to teach students how to integrate these tools as

they learn other clinical skills. They also identified the need for

academic administration support for nurse educators as they

implemented these tools [5,54]. Simulated EHRs are valuable

for students learning about informatics and computerized

charting; therefore, removing barriers to integrating them within

Canadian nursing education should be a priority [5,20,34,42,54].

Educating future nurses about digital health and informatics is

no longer an option but rather a core requirement in modern-day

nursing practice [5,34,40,42,54-59]. Although the abrupt

transition to remote delivery of education during the COVID-19

pandemic highlighted the current gaps in technology

infrastructure and created challenges for higher education

institutions worldwide, it also revealed opportunities for

embracing technology and virtual simulation. This could be an

important opportunity for nursing programs to capitalize on as

we navigate more virtual practice across all domains of nursing

[60-64].

Limitations

As this was a pilot study and voluntary participation was

appreciated, the small sample size and the use of a one-group

quasi-experimental design affected the power of the study.

Numerous contextual factors may also have influenced students’

willingness to participate in the study. The participants’

recruitment was interrupted because of the COVID-19 pandemic

and the public health guidelines restrictions. Students’academic

workload, disruption of clinical placements, stress and feelings

of uncertainty related to the COVID-19 pandemic, and the

uncertainty regarding the completion of their program and

entering the workforce in an evolving global pandemic may

have also influenced students’ desire to participate in this

research. Finally, students who agreed to participate might have

been more interested in the topic of the study compared with

those who did not participate, which may have resulted in a

response bias.

Conclusions

The integration of simulated EHRs within the nursing

curriculum has the potential to improve students’ knowledge

and understanding of informatics and build confidence in using

EHRs, including computerized charting. In this pilot study, the

opportunity to use DocuCare firsthand enabled our students and

educators to provide important insights and recommendations

to the curriculum committee on the suitability and value of this

educational tool for improving teaching and learning about

informatics, computerized documentation, and the use of EHRs.

This preliminary evaluation will also inform the planning of a

future larger, controlled evaluation study, inviting students and

educators from other sites within our collaborative nursing

programs in Alberta. Given the paucity of Canadian research

on simulated EHRs, the findings of this study may also be useful

to other schools of nursing.

Acknowledgments

The Teaching and Learning Enhancement Fund from the University of Alberta funded this study.

Authors' Contributions

MK was involved in funding acquisition, conceptualization, designing the methodology, investigation, formal analysis, project

administration, resources, supervision, and writing, reviewing, and editing the original draft. DJ was involved in investigation

and writing the review. UDW was involved in investigation, formal analysis, and writing and editing the review. SA was involved

in investigation, formal analysis, and writing and editing the review.

Conflicts of Interest

None declared.

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Abbreviations

EHR: electronic health record

EMR: electronic medical record

Edited by E Borycki; submitted 04.01.21; peer-reviewed by W Hansbrough, R Chan, T Hebda; comments to author 25.01.21; revised

version received 20.03.21; accepted 07.04.21; published 27.04.21

Please cite as:

Kleib M, Jackman D, Duarte Wisnesky U, Ali S

Academic Electronic Health Records in Undergraduate Nursing Education: Mixed Methods Pilot Study

JMIR Nursing 2021;4(2):e26944

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doi: 10.2196/26944

PMID:

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