Restrictions on Nursing Students' Electronic Health Information Access

Restrictions on Nursing Students' Electronic Health Information Access Wendy Hansbrough, PhD, RN, CNE; Kimberly Silver Dunker, DNP, RN, CNE; Jennifer Gunberg Ross, PhD, RN, CNE; and Marilyn Ostendorf, DNP, RN

ABSTRACT Background: Restrictions on students' use of electronic health information have been anecdotally reported as a threat to clinical learning, development of informatics competency, and adherence to personal health information privacy laws. However, evidence on which informatics education and policy strategies can be designed is lacking. Purpose: This study describes the scope of nursing students' access to and use of electronic health information systems as reported by clinical instructors. Methods: Clinical faculty (n = 193) in prelicensure programs from 25 states completed the online survey. Results: Students are often restricted in retrieving patient health information, charting assessment data and delivered care, and using medication administration systems. Students alternatively use faculty or staff nurses' system security access. Conclusions: Results suggest the need for critical review of nursing curriculum related to informatics competency and clinical site health records access policies. Keywords: electronic health record, informatics competency, nursing education, nursing informatics

Cite this article as: Hansbrough W, Dunker KS, Ross JG, Ostendorf M. Restrictions on nursing students' electronic health information access. Nurse Educ. 2020;45(5):243-247. doi: 10.1097/NNE.0000000000000786

ccording to the Bureau of Labor Statistics,1 there Nurse educators have been called on to effectively inte- willbea15%increasedneedintheRNworkforce grate the use of technology and informatics into the pre- A from 2016 to 2026. While more RNs will be licensure curriculum, recognizing the demand for newly needed, there are obstacles to meeting this workforce de- graduated RNs to be prepared to use EHRs and eMARs mand. Evidence shows that the lack of clinical placement upon entry to the workforce.3,4 Informatics is identified settings is the largest impediment to expansion of nursing as a prelicensure Quality and Safety Education for Nurses program enrollment; however, access to clinical sites is (QSEN) competency for nursing students.5 Quality and not the only concern.2 Nursing faculty are anecdotally Safety Education for Nurses describes the skills for infor- reporting that the quality of student clinical experiences matics competency as the ability to use the EHR to plan, is jeopardized, in part because of restricted access to es- document, and monitor care outcomes.5 In addition, the sential patient information via the electronic health care EHRisusedtocommunicateandcoordinateinterprofes- record (EHR) and electronic medication administration sional care and support clinical decision making.5 Thus, record (eMAR). accessing patient information by using the electronic systems is essential to planning and delivering safe health care. Furthermore, the National Council of State Boards of Nurs- Author Affiliations: Assistant Professor (Dr Hansbrough), School of Nursing, ing includes the utilization of information technology related California State University San Marcos; Associate Professor (Dr Dunker), School of Nursing, Worcester State University, Massachusetts; Assistant to promoting a safe and effective care environment in the 6 Professor (Dr Ross), M. Louise Fitzpatrick College of Nursing, Villanova National Council Licensure Examination-RN test blueprint. University, Pennsylvania; and Assistant Clinical Professor (Dr Ostendorf), In 2012, the Institute of Medicine described the chal- School of Nursing, University of Southern Indiana, Evansville. lenges of protecting patient safety and privacy within The authors declare no conflicts of interest. Dr Hansbrough, School of Nursing, California State complex technological systems such as EHRs and eMAR Correspondence: 7 University San Marcos, 333 Twin Oaks Valley Rd, San Marcos, CA systems. Guarding the integrity of these complex health 92096-0001 ([email protected]). informationsystemsistheresponsibilityofhealthcareorga- Supplemental digital content is available for this article. Direct URL citations nizations.8 This includes determining who will have access appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). to the information, training those who have access, and Accepted for publication: October 23, 2019 monitoring the systems to detect errors or misuse. Many Published ahead of print: January 8, 2020 members of the health care team must access and interact DOI: 10.1097/NNE.0000000000000786 with EHRs and eMARs, and everyone who accesses the

