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I. Introduction
As part of the 21st-century scientific transformation, nursing informatics (NI) has improved the quality, safety, and effectiveness of healthcare [1,2]. NI has accelerated the computerization of human healthcare tasks, in particular the transition of paper nursing records to electronic Medical Records [3,4]. Security and patient safety have been enhanced by introducing information technology (IT) to nursing, which can achieve the goal of converting data into useful knowledge [5,6]. Applying IT to nursing helps to integrate data, information, and knowledge in all areas to help patients, nurses, and other healthcare providers make decisions [7]. NI education on how to integrate and manage IT in nursing has become urgently necessary.
Competence in NI is key to minimizing medical errors, improving documentation of clinical information (e.g., patients’ diagnoses, treatments, and outcomes), and promoting evidence-based practice worldwide [5]. These competencies assist nursing students in acquiring computer utilization skills and information literacy, and being able to apply them to information management and clinical practice to achieve optimum safety and provide high-quality health services [7]. Computer and information literacy skills and overall information competencies have been identified as three core competencies that describe the ability of new nurses to learn NI [8]. Staggers et al. [9] proposed computer utilization technology, information knowledge, and IT as core competencies for nurses.
It is crucial for the NI curriculum to present the current and latest competencies and educational objectives presented by global administrators and organizations [10]. Various NI education models have recently been identified and introduced to highlight content that should be included in the curriculum. The concept of a curriculum refers to the learning expected to take place during a course or program [11,12]. Saba and McCormick [13] highlighted that a NI curriculum should include basic informatics concepts and applications, access to information systems, data and information system utilization, and the analysis, coordination, and integration of nursing information. This suggests that NI curricula must include fundamental skills based on the latest findings and learning experiences. Many institutions have introduced independent NI courses [2]. NI education has been found to reduce medication errors and improve productivity and enhance coordination among nurses and the rest of the multidisciplinary healthcare team [14].
A study conducted in 2016 in South Korea by Jeon et al. [2] reviewed the status of NI education and found that 55.3% of nursing schools had introduced an informatics course within the previous 5 years; these courses were introduced as electives rather than as mandatory courses. A survey conducted on NI education in 1999 in Korea by Park et al. [15] found that curricula varied between nursing schools, with content consisting of computer basics, concepts and elements of NI, and NI utilization in practice, education, research, and administration. The first standardized, competence-based NI curriculum was developed in 2007 by Yom et al. [8]. According to their research results, four domains should be included in NI curricula: informatics fundamentals, NI fundamentals, NI applications, and public health informatics/ social aspects.
Despite the efforts of previous researchers in NI, there remains a gap in the number of schools that offer NI classes and majors, and more schools still need to make NI courses mandatory. One of the major benefits of making NI courses mandatory is to keep electronic health records aligned with best practices for data processing, organization, and management [14]. Mandatory NI courses help develop and enforce privacy policies in accordance with ethics and regulations and enable more healthcare and IT professionals to communicate with each other more effectively [14]. An in-depth analysis of both the current status of NI and the development of a standardized curriculum is needed. This study, therefore, aimed to determine the current status of NI education and develop a standardized and up-to-date curriculum for both undergraduate and graduate programs as a collaborative project with the Korean Society of Medical Informatics Nursing Informatics Special Interest Group (KOSMI NI SIG).
II. Methods
1. Research Subjects
Information was elicited in two ways: surveys from nursing schools and a two-round Delphi survey conducted with experts. Sixty nursing schools were investigated to determine the current status of NI education and to develop a standardized curriculum. This study developed a standardized NI curriculum and assessed the challenges and difficulties in NI classes, training on educational content that NI instructors wanted to receive, and the resources necessary for NI classes. A Delphi survey is a research technique consisting of a panel of anonymous experts who complete questionnaires and provide feedback to reach a consensus on a specific topic [16]. There are six common types of Delphi survey: (1) classic Delphi, (2) modified Delphi, (3) decision Delphi, (4) policy Delphi, (5) real-time Delphi, and (6) Internet-based Delphi [16]. Fifteen experts—seven academics and eight practitioners—participated in the Delphi survey (Figure 1).
