Electronic Health Record Training for Nurse Leaders

CITATION: Carson, N., Campbell-Smit, B., Walters, W., Sharp, K., & Smailes, P. (2021). Electronic health record training for nurse leaders. Online Journal of Nursing Informatics (OJNI), 25 (2), https://www.himss.org/resources/online-journal-nursing-informatics

Abstract

Background: Electronic health record (EHR) training at our organization was historically catered toward staff nurses. While nurses in leadership positions must be familiar with staff nurse functionality, they also have very different system needs.

Problem: An EHR training class was being requested but did not exist for nurse leaders in roles such as directors, managers and charge nurses.

Approach: A pilot, instructor-led class was developed specifically for nine nurse leaders in January 2020. Two subsequent classes (n=23) were conducted virtually due to the pandemic with topics including manager lists, audits, downtime, reports, and unit workflows. All participants were given a survey using a five-point Likert scale to assess knowledge before and after class completion.

Outcomes: Using descriptive statistics, attendees reported improvement in mean scores related to system functioning over pre-test scores.

Conclusions: Due to positive feedback, this training will continue to be offered on a quarterly basis for nurse leaders.

Keywords: Nurse Leaders, Nurse Manager, Electronic Medical Record, Electronic Health Record, Training, Information Technology

Background

While the importance of end-user training for an electronic health record (EHR) is known, training for nurse leaders can be an afterthought for health care institutions. This may be because nurses in leadership positions are not providing patient care at the bedside. However, the absence of a direct patient care role does not negate the need for and importance of EHR competencies for nurse leaders. Nurse leaders should have awareness of the value between technology and nursing workflows and the resulting adoption of health information technology (HIT) (De Leeuw, et al., 2020). Not only is there benefit in knowing nursing documentation workflows in the EHR but capitalizing on EHR reporting features that show staff documentation compliance with both organizational and regulatory requirements can prove invaluable for nurse leaders. Nursing leadership can directly impact issues related to EHR satisfaction and usability by creating a positive culture that focuses on staff engagement with an EHR and promoting EHR adoption and use. They can serve as a reference point for bedside staff and, therefore, it is important for them to be proficient in all aspects of nursing duties including the use of EHRs. With improved knowledge of information systems, nursing leaders can better communicate with staff nurses and support the adoption of evolving functionality to improves patient care workflows. 

Oakes et al., (2015) identified that many clinician leaders may not have an adequate background to fully understand the technologies that are used for patient care and that impact clinical workflows, considering the constant evolution that occurs with 21st century technology. Education and training are necessary to develop technological competency, which is further solidified by experience. EHR training should occur not only for leaders, but all clinicians.  It has been shown that organizational EHR training programs have yielded positive results on end user confidence, efficiency and utilization while promoting patient safety (Kleib & Nagle, 2018; Kinnunen, et al., 2019). According to Strudwick et al., (2019), the result of nurse leader training is better informatics competencies among leaders, leading to improved guidance for staff nurses, thus making these leaders more effective in their roles.

While the evidence supports the need for specific nurse manager training on the EHR, the question is what should be included in such training and how should it be delivered?  The Delphi Study by Collins et al., (2017) showed that 74 EHR competencies were needed by most nurse leaders; yet, they acquired HIT knowledge through on-the-job training. If the knowledge acquisition occurs on the job, how can an organization be certain that the training nurse managers are receiving is consistent and is documented as having occurred?

Offering formal classes to nurse managers can close the gap. Strudwick et al., (2019) showed that informatics competencies for nurse leaders included such items as privacy and security knowledge, the ability to manage large amounts of data, knowledge of technological trends and issues, and effectively managing change.  Soriano et al., (2019) found that facilitators for accessing EHR information included ease of navigation, timeliness and accessibility of reports, and usefulness of EHR tools. One organization that created dashboards for nurse leaders found that nurse leaders developed an increased understanding of how dashboards could support and promote practice improvements and quality of patient care by gaining a better understanding of the required flowsheet documentation, subsequently enhancing organizational relationships with the help of training (Stuler, et al., 2017).