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. record must have his or her own personal username and Sample password to maintain integrity of the EHR.9 Registerednurses teaching a clinical course in a prelicensure The diversity of roles in the health care team contributes nursing program in the United States who work with pre- to the complexity of assigning access levels corresponding licensure nursing students at a clinical site were invited to to user needs without increasing the risk to patient informa- complete the survey. These instructors were selected as the tion safety.10 Protection of patient health records is essen- study population because of their firsthand knowledge of tial; however, information access limitations for students nursing students' access to patient information and docu- and faculty in the clinical setting can pose other risks. mentation via the EHRs and eMARs. Restricted access may result in astudent providing care with Snowball sampling was used to reach potential respon- incomplete information, having insufficient communica- dents from May 5, 2018, to October 18, 2018. The re- tion with the health care team, and being unable to accu- searchers distributed the online survey URL through rately document care. There is also a potential for health professional nursing organization networks and email con- information privacy protection misuses.11 tact lists to reach clinical instructors at schools of nursing. Healthcareorganizations maybeunable toprovidefac- This included distribution through the QSEN Academic ultyandstudentswithaccesstotheEHRandeMARsys- Clinical Practice Task Force and announcement at the tems because of limitations in their system infrastructure 2018 annual QSEN conference. In addition, email invita- to assign and train student users or concerns about technol- tions to participate were sent to school of nursing deans ogy competency and data entry errors.12 When access is and directors at the researchers' associated colleges and restricted by the health care organizations, students are sty- universities, with a request for distribution to their faculty. mied in gaining knowledge and skills to develop competency in using health information technology systems. In Survey Development fact, 76% of newgraduates indicate theyare not adequately The research team drafted the initial survey and distributed prepared in informatics to access and use EHRs.13 it for content review to the QSEN Academic Clinical Prac- In response to the need to meet the informatics compe- tice Task Force membership (n = 35). Revisions were made tency as cited in QSEN and the need for health information based on reviewers' recommendations, and the final 29-item technology training as identified by the Institute of Medi- survey was approved for face validity by the task force cine,many nursing programs rely on simulated or academic members. The reported results were obtained from 24 EHRs and eMARs.5,7,14-16 These systems have been shown of the 29 survey questions: 14 multiple-choice, 3 fill-in-the- to be helpful in student engagement and learning.17 How- blank, 5 dichotomous-answer, and 2 ten-point rating ever, without exposure to actual direct patient care docu- scale questions. At the close of the study period, data were mentation, there may be a skill gap in the new graduate downloaded and imported to IBM SPSS version 24 (2016; nurse's transition into the professional nursing role. Al- IBM Corp, Armonk, New York) for analysis. though simulated EHR and eMAR experiences contribute to developing nursing students' knowledge and skills in Results the use of technology,theylack the dynamic clinicalcontext Demographics of Respondents necessary to develop clinical reasoning with integration of Of the 274 survey respondents who signed into the survey, information to deliver patient care.18-20 61 did not agree to the consent, and 20 others did not com- The scope of the restriction of access to EHRs and pleteanyinformationafterconsenting, resultinginasample eMARs for nursing students in their clinical experiences is of 193 clinical nursing faculty who taught in a prelicensure not known. Therefore, the purpose of this study was to de- program. The respondents had a mean age of 53.58 years, scribe prelicensure nursing students' access to, and use of, with a mean of 9.6 years of experience as clinical faculty. EHR and eMAR systems in the clinical setting as reported Most respondents were female (95.9%) and white (88.6%) by clinical nursing faculty. and held a graduate degree (85%). Some respondents (9.3%) taught in more than 1 type of program, but 43.5% Methods taught exclusively in an associate degree in nursing (ADN) Study Design program, whereas 47.2% taught solely in a BSN program. For this descriptive, cross-sectional study, the researchers Most respondents were part-time clinical faculty (60.9%) surveyed a sample of clinical nursing faculty to collect data who spent a mean of 92.67% of their time in clinical about the clinical experience of students' use of EHR and instruction. Full-time non–tenure-line faculty spent an eMAR systems using a researcher-designed online survey. average of 60.12% of their teaching time in the clinical Information was gathered about the type of nursing pro- setting, whereas those who were on the tenure track aver- gram, faculty and student access to the electronic systems, aged 45.37% of their time in clinical instruction. There and the scope of the access. The institutional review board was a mean of 7.96 (range, 4-14) students in each clinical of the first author's affiliated university approved this re- group. Faculty represented all areas of acute care nursing search before participant invitations. All subjects were pro- practice (medical-surgical, obstetrics, pediatrics, mental vided with an electronic consent form at the start of the health, and critical care). Twenty-five states were repre- online survey. sented in the sample throughout all regions of the United

