Teaching and Learning in Nursing 11 (2016) 204–208

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Teaching and Learning in Nursing

journal homepage: www.jtln.org

Incorporating Electronic Documentation into Beginning Nursing

Courses Facilitates Safe Nursing Practice
Ann M. Bowling, PhD, RN, CPNP-PC, CNE ⁎
Wright State University-Miami Valley, College of Nursing and Health, Dayton, OH

a r t i c l e i n f o a b s t r a c t

Keywords: Advances in technology require nursing students to be prepared to practice in a technology-rich environment.
Nursing education The purpose of this project was to incorporate electronic documentation activities to facilitate student's skill
Electronic health records performance. Although students initially increased their electronic documentation competency, this was not
Computer literacy maintained. Electronic documentation activities are needed to facilitate nursing student's computer literacy
Undergraduate nursing education
skills. Therefore, nurse educators must examine best practice approaches to facilitate student's readiness to
Informatics
practice in today's technology-rich environment.
© 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.

Introduction expected to “use information and technology to communicate, man-

Advances in technology have completely transformed health
care and require nursing students to be prepared to practice in
technology-rich care environments. As patient care documentation
transitions from paper-based to electronic-based information manage-
ment systems across settings, students must be prepared to use these
systems that ensure safe patient care. The purpose of this project was
to develop and implement an active learning environment that incor-
porated simulated electronic documentation to facilitate students'
skill performance of electronic documentation.
Literature Review
The era of paper-based systems for documenting patient care is
drawing to an end. Federal legislation, such as the 2009 Health Infor-
mation Technology for Economic and Clinical Health Act, mandated
the use of electronic health record for health care systems for all
documentation practice (McGonigle & Mastrian, 2015). Nurses are
Funding information: This educational project was funded by an internal
2012–2013 teaching innovation grant from Wright State University.
Presentation Information: This article has been presented at: Bi-Annual Greater
Dayton Area Nursing Research Symposium, Dayton, OH, as a podium presentation on
March 20, 2015; 12th Annual International Nursing Simulation/Learning Resource Cen-
ters Conference, Las Vegas, NV, poster presentation on June 14, 2013; and 37th
Annual Midwest Nursing Research Society Conference in Chicago, IL, poster presenta-
tion on March 9, 2013.
⁎ Corresponding author. Tel.: +1 937 775 2596; fax: +1 937 775 4571.
E-mail address: ann.bowling@wright.edu.
age knowledge, mitigate error, and support decision making”
(Quality and Safety Education for Nurses [QSEN], n.d.). The transforma-
tion of the electronic health record requires specific competencies that
need to be mastered by all health care providers, including student
nurses. The need for these competencies is recognized by many
national nursing organizations. The National Council of State Boards
of Nursing (NCSBN) National Council Licensure Examination for
Registered Nurses test plan includes information technology as one
area of significance in the Safe and Effective Care Environment test
item category (NCSBN, 2013). Similarly, the American Association
of College of Nursing Essential IV: Information Management and
Application of Patient Care Technology describes the need for
baccalaureate nurses to be able to use information management
systems to support safe patient care (American Association of
Colleges of Nursing, 2008). In addition, the QSEN project identifies
informatics competencies as one of six competencies required
of undergraduate students in order to provide quality, safe care
(QSEN, n.d.). The Technology Informatics Guiding Education Reform
initiative, a collaboration between nurses, educators, and policy
makers, also recognizes the importance for practicing nurses to devel-
op computer literacy skills such as use of electronic documentation.
Therefore, nurse educators must be prepared to provide this education
(McGonigle & Mastrian, 2015).
Similar to other nursing skills, students must have the opportunity
to practice and develop the informatics and electronic documentation
skills that they will use in practice. To prepare students for clinical
documentation using electronic information systems, a variety of
methods have been and are being used. While traditional didactic
methods may be used to provide students an understanding of the