Identifying the Need for Nurse Leader Training

In October 2011, our organization went live with inpatient EHR functionality. To prepare nurses for system use, the organization provided nurses with 16 hours of in-person EHR training that covered fundamental workflows such as patient admission, shift duties, and patient discharge, as well as more complex workflows such as blood administration and restraint documentation. The focus of training at that time was on staff nurse workflows, with no curriculum specific to nurses in leadership positions. Nurse managers took the same training classes as staff nurses; however, over time it was acknowledged that nurses in leadership roles have unique needs beyond the role of staff nurses. While it is important for nurse managers to know the system workflows that are used by staff, knowledge of how to effectively use the EHR to identify unit metrics and documentation compliance is necessary. Having this knowledge allows leaders to have a better understanding of system usage by staff, patient dynamics, and overall unit functioning.   

Over time, nursing leadership asked for specific nurse manager EHR training. In response to this request, a concerted effort began to develop a curriculum specific to nurse manager workflows.  Our questions related to the training were:

• Will nurse managers benefit from EHR training specific to their roles?
• What content do nurse managers need to improve their effectiveness in their roles?
• What is the best way to deliver the content to nurse managers?
• How can we measure the satisfaction and impact of the training after the class?

This quality improvement initiative demonstrated the need for nurse manager training at our organization and our plan to design, implement, measure and evaluate the success of this program.

Curriculum Development

During the planning and development phases for the nurse manager EHR training class, we identified that charge nurses would benefit from a class, too. However, the class needed to focus on their specific responsibilities. Charge nurses often work second and third shifts without the on-site support of their managers. Knowledge of available EHR tools has the potential to provide an increased level of confidence and knowledge that can help charge nurses organize tasks that are designated to them. This led to the development of a charge nurse class.

Initially, we collaborated with nurse managers and charge nurses to determine what content was needed to help each carry out their respective responsibilities. We soon learned that there was an overlap in responsibilities of nurse managers, assistant nurse managers and charge nurses, since nurse managers often delegate some responsibilities to assistant nurse managers and charge nurses. For example, the nurse managers and assistant nurse managers are not generally involved in the day-to-day patient movement on the unit; however, the charge nurse and the unit clerk manage this function on the unit. In addition, the charge nurse is responsible for making the patient care assignments each shift. Therefore, not only does the nurse manager need to see and understand the patient workload score, so does the charge nurse. At this point, we decided to first develop the nurse manager class curriculum that would include assistant nurse managers and then modify that curriculum to fit the responsibilities generally assigned to the charge nurses.

After collecting information about the three roles, the following learning objectives were created for the training:

• Demonstrate an understanding of basic EHR terminology and concepts.
• Create a unit list to support nurse manager and assistant nurse manager workflows.
• Create patient lists to monitor unit documentation compliance along with safety and quality issues.
• Use and customize manager-related dashboards and reports to improve unit management.
• Demonstrate how to review patient charts to find current and historical patient information.
• Describe how to access patient information during downtime.

These objectives encompassed the needed training elements for these roles.

Implementation

In January 2020, the first nurse manager class was delivered at our organization. Thirteen nurse managers were hand selected to einsure a variety of specialties and experiences levels were represented. These nurses were also chosen because we could rely on them to give honest feedback about the curriculum and class. Eleven of the nurse managers responded that they would attend. The final group for the pilot training included nine nurse managers.

Prior to the pilot class, a pre-assessment survey was sent to those planning to attend. This survey assessed the nurses' baseline knowledge of our EHR and used a five-point Likert scale with 1= Strongly Disagree through 5 = Strongly Agree. The intention of this survey was to serve as a quality improvement tool to help show efficacy of the training.

The class was taught using a combination of our EHR training environment, the production environment, and a slide presentation. To be mindful of the Health Insurance Portability and Accountability Act (HIPAA), the instructor used the training environment to display the EHR and demonstrate key elements, such as creating and modifying patient lists, customizing dashboards, and marking reports as favorites. The instructor also used a slide presentation to present and discuss concepts such as the dashboard and different types of reports and to show step-by-step instructions for creating patient lists, saving a report as a favorite, and customizing dashboards. The nurse managers used the production environment for their own unit to create new patient lists, view reports, and review dashboards in real-time during the class. Class length was two hours with one 10-minute break. After class, a post-assessment survey was given to those in attendance with the same questions to determine if there was any change in scores.

COVID-19 Impact

Due to the COVID-19 pandemic, the planned quarterly offering for the nurse manager class was postponed indefinitely to reduce the number of in-person classes. After many months, the decision was made to resume the class using a virtual format. We knew this would not be the ideal format, but the only way to safely get the information to our nurse managers during the pandemic. 

