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Information technologies and the transformation of nursing education

Diane J. Skiba, PhD, FAAN, FACMI Helen R. Connors, PhD, RN, FAAN Pamela R. Jeffries, PhD, RN, FAAN, ANEF

Higher education is facing new challenges with the emergence of the Internet and other information and communication technologies. The call for the transfor- mation of higher education is imperative. This article describes the transformation of higher education and its impact on nursing education. Nursing education, considered by many a pioneer in the use of educa- tional technologies, still faces 3 major challenges. The first challenge is incorporation of the Institute of Med- icine’s recommendation of 5 core competencies for all health professionals. The second challenge focuses on the preparation of nurses to practice in informatics- intensive healthcare environments. The last challenge is the use of emerging technologies, such as Web 2.0 tools, that will help to bridge the gap between the next generation and faculty in nursing schools. Nurse edu- cators need to understand and use the power of technologies to prepare the next generation of nurses.

O ver a decade ago, Hooker proclaimed, “Higher education is on the brink of a revolution.” 1 Whether it is a revolution or an evolution, it is

obvious that the landscape of education has been transformed, and this trend will continue as new tech- nologies emerge. One early and noticeable change was the emergence of corporate educational systems di- rectly competing for the changing student population. As Dolence and Norris noted, if the academy was to meet the demands of the 21st century workforce, “ a new campus would have to be opened every eight

Diane J. Skiba, PhD, FAAN, FACMI, is a Professor, University of Colorado Denver College of Nursing. Helen R. Connors, PhD, RN, FAAN, is Professor and Associate Dean

for Academic Affairs, University of Kansas School of Nursing, Kansas City, KS. Pamela R. Jeffries, PhD, RN, FAAN, ANEF, is Associate Professor and Associate Dean of Undergraduate Programs, Indiana University School of Nursing, Indianapolis, IN. Corresponding author: Dr. Diane J. Skiba, University of Colorado Denver School of Nursing, Campus Box C-288-03 Bldg P28, 13120 E. 19th Ave, PO Box 6511, Education 2 North, Room 4215, Aurora, CO

80045.

E-mail: Diane.Skiba@uchsc.edu

Nurs Outlook 2008;56:225-230. 0029-6554/08/$–see front matter Copyright © 2008 Mosby, Inc. All rights reserved.

doi:10.1016/j.outlook.2008.06.012

days,” 2 but were quick to add that the solution was not the creation of more physical college campuses but the emergence of services (facilitators, learning agents and other intermediaries) that would provide competition for the traditional academic setting. Their message was considered “an information technology (IT) wake-up call for thousands of higher education leaders.” 3 More- over, Dolence and Norris’ message highlights the major impact IT had on the educational enterprise. This transformation, according to Hooker, was “a structural rather than a cyclical change and was the result of the confluence of two forces” 1 —the informa- tion and management revolutions. The information revolution has shifted the economy to a knowledge- based system where knowledge signifies the competi- tive advantage. Although higher education plays a key role in the facilitation of knowledge acquisition, the information revolution was freeing knowledge from the confines of the academy. At the same time, this shift was being compounded by the management revolution with its fundamental principle to produce a high quality product in less time and at a cheaper cost. Today, accountability and efficiency issues continue to be a constant headache for higher education administrators as they face scrutiny from the public as well as state and federal legislators. Both the information and manage- ment revolutions have made not only a significant but a permanent impact on higher education.

INFORMATION TECHNOLOGY EXPANDS LEARNING OPPORTUNITIES

There is no doubt information technology (IT) has changed the way we live, work, learn and play. The introduction of the Internet, especially the easy-to-use web, democratizes access to knowledge and provides opportunities for non-traditional providers (e.g., virtual colleges and for-profit educational institutions) to offer learning services that meet the life-long educational needs of the workforce. 2 This notion of leveling the playing field with access to information and knowledge on a global scale was brought to light in Friedman’s concept of the “flattening the world.” 4 The phenomenal growth of the Internet has given “rise to a global web-enabled playing field that allows for multiple forms of collaboration—the sharing of knowledge and

