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Nurse Education Today 30 (2010) 175–179

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Integrating problem-based learning in a nursing informatics curriculum

George Demiris *, Brenda Zierler
Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, BNHS-Box 357266, Seattle, WA 98195-7266, USA

a r t i c l e i n f o s u m m a r y

Article history: In recent years employers in health care organizations have been recognizing the need for nurses to enter
Accepted 9 July 2009 the workforce with a set of informatics competencies. Numerous nursing informatics programs have
been established worldwide. The challenge becomes to explore innovative tools that will equip nurses
with the appropriate skills to utilize information technology to improve health care quality and patient
Keywords: safety and redesign health care services. This paper presents the introduction of problem-based learning
Distance learning (PBL) modules into an existing nursing informatics curriculum, the Clinical Informatics and Patient Cen-
Problem-based learning
tered Technologies Master program at the School of Nursing, University of Washington. Additionally, we
Nursing informatics
discuss recommendations and challenges associated with the integration of PBL in nursing informatics
graduate education including the need for facilitators, flexible technology platforms, promotion and doc-
umentation of group work, faculty training and supervision by a program committee.
Ó 2009 Elsevier Ltd. All rights reserved.

Introduction how to use hospital information systems to retrieve patient infor-

mation; understanding the importance of confidentiality and data
Nurses are responsible for managing and integrating numerous security; and ensuring appropriate access to information (Saranto
sources of data, coordinating the services of multiple clinicians into and Leino-Kilpi, 1997). In a study of US nurse administrators,
the comprehensive daily management of individual patients and McCannon and O’Neal found that administrators ranked knowl-
communicating with a variety of stakeholders. With the rapid edge of nursing-specific information systems as the most critical
increase in both volume of patient information and evidence of IT skill needed among nurses (McCannon and O’Neal, 2003). Recent
best patient care practices, nurses increasingly employ effective studies suggest that nursing graduates are not adequately pre-
information and knowledge management strategies and are in- pared with respect to informatics competencies. In 2002, Chastain
volved in the design and implementation of information systems. compared student and faculty self-reported IT skills to employers’
Nurses are also asked to function as change agents and lead health- expectations. In both general computer applications and hospital
care organizations toward achieving goals of increasing patient information systems, employers had higher expectations of new
safety, improving the delivery of quality care and redesigning graduates’ knowledge than both students and faculty (Chastain,
services to increase efficiency. In this paper we discuss methods 2002).
to design and enhance a curriculum to prepare nurses for these The Institute of Medicine (IOM) Committee on the Health Pro-
new roles and challenges. fessions Education Summit highlighted the significance of educat-
ing health care professionals ‘‘to deliver patient-centered care as
members of an interdisciplinary team, emphasizing evidence-based
Nursing informatics practice, quality improvement approaches, and informatics (Greiner
and Knebel, 2003)”. More specifically, the American Nurses Associ-
In recent years, employers have been recognizing the need for ation Council on Computers in Nursing in 1992 called for the des-
nurses to enter the workforce with a set of informatics competen- ignation of nursing informatics as a specialty, defining it as a
cies. In 1997, a Delphi study of nurse managers, nurses, educators specialty
and patients examined the information technology (IT) require-
ments for practicing nurses (Saranto and Leino-Kilpi, 1997). More
than 85% consensus was reached for 28 items as being very impor- ‘‘that integrates nursing science, computer science, and infor-
tant or important. Among the items with 100% consensus were: mation science in identifying, collecting, processing, and man-
aging data and information to support nursing practice,
administration, education, and research; and to expand nursing
* Corresponding author. Tel.: +1 206 221 3866; fax: +1 206 543 4771. knowledge (American Nurses Association Council on Computers
E-mail address: (G. Demiris). in Nursing, 1995)”.

0260-6917/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved.
176 G. Demiris, B. Zierler / Nurse Education Today 30 (2010) 175–179

