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A study of transformational change at three schools of nursing implementing healthcare informatics

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Title:
A study of transformational change at three schools of nursing implementing healthcare informatics
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English
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Cornell, Revonda Leota
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University of South Florida
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Higher Education
Eckel and Kezar (2003)
St. Scholastica
University of Kansas
Electronic health record
Dissertations, Academic -- Adult, Career, & Higher Education -- Masters -- USF   ( lcsh )
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non-fiction   ( marcgt )

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Summary:
ABSTRACT: The Health Professions Education: A Bridge to Quality (IOM, 2003) proposed strategies for higher education leaders and faculty to transform their institutions in ways that address the healthcare problems. This study provides higher education leaders and faculty with empirical data about the processes of change involved to implement the core competency of healthcare informatics. I chose the core competency of health care informatics as a base from which to conduct semi-structured interviews with faculty and college leaders at three schools of nursing intending to capture their stories about how healthcare informatics has been implemented, what strategies were used, and why they were selected. All three nursing schools used patient case scenarios loaded into electronic health records in their computerized human simulation laboratories.Participants' at all three nursing programs reported increased use of the pedagogical approaches of active learning and problem-based learning in these simulation labs. These approaches encourage greater faculty-student and student-to-student interaction, engender more self-directed learning, and do a better job of providing students with a process for integrating previous learning. University of Kansas and Large State University Schools of Nursing demonstrated results that substantiate the viability of the Mobile Model for Transformational Change. One school used almost all the suggested methods and achieved transformation; the other, which used some of the methods, was not transformed. I suggest the model would benefit from specific ways of detecting the breadth in the application of the change markers and from the addition of strategies for creating a breadth of intensity to the change processes.The components of the model relating to the structural and cultural markers of change need to be further developed to focus on the breadth of change. Finally, I suggest the Mobile Model needs greater emphasis on and clarification of the role and nature of intentionality in the change process, as well as a greater focus on the relationship between the core strategies, support strategies, and the breadth of change. The intent of college leaders is important, in part because without it the breadth of change required for transformational change is not likely to be achieved.
Thesis:
Dissertation (Ed.D.)--University of South Florida, 2009.
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Includes bibliographical references.
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by Revonda Leota Cornell.
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Title from PDF of title page.
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Document formatted into pages; contains 261 pages.

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A Study of Transformational Change at Three Schools of Nursing Implementing Healthcare Informatics by Revonda Leota Cornell A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Education Department of Adult, Career, & Higher Education College of Education University of South Florida Major Professor: James Eison, Ph.D. Michael Mills, Ph.D. W. Robert Sullins, Ed.D. H. William Heller, Ph.D. Date of Approval: March 11, 2009 Keywords: Higher Education, Eckel and Kezar (2003), St. Scholastica, University of Kansas, electronic health record, IOM Copyright 2009 Revonda Leota Cornell

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Dedication Although neither my mother nor my uncle wi ll be able to celebrate with me in their physical bodies, their spir its will always be intertwine d with mine. To my mom, Betty Crews Wyles, thank you for instilling in me the importance of an education. To my Uncle Jimmy Crews, your valuable support and recognition throughout my life has been a treasured gift. I want to extend appreciation to all my fr iends who have patiently listened to my personal stories, trials and tribulations as I progressed on my journey to complete my doctoral studies. A special thanks to my friends Nancy Mills, Cathy Salas, and Julia Larson, who encouraged me every step of the way as I wrote this dissertation.

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Acknowledgements I would like to express my gratitude to my dissertati on committee, especially to Dr. Michael Mills, my chair and advisor. He continually amazed me with his calmness and endless patience through this challenging time of my life, and I will be forever grateful. A special thanks to Dr. Bill Heller who assisted me in beginning my personal journey to doctoral studies. Finally, to the Deans of Nursing who s upported my research at the schools of nursing: I hope this research serves beneficial to your on-going transformational change journeys.

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i Table of Contents List of Tables ix Abstract x Chapter One: Introduction 1 Statement of the Problem 2 Theoretical Framework 5 Rationale 7 Cases Selected 10 Qualitative Research Questions 11 Research Design and Methods 12 Educational Significance of the Study 13 Limitations and Delimitations 14 Researcher’s Personal Biases 15 Organization of Remaining Chapters 16 Chapter Two: Review of the Related Literature 18 Synthesis of the Change Model Literature 18 Teleological Change Models 18 Evolutionary Change Models 19 Life-Cycle Change Models 20 Cultural Change Models 20 Social-Cognition Change Models 21 Political/Dialectical Change Models 22 Recommended Change Principl es for Higher Education 23 Other Terms Commonly Used in Change Literature 24 Diffusion 24 Institutionalization 24 Reform 24 Summary of Change Model Literature 25 Transformational Change 26 Definition 26 Differentiating Transformational Change 27 Adjustment 27 Isolated Change 27 Far-Reaching Change 27 Transformational Change 28 Other Types of Change Co mmon to Higher Education 28 Innovation Implementation 28 Adaptation 28 Strategic Change 28

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ii Similarities 29 Dissimilarities 29 Mobile Model for Transformational Change 30 Formulation of Model 30 Key Aspects of the Mobile Model 31 The Role of Sensemaking 31 Five Core Change Strategies 32 Fifteen Supporting Strategies 33 Institutional Culture 35 Types of Evidence 36 Structural Evidence 36 Attitudinal and Cultural Evidence 37 Observations of Transformation Within Organizations 37 Mobile Model of Transformational Change (2003) Cited in Literature 38 Summary of Transformational Change Literature 39 Healthcare Informatics 40 Introduction 40 Strategy One: Common Language and Core Competencies 41 Definitions 41 Debate Over Broad-based Ve rsus Discipline-Specific Language 42 Professional Competencies for Nursing 42 Summary of Common Language and Core Competencies 43 Strategy Two: Integration of Core Competencies into Oversight Processes 45 Oversight Processes Defined 45 Nursing Oversight Agencies 45 State Nursing Licensing Laws 46 Regulating the Scope of Practice 46 Summary for Integration of into Oversight Processes 47 Strategy Three: Motivation, Support for Leadership and Monitoring Progress 47 Supporting Partnerships Between Academic and Practice Settings 47 Support Provided by Professional Organizations 48 Summary for Motivation, S upport for Leadership and Monitoring Progress 49 Strategy Four: Develop Evidence-Based Curricula and Teaching Approaches 50 Overview 50 Defining Evidence-Based Curricula 52 The Undergraduate Curriculum 52 Common Barriers to Informatics Curriculum Development 54 Existing Models for Nursing Informatics Curriculum 54

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iii Collaborative Partnerships 55 Evidence-Based Teaching Approaches for Informatics 56 Example of Education Efforts 57 Summary for Evidence-Based Curricula and Teaching Approaches 57 Strategy Five: Developing Faculty as Teaching/Learning Experts 59 Current Status of Faculty Informatics Competencies 59 A Collaborative Model 60 Incentives to Encourage Faculty Expertise 61 Summary for Faculty Development 62 Summary of Review of Related Literature 62 Chapter Three: Methods 66 Methods for Research Questions 66 Selection of Case Studies 67 Characteristics of Case Study Sites 68 Gaining Access to Study Sites 69 Assuring Protection and Addr essing Ethical Issues 69 Participant Selection 70 Data Collection and Storage 71 Document Review 71 Interviews 71 Design of Interview Questions 72 Opening Questions 72 Initial Questions Regarding Healthcare Informatics 72 First and Second Research Questions 73 Third Research Question 73 Fourth Research Question 73 Closing Question 74 Interview Guide Approach 74 Tape Recording of Interviews 74 Field Notes 75 Data Analysis 76 Computer-Assisted Qualitative Data Management and Analysis 76 Logical Analysis 76 Content Analysis 76 Convergence 77 Test for Completeness 77 Divergence 78 Determining Substantive Significance 78 Trustworthiness and Transferabil ity of Study Data and Findings 79 Chapter Four: Research Findings 82 Findings at University of Kansas School of Nursing 82 Introduction 82

