Study Design and Settings
The present study was an educational intervention to improve NI competency of nurses in critical care units from March to April 2019. The study was conducted using a pretest-posttest design with the intervention and control groups. The study settings were 18 critical care units, including10 intensive care units (ICUs), 6 coronary care units (CCUs), and 2 dialysis wards selected from three educational hospitals affiliated with Kerman University of Medical Sciences. Kerman University of Medical Sciences is the largest medical university in southeast Iran that has three large general hospitals. These hospitals have more than 1100 beds and admit patients from southeast of Iran, within the radius of 500 km. In the organizational chart of the Iranian hospitals, ICUs, CCUs, and dialysis wards are classified into critical care units [29], and nurses working in these units have the same benefits. According to the nursing curricula, nursing students pass critical courses in these settings. In addition, the distribution of nurses is similar in all Iranian hospitals. The majority of nurses have bachelor’s degrees and are recruited in all hospitals with the same pattern. There are no registered nurse (RN) and informatics nurse specialist in the study settings. According to the nurse manager, nurses working in critical settings are not fixed and have rotational shifts in many wards.
Experts in nursing education in Iran offered integration of NI competency and research in nursing into undergraduate nursing curricula in 2010. However, the undergraduate nursing curriculum included only 1.5 credits of research in nursing (34 hours, in the third semester) and one credit of information technology in nursing (26 hours, in the first semester) . Although basic skills research and the use of computers may be taught in courses, the demands of the nursing curriculum do not allow for more education. Consequently, there are gaps in integration of the NI competency into nursing education. Furthermore, nurses graduated before 2010 have not received formal training on NI competency.
It is noteworthy that authorities of Kerman University of Medical Sciences select appropriate e-Health applications for the hospitals. For example, Hospital Information System (HIS) is currently implemented in nursing stations, pharmacy, laboratories, radiology, outpatient and inpatient wards, etc. Hospitals have implemented HIS to automate hospital management tasks such as documentation of nursing care, cost management, resource management, medication management, accounting, nurses and physician performance assessment, and patient registration, etc. Following the implementation of HIS, nurses received regular training informally and formally. However, there is no formal education to improve nurses’ NI competency. The rapid growth of e-health has increased the demand for nurses with high NI competency in hospitals. Therefore, nurses require more continuing education to better meet requirements of their job.
Sampling
The study population included all nurses (N = 330) working in the critical care settings mentioned above at the time of data collection. The sample size was calculated according to a pervious study and the sample size formula. Regarding α = 0.05, test power of 80%, and a large effect size (Cohen d = 0.7), the required sample size was 27 participants for each group (54 participants are needed for the two groups). Sixty nurses were recruited in the study using the stratified random sampling method (30 nurses in each group) with ten percent dropout probability. The studied samples were selected equally from each hospital. Stratified random sampling was appropriate to have a representative sample of the population under study. We first prepared three separate lists of nurses working in critical care settings of the three hospitals. Owing to the fact that the number of nurses in the three hospitals was almost equal, we selected 20 nurses from each hospital with the random number table (10 nurses for the intervention group and 10 nurses for the control group). In total, 60 nurses were assigned into the intervention (n = 30) and control groups (n = 30). The inclusion criteria were nurses with a bachelor’s degree, at least six months of work experience in the critical care units as well as not being scheduled for a clinical shift on the days of the workshop. The exclusion criteria included being absent in one session and incomplete questionnaire. None of the nurses were excluded based on the inclusion criteria.
Instruments
The instrument used in this study consisted of two questionnaires. The first one was about the nurses’ demographic and professional information, including gender, marital status, age, work experience, work experience in critical care settings, work position, shift work, history of attendance at research, information literacy skills, information-seeking skills, and computer skills training (Table 2).
The second was Nursing Informatics Competency Assessment Tool (NICAT) developed by Rahman [5] in the US in 2015 based on ANA standards (2008), TIGER recommendations (2009), and Benner’s Dreyfus model of skill acquisition (1984). NICAT can be utilized for evaluation of educational and training programs on NI competency. This tool has the potential to assess and evaluate all nurses during the new hire process, orientation, education, and clinical informatics system implementation. NICAT may not be applicable to bedside nurses with advanced degrees. The NICAT assesses NI competency with 30 items in three dimensions:
- Computer literacy (10 items, items 1 to 10) shows the psychomotor skills to use computer tools, as well as knowledge of basic hardware and software functionality; these are all required for effective bedside nursing.