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. States: northeast (39.9%), midwest (22.8%), west (18.1%), (58%). Only 28% of faculty in the south had eMAR access. and south (13.5%). Of students who did not have personal login access to the eMAR, 66.2% used their faculty member's access, and Access to Patient Information 33.8% used the staff nurse's access to administer medica- Faculty rated the process for being given EHR access for tions. Moreover, 69.7% of the students without personal themselves and for students using a score of 1 to 10, with access to the eMAR documented medication administra- 1 being the easiest and 10 being the most difficult. They tion using their faculty's or staff nurse's eMAR account. rated the process for themselves as moderately easy (mean, There was no significant correlation between students' 4.3) and the process for students as slightly more difficult EHR restrictions and eMAR access. (mean, 5.04). Although the majority of faculty (92.2%) reported they had access to the EHR at the clinical agency Documentation where they teach, when asked whether they were restricted Despite personal access to the EHR, many students used from accessinginformationthatwouldbehelpfultoprovid- either their faculty's or staff nurse's login information to ing care or teaching students, 13.3% agreed. On the other access patient information and document care in the EHR. hand, only 78% of students had personal access to the Notably, students who had their own access but used either EHR at their clinical agency, with almost 30% of them their faculty's or staff nurse's access to document were more having more restricted access than their faculty member. likely to document vital signs, intake and output, physical ReportedEHR restrictions includedread-onlyaccess,anin- assessment, and delivered patient care, than students who ability to see diagnostic results, and limitations in documen- documented under their own login. This difference, how- tation. There was no difference in EHR access between ever, was not statistically significant. Overall, the majority faculty and students; however, there was a statistically sig- of students with their own EHR access were able to docu- nificant difference between the restrictions imposed on mentvitalsigns,intakeandoutput,patientcare,physicalas- faculty versus students' EHR access, with students having sessment, and risk assessments, whereas less than half of more restrictedaccess(χ2[1, N= 188] = 10.73, P= .001).De- students without personal access were able to document in spite having their own access, the majority of students any area of the EHR (Table). A significantly higher percent- (64%) who had a personal login to the EHR still used their age of students who had their own personal EHR access, clinical faculty's (46%) or staff nurse's (18%) EHR access even if the access was restricted, documented in the EHR to some degree. as compared with students who did not have personal ac- There was no difference in faculty access to the EHR cess to the EHR (Supplemental Digital Content, Table, based on region in the UnitedStates, but therewas a statisti- available at http://links.lww.com/NE/A737). cally significant difference in student access to the EHR Discussion across regions (χ2[3, N = 182] = 11.354, P = .01). Students in the midwest were the most likely to have their own access To the researchers' knowledge, this study was the first to re- to the EHR (93.2%), followed by the west (85.7%) and port nursing students' access to and use of EHR and eMAR south (80.8%). Students in the northeastern United States systems. The results from this survey indicate that there is a were the least likely to have personal access to the EHR great variance in experiences among nursing students re- (68.8%). Moreover, there was a statistically significant dif- lated to the use of electronic patient information within ference in student restrictions within the EHR based on re- the healthcare setting. Because of this variation, it is difficult gion (χ2[3, N = 182] = 10.497, P = .015), with the northeast to ensure that all students are receiving comparable and ad- having the most restricted access (50.1%), followed by the equate clinical experiences to gain the knowledge and skills west (45.7%) and south (30.8%). Students in the midwest had the least restricted access (22.7%). There was no statisti- Table. Student Documentation Type Based on EHR Access cally significant difference in EHR access for students based on program type (ADN or BSN), clinical unit type (medical- Personal surgical, obstetrics, pediatrics, mental health, or critical care), and Faculty Personal Faculty or or clinical group size. Documentation or RN EHR EHR RN EHR Type Access, % Access, % Access, % Medication Administration Vital signs 84.4 80.2 45.2 Among the respondents, there was a significant difference Intake and output 78.1 74.4 35.7 between faculty and student eMAR access (r =0.254, Patient care 65.6 67.4 23.8 P=.001), with 71.7% of clinicalfaculty having personal access to the eMAR and only 13.9% of students having direct Physical 62.5 64 21.4 access to the eMAR. There was a statistically significant dif- assessment ferenceinfacultyaccesstotheeMARbasedonUSregion(χ2 Risk assessments 51.4 61.6 16.7 [3, N = 166] = 37.293, P < .001). Faculty in the northeast Nurse's notes 43.3 53.5 21.4 were most likely to have access to the eMAR (88.2%), Nursing care plan 25.0 36.0 11.9 followed by faculty in the midwest (80.9%) and west