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iv Research Question One: How is Healthcare Informatics Core Competency Addressed? 83 Research Questions Two and Three: What Strategies Were Used, and Why They Were Selected? 85 Culture of Innovation at University of Kansas School of Nursing 85 Academic-Business Partnership 87 Attention to Academic Culture 89 The Role of Sensemaking 91 Academic Template Created Prior to Involving Faculty 92 Electronic Health Record Designed as a Teaching Platform 92 Existing Case Scenarios Computerized 93 Pilot Program began Fall 2001 95 Electronic Health Record Combin ed with Patient Simulator 97 Common Language and Co re Competencies 98 Center for Healthcare Informatics Announced 100 In Summary 102 Core and Supporting Strategies 103 Core Strategy: Senior Administrative Support 104 In Summary 107 Core Strategy: Collaborative Leadership 107 In Summary 109 Core Strategy: Staff Development 110 In Summary 112 Core Strategy: Flexible Vision 112 In Summary 115 Core Strategy: Visible Action 115 Demonstrating Balance 116 Research Question Four: Is University of Kansas School of Nursing Approaching the Shift to Healthcare Informatics as the Broad and Deep Change in Values, Culture and Structures th at Would Characterize a Transformational Change? 117 Findings at Large State Univer sity College of Nursing 121 Introduction 121 Research Question One: How is Healthcare Informatics Core Competency Addressed? 122 Research Questions Two and Three: What Strategies Were Used, and Why They Were Selected? 124 Nursing Informatics Expert Recruited 124 College of Nursing Receives a Federal Grant 125 Faculty Response to Healthcare Informatics Initiative 126 The Role of Sensemaking 129 Grant Year One 131 Electronic Health Reco rd Provider Chosen 131 Structure to Oversee Grant Activities 131

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v Grant Year Two 132 Informatics Content and Technology Implemented in Medical-Surgical and Cr itical Care Courses 132 Patient Case Scenarios Loaded into the Electronic Health Record 133 Nursing Informatics Competencies Established 134 Faculty Education and Development 135 Grant Year Three 136 Pedagogy 137 Student Learning and Assessment Practices 137 In Summary 139 Core and Supporting Strategies 142 Core Strategy: Senior Administrative Support 142 In Summary 143 Core Strategy: Collaborative Leadership 143 In Summary 145 Core Strategy: Staff Development 145 In Summary 146 Core Strategy: Flexible Vision 146 In Summary 148 Core Strategy: Visible Action 148 In Summary 148 Demonstrating Balance 149 Research Question Four: Is Large State University Approaching the Shift to Healthcare Inform atics as the Broad and Deep Change in Values, Culture and Structures that Would Characterize a Transformational Change? 150 In Conclusion 153 Findings at Saint Scholastic a School of Nursing 155 Introduction 155 Research Question One: How is the Healthcare Informatics Core Competency Addressed? 156 Research Questions Two and Three: What Strategies Were Used, and Why They Were Selected? 159 Faculty Subgroup One: Revision of the Undergraduate Nursing Curriculum 160 Faculty Subgroup Two: Implementation of Healthcare Informatics Competencies 160 Attention to Academic Culture 161 Strategies Employed in Academic Year 2002-2003 165 Healthcare Informatics 165 Infrastructure Established 165 Undergraduate Nursing Curricula 165 Review of Undergraduat e Nursing Curricula 165 Strategies Employed in Academic Year 2003-2004 165

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vi Healthcare Informatics 165 Faculty Lead Selected and Trained 165 Electronic Documentation Tools Created for Allied Health Professions 166 Undergraduate Nursing Curriculum 166 Outside Consultant Engaged 166 Active Learning Pedagogy Approach to Curricula Revision Begun 166 Strategies Employed in Academic Year 2004-2005 167 Healthcare Informatics 167 Electronic Health Record Used in One Course 167 Request to Load Case Scenarios into Electronic Health Record Received 168 Center for Leadership and Innovation in Healthcare Established 169 Undergraduate Nursing Curricula 170 Generalist Curricula Approach Selected 170 Strategies Employed in Academic Year 2005-2006 171 Healthcare Informatics 171 Alumni Health Records Load ed into Electronic Health Record 171 First Contract Signed for AT HENS Subscription Service Signed 172 Undergraduate Nursing Curricula 172 Electronic Health Record a nd Other Components Linked 172 Strategies Employed in Academic Year 2006-2007 173 Healthcare Informatics 173 Two Technologies Integrated 173 Title III-A Grant Obje ctives Accomplished 174 Undergraduate Nursing Curricula 174 New Undergraduate Nursing Curricula Phased In 175 In Summary 177 The Role of Sensemaking 178 In Summary 180 Core and Supporting Strategies 181 Core Strategy: Senior Administrative Support 181 In Summary 184 Core Strategy: Collaborative Leadership 184 In Summary 185 Core Strategy: Staff Development 186 In Summary 189 Core Strategy: Flexible Vision 189 In Summary 192 Core Strategy: Visible Action 193 In Summary 193

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vii Demonstrating Balance 194 Research Question Four: Is St. Scholastica School of Nursing Approaching the Shift to Healthcare informatics as the Broad and Deep Change in Values, Culture and Structures that Would Characterize a Transformational Change? 195 Structural Evidence Markers 196 Attitudinal and Cultura l Evidence Markers 196 In Conclusion 197 Chapter Five: Conclusions and Discussion 199 Research Question Four: Transformational Shift to Healthcare Informatics 200 Research Findings 201 Implications of Findings 202 Suggestions for Further Research 203 Research Question One: Teaching Methods, Assignments and Labs 204 Research Findings 204 Implication of Findings 205 Suggestions for Further Research 206 Research Questions Two and Three: Strategies Used and Why 207 Research Findings 208 Why College Leaders Embarked on Major Change 207 Selection of Change Leaders 209 Sources of Funding 210 Healthcare Informatics Core Competencies 211 Development of Competency-Based Curricula and Teaching Approaches 211 Faculty Development 213 Core and Supporting Strategies 213 Attention to Culture and Sensemaking 217 Attention to Balance 221 University of Kansas School of Nursing 221 St. Scholastica School of Nursing 222 Large State University College of Nursing 223 Implications of Findings 223 Suggestions for Further Research 227 Implications for Theory 228 Conclusion 229 References Cited 231 Appendices 248 Appendix A: Eckel and Kezar’s (2003) Mobile Model for Transformational Change 248 Appendix B: Eckel and Kezar’s (2003) Typology of Change 249

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viii Appendix C: Nursing Informatics Experts Recommended 250 Appendix D: USF IRB Approval Letter 252 Appendix E: USF IRB Approved Consent Form 254 Appendix F: Interview Guide 257 Appendix G: Deans of Nursing Appr oval Letter to Iden tify Institution 259 Appendix H: Cerner Corporation Appr oval Letter to Identify Company 261 About the Author End Page

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ix List of Tables Table 1: St. Scholastica Timeline by Year of Strategies of Two Separate Faculty Groups 164 Table 2: Supporting Strategies Evident in the Three Cases 215

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x A Study of Transformational Change at Three Schools of Nursing Implementing Healthcare Informatics Revonda Leota Cornell ABSTRACT The Health Professions Education: A Bridge to Quality (IOM, 2003) proposed strategies for higher education leaders and faculty to transform their institutions in ways that address the healthcare problems. This study provides higher education leaders and faculty with empirical data a bout the processes of change i nvolved to implement the core competency of healthcare informatics. I chose the core competency of health care informatics as a base from which to conduct semi-structured interviews with faculty and college leaders at three schools of nursing in tending to capture th eir stories about how healthcare informatics has been implemented, what strategies were used, and why they were selected. All three nursing schools used patient case sc enarios loaded into electronic health records in their computerized human simulati on laboratories. Participants’ at all three nursing programs reported increased use of th e pedagogical approaches of active learning and problem-based learning in these simula tion labs. These approaches encourage greater faculty-student and st udent-to-student interaction, engender more self-directed learning, and do a better job of providing student s with a process for integrating previous learning.

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xi University of Kansas and Large State University Schools of Nursing demonstrated results that substantiate the viability of th e Mobile Model for Transformational Change. One school used almost all the suggested methods and achieved transformation; the other, whic h used some of the methods, was not transformed. I suggest the model would bene fit from specific ways of detecting the breadth in the applicat ion of the change markers and from the addition of strategies for creating a breadth of intensity to the change processes. The components of the model relating to the structural and cultural markers of change need to be further developed to focus on the breadth of change. Finally, I suggest the Mobile Model needs greater emphasis on and clarification of the role and nature of intentionality in the change process, as well as a greater focus on the re lationship between the core strategies, support strategies, and the breadth of change. The inte nt of college leaders is important, in part because without it the breadth of change re quired for transformational change is not likely to be achieved.