- Informatics literacy (13 items, items 11 to 23) is the nurses’ abilities to recognize , retrieve, evaluate, and use information for patient care appropriately.
- Information management skills (7 items, items 24 to 30) apply the data to support clinical decisions, documentation, data integrity, confidentiality, and security. Information management skill shows the value of information system in improving patient safety, quality, and outcome.
The NICAT is scored on a five-point Likert scale ranging from one to five: not competent (1 points), somewhat competent (2 points), competent (3 points), very competent (4 points), and expert (5 points). The overall score range of the instrument is 30-150. The higher the scores the higher the NI competency; a total score of 30 shows a novice nurse, a score between 31-59 represents advanced beginner, a score between 60-89 indicates a competent nurse, a score from 90 to 119 offers a proficient nurse, and a score between 120-150 is considered as an expert. Benner’s model outlines nursing skill acquisition from novice to expert. The novice learns the tools and thinks like a nurse. The advanced beginner applies clinical knowledge and judgments in delivering care. A competent nurse can use the tools and reason through issues familiar with the patient population. A proficient nurse can use all tools, recognize and anticipate patient needs. An expert nurse, in addition to all the above, has the vision to compose a team, look beyond the current moment, analyze system issues, and seek continuous improvements in practice [5].
Three groups, including the nursing informatics team, the department of education, practice, and research, and the hospital clinical outcome department validated the original NICAT. Clarity, readability, accuracy, question sequence, comprehensiveness of the questions, relevance, and appropriateness of the item were rated during the expert content validation and review. Abd El (2017) assessed the nursing informatics competencies of the critical care nurses. Researcher determined content validity with the help of information technology expert and confirmed the reliability using internal consistency. Cronbach’s alpha coefficient was 0.824 for each dimension and 0.846 for all items indicating sufficient internal consistency [13].
The authors of this study translated and validated NICAT in Iran. For cross-cultural adaptation, the original NICAT was accurately translated into Persian (forward translation). A proficient English translator did the backward translation of Persian version. Then, the translated version was matched with the original version. Nurses’ perceptions of the items were investigated to check the face validity of NICAT. Two medical informatics specialists and eight nursing faculty members confirmed the content validity of the adapted version of NICAT. Content validity was enhanced by using experts’ direct quotes, face-to-face discussions, and comments. Furthermore, 30 nurses participated in the pilot-test of the questionnaire and the Cronbach’s alpha coefficient was used to assess its reliability (α= 0.95).
Data collection
The aim was to assess the effect of an educational program on the critical care nurses’ NI competency. Data were collected using an anonymous, self‐reported, and structured questionnaire. To collect data, the first researcher referred to the study settings in different shift works, distributed the questionnaires among nurses of the intervention and control groups in the pretest (before workshop) and posttest stages (one month after the workshop). She also trained participants how to fill out the questionnaires. To attain the highest response rate, the researcher spent appropriate time on data collection and coordination of workshop time with nurses in the intervention group. She established a friendly relationship with the participants and determined a deadline to deliver completed questionnaires. Moreover, she reminded the intervention group to attend the workshop in the scheduled time. It should be noted that all of the participants completed questionnaires during paid work time simultaneously with routine or traditional training programs in hospitals, except that the intervention group was provided with additional materials derived from workshop and the control group did not receive this educational program. In other words, the two study groups had equivalent conditions for work duties and attendance in other educational programs in hospitals. However, to increase internal validity of the study, researchers monitored the study conditions thoroughly to ensure that the intervention and control groups were identical in all aspects, except attending the educational program.
Intervention procedure
A three-day workshop was held in three weeks (an eight-hour session on a day) in the informatics center located in Kerman University of Medical Sciences, with an adequate number of personal computers and internet access. The intervention group was divided into two groups of 15 people to increase the opportunity of engagement in the workshop. Therefore, all the workshops were held with the same structure and topics in six days.