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work—in real time.” 4 Information and knowledge, no longer hidden behind the walls of the academy, are now accessible to a variety of populations across the world. This access not only fosters communication and con- nections but also opens the door for the globalization of education. Perhaps one of the most obvious and significant IT changes to the educational landscape was the introduc- tion of online classes and programs. The most recent Online Nation Report 5 was released in October 2007. The report, based on responses from 2500 colleges and universities, provides answers to 5 specific questions about online learning. There were 3.5 million students who took an online course in the fall of 2006. A notable finding is that “online enrollments have been growing substantially faster than overall higher education enroll- ments.” 5 The most growth occurred in associate degree schools, with the slowest growth in baccalaureate level programs. According to the report, student access is the top reason for offering online courses and programs. Cost reduction is one of the least-supported reasons for offering online courses or programs. In terms of future growth, it is important to note that “approximately one-third of higher education institutions account for three-quarters of all online programs.” 5 The growth will continue as these institutions add new programs and continue to grow their existing programs.

GENERATIONS DIVIDED

Another change in the landscape is the changing student population. Two new student populations have entered higher education with differing demands and expecta- tions. The first is the non-traditional learner who is older ( 25 years of age), working and attending school part-time. According to the National Center for Educa- tion Statistics, the enrollment of students 25 years old increased by 31% whereas there was only a 17% increase for those students 25 years during the years from 1990–2004. 6 They also projected that college enrollments will rise 11% for those students 25 year olds and increase by 15% for those students 25 years from 2004–2014. To further confuse the landscape, the 25 year-old student population is a new generation of students unlike previous generations. This growing population of digital natives, 7 or millenials, 8 is now entering the higher education system. The digital natives represent a new student population who differ in terms of their technology savvy and their desire to learn using active and interactive learning strategies. According to Skiba and Barton, “the impact of the Net Generation is particularly intense considering the complicating im- pact of IT in higher education. Information technologies have become so pervasive on campus, it is hard for faculty not to embrace them in the instructional process. In addition, colleges and universities must cope with the growing demand to provide infrastructure support for

learner’s personal technologies, such as wireless lap- tops, PDAs, and IPods.” 9

THE CHANGING PEDAGOGY

The education landscape is further compounded by what Brown and Alder, have labeled a “brewing perfect storm of opportunity.” 10 The storm includes a variety of new philosophies and teaching/learning strategies. It consists of the movement in authentic learning 11 and social learning 10 strategies coupled with Open Educa- tional Resources (OER) phenomenon. Authentic learn- ing or learn-by-doing focuses on real world, complex problems and their solutions and makes use of a variety of emerging technologies to provide a highly interac- tive, collaborative and reflective learning environ- ment. 11 Social learning is best described by Brown and Alder as being “based on the premise that our under- standing of content is socially constructed through conversations about the content and through grounded interactions, especially with others, around problems or actions. The focus is not so much on what we are learning but how we are learning.” 10 The OER move- ment, such as the MIT OpenCourseWare project, pro- vides access to a wealth of undergraduate and graduate course materials for anyone who chooses. These move- ments are highly dependent and interconnected with the growing use of Web 2.0 tools to facilitate and create virtual communities of learning.

NURSING EDUCATION TRANSFORMATION SUCCESSES

The landscape in higher education has indeed changed and these changes will shape the way nursing education is delivered to prepare our next generation of nurses. Nursing, in comparison to other healthcare professions, is often seen as an early adopter of educational innova- tions. Nurse educators have taken major steps to transform their curriculum and make use of a variety of educational technologies to facilitate learning. Nursing schools in particular have struggled with multi-generational stu- dent populations and the selection of the most appro- priate teaching strategies for these differing student populations.