http://dx.doi.org/10.1016/j.teln.2016.06.001
1557-3087/© 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
 A.M. Bowling / Teaching and Learning in Nursing 11 (2016) 204–208
basics of documentation systems and their legal ramifications, educa-
tors are being challenged to incorporate more active learning strategies
that enhance learning outcomes (Benner, Sutphen, Leonard, & Day,
2010). This is especially challenging for nurse educators as many facul-
ty remain novices in using technology skills (Miller et al., 2014).
Many nursing programs do not have access to an actual electronic
medical record system that can be used for educational purposes;
therefore, many nurse educators have incorporated use of academic
health records into curricula to provide students the hands-on expe-
rience of using an electronic clinical documentation system. These
academic systems emulate actual systems and allow students to expe-
rience the functionalities of an actual system within a safe, secure
academic environment. These systems vary in features and costs, but
may include case studies, companion software activities, and options
to build patient cases for students to practice documentation activities.
Practicing with these systems, students are able to develop the skills
for appropriate legal documentation of patient care (Gardner &
Jones, 2012). These programs are often used in conjunction with
simulation activities that allow students to practice patient care and
then practice the documentation of that care (Jeffries, 2014).
Costs, limited funding, and faculty issues, however, have been
major barriers in nursing education to the use of commercial academic
health records (Gardner & Jones, 2012). Many faculty may be resistant
to trying new technologies (Titzer & Swenty, 2014). Faculty and
student time required to learn the software systems, as well as lack
of modifiability of the commercial product, have also been identified
as barriers (Hanson, 2013). The incorporation of an electronic docu-
mentation system into the existing learning management system
may provide an option for nurse educators. This option would allow
students the opportunity to practice electronic documentation with-
out having to learn another computer program. By incorporating
these learning opportunities early into the nursing curriculum,
nursing faculty can identify and work with struggling students and
facilitate a smoother transition into the clinical practice arena and
promote patient safety.
Project Description
The specific aim of this project was to develop an electronic docu-
mentation system for use in the nursing assessment and nursing skills
courses. The project was conducted in a publicly funded college of
nursing in the midwest. Students in the college are admitted to the
nursing sequence as sophomores and begin their program of study
with a course in health assessment that is followed by a fundamentals
course in the subsequent semester. To facilitate the development of the
student's skill performance of electronic documentation, active
learning assignments and electronic documentation assignments
were incorporated into these first two courses. The electronic docu-
mentation assignments were developed to mimic the real-life docu-
mentation system used in most facilities in the region. To avoid
faculty and students needing to learn a new software program, the
quiz component of the learning management system was used to de-
velop the documentation assignments.
The evaluation of the educational project was approved by the
university's affiliated institutional review board. To allow for subject
anonymity, a waiver of informed consent was approved because
the informed consent would be the only record linking the subjects
to the educational experiences. Confidentiality of participant
responses was maintained throughout the educational activity.
Participants
A convenience sample of 93 sophomore Bachelor of Science in
Nursing students (second year in college, first year in nursing) en-
rolled in the beginning nursing course, health assessment, was used.
205
The comparison group consisted of a convenience sample of 85 junior
Bachelor of Science in Nursing students (third year in college, second
year in nursing) enrolled in a pediatric nursing course. All students com-
pleted the electronic documentation assignments as part of their course
requirements. These assignments were pass/fail with students receiving
a passing grade for completing the assignment. The documenta-
tion assignment score was not applied to the individual student's
grade.
Instruments to Evaluate Learning
Time 1 Physical Assessment Assignment
The Time 1 physical assessment assignment was a 50-item elec-
tronic documentation assignment that I developed based on an
existing course activity that was developed by the physical assessment
course instructor. The physical assessment assignment required
students to complete a focused physical assessment on a simulated
mannequin and then electronically document their assessment
findings. The assessment included both normal and abnormal assess-
ment findings. The electronic documentation of the physical assess-
ment was completed immediately following the completion of the
physical assessment. Students were allocated 15 minutes to complete
the focused physical assessment and 15 minutes to electronic docu-
ment their assessment findings.
Time 2 Assessment Assignments
The Time 2 wound assessment assignment was a 16-item electronic
documentation assignment that I developed. For the wound assess-
ment assignment, students electronically documented the wound
assessment and dressing change based on care given to a human pa-
tient simulator. Students were required to document who completed
the dressing change, the type of wound, location, measurements,
dressings used, drainage, and patient's response to the dressing change.
The Time 2 urinary assessment assignment was a 19-item elec-
tronic documentation assignment that I developed. The urinary
assessment assignment focused on documentation requirements for
Foley catheter insertion based on care given to a human patient
simulator. Documentation focused on when and who completed
the Foley insertion, type and size of catheter and balloon, urine return
with insertion, securement of the catheter, and patient's response to
the catheter insertion (see Fig. 1). Both Time 2 assignments were
completed immediately following the performance of the assessment
and skill.
Time 3 Wound Assessment Assignment
The Time 3 wound assessment assignment was a 55-item electronic
documentation assignment that I developed. The wound assessment
assignment required students to document their assessment of five
different wounds. The wounds consisted of a chest incision, an ab-
dominal incision with a drain, and three laparotomy incisions. Each
wound assessment consisted of 11 items each and focused on the
assessment of the type of wound, location, wound bed, type of
dressing, and drainage. The Time 3 wound assessment assignment
was completed in the computer laboratory immediately following
the wound assessments. Students spent between 20 and 30 minutes
to complete the wound assessments and electronic documentation of
the wounds.
Surveys—Initial and Follow-up
The initial survey was an 8-item survey that included four Likert-
scale questions. The questions asked how easy the assignments were
to complete, how helpful were they to their learning, how important
electronic documentation is to their nursing education, and how
important is being proficient at electronic documentation to their
nursing career. Students were also asked to include comments
206 A.M. Bowling / Teaching and Learning in Nursing 11 (2016) 204–208