Since then, several nursing informatics undergraduate and As Margetson et al. (1985) argue, integration of PBL in a course is
graduate programs have been created worldwide. Recognizing manifested by a problem-focus from the beginning of the course,
the importance of nursing informatics competencies, the National facilitation of initial inquiry, availability of consulting resources,
Advisory Council on Nurse Education and Practice, within the encouragement of reflection, refinement and development and
Department of Health and Human Services, recommended five iteration of all these elements. In a contemporary healthcare envi-
strategies for addressing sufficient nurse preparation in IT manage- ronment characterized by a rapidly-changing and expanding
ment: (1) inclusion of informatics content within curricula; (2) knowledge base, regulations and policies and scientific advances,
preparation of nurse informatics specialists; (3) use of informatics nurse informatics leaders need to possess critical thinking skills
projects to enhance nursing practice and education; (4) prepara- and expertise in flexible, individualized, situation-specific problem
tion of faculty in informatics; and (5) increase of collaborative solving (Higgins and Jones, 2000). A nursing informatics curricu-
efforts in nursing informatics (Gassert, 1998). lum as is the case with any nursing education initiative, must fos-
Ongoing initiatives are addressing the importance of nursing ter the development of students’ critical thinking (Bowles, 2000).
informatics education and are highlighting standards and compe- Therefore, the use of PBL in nursing informatics education holds
tencies that need to be integrated into graduate nursing informat- promise for the preparation of future nurse leaders.
ics education. The American Nurses Association (ANA) has Problem-based learning bears several challenges. Students
developed a set of standards and practices for nursing informatics. when asked to review multiple sources in pursuit of answers,
The Technology Informatics Guiding Education Reform (TIGER) may feel challenged by the self-directed study and at times unsure
Initiative (supported by the Alliance for Nursing Informatics, a col- what information is relevant and useful (Wood, 2003). A further
laborative effort between the Healthcare Information and Manage- challenge is identifying ways to evaluate PBL programs in a mean-
ment Systems Society and the American Medical Informatics ingful way. Boud and Feletti (1991) point out the lack of valid
Association) aims to enable practicing nurses and nursing students acceptable measures as standardized testing approaches often in-
to fully engage in the unfolding digital era of healthcare (Dulong clude multiple-choice questions, that are not readily adapted to
and Gassert, 2008). Over 100 nursing leaders from more than 70 measuring the process skills needed for critical thinking. Ensuring
organizations participated in the development of the TIGER vision that PBL assignments are carried out within small student groups
and action plan in 2006. The goal is to strengthen the voice of the guided by facilitators can be a more costly approach compared to
nursing profession in the transformation of healthcare for the 21st traditional lecturing.
century by creating a vision for the future of nursing education and In the following we present the introduction of PBL modules
practice (Dulong and Gassert, 2008). into an existing nursing informatics curriculum (the Clinical Infor-
The challenge in the design of a nursing informatics curriculum matics and Patient Centered Technologies Master program at the
lies in the integration of learning objectives and competencies that School of Nursing, University of Washington) and discuss recom-
will prepare nurses to not only accept and utilize information tech- mendations and challenges associated with the integration of PBL
nology (IT) but be in a position to integrate IT to redesign health in nursing informatics graduate education.
care services and improve quality and safety of care. This calls
for pedagogical tools that facilitate the understanding of clinical,
administrative and technology concepts and their application in The clinical informatics and Patient Centered Technologies
actual practical settings. One such pedagogical approach that fos- program
ters critical thinking and decision-making and therefore, can be
of value to a nursing informatics curriculum is problem-based In 2004, the University of Washington School of Nursing estab-
learning (PBL). lished the Clinical Informatics and Patient Centered Technologies
(CIPCT) Master of Science program addressing global trends and
Problem-based learning (PBL) federal recommendations to provide training for nursing profes-
sionals to become informatics specialists and leaders in utilizing
Problem-based learning was first introduced to the health pro- IT to redesign health care. The CIPCT program was designed to train
fessions as a curricula modality at McMaster University in Canada nurses to assume leadership roles in environments that support
in the seventies and since then its value for health related curricula quality improvement, professional practice, exemplary patient
has been documented in and supported by an extensive body of lit- care and career growth, and prepares nurses to address aspects
erature (Albanese and Mitchell, 1993; Foley et al., 1997; Verson of the growing US nursing shortage. The program equips nurses
and Blake, 1993). While this model has been primarily used for with skills that will allow them to remain in practice, supporting
clinical courses with the integration of what the Joint Commission on Accreditation of Healthcare Organi-
zations (2002) has called ‘‘a culture of retention”. It does so by
equipping nursing leaders with expertise in the implementation
‘‘patient problems as a context for students to learn problem-
and evaluation of health information technologies within a system
solving skills and acquire knowledge (Albanese and Mitchell,
of care. The CIPCT program is a 2-years Master’s program that uti-
lizes distance learning technologies to enable working profession-
als to pursue graduate education without having to commute daily
PBL can also be used beyond clinical scenarios (Carlisle and to the Seattle campus.
Ibbotson, 2005), and applied to building research capacity, acquir- The core curriculum covers the following competencies and
ing administrative, project management and other skills. As such, skills:
PBL is an essential enhancement of a graduate curriculum that
trains nurses to assume leadership roles in an interdisciplinary Analytic and information management skills
field requiring reasoning and problem-solving skills.  Applying knowledge of information systems to improve clinical
Three underlying principles of PBL are: (1) integration of prac- and organizational effectiveness.
tice and theory to enable both sound understanding and action;  Applying principles of biomedical informatics to nursing and
(2) an educational process carefully designed to achieve the syn- care management processes.
ergy and integration of practice and theory; and (3) reflection of  Utilizing databases for decision support systems and principles
the generation of knowledge in the area of study (Alavi, 1985). of data mining.
G. Demiris, B. Zierler / Nurse Education Today 30 (2010) 175–179 177