Simulation

During the past decade, the use of simulations as a teaching-learning intervention in nursing curricula has increased greatly. Nursing students, clinicians, and educators alike appear to be strongly in agreement about the importance of incorporating simulations as a teaching practice into the nursing curriculum. Simula- tion development and implementation draws from the expertise and clinical experience of faculty that possess both creative and technological skills. Successful inte- gration of simulation stems from the fervor of innova- tive faculty embracing student-centered learning and a commitment of the institution. Simulation involves

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curricular consideration; appropriate faculty develop- ment; detailed preparation; and collaborative efforts between faculty, staff and administration. However, as this new technology is moving into the curriculum, not all educators feel prepared for this type of teaching

strategy. Learning to develop, implement, and evaluate simulations is not a skill set nursing educators feel prepared to utilize in their courses unless they engage in some kind of professional development. Nor do they understand the potential impact that adopting this edu- cational method has on student learning. 12 For faculty to increase their knowledge and ability to design, implement, and evaluate simulations, information and skill development are needed so the pedagogy can be delivered in the method desired in order to obtain optimal student learning outcomes. At times, nurse educators are placed in a learning environment where they have to teach students using simulations without being prepared to facilitate learning in this innovative, student-centered approach. As schools purchase simu- lators to support and enhance clinical education, it is imperative for faculty to be prepared for the challenge and paradigm shift. The challenge is: how can educators be prepared for this transformational pedagogy in such

a way as to assure a level of comfort and skill in teaching while maximizing the learning outcomes?

E-learning and Other Interactive Technologies

Nursing education has opened learning opportunities for many through the early adoption of web-based courses and, in some cases, entire online degree pro- grams. Nursing schools used web-based programs as a means to extend their campus to different student populations, transcending traditional barriers of time, geography, and physical space. The different student populations included rural students, ethnically diverse

students, and older non-traditional students. Schools of Nursing were able to accommodate new learners with their “clicks and bricks” programs. Although there are limited statistics noting the use of online programs for nursing, a quick scan of web sites like AllNursing- Schools indicates a wealth of online program opportu- nities. For the last decade, the Health Resources and Services Administration’s Division of Nursing has funded a large number of online Registered Nurse- to Bachelor of Science (RN-BS) completion and ad- vanced nursing education programs. Despite the in- creasing numbers of online courses and programs, there

is large variation in the design of online courses—from

simple dissemination format of lecture slides and 2 discussion questions per week to podcast lectures to highly interactive and dynamic learning environments. All fall under the rubric of web-based courses. Again the question arises, how do we insure that faculty members have the necessary preparation for designing and teaching in online environments?

There is also a growing group of nurse educators who have successfully integrated the use of various educational technologies into the classroom, creating active learning environments that engage students. It is commonplace for faculty to use slides to accompany lectures. Many classrooms are now wireless and pro- vide connections to the web, allowing faculty and students to access the web for additional information and knowledge resources. Faculty members are now using audience response technologies also known as “clickers” in the classroom to create more interactive and participatory learning environments. Although there has been much progress in the use of these technologies in the classroom, there are relatively few articles in the nursing literature referring to use of emerging technologies, such as Web 2.0 tools, in nursing curricula. A recent study by Carnegie Foundation for the Advancement of Teaching examined the education of professionals in nursing, medicine, law, engineering, and the clergy. 13 One finding of the study was that “universities need to instill in their professional stu- dents ‘the three habits:’ the habit of mind, teaching to help students understand content; the habit of hand, providing the opportunity to practice what they learn; and the habit of heart, instilling a sense of values and commitment to service.” 13 The results of the study identified 7 general principles for signature teaching methods across the professions. The principles 13 are:

1. routine, habitual and pervasive

2. involve a need for public performance from stu- dents

3. instill a sense of interdependence

4. mirror practices of uncertainty

5. are not emotionless

6. have a sense of character and a sense of value

7. instill a sense of personal responsibility

NURSING EDUCATION CHALLENGES

As pointed out earlier, although nursing education has been on the leading edge in some educational arenas, there are still many challenges to face. This is particu- larly true in 3 specific areas. First, nursing and other health care professions have been slow in incorporating the 5 core competencies set forth by the Institute of Medicine (IOM). 14 In this report, the demand to completely overhaul the educa- tion for health care professionals was very clear in the statement that “clinical education has not kept pace with patient demographics or desires, changing health system expectations, evolving practice requirements, staffing arrangements, new information, focus on qual- ity improvement or new technologies.” 14 The IOM vision states “All health professional should be edu- cated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based

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practice, quality improvement approaches and infor-

matics.” 14 Today, there are relatively few schools of nursing that have incorporated these core competencies into their nursing curriculum.