documentation and assessment skills by completing the Time 1 phys-

ical assessment assignment.

Time 2
During the fundamentals course, students participated in a weekly
laboratory experience where the students performed and were
evaluated on nursing skills, such as urinary catheterization, wound
care, and administration of a gastrointestinal tube feeding. As part of
the laboratory experience throughout the semester, students
completed electronic documentation of eight of their nursing skills
(vital signs, pain assessment, wound care, antiembolism stocking
application, administration of gastrointestinal tube feeding, urinary
catheterization, and iv insertion). Students completed the nursing
skill in the nursing laboratory and then electronically documented
the nursing skill in the nearby computer laboratory. Similar to the
health assessment course, the laboratory instructor evaluated the
electronic documentation for accuracy and provided individual
instruction for any student who was struggling.
Near the end of the semester, students participated in a skills rodeo
where they were reevaluated on the nursing skills that they learned
throughout the semester. Two of these skills, wound care and urinary
catheterization, were evaluated for electronic documentation using
the Time 2 assessment assignments. Students also completed the initial
survey following the completion of the fundamentals nursing course.

Time 3
One year later, students who participated in the educational activity
were evaluated for retention of their electronic documentation skills
and satisfaction with the active learning assignments via the Time 3
wound assessment assignment and follow-up survey. The students'
performance was also evaluated against a comparison group of
students who did not receive the electronic documentation activities.
During the pediatric nursing course, students in the comparison
group completed the Time 3 wound assessment assignment. These
students were enrolled in the pediatric nursing course 1 year prior to
the students in the active learning group. Prior to completing the
Fig. 1. Electronic Documentation—Urinary assignment.
assessment assignment, the comparison students were provided with
the cover letter explaining the active learning project.

about what they liked best and least about the assignments and what Evaluation
changes they recommend. The follow-up survey, a 4-item survey,
contained the same questions as the initial survey, except it did not Participants
include how easy the assignments were to complete, suggestions
for improvement, and what they liked least and best about the as- There were 91 sophomore students who completed the Time 1
signments. All quizzes and surveys were author developed and had electronic documentation assignment with 63 students completing
not previously been used, except for the Time 3 quiz, which had the Time 3 electronic documentation assignments (see Table 1).
been used previously in the pediatric nursing course. The difference in the number of students between Time 1 and Time
3 is because of students having been unsuccessful in the previous
Project Procedures nursing course, resulting in 28 students having to repeat one of the
nursing courses and not being able to continue in the evaluation pro-
Time 1 ject. The comparison group consisted of 83 junior nursing students.
Prior to completing the active learning assignments, all students in
the health assessment course were provided with a cover letter Reliability of Instruments (Assignments)
explaining the educational project. During each week of the health
assessment course, students completed a system assessment (respira- As new evaluation instruments, each of the assignments used to
tory, cardiac, etc.) on a fellow student and electronically documented assess documentation accurately were analyzed for reliability using a
the assessment findings. To ensure that students were accurately Cronbach's alpha. The reliability of the four instruments showed that
documenting their assessment findings, we verified the electronic
documentation for accuracy by the laboratory instructor. The labora-
Table 1
tory instructor provided individual instruction to any student who Participants
struggled with accurately documenting their assessment findings.
Students who were struggling with documentation were identified Time 1 Time 2 Time 2 Time 3 Initial Follow-up
Wound Urinary survey survey
by their assignment grade; the lower the grade, the more the student
was not accurately documenting. Near the end of the health Number of 91 71 72 63 18 (25%) 17 (27%)
participants
assessment course, students were evaluated on their electronic
 A.M. Bowling / Teaching and Learning in Nursing 11 (2016) 204–208 207