 Utilizing knowledge of techniques for protecting privacy of organizations (a series of four courses focusing on organizational
health information. effectiveness, health care systems and leadership), case studies in-
Evidence-based practice clude challenges faced by the executive team in reorganizing ser-
 Applying knowledge of evidence-based clinical practice and vices and exploring shared governance. In the courses covering
management. health information technology, database design and electronic
 Applying research skills to current clinical and management medical records, the case studies pertain to challenges associated
problems. with the implementation and maintenance of information systems,
 Utilizing approaches to scholarly inquiry as applied to clinical issues of interoperability, training and cost. Finally, in the courses
practice in HC. on patient centered technologies, cases involve decisions needed
Communication skills to be made about endorsing home-based technologies and explo-
 Developing effective oral and written communication. ration of personal health records. Each case introduces a problem
 Presenting information and data clearly and accurately. that covers practical, technical, ethical, organizational and financial
US health care system and policy. implications.
 Understanding organization of the US health care system.
 Applying understanding of external policy, political and eco- PBL considerations/recommendations
nomic HC environments.
 Utilizing knowledge of health care financing and payment, legal, The following concepts are essential to the successful design of
regulatory and legislative issues. PBL in an informatics curriculum and to overcoming obstacles or
Management and leadership barriers to the implementation of PBL.
 Utilizing knowledge of trends in health care organization and
 Understanding and providing leadership to health care
As Katz points out, sound governance and facilitation are crucial
 Utilizing a range of approaches to managerial decision-making.
to introducing PBL successfully into a course (Katz, 1985). The pur-
 Employing an ethical framework for management and
pose of facilitation is the introduction of a setting in which partic-
ipants are encouraged to clarify and further their own learning
Cultural competence, diversity and health disparities
objectives, developing problem-solving skills and their creativity
 Understanding the forces that contribute to cultural diversity.
in identifying and gathering necessary resources. Thus, the main
 Utilizing knowledge of diverse populations and their needs.
goal of facilitated learning is not the transfer of empirical data
 Understanding disparities based on race, ethnicity, gender,
but rather assisting individual students to integrate theory and
socioeconomic, and geographic differences.
practice, develop appropriate skills to identify what knowledge
to acquire and how to do so. Facilitation is a process role which in-
In the summer of 2008, we introduced an initiative to enhance
volves examining the content of a learning package, monitoring
the curriculum by integrating PBL into most of the CIPCT courses.
and assisting with skills development, and evaluating intra-group
The approach we took was not to convert all existing courses into
processes (Katz, 1985). The facilitator mentors the students
PBL courses, but rather to integrate PBL with the use of case studies
through this enquiry and decision-making journey, critiques the
in all courses allowing for a complex scenario with multiple and
rationale of their judgments and challenges their assumptions
challenging questions to provide a common thread across all
when necessary and in the context of the interactive group process.
courses and introduce students to the complexity of a real world
setting. The underlying premise was the use of PBL as a student-
centered approach to learning which enables students to work Promotion of group work
co-operatively in small groups and to seek solutions to complex
problems (Rideout and Carpio, 2001). These problems are chosen An important feature of PBL as introduced in the curriculum is
to highlight the diversity and magnitude of issues in a health care that it assumes and fosters group work. Problem-based learning
setting including administrative, ethical, socio-technical, financial is based on the values of co-operative decision-making and prob-
and clinical challenges that require deep understanding of nursing lem solving. In our program students come in varying stages of
informatics theories and concepts. The scenario pertains to a hypo- ability and readiness for critical reflection, and it is the design of
thetical health care organization that is described to reflect the PBL cases and the role of the facilitator that ensures that the inter-
needs and trends of actual real world settings familiar to many active group work addresses the educational needs of all partici-
of the students who are already employed health care profession- pants. Given the distance learning nature of our curriculum,
als. The actual questions that call for students’ judgment and crit- emphasis is placed on online collaboration tools, formal and infor-
ical thinking are based on literature reviews, synthesis of mal synchronous and asynchronous communication tools (e.g.,
controlled evidence, and analysis of current and future trends. Stu- chat rooms, video-conferencing software for the former, discussion
dents are asked to face the problem-solving situations in small and message boards for the latter).We also emphasize a flexibility
groups. These groups have to decide what information they need in using various technology solutions as discussed later.
in order to identify the issues, understand them, communicate
them to others in the group and the facilitator, and then re-formu- Documentation of the group process
late them to enable a solution plan. Group discussions are a pow-
erful tool that can foster students’ critical thinking (Wood, 2004). The term group process describes the actions, interactions and
The hypothetical health care organization used throughout the dynamic relationships of members within the group that ensure
curriculum is a multi-hospital system, with ten hospitals in one its operation as one entity. Group process includes defining or
state; all hospitals are community-based with 50–300 inpatient refining core elements such as the purpose and objectives of the
beds. Additionally, this system has primary and multi-specialty group, the group structure and leadership, expectations regarding
clinics, all owned by the corporation that also employs all physi- members’ contributions, negotiation and setting of regulations
cians and mid-level providers and has its own insurance company. such as how information will be shared, and the way the group
In courses dealing with organizational effectiveness of health care examines and monitors its own process.
178 G. Demiris, B. Zierler / Nurse Education Today 30 (2010) 175–179

