1. Gray, Catherine RN-BC, BSN
  2. Bee, Sharon RN-BC, BSN
  3. Bertka, Kenneth MD

Article Content

Over the course of the past century, we've evolved from horse and buggy travel to globalized access for everyone to virtually everything via the Internet. As our world rapidly evolves, so too does health-care. To meet the growing information needs of modern healthcare, medical informatics was born. The American Medical Informatics Association defines medical informatics as having to do "with all aspects of understanding and promoting the effective organization, analysis, management, and use of information in health care."1 This includes the use of the Internet, medical facility intranets, electronic health records (EHRs), and telehealth technologies.


The future of healthcare data management and evidence-based care lies within the informatics arena, and nursing is an integral partner in this process. According to the American Nurses Association, nursing informatics education "is a critical component of many nursing informatics functions and may directly affect the success or failure of any new or modified information technology solution."2 To provide optimal patient care, nurses must become proficient in the use of informatics.3


The nurse's proficiency with the utilization of a computerized order entry (COE) system is important for patient safety. The quest for nursing EHR literacy prompted Mercy Health Partners' Information and Process Services (IPS) education team to implement and evaluate various methods of EHR training for nursing staff. At the time of the start of the study, little published research existed regarding the most effective way to train nurses in the use of an EHR system, specifically COE. Our organization trained hospital nurses using two 4-hour classes to provide instruction on use of COE, the most challenging component to this organization's EHR for nurses and physicians. This study included a benchmark for evaluation and revision of training methods for our organization in training nurses to effectively use an acute care EHR for order entry and management.


Currently, approximately 900,000 orders are entered electronically each quarter, with 56% of orders entered directly by physicians across four regional hospitals. For patient safety, all users must have optimal understanding and competency when utilizing the EHR system. Therefore, regional EHR training is an essential component of nursing orientation.


Study components

Benner's nursing theory on the transformation of a nurse novice to expert was the theoretical framework for this study.4 In our study, we provided the nurses in the experimental group assignments between classes that they were able to do independently in their work setting to achieve practical knowledge.


This study was limited to newly hired nurses in the cardiovascular nursing units at one of our hospitals with COE. This area was undergoing expansion, so subjects for the study were more readily available at the time. The subjects for this study were composed of two groups of nurses undergoing orientation: A control group that would receive our standard method of EHR order entry training and an experimental group that would participate in a modified study curriculum. The control group received our standard two 4-hour computer-based classroom experiences without assignments outside of class. Both classes were completed within days of each other.


The study teaching method consisted of two computer-based classes with an intervening independent clinical learning assignment. Within the study group, the first class consisted of a 3-hour high level overview of order entry and data retrieval with an independent learning assignment given out at the end of class. This assignment was to be completed under unit preceptor supervision during scheduled unit work days using actual patients and requiring the types of orders that impact patient safety. If no opportunity existed to perform the assigned tasks on actual patients, test patient accounts in the EHR system were to be used.


The second class was 4 weeks later and was a 2-hour, advanced skills class with the students returning their completed assignment sheets. The differences between the control and study groups were in the independent clinical learning assignment, the hours spent in the computer training lab, and the time period between the first and second class. All of the classes for both the experimental and control groups were held in the same computer training lab using the same equipment.


Study participants were newly graduated nurses, hired between December 2006 and September 2007. Assignment of nurses to the control and study groups was based upon hiring date. Demographic data were gathered on all participants to identify possible trends or influencing factors, including any past EHR experiences. No person was excluded based on gender, age, ethnicity, or any other demographic data. All nurses in this study were hired for 12-hour, night-shift positions. A competency test was administered at the third and sixth month of the participant's orientation period to ascertain COE knowledge retention.


All participants were provided with computer-based training on use of EHR for COE. Specific skill categories based on order types that impact patient safety, such as medications, order sets, and lab testing, were included in the competency test. The test was designed by our clinical support educators and consisted of 11 questions in the form of orders printed on paper which the nurse then entered into the EHR. The test represented common orders encountered in the nursing units on which the students would be working.


The demographic survey information gathered at the time of testing included information on the user's age range, highest level of education obtained, length of nursing experience, and questions related to the user's history of and comfort with computer utilization. Competency tests and demographic data sheets were gathered anonymously.



Training and competency testing was completed by eight nurses in the study group and five nurses in the control group. Two members of the study group dropped out due to scheduling issues. This resulted in a total of six individuals completing the program for the study group. All five members of the control group completed the study. The age range for the two groups was 20 to 45 years without a statistically significant difference between the control group and study group.


The control group consisted entirely of associate degree nurses while the study group was composed predominantly of associate degree nurses but also included one licensed practical nurse and two bachelor-prepared nurses. All participants were female. All were new nurses who had graduated from nursing school within 1 year of being hired with the exception of one nurse who had graduated within the year from an associate degree program but had received a licensed practical nurse certification 2 years prior to that.


All participants owned a personal computer and, with one exception, all had home Internet access. Eight of 11 utilized personal e-mail accounts but less than half utilized instant messaging. Participants reported a mean of 7.5 hours of home computer time per week. The control and study groups had similar access to and experience with computer use.


Even though the study group scored slightly higher on testing (81.3 vs. 78.4), the mean of the two groups wasn't statistically significantly different; variance in test scores may be due to chance. There wasn't a statistically significant difference in competency test scores between the control group and the study group.


Nursing implications

Our new teaching method was as successful as our original computer-based EHR classroom instruction but required less computer classroom hours and, hence, less time away from clinical units. Nurses who participated in the study curriculum came back to their second class with more refined questions and appeared to demonstrate an increased engagement in the class itself. They were also better able to share information they learned with their peers and its application to real clinical situations.


Even though the test scores between the study and control groups didn't show statistically significant differences, the reduction in classroom time for the study group has potentially significant cost savings benefits. For our organization, which hires as many as 200 new nurses annually, a 2-hour reduction in classroom time using the new method of COE training would be expected to save approximately $12,000 annually. Exploring other teaching techniques may produce further opportunities for cost savings and a better, more optimal retention outcome.


As more hospital systems incorporate EHRs in the coming years, the number of nurses needing to obtain proficiency in computer-based applications will grow exponentially. This study was performed to assess an alternative method for computer-based COE training. We believe the results can serve as a catalyst for additional research in this important area of nursing informatics.




1. American Medical Informatics Association. About informatics. [Context Link]


2. American Nurses Association. Scope and Standards of Nursing Informatics Practice. Washington DC: American Nurses Publishing. 2008;25. [Context Link]


3. Barton AJ. Cultivating informatics competencies in a community of practice. Nurs Adm Q. 2005;29(4):323-328. [Context Link]


4. Alligood MR, TomeyAM. Nursing Theory: Utilization and Application. 3rd ed. St. Louis: Mosby; 2006. [Context Link]