To prepare and develop the workshop content, the researchers reviewed the literature to find necessary NI competencies for clinical nurses, and their educational needs in NI competency [4, 12-14, 30-32]. They discussed the extracted topics to achieve a consensus concerning goals, contents and teaching strategies. The literature revealed three key areas in NI competencies: computer literacy, informatics literacy, and information management skills applicable to the nursing care. These areas met ANA standards (2008) and TIGER recommendations (2009). The researchers employed the TIGER NI competencies as a guide and selected essential NI competencies. Nurses with a standard and consistent set of competencies can use HER better. The researchers also consulted with a multidisciplinary team, including three medical informatics specialists, two nursing faculty members, an expert in the field of medical education, three educational supervisors, and two critical care nurses. The team members presented their experiences and perspectives on required training and competencies of clinical nurses concerning nursing informatics in current practice, as well as teaching-learning activities and available educational programs for health informatics in study settings. In this step, the topics were developed using focus group discussion and then the team reviewed them for suitability, feasibility, applicability and relevance to the nursing workflow. Each item of the developed content was frequently reviewed and revised. After coming to an agreement on the NI competencies, the researcher drafted the content of workshop.
Two medical informatics specialists and six nursing faculty members who were not in the research group approved the content validity of the educational content. Few corrections were made based on their comments. Finally, a PhD in nursing and three experts in medical informatics taught the generated content as follows: lecture, demonstration, question and answer, slide presentation, hands-on exercise, group discussion and work, and online exercise (with examples of literature search using topics suggested by nurses), homework, video film, and educational CDs. The workshop in each day included training sessions in theory and practice. The topics presented in the workshop are shown in table1.
Table 1 Main topics presented in the workshop
Familiarity with and ability to use computer in the following areas:
· Windows, data storing and processing, data access and security
· Introducing different file formats, and key notes about advanced word processing functionalities, presenting slides and key notes (hyperlink, transition, slide master, design), managing reference
· Using telecommunication, telenursing and software tools such as email, adobe connect, skype, and Lync
· Managing computer systems security to protect data, devices, passwords and detect viruses
· Demonstrating how to search for policies and procedures, just-in-time training materials
· Demonstrating Internet tutorial and introducing databases and search engines, Google and key notes (translate- image- books- directory-scholar … ), searching for policies and procedures and information, training just-in-time materials on the web
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Session 1
(in the first week)
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· Introducing and orientating variety of information sources including hard copies, electronic files
· Demonstrating medical and nursing databases such as Current Nursing and Allied Health Literature )CINAHL(, PubMed, Scopus,…
· Using search strategies in databases such as PubMed and Scopus
· Searching articles in Persian databases such as Scientific Information Database )SID(, Medlib, Iranmedex, and Magiran
· Demonstrating a variety of electronic search capabilities such as the ways to subscribe and receive free articles
· Doing simple and advanced search, and conducting limited search based on the publication year, full text, keywords, Medical Subject Headings (MeSH), and using search operators such as AND, OR, NOT and etc.
· Doing practical exercises. For example, retrieving related articles in databases such as PubMed and Scopus for “Intubate Patient Care” with related keywords and providing search results
· Sending results of search through email to the professors for receiving feedback from them
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Session 2
(in the second week)
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· Presenting instances and practical exercises about the topics taught in the second session
· Reviewing IT initiatives such as HIS and its various capabilities such as documenting care plan in the medical record, collecting and maintaining patient care data like laboratory data, the picture archiving and communication system, patient admission and discharge
· Identifying human-computer interaction bottlenecks to enhance care quality, implementing HIT for higher care quality and patient-nurse communication.
· Introducing the use of informatics tools for the design of effective care plan such as: nursing interventions classification (NIC), and nursing outcomes classification (NOC)
· Correcting some flaws in the nursing care systems, data recovery and security, levels of safety and access to health information
· Discussing about barriers to timely documentation, reviewing methods to improve documentation in an efficient and timely manner and providing egregious examples
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Session 3
(in the third week)
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Statistical analysis
The data were analyzed in SPSS 21 using descriptive (frequency, percentage, mean and standard deviation) and inferential statistics (independent samples t-test, paired t-test, chi square test, and the analysis of covariance). The Kolmogorov-Smirnov test showed that the data followed a normal distribution. The significance level was considered ≤ 0.05.