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1 Chapter One Introduction A national panel of health care experts c oncluded that the American Health care system may be dangerous to our heal th; estimating that between 44,000 and 94,000 hospital patients die annually in the United St ates due to medical e rrors. Medical studies documented overuse, misuse and underuse of health care services: over-prescription of antibiotics, incorrect dosages of drugs, and lack of effective prevention strategies with patients (Chassin, Galvin, & the National Roundtable on Health Care Quality, 1998; Schuster, McGlynn, & Brook, 1998; (U.S. Departme nt of Health Resources and Services Administration [HRSA], 2000). The Institute of Medicine [IOM] confir med these safety problems and published recommendations in their report, To Err Is Human: Buildi ng A Safer Health System (1999), declaring that serious safety problems exis t because of the health care system’s ineffectiveness in translating knowledge into practice, in using new technology, and in making the best use of its human and fina ncial resources. The report reiterated the responsibilities of heal th care systems for employing profe ssionals to enhance the clinical environment by (a) redesigning clinical system s in which they practice, and (b) ensuring that schools of higher education adequately prepare health care professionals to enter the health care system. A second report from the IOM, Crossing the Quality Chasm (IOM, 2001) provided its vision for the American health care system, establishing an ambitious

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2 agenda for leaders to redesign a broken syst em and making it clear that reform around the edges would be inadequate. As a result, the national advisory counc ils in medicine a nd nursing are facing intense pressure to transform the way nurses and doctors are educated and trained in the United States. Representative members from HR SA, the Bureau of Health Professions, Division of Nursing, the Council on Graduate Medical Education (COGME), and the (National Advisory Council on Nurse Educa tion and Practice [NAC NEP], 1997) reported to Congress that existing pr ofessional cultures and the re latively slow evolutionary processes that govern change in higher education are inadeq uate to counter the present level of threat to patie nt safety (HRSA, 2000). Statement of the Problem Despite the many calls for reform and tr ansformation in health professions' education, higher education cha nge literature does not fully address the processes needed to implement transformational change (Kezar 2001; Eckel & Kezar, 2003). According to Eckel and Kezar (2003), “Transformational chan ge is unfamiliar territory for most higher education leaders, uncommon for most institutions, and little discussed in the literature” (p. ix). In their book, Taking the Reins: Institutional Transformation in High Education (2003) they continue: Institutional leaders and policy makers have neither the experience with institutional transformational nor a solid empirical literature base on which to draw. There is little meani ngful data to advance an understanding of the process of large-scale or transfor mational change. (p. x)

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3 Thus, no adequate road map exists for accomplishing the significant changes the IOM is seeking. In 2001, HRSA requested the IOM’s Boar d to convene an interdisciplinary education committee to create strategies for restructuring the alli ed health, medical, nursing, and pharmacy professions’ educatio nal systems. The Health Professions Education Summit held June 17-18, 2002, includ ed 150 individuals whose participation was recommended by COGME, NACNEP (1997) and HRSA. Literature, including the existing requirements and standards promul gated by accrediting and licensing bodies and interested organizations, provi ded evaluative data for the summit participants. They worked in small interdisciplinary groups to draft an overall vision statement and to propose strategies for educational reform. Th is resulted in a third published report (IOM, 2003). The third report, Health Professions Education: A Bridge to Quality (IOM, 2003), provided the following vision statement, inclusiv e of five core competencies: “All health professionals should be educat ed to deliver patient-cente red care as members of an interdisciplinary team, emphasizing eviden ced-based practice, quality improvement approaches, and informatics” (IOM, 2003, p. 23). Five cross-cutting strategies were recommended for each of the competencies: 1. define a common language and core competencies across the health professions 2. integrate the core competencies into the oversight process 3. motivate and support leaders and mon itor the progress of the overall reform effort

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4 4. develop evidence-based curricula and teaching approaches relating to informatics 5. develop faculty as teaching a nd learning experts. (p. 156) According to Ehnfors and Grobe (2 004), the core competencies are inoperable without health care profe ssionals who are knowledgeable about informatics. In my research, I define informatics as the information technology needed in the deliver y of patient care. Crossing the Quality Chasm (IOM, 2001) refers to healthcare informatics as the most significant tool to improve patient safety, to translate scientific clinical know ledge into practice, to decrease the chasm between what is acknowledged as good car e and the care actu ally provided, to enhance communication among the health care teams, to increase effective coordination of patient care, to redesign processes of patie nt care, and to effectively use human and financial resources. Nursing is a major professional discipline within the health care industry. A report published by the NACNEP (1997) revealed th at practicing nurses are not generally computer literate and recommended incorpora ting informatics skills and competencies at all levels of nursing education. Incorporating informatics skills and competencies can be accomplished, according to the report, by teac hing information seeking and evaluation skills and integrating nursing informatics into nursing science, prac tice, and education. Healthcare informatics is a new core competen cy but still is not re quired for licensure by any state boards in any of the health care professions.

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5 Theoretical Framework The Health Professions Education: A Bridge to Quality report (IOM, 2003) clearly documents the need for reform and transformation of higher education. Reform refers “to an innovation that is typically exerted from the top of a system or organization, or from outside the organization” (Kezar, 2001, p. 14). A number of the IOM recommendations focus on oversight organizations because the IOM committee believes that integrating a core set of competencies one that is shared across the professions into health professions’ oversight pr ocesses would provide a good deal of leverage in terms of reform and is an important first step in aligning incentives and providing a catalyst for both educ ational institutions and professional associations to make necessary change s. This effort would build upon existing efforts and create synergies across the disciplines. (IOM, 2003, p. 121) Thus, external bodies are being called upon to help encourage the institutions of higher education to transform c linical training, to conduct rese arch, and to participate in leadership development and training of facu lty toward meeting the overall vision (IOM, 2003). Transformational change is defined as “change affecting institutional cultures, [as] deep and pervasive, [as] intentional, and [as] occurring over time” (Kezar, 2001, p. 27). This type of change alters “organizat ional structures and processes, leads to reorganized priorities, affects organizatio nal assumptions and ideologies, and is a collective, institution-wide undertak ing” (Kezar, 2001, p. 53). The 2002 Health Professions Educational Summ it recommends transformation of the educational system

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6 by involving the culture, prof essional values, and the existi ng infrastructure in which professions are educated. This provided an opportunity for me to conduct case studies of the change process in three U.S. baccalaur eate schools of nursing that have demonstrated exemplary progress toward meeting the h ealthcare informatics core competency. Eckel and Kezar’s (2003) Mobile Model for Transformational Change (See Appendix A) provides a structur e to conceptualize transformational change processes, and serves as a coherent fram ework to guide me in capturing emerging themes within the change process in the selected schools. Tran sformational change is different from other types of change in its focus on institutional culture, values and ba sic assumptions, as well as, intentional conversations re lating to the impact of the da ily work environment of the people involved. Eckel and Kezar (2003) found getting “pe ople to think differently” is more important than anything else Leaders at the transformi ng colleges and universities explore the meanings of proposed changes fo r faculty work and pedagogies, and create a personal reality by continually negotiating m eaning and trying to reach consistent new understanding within the shifting faculty work environment. This process of “getting people to adopt new mind-sets is a cognitive and intellectual process spurred by a set of activities that can be intentionally designe d to leave behind old ideas, assumptions, and mental models” (p. 73). In the organizational behavior literature this process is known as organizational sensemaking (Gioia & Chittipeddi, 1991; March, 1994; Weick, 1995). The Mobile Model (See Appendix A) consists of five core change strategies: (a) senior administrative support; (b) collaborative leadership ; (c) staff development; (d) flexible vision; and (e) visible action. An additional 15 supporting strategies, which do

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7 not occur as frequently as the five core stra tegies, play a significant role in facilitating transformational change. Like a mobile, the va rious interdependent change strategies may move independently, and are connected dir ectly or indirectly to one another. Transformational change is associated w ith particular strategies and activities directed toward implementation of new pro cesses inclusive of structural, cultural and attitudinal markers of progress. The structural evidence markers are those familiar concrete measurements that can be counted a nd measured to baseline sets of data. The additional evidence of attitudi nal and cultural shif ts suggests more depth to the change. The 2002 Educational Summit strategies refere nce various structural, attitudinal, and cultural changes as objectives and/or issues needing to be addressed. For example, structural markers of progress cited by both Eckel and Kezar (2003) and the 2002 Educational Summit strategies include cha nges in curriculum in pedagogies, student learning and assessment practices, policies, budgets, new departments and institutional structures and new decisionmaking structures. Examples of cultural and attitudinal markers of progress cited include changes in the patterns of interactions between individuals or groups, changes in the campus self-image, changes in the types of conversations, and in new attitudes and beliefs. Rationale The literature on change in higher education does not fo cus on transformation as a specific type of change. Instead, as (Eck el & Kezar, 2003, p. x) remark, “change, as a broad topic, is informative about the content of change, what factor s are related to the change outcomes, and the conditions related to change, but not the processes leaders must use to bring about change, let alone transformation”.