2. Research Procedure
The research procedure was conducted in three stages. First, the current status of nursing information education was researched. Second, a two-round Delphi survey based on a competence-based curriculum related to nursing information derived from 15 experts. In this stage, the experts tried to identify content suitable for the curriculum based on other local experts teaching NI. In the last stage, a standardized NI curriculum was developed based on content agreed upon by the 15 experts in the Delphi survey (Figure 2).
1) Current status of nursing informatics education
A survey was conducted to assess the status of NI education. The NI education survey included questions about the timing of NI courses within the program, the types of NI courses to be offered, the necessity to offer a required major (undergraduate) or major track (graduate school) in NI courses, the respective instructor in charge of NI within the last 2 years, the affiliation of the instructor responsible for teaching NI, the nursing major, or other major disciplinary specializations of the professor responsible for teaching NI, curriculum development for various major courses, the number of credits, the appropriateness of the credits, the necessity of a standardized NI curriculum, the location where NI is taught, teaching methods for NI classes, location of the practicum for NI courses, and sources of information for NI courses. The aspects assessed as part of the current status of nursing information included challenges and barriers to teaching NI classes, training on educational content that instructors wanted to receive, and the resources needed for NI classes.
2) Curriculum development
The NI curriculum was developed through a modified Delphi survey, in which experts met to discuss and rate the results. A two-round modified Delphi survey was conducted based on knowledge and skills presented in the Nursing Informatics Practice Standards and Scope of the American Nursing Association from 2015, the Technology Informatics Guiding Education Reform (TIGR)-based assessment on NI, the informatics competencies of the Quality and Safety Education for Nurses (QSEN) project and Healthcare Information Management System Society, and the Healthcare Leaders Association of the United States. It was also based on information and communication technology (ICT) competencies developed by the Canadian Association of Schools of Nursing. NI competencies were developed based on those from the American Nurses Association. These competencies included basic computer skills, information literacy, information management ability, practical guidelines for applying medical ICT to promote patient safety, health delivery system improvement, and policy development and supervision. Information literacy refers to a set of skills and abilities requiring people to recognize when information is needed [16]. Basic computer skills were an entry requirement, and practical guidelines for applying medical ICT were provided at a doctoral level and in advanced practice, making it a specialty [16]. A 5-point Likert-scale (1 = very unnecessary, 2 = unnecessary, 3 = not sure, 4 = necessary, 5 = very necessary) was used to rate the responses of the 15 experts participating in the Delphi survey to 72 learning objectives. A higher score indicated higher demand for the learning objective.
3. Data Collection
The study was approved by the Institutional Review Board of Chungnam National University (No. 202008-SB-110-01). Data were collected in two steps. The first step was an online survey that investigated the homepages of 200 nursing schools, of which only 104 of them offered NI courses. Sixty of these 104 schools agreed to participate and responded to the survey investigating the current status of NI education over a period of 3 months (from December 2020 to February 2021), resulting in a participation rate of 57.7%. Those who agreed to participate in the study provided informed consent, and then data were collected using an online survey questionnaire. The second step was a two-round Delphi survey among 15 nursing information experts (eight from academia and seven from practice). The Delphi survey was used to confirm the validity of NI topics and learning objectives for undergraduate and graduate courses. The two-round Delphi surveys were conducted 2 months after the online survey, from March 2021 to April 2021.
III. Results
1. Current Status of Nursing Informatics Education
Out of 60 nursing schools, 53 responded to this study, resulting in a response rate of 88.3%. Forty-two nursing schools were categorized as universities (4-year training) and 18 were nursing colleges (3-year training).
1) Timing of nursing informatics classes within the program
NI classes were offered in 39 undergraduate programs (73.6%), and 11 NI courses (20.8%) were open to both undergraduates and graduate students. Eighteen out of 53 (34.0%) schools offered NI courses for fourth-year undergraduate students, while only two schools (3.7%) offered NI courses for first-year students (Table 1).
2) Nursing informatics class characteristics
Among 53 undergraduate nursing schools, 41 schools (77.4%) offered NI courses as electives, and 35 full-time professors (66.0%) were responsible for teaching NI over the past 2 years. Fifty-one professors (96.2%) were affiliated with the nursing departments, and NI courses were usually allocated two credits (64.2%). Among the 14 graduate programs, three (21.4%) offered mandatory NI courses as part of the degree programs. Ten (71.4%) of the professors in charge specialized in NI, two credits were allocated to the NI course, and 11 schools (78.6%) reported that the number of credits offered for NI coursework was appropriate (Table 2).