A recent initiative, Quality and Safety Education for

Nurses (QSEN), 15 is helping faculty to provide students and new health professionals with the knowledge, skills, and attitudes to continuously improve the health care systems. This initiative, funded by the Robert Wood Johnson Foundation, explicates the knowledge, skills, and attitudes needed in each of the 5 competency domains. Fifteen schools of nursing are participating as pilot schools to integrate these competencies into their pre-licensure curriculum and share their resources, such as learning activities with others. This project will jumpstart nursing education efforts to incorporate not only these core competencies but to introduce a new generation of nurses to a culture of quality and safety.

A similar need exists in terms of preparing practicing

nurses to use informatics tools to “communicate, man- age knowledge, mitigate error and support decision making.” 16 As informatics-intensive care delivery de- velops in the clinical arena, nursing education needs to grapple with how best to prepare nurses to practice in a transformed healthcare environment. According to Skiba, “schools of nursing will begin to experience a new type of digital divide. Faculty who do not have access to the various clinical information systems that nurses will use as integral components of practice will have difficulty understanding how the nursing curricu- lum needs to change.” 16 Although there is much written about informatics in nursing education, there is relatively little integration of the principles into the nursing curriculum. A recent study by the National League for Nursing of faculty and administrators in schools of nursing documented that, although computer competency and information liter- acy were integrated in almost 50% of schools, infor- matics competencies were not addressed. 17 In fact, informatics competencies were often confused with computer and information literacy skills, and with the use of educational technologies to deliver educational experiences. For many, using simulations and taking online courses were considered methods to learn about informatics. There were relatively few schools that had incorporated knowledge, skills, and attitudes related to the use of informatics tools to facilitate communication among the interdisciplinary team and with patients, manage knowledge, diminish error, and support clinical decision-making. However, the American Association of Colleges of Nursing has identified competency in the use of information systems and patient care technology as an essential component of doctoral education for advanced nursing practice (i.e., the Doctor of Nursing Practice). 18 Similarly, information management and application of patient care technology will be included as an expected competency in the revised Essentials of

Baccalaureate Education for Professional Nursing Practice . 19 More recently, the National League for Nurses (NLN) Position Statement on “preparing the next generation of nurses to practice in a technology- rich environment” drives the informatics agenda even further. 20 As an outcome of these initiatives, we are likely to see a great deal of curriculum revision as schools of nursing attempt to meet these criteria for preparing the future nursing workforce. Although some schools are making the transition to incorporate the IOM competencies in their curriculum, there are relatively few exemplars. The University of Kansas, in collaboration with Cerner Corporation, has developed an Academic Education Solution that utilizes clinical information systems throughout the curriculum to foster the development of informatics competencies. This Simulated E-hEalth Delivery System (SEEDS) Project used by both nursing and medical students, is an evidenced-based approach to learning that promotes critical decision-making skills and enhances students’ access to state-of-the-art technology used in clinical practice settings. 2123 The Cerner Academic Solutions has already spread to other schools of nursing at St. Scholastica, 24 University of Utah, the University of Maryland, and a consortia of schools in the Kansas City area. Another exemplar is the work at Johns Hopkins University School of Nursing and Eclipsys Corporation that re-engineered the nursing curriculum using clinical information technology. 25 The clinical information sys- tem was integrated into the 3 simulation labs in the school and is incorporated in each of the undergraduate courses. The goal is to increase the healthcare informa- tion technology competence of their nursing graduates and to design new ways of delivering safe and efficient health care utilizing healthcare information technology. Other models used in schools of nursing include forming a partnership with one of their clinical agencies and their clinical information systems vendor. The Ohio State University College of Nursing partnered with its vendor to develop an academic version of its intelligent charting solution at The OSU Medical Center and specially designed version of the CIS within the class- room. 26 This clinical system simulated the clinical practice environment through faculty-developed patient cases. These cases were integrated throughout the baccalaureate curriculum and connected to the use of high fidelity human simulators. Other examples include Ball State University, who uses McKesson 27 and Wake Forest State University. 28 The last challenge focuses on the use of emerging technologies into nursing education. Schools of nursing have struggled to keep pace with emerging educational technologies. Many schools of nursing are just begin- ning to use a variety of tools associated with the emergence of Web 2.0. The web is transforming from an information dissemination platform to a web that is more interactive, customizable, social- and media-