Fig. 2. Comparison of quiz means over time.

the Time 1 physical assessment assignment (Cronbach's alpha = .70) documentation that is usually seen in hospitals and some nursing
and Time 3 wound assessment assignment (Cronbach's alpha = .71) homes” and “user friendly and easy to navigate.”
had a high level of reliability, but the Time 2 assessment assignments There was a decrease in how helpful the students felt the electronic
(wound—Cronbach's alpha = .16 and urinary—Cronbach's alpha = documentation assignments were between the completion of the
− .09) were not found to be reliable. educational activities and the follow-up survey 1 year later (see
Table 2). One student specifically stated, “the electronic documenta-
tion does not closely resemble the electronic medical record, so I feel
Skill Performance
there is still a big learning curve in the clinical setting for electronic
documentation.” Another student stated that the assignments were
To allow for comparison of the scores over time, the raw assign-
“somewhat helpful when they had no previous experience with elec-
ment scores were converted to percentages. Because of violations of
tronic documentation and helped me to understand what a complete
the assumption of sphericity (compound symmetry) and the lack of
assessment, wound assessment, etc., should include.”
reliability of two of the four instruments (Time 2 assessment assign-
ments), statistical analysis for differences over time could not be per-
formed. The scores did show that over the course of two semesters,
Discussion and Implications for Nurse Educators
students did have an increase in the electronic documentation assign-
ments scores indicating that they had an increase in their electronic
Documentation of nursing care has historically been an important
documentation competency. Students had an increase in the average
nursing skill included in nursing curricula. The new electronic health
score on the Time 1 physical assessment assignment of 72.1% (range:
care environment has challenged nurse educators to prepare new
52% to 92%) to an average of 82.5% (range: 62.5% to 100%) and 94.7%
graduates to learn the skills of documentation using electronic
(range: 84.2% to 100%) on the Time 2 assessment assignments
formats. Competencies of nurse graduates related to informatics
(wound and urinary, respectively). Regretfully, the increase in elec-
and health information technology have been suggested (American
tronic documentation in skill performance, 1 year later, was not
Association of Colleges of Nursing, 2008; McGonigle & Mastrian,
retained as the students average score on the Time 3 wound assess-
ment assignment was a 75.6% (range: 54.6% to 89%) (see Fig. 2).
Table 2
Because of lack of homogeneity of variance, the Mann–Whitney U Satisfaction with active learning assignments
was used to assess for differences between the two groups (experi-
mental versus comparison). The Mann–Whitney U test indicated a Question Initial survey (n = 18) Follow-up (n = 17)

nonsignificant difference between the two groups (p = .235). Very Somewhat Not Very Somewhat Not