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. necessary to develop informatics competency. Notably, the dialogue to determine the appropriate faculty and nursing findings of the restrictions placed on nursing students for student EHR and eMAR access levels.25 the documentation of basic nursing care in the EHR, such The academic-to-practice gap is likely to widen as nurs- as vital signs and intake and output, are of great concern. ing programs' pedagogical models remain dependent on When students are not permitted to document their patient health care facilities, which curb students' direct care expe- assessment, interventions, and outcomes, they are missing a riences.Therifebecomesbroaderconsideringdisagreement vital step in the provision of care. on priorities for newly graduated nurses' entry-to-practice Achievement of the informatics competency for pre- preparation as viewed by nursing educators and potential licensure nursing students, as defined by QSEN, requires employers. In a comparison study of the 3 most important knowledge of technological tools health care professionals knowledge, skills, and attitudes for the QSEN informatics use to promote communication, safety, and high-quality competency, only employers rated the skill to document care.5 The skills related to the informatics competency and plan patient care in an EHR as most important.26 Both include being able to navigate the EHR, use it to docu- facultyandemployersratedtheattitudetoprotectconfiden- ment care and monitor outcomes, and use the embedded tiality of patient health information and the skill to respond decision-making tools to support clinical reasoning and appropriately to clinical decision-making supports and identify potential errors. Using the EHR also allows stu- alerts in the top 3.26 The reported high value placed on dents to gain documentation skills by seeing what experi- entry-to-practice EHR competency by employers is para- enced nurses have documented.16 Active use of electronic doxical with the findings in this study, which found that information systems in the context of the clinical experi- agencies placed restrictions on students' EHR access. Nurs- ence is a key component of nursing students' experiential ing students should have EHR access during their pre- learning. Without the opportunity to use the EHR and licensure education to develop the employer-valued skill eMAR in the clinical setting, the development of students' of EHR proficiency. entry-level informatics competency is adversely affected. With the variation in nursing students' use of EHRs and These restrictions also limit the students' access to the eMARs in the clinical setting, nurse educators are called on clinicaldecision-making tools embedded in the eMAR tech- to use innovative teaching strategies to ensure all students nology. Because medical errors are now cited as the third gaintheknowledgeandskillsneededtodevelopinformatics leading cause of death in the United States21 and medication competency and provide safe, quality patient care using errors are the most common type of medical error,22 it is today's health care technology.27 One strategy schools of vital that nurses are competent to use medication adminis- nursing can adopt is the use of academic EHR and eMAR tration technology. Ultimately, restricted access to health programs. These software programs provide students, in information technologies contributes to a nursing student's a simulated setting, an opportunity to practice electronic failure tolearnthe skillsnecessary forcompetent practiceon documentation with faculty instruction.17,23 However, graduation and licensure. This study supports findings that these programs may be cost prohibitive to many nursing newly graduated nurses begin their professional practice programs. unprepared to use EHRs.19 The findings of irregular access to patient electronic Limitations health information by students whose personal access is re- Despite the importance of the results, this descriptive study stricted raise ethical and legal concerns. When nursing stu- had limitations. The design of the online survey allowed re- dents are restricted in using EHRs and eMARs, they may spondents to select multiple answers to some questions, not know pertinent patient care information, and it is likely which limited the extent of the data analysis. In addition, that a portion of their patient care is not documented. The the snowball sampling technique limited the generalizabil- results of this study show that students work around this ity of the results. problem by operating within their faculty's or staff nurse's secure electronic access. This is a failure to uphold the ethi- Conclusion cal obligation for veracity in health care documentation Informatics competency is necessary for all entry-level and a violation of the legal requirement limiting authorized nurses working in the current health care system; thus, users to access health care records to protect patient privacy it is critical that all prelicensure nursing curricula have in- and confidentiality.23,24 It is the responsibility of the health formatics competencies integrated as program learning care organization's privacy or compliance officer to deter- outcomes and that nurse educators implement appropriate mineelectronicrecords'securityaccesslevelbasedonhealth teaching and learning strategies to support informatics care worker role, provide adequate training,follow security education. Yet, across the United States, there is consen- authorization procedures, and monitor user activity.10 It is sus among clinical faculty that students' opportunities equallyimportantforhealthcare informationusers toabide to develop informatics competencies are limited because by access policy. When there is a mismatch of user access of inadequate EHR and eMAR access in the clinical set- need and actual user permission, as described in these re- ting. Future research is needed to more fully understand sults, it is critical that representatives from schools of nurs- the effect of limited electronic health information access ing and clinical practice partners engage in a concerted on nursing students' learning outcomes. Moreover, nurse