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8 In 2001, the National Advisory Councils in Medicine and Nursing publicly acknowledged a need for tran sformational change in the way nurses and doctors are educated and trained in the United States The 2002 Health Professions Education Summit published a vision statement and strategi es for restructuring the allied health, medical, pharmacy and nursing professions’ educational systems in the IOM (2003) document. Governmental and regulatory agen cies overseeing health care quality have scheduled conferences and meeti ngs to address the serious pati ent safety issues raised in the IOM reports. The external bodies governing professiona l nursing education are establishing accountability processes to monitor the progres s of the overall reform effort. The IOM (2003) recommended biennial inte rdisciplinary summit meetings to be held beginning in 2004. These summit meetings were to focus on reviewing progress toward explicit targets as well as establishing objectives for the next phase in preparing professionals for the 21st century health care system. The Agency for Health care Research and Quality [AHRQ], 2005, as the nation’s lead research agency on Health care quality, patient safety, efficiency and effectiveness, serves a critic al oversight ro le of the adoption of health information technology. AHRQ (2005) assembled the first joint conference for Patient Safety and Health Information Technol ogy June 6-10, 2005 and awarded $139 million to promote adoption of and access to health information technology and to establish mechanisms for monitoring reform efforts. Long-standing professional values of each school, i.e., allied health, medical, nursing and pharmacy, as well as clinical arenas housed within separate infrastructures, have resulted in the protection of specific specialties or interest s (Enarson & Burg, 1992;

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9 Regan-Smith, 1998). Factors contributing to a lack of coordination and collaboration among health professions’ education leadersh ip and faculty members include: differing professional and personal perspectives and values ; role competition; turf issues; lack of a common language; variations in professi onal socialization processes; differing accreditation and licensure regulatory bodies; different payment systems; as well as existing hierarchies that emphasize individua l responsibility for decision making and result in hesitancy to solic it input of others (IOM, 2003). Specific issues relating to curriculum include, but are not confined to, the limited efficacy of a competency-based and/or evidence-based curriculum and the hidden curriculum. Faculty time and the reward system within higher educa tion are issues across the transformational change process, which, however, become reality at the grassroots level in revising the curriculum across disc iplines. The reward system within higher education provides incen tives to conduct research. The revision of a curriculum across disciplines involves time and c onflict, with little or no reward for being involved. Distrust and hostility continues to ex ist over the scope of practi ce among the professions (IOM, 2003). I designed an interview guide (Appendix F) to ask open-ended questions to capture the participants’ own stories relati ng to how each school is addressing the new competency of healthcare informatics. I focused on the respective strategies (critical decisions, improvements, and/or processes) being used, and why these particular strategies were selected. The case study me thod allowed enough flexibility and openness that participants were encour aged to tell about their expe riences and the meanings they attached to the processes of the changes. I will link data collection to the Mobile Model

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10 to answer my fourth research question, “Are these institutions approaching the shift to healthcare informatics as a broad and deep chan ge in values, culture and structures that would characterize a tran sformational change?” Cases Selected The IOM (2003) recommendations included co nducting “a best-practice review of universities that have integrated the five co mpetencies into their curricula to understand what they do and how/why it is a best practice” (IOM, page 166). In line with this, I have selected three Schools of Nursing perceived by nursing informatics experts as exemplary in their efforts to meet the core competency for healthcare inform atics. These schools are : (a) the University of Iowa, Iowa City, Iowa ; (b) University of Kansas Medical Center, Kansas City, Kansas; and (c) St. Scholastica. The University of Iowa did not meet the inclusion criteria, necessitating the need to select a third case site. During my on-site visits, the University of Ma ryland and Large State Univer sity (anonymity requested by Dean of Nursing) were mentioned as potenti al sites to study. The Un iversity of Maryland did not meet the inclusion criteria for my study. The College of Nursing at Large State University did meet the incl usion criteria for this study. All three nursing programs are accredited by the Commission on Collegiate Nurs ing Education and th eir respective state boards of nursing. The University of Kansas is a major public research and teachi ng facility with an overall 2005-06 student enrollment of 29,272. The baccalaureate nursing program enrolls some 300 students. The website notes th at the school is the first to incorporate healthcare informatics into its curriculum. It is ranked 21st in the nation among public

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11 nursing schools funded by the Natio nal Institutes of Health ( http://www2.kumc.edu/son/centennial.htm). St. Scholastica is a private college with an overall 2005-06 student enrollment of 3,249. The baccalaureate nursing program enro lls up to 112 students each fall semester. The main campus is located in Duluth, Minnesota ( http://www.css.edu/About _St_Scholastica.html ). Large State University is a coeducati onal public research university with an enrollment exceeding 50,000. A faculty numbering more than 2,000 offers over 170 majors. There are 23 different schools and co lleges, including pr ofessional schools in dentistry, law, veterinary medicine, medical professions, medicine and public health, nursing, and social work. It has 120 nursing faculty member s. In 2007, the college of nursing graduated 225 students (Large State University reference 1). Qualitative Research Questions The research questions that will guide this study are: 1. How is healthcare informatics core competency being addressed in three exemplary schools of nursing? 2. What are the institutions’ particular strategies (critical decisions, improvements, and/or processes) bei ng used to address the healthcare informatics core competency? 3. Why are those particular strategies (critical decisions, improvements, and/or processes) being used?

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12 4. Are these institutions approaching the sh ift to healthcare informatics as a broad and deep change in values, culture and struct ures that would characterize a transformational change? Research Design and Methods Yin (1994) identifies three conditions for the case study method: 1) the research questions are ‘how’ and ‘why’ questions; 2) the researcher has limited control over events; and 3) the focus is on a contemporar y, real-life phenomenon in which context is important. My research questions focus on how each school of nursing is implementing widespread transformational change and why its particular strategies (critical decisions, improvements and/or processes) aimed at addressing the healthcare informatics core competencies are working. The second condition is met because I have no control over the plans and actions of the nursing colle ges as they take on the challenge of implementing healthcare informatics. The th ird condition, a focus on contemporary, reallife phenomena and organizati onal context is important for fully understanding the patterns of change and change processes in each of the thr ee schools of nursing. The case study method will allow inside r descriptions and interpretations regarding the ways in which the three schools are addressing healthcare informatics. Additional insight may be obtained by identify ing the core change strategies employed by college leadership and faculty. This could incl ude responsiveness to in ternal or external environments, involvement of organizati onal members, and planned or unplanned components of the change process. The qualitative research methods empl oyed in this study will allow enough flexibility and openness that the participants can relay the experiences and the meanings

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13 they attach to them during interviews. Case studies of three exemplary schools of nursing will provide insider desc riptions and interpretations of the meaning of experience by the participants relating to the inner workings of the chan ge components, core change strategies, including interrela tionships among the strategies, the role of sensemaking and the institutional culture. Inquiry into successful strategies, critical decisions, improvements, and processes should reveal concepts relating to the for ces and sources of change (Kezar, 2001). The emerging themes should provide insight into whether the instituti ons are, in fact, approaching the shift to healthcare informatic s as a broad and deep change in values, cultures and structures indicativ e of transformational change. Educational Significance of the Study Providing leaders and faculty within higher education with empirical data can be beneficial in that they will be able to review the study fo r applicability to their own institutions. Again, Eckel and Kezar (2003, p. xi): When institutional leaders (both faculty and administrators) can take the reins of change, they and the institutions they se rve are in much better positions to fulfill the important social roles colleges and uni versities must play in a future highly driven by information and knowledge. IOM (2001) established an ambitious agenda to transform the educational system and to address serious safety problems with in the American health care system. The causes of patient safety problems as cited by IOM (2000) include th e inability of the health care graduates to tr anslate knowledge into pract ice, to use new technology appropriately, and to make effective use of available resources. This study will focus on

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14 capturing the activities of institutions of highe r education during the initial years of their response to the IOM (2003) recommendations. Lincoln and Guba (1985, p. 229) noted that “what is written by organizations is rarely closely related to what is actually implemented.” My di rect observations and interviews with participants within three schools of nursing are intended to capture independent accounst of what has been impl emented and the organizational conditions and processes that contributed to it. Kezar (2001) asserts there is only limite d research examining the role of accreditation and/or professional associations in the change process. This study may expose some professional culture, values, a nd perceptions related to regulatory and/or governmental agencies mandating and pressuring for change. Limitations and Delimitations Locke, Spirduso, and Silverman (2000) define limitations as the ‘limiting’ conditions or restrictive weaknesses of the research conducted. By nature, qualitative findings are highly context a nd case dependent. Delimitations describe those populations to which generalizations may safely be made. The three kinds of sampling limitations which typically arise in qualitative research designs are applicable to this study. The sites I have chosen are exemplary nursing schools as perceived by nursing inform atics experts. Clearly delineating the purpose and limitations of the sample studied —and, therefore, be ing cautious about extrapolating or generalizing the findings —i s paramount. Maintaining proper context in reporting both methods and results will avoi d the many controversies that result from overgeneralization from purposeful samples (Patton, 2002).