In-person classes were planned to accommodate 15 to 20 participants with one instructor and one assistant instructor. The first virtual class was held in November 2020 and was limited to 10 participants so that the instructor could adjust to the new format. The feedback related to the format from participants and the instructors in the virtual class was positive. Based on the feedback, the decision was made to continue holding the class in the virtual format until we could safely resume in-person classes. Since then, we have held two more virtual classes. As word spread about the class, nursing directors, clinical nurse specialists and quality managers began requesting to take the class and were accommodated.   

Evaluation

Instructor-Led Pilot

Quantitative data were obtained using a Likert scale survey with descriptive analysis both before and after the training session. The mean and standard deviation were calculated from attendee’s responses to each survey question (Table 1).

Table 1: Mean Likert scores from pilot Knowledge Assessment questions

The results show an increase from the pre-class to post-class mean for all questions. The greatest knowledge gains were patient lists for nurse manager workflows (M=2.75 pre-class, M=4.44 post-class) and downtime procedures (M=2.68 pre-class, M=4.33 post-class).

Open-ended questions were used to solicit qualitative feedback on the pilot. Participants were asked what the most helpful topics covered in class were. The topics were identified as manager lists, documentation compliance, downtime, dashboards, reports, and chart review. Participants reported that they found the use of patient lists more efficient for viewing required documentation compliance than opening multiple reports from a dashboard.

The participants reported the biggest knowledge gain in downtime procedures. This reinforced our knowledge that the downtime curriculum was much needed. The least helpful topic related to dashboards due to occasional displays of inaccurate data. To resolve this, dashboard flaws were reported to the information technology build team for immediate correction.

The response to the terminology section of the class showed the least knowledge gain. This could be attributed to the length of time that the organization was live with the EHR before this class was developed, thus allowing for this knowledge acquisition to have already taken place. In addition, suggestions were received to allow for more hands-on time during class to create patient lists and build and filter reports. Overall, the general feedback was that the course was very helpful. 

Virtual Sessions

The quantitative and qualitative feedback from the virtual participants was very positive overall and anecdotal remarks were similar to the pilot class. Quantitative data were again calculated using mean and standard deviation (Table 2). The virtual format did not hinder the effectiveness of the class, as seen in the improvement of mean scores.

Table 2: Mean Likert scores from virtual training Knowledge Assessment questions

 The post self-assessment for the virtual classes included two new questions:

• Was this class effective in the online meeting format and why?
• Would it be more effective in-person and why?

Four participants responded to the first question, stating they found it effective and were able to follow along with the presentation. One participant responded that they were indifferent about class format, while another stated that in-person would most likely be better. The rest of the participants did not respond to the qualitative questions.      

Limitations

Participants were not assigned an identifier, so there was no means to compare the assessments before and after training. It was found that some participants did not complete either the pre- or post-assessment. This may have been due to a lack of anonymity since participants were asked to email the assessments to the instructor. The sample size is small and limited to a single academic medical center, but the hope is to continue this class with larger groups of attendees in the future.  We also learned that given the dialogue, interaction and collaboration during the training, the curriculum is best suited as instructor-led training as opposed to virtual learning. This was especially apparent with the pilot class.

Future Direction

Results showed that the nurse leader EHR training improved the knowledge of system use for the three sessions of nurse leaders. Knowledge gained was greatest in downtime procedures and creating patient lists to see unit compliance at a glance. Overall, the response to the virtual format for the class has been positive. We have continued to hold the class quarterly as planned and, while limited, the feedback has been comparable to the in-person class. In the future, we hope to refine the curriculum, expand the class, and continue to offer it quarterly to all nurse managers, assistant nurse managers, directors, clinical nurse specialists, and managers of nursing departments. Ideally, we want this course to be a part of the on-boarding process for all new nurse managers and assistant nurse managers.  

This class will revert to an in-person format once it is safe to do so after the pandemic. The in-person format offers a more personal connection between the instructor and the participants. We hope to incorporate an optional 30 to 60 minute open lab session after the class to provide personal assistance to participants with setting up unit specific lists, customizing dashboards, and saving their favorite reports. Now that the class has been implemented and improved based on feedback, the importance of ongoing maintenance with current curriculum is crucial. We anticipate that the content will change and evolve as new tools, such as self-service reporting for nurse leaders, are developed within the EHR. Training evaluations will continue to be used after each session and the course adjusted as needed for constant quality assurance.