3) Teaching methods in nursing informatics classes
Out of 53 undergraduate nursing schools, 42 (79.2%) preferred an on-campus classroom for teaching NI, and 50 schools (94.3%) chose lectures as the preferred teaching method. Twenty-one schools (39.6%) preferred universities as the practical location for NI classes, and 50 schools (94.3%) selected textbooks as the main source of NI classes. Out of 14 graduate programs, 12 (85.7%) chose an on-campus classroom as a location for teaching NI. Half of the nursing schools preferred an in-school practicum as a teaching method for NI courses. Four schools (28.6%) preferred universities as the practicum location for NI classes. Fourteen schools (100.0%) preferred academic journals as the main source of information for NI classes (Table 3).
4) Difficulties in operating nursing informatics classes
Out of 53 schools, 10 (18.9%) indicated that a lack of educational materials was the most common challenge. Only three schools (5.7%) reported that a lack of instructor competence was a challenge.
Out of 53 schools, 21 (39.6%) needed environmental support, such as training-related equipment. In contrast, only seven schools (13.1%) needed support for enhancing instructors’ abilities. Out of 43 schools that indicated their educational content needs, the instructors from nine schools (20.9%) specified that they wanted to receive education on information system utilization and training on the latest ICT skills (Table 4).
2. Development of a Standardized Nursing Informatics Curriculum
The results from the second round of the Delphi survey reflected that the following topics are appropriate for undergraduate curricula: nursing information system-related concepts, definition and components of healthcare information systems, electronic medical records, clinical decision support systems, mobile technology and health management, medical information standards, personal information protection and ethics, understanding of big data, IT in nursing research, and practical use of the latest ICT.
Topics identified as more appropriate for graduate curricula were healthcare IT concepts, the use of IT in evidence-based practice, the use of IT in community nursing, and the use of genome information, artificial intelligence, clinical information systems, administrative management systems, and IT in nursing education. The mean values in the second-round Delphi survey for undergraduate and graduate curricula ranged from 3.33 to 4.80 and from 3.66 to 5.00, respectively (Table 5).
IV. Discussion
This study has provided comprehensive statistics on the current status of NI education in South Korea, challenges in providing NI classes, the resources needed by NI instructors, and the training on educational content that NI instructors want to receive, and developed a standard curriculum for NI for both undergraduate and graduate nursing schools using 72 learning objectives.
This study showed that 65.6% of undergraduate programs and 44.5% of graduate nursing programs offered NI courses. A study conducted by Park et al. [15] in Korea among 77 nursing schools found that 20.8% of undergraduate and 25.0% of graduate nursing programs offered NI courses. Later, another study conducted by Jeon et al. [2], among 38 nursing schools in Korea showed that 56.9% of undergraduate and 35.7% of graduate programs offered NI courses from 2005 to 2014. Even though increasingly many schools have introduced NI classes, more nursing schools should introduce NI as an additional major on top of the currently available majors.
In undergraduate schools, the findings of this study revealed that NI courses were offered from the first to fourth years, with many nursing schools introducing NI courses in year 2 (32.1%,) and year 4 (34.0%). In the similar study of Park et al. [15], NI classes were mostly introduced for first- (43.7%) and second-year students (37.5%), while Jeon et al. [2] revealed that NI classes were predominantly introduced in the second (31.6%) and third years (36.8%). The findings of Jeon et al. [2] are similar to those of this study. These comparisons indicate that NI classes could be offered at any level, depending on the school’s preferences. More nursing schools have introduced NI classes for students in the third and fourth years to increase the time spent on its teaching. Many nursing schools have chosen to offer NI courses due to the importance of NI in supporting nurses and patients in making the best decisions to achieve optimum health outcomes.