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15 The limitations of the data collected usi ng the interviewing approach may involve any of the following: a) I may affect the s ituation during the inte rview in unknown ways; b) my observations focus only on external behaviors which I observe; and c) my observations focus on those limited activities actually observed and responses garnered during one-hour interviews. In addition, res ponses by faculty member s are influenced by any number of factors, includi ng personal biases, subject re call, self-serving motives, openness and honesty. The deans of schools of nursing or their designees will recommend the people to be interviewed. The participants may, therefore, be advocates who represent the administration position on the changes to informatics. My study relies on the participants being open and candid in their discussion of the events and issues. I intend to connect the broa der literature of transfor mational change, the Mobile Model, the larger lessons about change, and appropriateness of theore tical considerations to the data collected from three scho ols of nursing. Patton (2002) supports the generalization for case study findings of le ssons learned from program improvement processes. Researcher’s Personal Biases The knowledge of and bias regarding the to pic can influence the interview and the analysis of the data collect ed. My professional experience includes serving as a hospital chief operating officer, chief nurse executive, an d independent health care consultant, all roles in which I was involved in major cha nge processes. Additionally, I have recent experience implementing healthcare informatic s in hospitals. I do not have any prior experience in nursing education and I have no knowledge of or working relationships with the three institu tions that are the sites for the study.

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16 My own personal biases that could impact the study include the following: First, I support a combination of several change m odels to enhance understanding of the complexity of organizational change. The evolutionary, social cognition, cultural and political/dialectical change m odels, further described in Chap ter 2, are my preference for consideration in any change strategy. I feel th e Mobile Model for Transformational Change provides a practicable framework. A second bias is that I anticipate the School s of Nursing will be in the ‘isolated change’ or ‘far-reaching’ change quadrants vers us at the transformational change of high depth and high pervasiveness (See Appendix B). Eckel and Kezar’s (2003) research confirmed transformational change takes time to reach fruition. University of Kansas School of Nursing had addressed the core co mpetencies of healthcare informatics six years prior to my on-site visit; and has, by measure of Eckel and Kezar’s (2003) Mobile Model, achieved transformational change. My third potential bias relates to the broad-based versus discipline-specific competencies. I believe the competencies cited in the IOM (2003) recommendations provide the core competencies that each h ealth care professional should possess in order to enhance communication across the discip lines. In addition, discipline specific competencies are needed for each health care profession at various levels of knowledge and experience. Organization of Remaining Chapters Chapter Two includes the review of litera ture relating to the following: (a) Kezar’s (2001) overall s ynthesis of current change theories in higher education; (b) brief overview of transformational change; (c) di scussion of Eckel and Kezar (2003) Mobile

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17 Model of Transformation Change for higher ed ucation; and (d) the nature and status healthcare informatics organized according to five cross-cutting strategies proposed by the participants in the 2002 Education Summit to transform the American educational system. Chapter Three includes a description of the qualitative method and design of the study.

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18 Chapter Two Review of the Related Literature The purpose of this chapter is to provide a brief overview of (a) of Kezar’s (2001) synthesis of current change models, (b) tr ansformational change, (c) the Mobile Model for Transformational Change, and (d) the five cross-cutting strategies proposed by the 2002 Education Summit participants rela ting to healthcare informatics. Synthesis of the Change Model Literature Kezar (2001) conducted an extensive review of the change model literature across the multidisciplinary fields. Six models of change exist: a) teleological, b) life cycle, c) evolutionary, d) dialectical, e) social cognition, and f) cultura l. A brief explanation of the teleological, life-cycle and evolutionary models of change will provide a more detailed explanation of the models in which the di stinctive organizationa l features of higher education are best interpreted: cultural, social-cognition, and political/dialect ical (Kezar, 2001). Teleological Change Models Although the teleological change models are the dominant models and the evolutionary models the second most comm on category in the change literature, the assumptions within these models are counter to the culture with in higher education institutions. Teleological models make the assumption that organi zations are purposeful and adaptive, and place the least amount of fo cus on individuals as active participants of

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19 the change process. Teleological models em phasize the critical n ecessity of planned change in a rational and lin ear process (Kezar, 2001). Evolutionary Change Models The evolutionary models of change fo cus on the interaction between external forces and the organization (Kezar, 2001). The organization must respond to the demands of the external environment in orde r to survive (Cameron, 1991; Kezar, 2001). Accreditation agencies, foundations, and legi slatures are some of the environmental forces or sources demanding change. The determ inistic nature of the evolutionary models limits any human influence, strategic c hoice, and creativity in response to the environment (Kezar, 2001). According to Co llins (1998), evolutionary models fail to provide needed assumptions about human ps ychology, organization of work, and the way organizations fit into societ y (Collins, 1998; Kezar, 2001). Although the evolutionary model assumptions have mixed reviews in the change literature of higher education, they may pr ovide useful insights (Kezar 2001). Higher education often responds to the external environment by accepting additional responsibilities and functions, and change o ccurs by differentiation and accretion (Clark, 1983; Kezar, 2001). According to Gumport and Pusser (1999), the organization becomes more fragmented and less coordinated in an already structurally complex and differentiated system. Clark’s ( 1983) analysis of change in higher education over the last few hundred years revealed tremendous amount s of change. The disorder of change within loosely coupled structures often hides the ongoing adaptiv e change processes within higher education.

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20 Life-cycle Change Models The major assumptions of these models include the utilizatio n by leadership of pre-determined principles for each stage of organizational development to guide the individuals within th e organization. Individual developm ent, training and development, and learning and unlearning habi ts are some of the key priorities within these models (Kezar, 2001). Cultural Change Models The cultural change models assume that ch ange occurs in resp onse to alterations in the internal human environment (Morga n, 1986), including alteration of values, beliefs, myths, and rituals (Cohen & March, 1974; Schein, 1985; Kezar, 2001; Eckel & Eckel, 2003). The cultural models tend to pl ace emphasis on the collective process of change and the significant role of each individua l in the change process. Such change is long-term, slow, unpredictable, non-sequentia l, and seemingly unmanageable (Kezar, 2001). Some cultural models focus on the lead ers’ ability to shape both organizational and shared culture, while other cultural mode ls focus on all organi zational participants’ interpretation of creating cha nge (Martin, 1992; Kezar, 2001). According to Kezar (2001) cultural m odels provide the following themes to consider in understanding change within higher education: 1. institutional history and tradi tions need to be understood and incorporated into the planning process 2. symbolism can create change 3. culture affects the change process 4. deep transformational change is uncommon

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21 5. characteristics of the change pr ocess include irrationality and ambiguity 6. a frequent lack of interpretive pow er of the notion of a culture of change. (p. 105) Social-Cognition Change Models According to Collins (1998) and Kezar (2001), the social-cognition models follow the cultural theorists and incorporated human behavior Both cultural and socialcognition models agree that change can be planned or unplanned, can be regressive or progressive, and can contain intended or non-intended outco mes and actions (Smirich, 1983; Kezar, 2001). Change as a result of cogniti ve dissonance pays greater attention to individual learning and indi vidual sense-making, and alte rs individual beliefs and construction of reality. The social cogniti on models emphasize discussion and learning among the participants. Accordi ng to Weick (1995), the opport unity for participants to discuss, debate, reframe, and make sense of the proposed changes allows for creative results. Social-cognition models examine the how of change rather than merely identifying variables associated with the cha nge process. It examines how leaders shape the change process through framing and inte rpretation, and how indi viduals interpret and make sense of change (Harris, 1996; Kezar 2001). The criticism of social-cognition models is that they have a tendency to lo se sight of the larg er perspectives, the interconnectedness within the organization and the influence of the environment and external factors on change (Kezar, 2001).