Flexibility in the use of technological platforms may require a paradigm shift and the integration of innovative
practices in the curriculum.
Given the distance learning format of our program, we utilize a The integration of PBL in a nursing informatics curriculum
variety of tools to support both synchronous and asynchronous requires preparation and detailed and thoughtful planning as it
communication between instructors and students, and also requires a paradigm shift for both instructors and students. One
between members of student groups. Each course is hosted in of the challenges is the recognition of the need for students to take
Moodle-an online, interactive class management system that al- responsibility for their own learning with PBL and for instructors to
lows students to access course information, discussion boards, enable that learning primarily as facilitators-a process, which in
reading assignments, as well as electronic resources for their PBL some cases can increase anxiety as instructors recognize that they
cases. Furthermore, we use ConnectPro Live, a real time web con- will have to give up some control of the learning environment. Re-
ference software, to support live interaction between participants sources and extensive planning can provide all stakeholders with
separated by geographic distance. It is imperative to the success the necessary tools to prepare for the integration. Clearly, forma-
of PBL to utilize diverse sets of IT tools and platforms based on stu- tive evaluation to assess the ongoing process, barriers and facilita-
dent needs, learning objectives and related processes for each PBL tors allows for early identification of issues that may need to be
case. We also aim to ensure reliability of the performance of in- resolved or additional resources and materials needed to provide
volved software and hardware and provide ongoing and tailored insight or clarification.
technical support to faculty and students. For our CIPCT program we did not convert our existing curricu-
lum into a PBL based one, but rather integrated PBL into most of
Coordination by a curriculum committee the courses using case studies. One of the reasons for this hybrid
approach is the concern expressed by Milligan who cautions that
Prior to initiating the PBL integration into the curriculum, we a wholesale adoption of PBL as a curriculum model may not
established a program-specific curriculum committee that was respond effectively to differing student learning styles (Milligan,
asked to not only work with individual instructors to ensure that 1999). A meta-analysis study by Dochy and colleagues explored
the learning objectives and PBL competencies were met, but also the main affects of PBL on knowledge and skills, and identified a
to provide consistency, standardization and detailed documenta- robust positive effect from PBL on students’ skills (Dochy et al.,
tion of all implemented changes throughout the curriculum. The 2003). The same study also concluded that students undertaking
curriculum committee worked closely with the instructors and PBL gained slightly less knowledge, but remembered more of the
administrators of the program as well as external consultants. acquired knowledge (Dochy et al., 2003). The ongoing evaluation
We organized faculty retreats to enable all program faculty to of the efficacy of PBL highlights the need for an increased evidence
become familiar with all course content and learning objectives base that facilitates comprehensive guidance on both its advanta-
of the curriculum and ensure that PBL cases were chosen to follow ges and potential limitations especially for competency-based
an underlying thread and build on knowledge delivered by other professional programs. At the heart of PBL implementation is the
courses. construction of case scenarios based on real-life situations, which
are the main triggers for the student groups to debate.

Faculty training
The integration of PBL whether it affects the entire curriculum
or individual courses does imply a paradigm shift for trainers This project is supported in part by funds from the Division of
who are mostly familiar with traditional lecture format courses. Nursing (DN), Bureau of Health Professions (BHPr), Health
Thus, this recognition of a paradigm shift requires that the actual Resources and Services Administration (HRSA), Department of
instructors be trained to prepare for the successful integration of Health and Human Services (DHHS) under Grant Number
PBL tools. We have created a repository of resources that is avail- D09HP09358 Graduate Nursing Informatics Education (Demiris, PI).
able to all faculty that includes the theoretical framework of PBL, The information or content and conclusions are those of the
examples of its successful use, and recommendations for the crea- authors and should not be construed as the official position or pol-
tion of PBL cases. We have discussed and reviewed PBL cases dur- icy of, nor should any endorsements be inferred by the Division of
ing faculty retreats and made sure that the integration of PBL is Nursing, BHPr, DHHS or the US Government. The website for the
consistent and standardized across courses, with feedback from Clinical Informatics and Patient Centered Technologies Program
all involved faculty and in accordance with both the individual is
course objectives as well as the overall program goals and objec-
tives. Effective faculty development and staff preparation for PBL, References
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