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intensive. The web is shifting to a platform in which content is created, shared, remixed, repurposed, and

passed along. 29 Web 2.0 is all about connecting people to boost their knowledge and their ability to learn. Web

2.0 tools are focused on communication, collaboration,

interactivity, connecting with people, and creating value through the sharing of ideas and making use of the collective wisdom of the web community. Web 2.0 tools include the use of social writing, booking and networking tools as well as data visualization tools, mashups, virtual worlds, and user-generated tools to create podcasts and videos. 3034 The slow response of faculty to the integration of these tools in curriculum highlights the expanding divide between the digital natives (millenials) and the digital immigrants (educa- tors) in our schools of nursing. This chasm between the digital natives and immigrants will continue to widen in the upcoming years. 35 This notion is echoed in the recent Horizon Report that summarized 7 metatrends observed over the last 5 years. 35 The metatrends include the following:

1. Communication between human and machines

2. Collective sharing and generation of knowledge

3. Games as pedagogical platforms

4. Connecting people through the network

5. Computing in three dimensions

6. Shifting content production to users

7. Evolution of a ubiquitous platform

There is no doubt these metatrends will significantly impact not only how we teach and how students will learn, but how the higher education landscape will continue to evolve over the next decade.

Solutions

Although challenges remain, there are many solu- tions to help faculty implement educational transforma- tion. One solution is the HRSA Faculty Development Initiative (Faculty Development: ITNEP) that provides support for faculty development. 36 The purpose of this initiative is to help faculty gain knowledge and skill to use information and other technologies to expand the capacity of schools of nursing to educate students for 21st century healthcare practice. 36 Information, tools, and other technologies in nursing education and prac- tice include informatics, telehealth, mannequin-based and patient simulators, computer-based instructions, virtual simulation, interactive simulated case studies, advanced 3D graphics, and e-learning technologies. To date, 4 collaboratives have been funded. Duke Univer- sity’s Technology Integration Program for Nursing Education and Practice (TIP-NEP) was funded in 2006 as a collaborative effort between Duke University School of Nursing, Western Carolina University, and Fayetteville State University. Also funded in 2006 was the University of Wisconsin statewide faculty develop-

ment program, Wisconsin Technology Enhanced Col- laborative Nursing Education. In 2007, two additional grants were awarded to the University of Pittsburgh and the University of Kansas. The University of Pittsburgh created the ELITE (Emerging Learning and Integrated Technologies Edu- cation) Faculty Development Program. The University of Kansas formed an educational collaborative with the University of Colorado Denver, Indiana University, and the National League for Nursing. This collaborative developed a partnership with the QSEN initiative to incorporate their work as an underlying framework for this educational collaborative. This collaborative, Health Information Technology Scholars (HITS) project, is de- signed to reach the following goals:

Transform teaching and learning in the 21st century— Merge informatics, telehealth, simulation, and e- learning to create powerful learning environments. Improve Nursing Education and Practice—Develop faculty to integrate IT in curricula to educate future practitioners. Expand Infrastructure for Clinical Learning Processes—Educate a cadre of well-informed faculty who focus on real-world applications of technologies in their education practices. Optimize Patient Safety and Drive Improvements in Healthcare Quality—Better educate future workforce with competencies to provide safe, quality, and efficient health care through use of technologies.

SUMMARY

It is important for nursing education to remain at the forefront of this transformation in higher education. Nurse educators need to continue their lifelong learning to keep pace with the technological changes not only in the classroom but also in the practice arena. It is incumbent upon the members of the academy to use the power of emerging technology tools to create learning communities for sharing and exchanging ideas, re- search, and knowledge about nursing education.

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