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22 Political/Dialectical Change Models The political/dialectical models are the final category of change models. These models are deterministic in nature, assuming that inherent conflict will create change. The term dialectical is used interchangeably w ith political and refers to ‘a pattern, value, ideal, or norm in an organization [which is] always…present with its polar opposite’ (Schein, 2004, p. 40). Here, change is the result of conflict and clashing of belief systems, and is the natural part of human interactions. Dominant coalitions manipulate their power to preserve status quo and maintain their privilege. As an elite group or ideol ogy tries to maintain power and authority, tension builds and the two forces eventually clash, resulting in radi cal change. Inactivity is prevalent, with people flowing in and out of groups, and mobilizing when resources are constrained and changes are pending. Activities are not the focus; rather, it is bargaining, persuasion, and conflict. Environmental influe nces are not addresse d and the change is not always progressive (Kezar, 2001). Political or dialectical m odels appear to have st rong explanatory power for understanding the way change occurs and in providing strategies for effectively facilitating change. Key findings include: 1. interest groups and power within higher education are important for creating change 2. engagement of persuasion and in fluence strategies are necessary 3. informal processes are significant to change 4. an assessment of the efficacy of persistence is important

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23 5. the realization that politics can prevent change 6. change frequently requires mediation. (Kezar, 2001, p. 93) Recommended Change Principles for Higher Education Several principles emerged from Kezar’s sy nthesis for change agents to consider regarding change within hi gher education. The understa nding of the distinctive characteristics of higher education such as shared governance, as well as the loosely coupled environment of higher education should always be considered. Change must be realized as a human process, encouraging in clusiveness of organizational members. It must be understood that institutional culture s shape the reason change emerges and the way the process occurs, as well as shaping the change outcomes. It is necessary to analyze the existing political groups, political dynamics, and conflicts, as well as the motivations behind each political group and/or conflict. Informal political processes can be used in change processes. Hearn (1996) pr ovides leaders with so me applications of change research for use on cam puses. In his article entitled Transforming U. S. Higher Education, he argues that four overall propositio ns can be made about change: 1. it is nave not to recognize the politics within an institution 2. effective change strategies must be successfully integrated into the existing institutional culture 3. organizations must be in accord with their critical sources of funding, prestige, and personnel 4. disruption and accretion are both require d in any change effort. (Kezar, 2001, p. 113)

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24 Other Terms Commonly Used In Change Literature Many higher education leader s think of change in terms of diffusion or institutionalization. Both are pa rts of particular change m odels, but are not distinctive change models in themselves. Diffusion a nd institutionalization have become popular because they respond to different challenges in the change process (Kezar, 2001). Reform is also defined below. Diffusion. According to Kezar (2001), ther e is a difference between the terms diffusion and diffusion models When people consider how to make others adopt a particular idea or trend in the environment, they are typically thinking about diffusion. Diffusion is an important change strategy, but is not a change model or an overall approach to change (Kezar, 2001, p. 13). Diffusion models tend to rely on innovation. These models are popular in th e area of technology where in novations occur at a rapid pace, and adoption often happens at the individual level. Institutionalization. Institutionalization is discussed as a process and as a change outcome, examining only a part of the process, and whether the change process alters the work of the individuals over time (Curr y, 1992; Kezar, 2001). As a change process, institutionalization includes preparing the organization for the change (mobilization), introduction of the change, implementation of the change, and stabilization of the system in its new state (institu tionalization) (Kezar, 2001). Reform. Reform refers to “an innovation that is typically exerted from the top of a system or organization or from out side the organization” (Kezar, 2001, p. 14). Innovation refers to a ‘tangible pr oduct, process, or procedure th at is new, intentional, not routine,

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25 that is aimed at producing benef its, and is public in its effects. There is less literature on reform in higher education due to its decen tralized, autonomous structure’ (Kezar, 2001, p. 14). Summary of Change Model Literature The Health Professions Education: A Bridge to Quality (IOM, 2003) goal is deep and pervasive change to affect institutional cu lture within health ca re professional higher education organizations. The ex isting professional cultures and the relatively slow evolutionary processes which govern higher education are inadequate to meet the acknowledged patient safety problems. The cha nge literature lacks the broad, conceptual knowledge base necessary to cr eate and sustain change with in higher education. Higher education change literature does not fully addr ess the processes needed for leaders within higher education to implement the IOM (2003) transformational change expectations. Van de Ven and Poole (1995) and Kezar (2001) recommend a combination of several change models, each with key processes, to enhance the understanding of different aspects of organizational change within higher education. Kezar’s (2001) synthesis of the change litera ture reveals six change mode ls, each consisting of writers who believe in only one approach to facilita te change. The dis tinctive organizational features in which higher educa tion is best interpreted rely more on the cultural, socialcognition, and political change models. The ev olutionary change models provide insight into the role of the external environment. Reform of higher education begins with innovation exerted from outside the organization, in this situation, accreditation and licensure, to align incentives to provide a catalyst for both educational institutions and professional associations to transform the highe r education of health care professionals.

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26 Kezar (2001) discusses some terms commonly used in the change literature which are part of particular change models, but are not distinctive change models in themselves. I may encounter references to these terms in my research. For example, diffusion models are popular in area of technology where adoptio n often happens at the individual level. Another term, reform, is used in both my re search review and Keza r’s synthesis of the literature. Kezar posits there is less literature on reform in higher education due to the latter’s decentralized and aut onomous structure. Reform of higher education begins with innovation exerted from outside the organizations, in this situation, accreditation and licensure, to align incentives to provide a catalyst for both educational institutions and professional associations to transform highe r education of health care professionals. Transformational Change Definition Transformational change is defined by Eckel and Kezar (2003) as a particular type of change associated with intentiona l strategies to influence deep levels of organizational behavior over a period of time. They assert a lack of empirical data in studies described in the litera ture about transformational chan ge in higher education. This literature predominately tends to be reflect ions of university leaders (e.g., Kerr & Gade, 1986; Birnbaum, 1988, 1992, 2000; Bolman & Deal, 1991; Tierney, 1991; Altbach, Gumport & Johnstone, 2001; Rhodes, 2001; Eckel & Kezar, 2003). The conceptual models, cultural, social-cognition, and po litical, are models for analyzing and understanding change. Research from cultu ral, social-cognition, and political models demonstrate that transformational change is unlikely at most institutions, incremental adjustment being more likely (Kezar, 2001).

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27 Differentiating Transformational Change Eckel and Kezar (2003) differentiate tran sformational change from adjustment, isolated change, and far-reaching change w ith two characteristics: pervasiveness and depth (See Appendix B). Pervasiveness refers to the extent to which a change crosses unit boundaries and affects a range of units and programs within an organization. Depth of change implies a shift in values and a ssumptions, with people thinking and acting differently. Adjustment. Adjustment is located in the low depth and low pervasiveness quadrant of Eckel and Kezar’s (2003) descript ion of movement toward transformational change. Adjustments are the modifications or extensions to improve existing practices and current activities. This t ype of change does not lead to deep change and does not extend very far with in the organization. Isolated change. Isolated change is located in the high depth and low pervasiveness quadrant. The cha nge is deep; however, it is li mited to a single program or a particular area. The depth of the change results in a shift in values and assumptions in the ways of doing things: people think and do th ings differently. The change is limited in its impact on the organiza tion (Eckel & Kezar, 2003). Far-reaching change Far-reaching change is located in the low depth and high pervasiveness quadrant. The change is extens ive within the institution; however, it is limited in its depth and has little impact on va lues, beliefs, and practices (Eckel & Kezar, 2003). Transformational change Transformational change is located in the high depth and high pervasiveness quadrant. It is isol ated change that is far-reaching, and which

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28 affects the underlying assumptions. “These assumptions tell the institution what is important; what to do, why, and how; and wh at to produce” (Eckel & Kezar, 2003, p. 33). Other Types of Change Common to Higher Education Innovation implementation Innovation implementation as described by Eckel and Kezar (2003) includes new, specific, tangible pr oducts, processes, services, or procedures that are intentionally introduced within an organization with expectation of positive and perhaps significant benefits. Innovation pus hes the organization to respond beyond its current established processes. Leadership r ecognizes potential cont ributions of the new innovation within the organiza tion, and adopts the specific, tangible product, process, service, or procedure. Adaptation. Adaptation is described as a delibe rate modification or adjustment by the organization or its units in response to the external e nvironment. The modification or adjustment may be proactive, anticipatory, or reactionary; it can be intentional, or emergent and unplanned, and typically evolve s over time. Adaptati on is systemic; it is comprised of interdependent re lationships with the external environment which can be at the individual unit level vers us organizational-wide; and can allow subunits to adapt to change without widespread organizational disequilibrium. A loosely coupled system can, however, evince lack of coordination, diffi culty responding to change in an unified manner, and communication that is inconsistent (Eckel & Kezar, 2003). Strategic change Strategic change is the proc ess of making an organization distinct from its competitors. It may require that the organization undertake specific changes that will alter its position within its co mpetitive external market (Eckel & Kezar, 2003). Eckel & Kezar also suggest that strategic change is about reshaping the patterns of