How helpful did you find the 4 12 2 2 8 7

electronic documentation
Survey Results assignments for learning
how to document
During the completion of the anonymous survey regarding elec- electronically?
tronic documentation, 94% of the students (n = 17) identified being How important is electronic 10 6 2 15 2 0
documentation in your
proficient at electronic documentation to be very important in their
nursing education?
nursing career (see Table 2). In the initial survey, all students rated How important do you think 17 1 0 16 1 0
the ease of completing the electronic documentation systems as very being proficient at
easy (50%), easy (28%), or neutral (22%), with no students indicating electronic documentation
that the assignments were difficult or very difficult to complete. will be in your nursing
career?
Students' comments included “exposed me to the idea of electronic
208 A.M. Bowling / Teaching and Learning in Nursing 11 (2016) 204–208
2015; NCSBN, 2013), and nurse managers have identified that it takes
more than 2 months to orient new nurses to electronic documentation
and informatics requirements (Miller et al., 2014). This project examin-
ing the use of simulated electronic documentation experiences to pre-
pare nursing students did not produce the expected outcomes.
One possible reason for the outcomes is that the data collection in-
struments used were not reliable, resulting in a limited ability to
evaluate the effectiveness of the electronic documentation educa-
tional experience. Although there was no statistical difference in
documentation skills, the affective outcomes indicated that students
were able to acknowledge the importance of electronic documenta-
tion skills. This is similar to findings by Warboys, Mok, and Frith
(2014) who identified that multiple exposures to a simulated health
record in an academic setting lead to positive student perceptions.
In addition to the lack of reliable measurement tools, the outcomes
of this project may also be related to barriers in implementation of the
project. Barriers to implementing evidence-based practice approaches
for informatics and health information technology skills, similar to
that in published studies, include a lack of faculty time and experience
with health information technology (Hanson, 2013; Miller et al., 2014;
Titzer & Swenty, 2014). Outcomes of this project may be related to
the barriers of lack of faculty experience with the new electronic
documentation and lack of time within the laboratory setting as
they strive to meet the other course requirements. This project
required each laboratory instructor, who is assigned 10 students
per laboratory, to evaluate the electronic documentation of the
nursing skill for accuracy. The total number of students per laboratory
instructor ranged from 10 to 40 students. Because of a lack of time,
some students did not receive feedback on the accuracy of their elec-
tronic documentation and expressed that the documentation activi-
ties were a waste of time. Future implementation of the project
should include the examination of faculty development to promote
the faculty understanding of the electronic documentation assign-
ment, the required skills (Kowitlawakul, Chan, Wang, & Wang,
2014), and implementation of change models with faculty and stu-
dents (Titzer & Swenty, 2014).
Even though results were not statistically significant, student
responses indicate that the documentation experiences in the labora-
tory setting were valuable experiences. These experiences allow
nurse educators to assist students with learning how to appropriately
document their assessment findings and procedure completion early
in their nursing program. This can help ensure that students under-
stand the legal standards of documentation and facilitate their
computer literacy skills. With evidence emerging that supports the
use of simulation in nursing education (Hayden, Smiley, Alexander,
Kardong-Edgren, & Jeffries, 2014), simulated learning experiences
can be used to provide opportunities for students to practice needed
electronic documentation skills.
Another factor that possibly affected the outcomes was the simula-
tion experienced used for the Time 1 physical assessment assignment.
When using simulated experiences, it is imperative to ensure that
what is programmed into a human patient simulator is actually
what can be assessed by the student. Over the course of the study
and in subsequent semesters, it was identified that even though the
human patient simulator was programmed to have a heart murmur,
the heart murmur was not able to be heard at all four heart valve
locations as was expected. It was also noted that while the student's
assessment course focused on normal assessment findings, the
physical assessment assignment also focused on abnormal findings.
Nursing faculty must ensure that level of simulation and technological
capabilities match proposed learning activities.
This project was limited to the use of only one group of nursing
students enrolled in one baccalaureate nursing program. Instruments
used in the project were newly developed tools that did not have
documented reliability and validity. In addition, the project only mea-
sured data entry skills. Computer literacy skills required for nurses to
promote safe, patient care, such as results retrieval, use of decision–
support tools, care plan development, and documentation of patient
teaching, were not addressed in this project (QSEN, n.d.). Finally, a
limitation of this project was that impact on outcomes of electronic
documentation in actual care settings was not examined.
Conclusion
The movement toward ubiquitous, electronic documentation
systems across settings will continue to impact health care providers,
including nurses. Nurse educators must prepare new nurses to function
in settings that utilize electronic documentation in a way that supports
legal standards and promotes safe, quality care. Allowing students to
practice computer literacy skills in the safe environment of academia
can help prepare students for practice in actual settings. Nurse educa-
tors must examine best practice approaches that ensure that students
are ready to practice in today's electronic health care environment in
ways that are cost-effective and meet needs of students, educators,
and settings where students will practice in the future.
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