How the Electronic Medical Record Has Changed Clinical Nursing Education

Abstract

Reflecting on two decades of clinical teaching, I have experienced changes in clinical settings, teaching and learning models, nursing student learning needs, and a struggling economy affecting education in the industrial, automobile state of Michigan. But none of the previous changes has affected how I teach clinical nursing as the recent implementation of the electronic medical record (EMR) in the acute care pediatric setting. Why was I blindsided and not prepared for these changes? Learning a new paperless computer system was my focus. While I conquered the technical component of the new system and became competent to instruct students, I was not prepared in how my clinical teaching would need to change. Why did I not have a nursing diagnosis and interventions for myself to anticipate and plan? Was it a knowledge deficit, anxiety related to unfamiliar electronic environment, or powerlessness related to communication and control relinquished to the EMR? Clinical teaching has evolved and changed just as our students have also evolved and changed, but how can faculty enhance clinical teaching in this new EMR environment to prepare future pediatric nurses? Perhaps historical aspects of pediatric clinical teaching will give insight into a contemporary climate for pediatric nursing care. In Florence Nightingale's 1859 book Notes on Nursing, she described children's nursing care needs as, “It is the real test of a nurse whether she can nurse a sick infant" (Nightingale, 1859/1992Nightingale, F/Skretkowicz V. (1859/1992). Florence Nightingale's Notes on Nursing. (Revised, with additions). London: Scutari Press (Original work published in 1859).Google Scholar). Conolly, 2005Conolly C. Growth and Development of a Specialty: The Professionalization of Child Health Care.Pediatric Nursing. 2005; 31: 211-213PubMed Google Scholar stated, “Early publications highlighted such practices as infant feeding techniques and pediatric nursing procedures. Pioneering pediatric nurses such as Anna Haswell, 1907Haswell A.J. Nursing young children.American Journal of Nursing. 1907; 8: 115-119Google Scholar also stressed the special personality type required for children's nursing, asserting that:“The nursing of young children stands out as a division of our work needing special study. We have no branch that is more important… Let us be willing to do anything which will accomplish the greatest good for the child, and honor our profession by becoming more and more efficient in our ability to care for sick children (p 115).” How can clinical nursing faculty continue to provide learning for the “greatest good and honor of our profession” and prepare future pediatric nurses with the new “division of our work” shared with the EMR? How can we become “more and more efficient in our ability to care for sick children,” viewed as a challenge in 1907 by pioneer pediatric nurse Anna Haswell? In past acute care settings, it was common to see student nurses' handwriting nursing diagnosis and interventions with nursing faculty evaluating the steps involved in their thinking process. The former times of clinical nursing faculty evaluating how students think through their writing in a paper chart is now observed in checked boxes, nursing care plans are clicked from a menu, and discharge teaching patient education handouts are printed from a standard software program. The boxes are checked and patient education handouts are printed, but how does clinical nursing faculty evaluate critical thinking in the acute care setting? This is the new challenge. Emphasis needs to include maximizing time to communicate effectively with each student to assess how the student is thinking critically, prioritizing, providing safe nursing care, and understanding key concepts. How do we find the time when each EMR entry needs to be co-signed by the clinical faculty? EMR entries include medication supervision and administration, physical assessments, and child/family responses. In addition, EMR entries are conducted in settings where acuity of hospitalized children is increasing. How do we balance our time so we are not viewing the computer screen and spending too much instructional time with students at the expense of spending clinical time with children and families? Or rather, how do we embrace the EMR to enhance clinical teaching and benefit both nursing students and children/families? Utilizing each screen of the EMR can be a powerful backdrop for teaching/learning opportunities. For example, when the highlighted abnormal sign appears for a laboratory test, we should question the student on the meaning, normal values, and rationale for laboratory test. The opportunity for EMR documentation in the patient room allows for continued assessment of the child/family, validation of student nurse assessment findings and nursing process while including the patient and family in the teaching/learning journey. The provision for family-centered care, learning, and communication can be enhanced. The EMR means a new physical learning environment and a new tool in our toolbox of clinical teaching; questions can still be invited and responded to and critical thinking and nursing process can still be evaluated in a diverse but exciting venue. Maximizing EMR screen time is a method to provide teaching/learning, communication, and evaluation of learning. It is comfortable to reminisce about the former simpler days of clinical teaching, but nursing faculty's responsibility is to prepare the next generation of pediatric nurses to be successful in the new era of EMR and ever-changing health care. Changing ourselves to embrace a new teaching/learning environment inclusive of the EMR is the challenge. Bring on the EMR!