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29 decisions and activities w ithin an organization. Raja gopalan and Spreitzer (1996) describe the purpose of reshaping those patter ns as having the inte ntion of testing the external environment and the organization's place within that external environment. Similarities. Transformational change shares some elements of innovation implementation, adaptation, and strategi c change. Innovation implementation and transformational change can be responses to in ternal desires, pressures from the external environment, or a combination of both; and mu st be consistent with organizational needs. Adaptation is similar to transformational cha nge in that both in clude ongoing processes rather than single events and responses to environmental changes. Strategic change and transformational change include change occurr ing in small steps that add up to large effects. Both require changes in decisions a nd activities that most likely occur over time and are responses to changing envi ronments (Eckel & Kezar, 2003). Dissimilarities. Transformational change is dissimilar to innovation implementation in that it focuses on greater breadth and depth of transformation; change is predominantly focused on a specific tangible product, service, or procedure, but may, however, include a variety of innovations. Tr ansformational change is organizationalwide and intentional as compared to adaptati on, the latter of which may be local or not necessarily organizational-wide, and may lack intentionality. Tran sformational change differs from strategic change in that it is inte ntional, cultural and deep, with a widespread impact. Strategic change may simply be exte nding current activiti es to new areas or markets; it may not be comprehensive and may not have the same degree of intentionality (Eckel & Kezar, 2003).

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30 Mobile Model for Transformational Change Formulation of Model Eckel and Kezar (2003) formulated thei r Mobile Model for Transformational Change based on a study of 26 diverse colleg es and universities pa rticipating in the American Council on Education (ACE) Proj ect on Leadership and Institutional Transformation. The purposes of the ACE Project include assisting institutions to: 1) set and make progress on their own agendas for la rge-scale change; 2) develop reflective skills to understand their change processes; and 3) learn from project institutions so others may benefit. The projec t, originally funded for three and a half years by the W. K. Kellogg Foundation, was later extended for two additional years. All institutions were part of the follow-up; however, as an indicator of the difficulty in implementing transformation change in higher educati on, the book focused on the six institutions actually accomplishing major changes. The six institutions select ed included those institutions making the most progress toward transformational change. Each institut ion experienced a different type of change and employed different change strategies; however, all includ ed significant change that was both deep (values and culture) and broa d (included all or a large portion of the institutions’ faculty and staff). The institutio ns provided important data for understanding which processes helped to effect transfor mation. Eckel and Kezar (2003) asserted the reason most institution-wide change failed was a breakdown in the processes addressing the ‘how’ of change. The distinction reflect ed the authors’ belief that leaders do not spend enough time, energy and/or focus in a ddressing institutional norms, getting the

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31 right people involved, or acknowle dging individuals’ feelings of value during the change processes (Eckel & Kezar, 2003). Key Aspects of the Mobile Model Key aspects of the model include the role of sense-making within organizations, core change strategies, inte rrelationships among core and supporting strategies, and the critical need to pay close attention to th e institutional culture (See Appendix A). Eckel and Kezar (2003) created the metaphor of a mob ile to illustrate the interconnectedness of the transformational components. A mobile moves in haphazard swirls, as does the constantly changing environment within inst itutions. It requires balance and is only functional as a unit. If one part is upset, the whole is impacted. Likewise, the change process consists of various interdependent strategies – independe nt, yet closely linked, either directly or indirectly. The Role of Sensemaking Transformational change creates an un certainty that asks for a collective interpretation of three key ques tions: 1) “what is ’out there’, what is ’in here’, and ‘who must we be’ in order to deal with thes e questions”? (Weick, 1995, p. 70). People within an organization attempt to create a subjectiv e reality by continually negotiating meaning and trying to reach a consistent understandi ng. During significant change periods, this process occurs more frequently. The need for a fresh understanding of the impact of the proposed change has on an individual becomes more important as he/she attempts to fathom the shifting terrain of his/her pe rceived world. Leaders at the transforming colleges and universities explored the meani ngs of proposed changes for faculty work

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32 and pedagogies, creating a personal reality by continua lly negotiating meaning and reaching consistent new understanding within the shifting faculty work environment. Eckel and Kezar (2003) found ‘getting ‘peopl e to think differently’ is the most important factor needed for transformati onal change. According to Schein (1992), cognitive redefinition must precede or acco mpany behavioral change. The institutions forged two types of new understandings. First, they attached new meanings to familiar concepts and ideas; and sec ond, they developed new language and adopted new concepts to describe the changed institution. This pr ocess is known in organizational behavior literature as organizational sensemaki ng (Gioia & Chittipeddi, 1991; March, 1994; Weick, 1995). “Getting people to adopt new mind-sets is a cogn itive and intellectual process spurred by a set of ac tivities that can be intenti onally designed to leave behind old ideas, assumptions, and mental models” (Eckel & Kezar, 2003, p. 73). Five Core Change Strategies The Mobile Model consists of five core change strategies: (a) senior administrative support, (b) collaborative leader ship, (c) staff development, (d) flexible vision, and (e) visible action. Th ese core strategies provide leadership guidance through the change process and a structure to concep tualize the transformation process. Initial steps of the change process incl ude the following provisions: 1. to begin dialogue with challenging questions 2. to create collaborative processes 3. to develop strategies to understand campus culture 4. to clearly articulate the criteria and process of charting the change. (Eckel & Kezar, 2003)

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33 Fifteen Supporting Strategies The process of transformational change is complicated and multifaceted with numerous strategies occurring simultaneous ly. Eckel and Kezar (2003) identified the necessity of an additional 15 strategies wh ich play a significant role in facilitating transformational change. These supporting stra tegies do not occur as frequently as the five core strategies; however, they play a cr itical role in effecti ng transformation. These 15 supporting strategies are described thusly: 1. Framing the local challenge in a br oader context, extending the issues beyond the campus, raises the level of importance and makes the local challenges more legitimate a nd depersonalizes the issues. 2. Institutional leaders publicly commun icated two types of expectations. The first set of expectations addresse s the objectives to accomplish and the ways in which the campus would be different and better. The key constituencies must believe the proposed change will address something important. The second set of expectat ions addresses campus behavior and priorities. These behaviors and prior ities are developed through extensive consultation and listening to change leaders, faculty, administrators and various campus subgroups. Once the expectations are articulated and agreed upon, then leaders establis h frameworks to hold individuals accountable. 3. Develop extensive internal communicati on plans with a range of strategies to communicate. 4. Leaders must invite involvement and create intentional diverse

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34 opportunities for involvement with th e realization that ‘involvement’ means different things to different individuals. 5. Two components of involvement are cr itical to transformational change processes; participation and the opportunity to influence results. A process of acknowledging contributions is required. 6. Leaders fostered the creation of brin ging people together in new ways to foster communication across the campus. The communication focus on instilling a sense of trust, clarifi cation of potential misunderstandings and rumors and a sense of community. 7. Administrative processes are alte red to support the changes, which reinforce the changes as a part of daily operations. 8. Moderate of the pace of change is a significant strategy. Too much change too quickly can overwhelm and exhaus t members of the organization. Too little progress and the change processes may stall. 9. New structures are necessary to support the change processes. 10. Financial resources are provided with new sources of revenue and/or reallocation of existing funds. 11. A range of incentives are created to facilitate the change processes. 12. Leadership plan approaches to affec ting change as a long-term endeavor while at the same time, employ stra tegies that capture and hold the organizational members’ collective attention. 13. Leaders facilitate the id entification and creation of linkages among various activities on the campus. Communica tion of the multiple projects

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35 occurring and the connections am ong them reassures organizational members they are a part of a commun ity, not working in isolation, helping to push the change momentum. Bu ilding additional linkages with organizations and activities in the broa der context within higher education facilitates the change processes. 14. Leaders constructively used events a nd activities outside the organization to promote change internally. These ex ternal contextual elements provide legitimacy, confirm beliefs and assump tions, and opportunities to reflect on local progress, local action plans, and often provide needed local resources. 15. External linkages provide opportunities to tap outsiders’ perspective that help advance change at the local leve l. Opportunities to explore ideas and assumptions different from local pr evailing assumptions helped with developing new ways of thinking, an d surface unexplored assumptions and beliefs. Institutional Culture Institutions of higher education share a co mmon academic culture as well as have their own culture which makes them behave in unique ways (Eckel & Kezar, 2003). Peterson and Spencer (1991) de fine culture as “the d eeply embedded patterns of organizational behavior and the shared values assumptions, beliefs, or ideologies that members have about their organization or its work” (p. 142). Eckel and Kezar (2003) use the following elements from a survey of the literature conducted by Kuh and Whitt (1988). Culture involves norms that shap e conduct; agreed upon values espoused