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. educators should collaborate with health care organiza- 14. Gardner CL, Jones SJ. Utilization of academic electronic medical re- tions to determine appropriate security access levels for cords in undergraduate nursing education. Online J Nurs Inform. 2012;16(2):31-37. students and faculty to promote the delivery of safe and 15. Bowling A. Incorporating electronic documentation into beginning accountable health care. nursing courses facilitates safe nursing practice. Teach Learn Nurs. 2016;11(4):204-208. References 16. Choi M, Joon Ho P, Hyeong Suk L. Assessment of the need to inte- 1. Bureau of Labor Statistics, US Department of Labor. Employment grate academic electronic medical records into the undergraduate projections program. Available at https://www.bls.gov/ooh/healthcare/ clinical practicum. Comput Inform Nurs. 2016;34(6):259-265. registered-nurses.htm#tab-6. Updated April 12, 2019. Accessed 17. 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Noble-Britton P. Strategies to enhance nursing students' use of infor- ing. Nurs Educ Perspect. 2017;38(2):57-62. matics and technology. JOCEPS: The Journal of Chi Eta Phi Sorority. 20. Mitchell J. Electronic documentation: assessment of newly gradu- 2014;58(1):6-11. ated nurses' competency and confidence levels. Online J Nurs Inform. 5. Quality and Safety Education for Nurses (QSEN). QSEN competencies. 2015;19(2). Available at http://qsen.org/competencies/pre-licensure-ksas/ 21. Makary MA, Daniel M. Medical error—the third leading cause of #informatics. Accessed May 13, 2019. death in the US. BMJ. 2016;353:i2139. 6. National Council of State Boards of Nursing. NCLEX-RN examination. 22. Garrouste-Orgeas M, Philippart F, Bruel C, Max A, Lau N, Misset B. Effective April 2019. Available at https://www.ncsbn.org/2019_ Overview of medical errors and adverse events. Ann Intensive Care. RN_TestPlan-English.pdf. Accessed June 8, 2019. 2012;2(2):2. 7. 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TEACHING TIP Recommendations for Faculty and Expected Student Etiquette in an Online Environment During the Global COVID-19 Pandemic and Beyond

ince transitioning to an online learning environment, one thing is certain: we have all seen or heard funny, awkward, and S sometimes inappropriate sounds and visuals. Ground rules of the online environment should be clearly communicated to students in the beginning of a course as they would for a face-to-face course to avoid an embarrassing situation. Communicating clear expectations of your online course provides students with structure and may also prevent multiple clarification emails. Points to consider include clear communication, accountability, and student etiquette. Faculty suggestions and student expectations are provided on the Supplemental Digital Content Table, http://links.lww.com/NE/A794.

By MaryAnn D'Alesandro, DNP, RN, Department of Nursing, The University of Tampa, Florida, [email protected]. DOI: 10.1097/NNE.0000000000000877

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