This study found that 96.2% of professors in charge of NI courses were nursing professors who specialized in NI and nursing management. Park et al. [15] found that 50% of the professors in charge were nursing professors. Another study conducted in 2016 reviewing the current status of NI education found that 86.4% of professors in charge of NI courses were nursing professors [2]. The present study found that more nursing professors were in charge of NI courses than in previous studies conducted in Korea. This finding highlights that more nursing professors now specialize in NI, which reflects their broader knowledge in the field [17,18]. Nursing professors responsible for teaching NI help optimize health IT methods and software tools in nursing to improve healthcare outcomes [2,15,19]. These nursing professors are important in the development, management, and processing of data in healthcare facilities.
The most significant challenge to teaching NI is the lack of educational materials, which further leads to poor functionality and an impaired ability of nursing students and nursing professors to perform at an optimum level [20,21]. This challenge may be due to schools not prioritizing NI courses as essential, unlike other nursing courses, where it is ensured that materials such as books are always available. The optimum provision of proper NI educational materials is therefore important and should be addressed and improved upon at all nursing schools.
Practice equipment is one of the most important resources that NI instructors need to teach. Practice equipment in NI helps in the attainment of skills during class activity in a safe, acceptable, and effective way [22,23]. Practicing with the relevant equipment during NI classes helps improve performance, minimize errors, and increase accessibility during nursing practices in healthcare facilities [23,24]. Nursing schools that offer NI programs are advised to have all the necessary practice equipment to enable easy skill teaching by nursing professors and other instructors.
The Delphi survey provided experts an opportunity to reflect on the learning objectives selected based on the respective topics. Involving 15 experts working as nursing professors and practitioners in different universities made the curriculum unique and increased the likelihood of the results being relevant and applicable to undergraduate and graduate nursing programs [20].
The results obtained in this study indicate the topics that should be included in undergraduate program curricula. A study conducted in 2007 by Yom et al. [8] suggested four competencies for the curricula: informatics fundamentals, NI fundamentals, NI applications, and public health informatics and social aspects. A study conducted in 2017 found that NI curricula should include informatics used in nursing and midwifery practice, the history of present health and nursing IT systems, tools used in IT, the proficient use of electronic patient records for patient assessments, performing a nursing diagnosis, designing and executing a care plan, evaluating a care plan and nursing interventions, the use of the internet and other research tools, the use of nursing and midwifery taxonomies and NI standards, the vocabulary of IT terminologies, and contemporary issues in nursing and midwifery informatics [25]. A study conducted by Saba and McCormick [13] highlighted that NI curricula should include basic concepts and application of informatics; access to information systems; the utilization of data, information systems, and analyses; and the coordination and integration of nursing information. These findings are all similar to those in the present study, but our findings covered more competencies to be included in the curriculum. The structured undergraduate curriculum will assist in promoting a sense of structure and consistency across all nursing schools.
This study found that 26 of the 72 learning objectives were more appropriate for graduate NI courses. A study conducted in the United States indicated that NI curricula should include historical perspectives of computers in nursing and healthcare; computer hardware and software; system analysis and design; applying computers to nursing in education, clinical practice, administration, and research; the role of the nurse in selecting, implementing, and evaluating hospital information systems; and professional issues related to the use of computer systems in healthcare [25]. These topics will assist in strengthening competence-based NI education for undergraduate and graduate nursing students [12,26]. A curriculum of this type can help to ensure that future graduate nurses are proficient and competent in NI.
The study has provided recommendations for improving NI curricula in Korea. First, nursing schools need to support NI learning by providing educational materials and practical equipment that are currently lacking. Secondly, more uninvolved instructors and nursing professors should be given opportunities to attend training courses on understanding NI. An example of a training course for instructors and professors is furnished by the NI leadership and specialization courses provided by the University of Minnesota, United States of America [25]. This course focuses on going deeper into the training and education leadership skills that are helpful for NI leaders [25]. Voluntary refresher training programs should be introduced for NI instructors. These training programs would provide them with more knowledge about the NI field. Lastly, training of instructors on information systems, the latest IT, and a standard curriculum in NI were considered important.
One limitation of this study was that not all selected nursing schools responded, with response rates of 48.6% and 62.7% for colleges and nursing schools, respectively. However, these response rates were markedly higher than that of 35.3% for the 77 nursing schools analyzed in 2016 by Jeon and colleagues.
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