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36 throughout the organization; and the philo sophy that guides the campus attitudes, understandings, priorities and actions regard ing students, staff, faculty, and teaching, research and service (p. 130). Eckel and Kezar’s (2003) summary of the experiences of the institutions they studied suggest that culture plays a significan t role as something that is changed as a result of transformation and is a key factor in the process of change. They propose that leaders need to understand the way their institution’s culture shapes change processes or strategies. The culture is the modifying element rath er than the subject of the modification. Leaders must learn to take their institutional culture, in addition to the type of change and the substance of their cha nge agenda, into consideration. Leaders should take the existing culture into cons ideration and use the culture wisely to shape their change processes as they em bark on transformational change. (Eckel & Kezar, 2003, p.131) Types of Evidence Two types of evidence, attit udinal and structural, were identified as intrinsic in transformational change. Structural evidence. Eckel and Kezar (2003) identifie d seven structural change indicators of the Mobile Mode l for Transformational Change: 1. changes to the curriculum 2. changes in pedagogies 3. changes in student learning and assessment practices 4. changes in policies

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37 5. changes in budgets 6. new departments and institutional structures 7. new decision-making structures Structural evidence by itself did not nece ssarily suggest transformational change. There is a need for an additional set of evidence to identify the cultural impact of the transformation. Attitudinal and cultural evidence. Eckel and Kezar (2003) identified a second type of evidence that indicates transformationa l change, namely attitudinal and cultural evidence. The additional indicators/markers are: 1. support of changes in the ways groups or individuals interact with one another 2. changes in the language the campus used to talk about the process 3. changes in the types of conversations by faculty 4. old arguments abandoned 5. new relationships with stakeholders that occurred. Observations of Transformation Within Organizations Transforming institutions discovered and reinforced new relationships consistent with stated values and recognized the need fo r key policies, structures and mind-sets to reinforce these interactions. Relationships included faculty, administrative staff and students interacting both inside and outside th e classroom. A different self-image of the entire institution evolved over time until th e new language and self-concepts became part of the institutional fabric. C onversations reflected new pr iorities and commitments. Leadership observed that faculty and staff view ed issues differently and with a fresh look,

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38 signaling important shifts in the instit utional norms, beliefs, and culture. New relationships with stakeh olders led to new types of relati onships with trustees, alumni and donors, community groups, local businesses, foundations, civic groups, and community agencies (Eckel & Kezar, 2003). Mobile Model of Transformational Change (2003) Cited in Literature A review of the literature identifies several citations of Eckel and Kezar’s (2003) Taking the Reins but contains limited referen ce to the Mobile Model for Transformational Change. The relevance of thes e studies does not appear to be strong, and the definition of transformational change se ems to differ. This is not surprising, since of the 26 examples cited in Eckel and Keza r’s study, only six were identified as making major changes over a period of five years. This may be one reason there are few research studies citing the model, since a mere three years have passed between the introduction of the Mobile Model and the writing of this paper. Covington and Froyd (2004) address some of the principles of change, for example, asserting that faculty are the prin cipal population maintain ing the institutional culture; and the creation of a pervasive, transformational change in higher education, requires change among the faculty. Personal an ecdotes related by the participants, along with meaningful dialogue, appear to be the most important catalysts for change. Barnett, K. (2005) cited Taking the Reins in her doctoral dissertation Creating Meaning in Organizational Change: A Case in Higher Education. Her study explores the creation and use of meaning among faculty du ring the implementation process of a new state master plan for admi ssions criteria framework.

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39 Morris (2005) cites the five core strategies critical to transformational change. The 2003 Foundation of Excellence project agrees with Eckel and Kezar’s description of transformation, i.e ., it comes from leadership, coll aboration and visible action. The Foundation of Excellence project chose 13 inst itutions for case studies capturing the details of activities, assessments and outcome s during students’ first year of college. The details are included in the foundation’s report, Achieving and Sustaining Excellence in the First Year of College In 2003, over 200 institutions part icipated in defining standards of excellence and forms of ev idence that validate the presen ce of the characteristics, resulting in a set of Foundational DimensionTM statements. Mavrinac (2005) reinforces the concep t that an organization experiencing transformational change can remain true to its values and roles as stated by Eckel and Kezar (2003). Mavrinac, a librarian, discusse s peer mentoring, a learning process in harmony with values-based tr ansformational leadership and change. Transformational change, the deep and lasting change, require s time and energy, intention, congruency, and interrelatedness across depa rtments and employee groups. Summary of Transformati onal Change Literature Eckel and Kezar (2003) formulated th e Mobile Model for Transformational Change taking into account the combination of several change models as suggested in Kezar’s (2001) synthesis of the change literature. This model provides a template inclusive of the assumptions of the cultu ral, social-cognition, and political and evolutionary change models. I intend to use th is template provided by Eckel and Kezar to observe the key aspects of the change pro cess, that is, core change strategies, interrelationship among strategies, role of sense-making, and the critical need to pay

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40 close attention to the institutional culture. They offer structural and attitudinal and cultural evidence that will assist me in captu ring potential themes th at may arise from my research. Eckel and Kezar (2003) note a lack of empirical data about transformational change within higher educati on literature. They describe the three types of change leading to transformational change: incremen tal adjustment, isolated change and farreaching change. Transformational change is differentiated based on two characteristics: pervasiveness and depth of the change and th e influence of organi zational behavior over a period of time. By this definition, only six institutions from a study of 26 diverse colleges and universities actually accomplishe d major changes. Kezar (2001) identifies research from the cultural, so cial-cognition, and political mode ls which demonstrates that transformational change is unlikely at most institutions; instead, incremental adjustment is the more likely result. Studies which cite the Mobile Model do not appear to demonstrate a particularly strong relevance to the model. I intend fo r my study of the transformational change processes at three schools of nursing to pr ovide empirical data about the change processes involved during the initial years after the IOM (2003) published recommendations for incorporating the core competency of healthcare informatics. Healthcare Informatics Introduction The five cross-cutting strategies recommended by the 2002 Education Summit members to transform the educational system serve as an outline for the following informatics core competency literature review. These strategies include:

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41 1. establishment of common language and core competencies for informatics across all health care professions 2. integration of informatics core competencies into oversight processes 3. provision for motivation and support to leaders and the monitoring of reform efforts 4. development of evidence-based cu rricula and teaching approaches 5. development of faculty as informatics teaching and learning experts. Strategy One: Common Language and Core Competencies Definitions. A critical first step in aligning the incentives and providing a catalyst for higher education institutions is th e creation of a common language with corresponding competencies for healthcare info rmatics across all health care professions. A common language allows all Health care pr ofessional graduates to understand, value and use informatics in all areas of health care for purposes of managing knowledge, making decisions, communicating to one anothe r, and reducing potenti al medical errors (IOM, 2003). The following definitions are provided: All health professionals, re gardless of their competencies, need to master… or better yet, … of their discipline: [to] employ… [to] search… [to] communicate… [to] understand… (IOM, 2003, p. 63). Core comp etencies are defined as specific skills sets, knowledge, or expertise shared across the health professions (IOM, 2003). Professional competencies are define d as the routine and careful use of communication, knowledge, technical skills, clinical reasoning, emotions, values,

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42 and reflection in daily practices of the professional. (Hundert, Hafferty & Christakis, 1996; IOM, 2003). Debate over broad-based versus discipline-specific language According to Masys, Brennan, Ozbolt, Corn, and Shortl iffe (2000); and IOM (2003), the debate regarding Healthcare informatics core competen cies across all health professions, and the distinctions between broadbased and discipline-specific language and competencies, hinders widespread progress within medical education. Medical informatics includes the medical decision-making process of physic ians (Hogarth, 1997). Nursing argues the application of technology in nursing decision-making is differe nt from that in medicine. Nursing management of data, information, and the processing of the information is closely tied to specific nursing professiona l practices. As a consequence, informatics practice, education, competencies, and corre sponding curriculum development for the health professions have proceeded slowly a nd lack consensus regarding essential building blocks (Staggers & Bagley-Thompson, 2002). Professional competencies for nursing. Attempts at creating a list of competencies for nurses include: 1. Bryson (1991), skills needed for co mputer training in BSN programs 2. Staggers (1994), a list of skills and knowledge for nurses 3. Staggers, Gassert and Curran (2001), the first research-based master list of informatics competencies for nurses by level of practice 4. Curran (2003), an initial proposed li st of informatics competencies essential for nurse practitioner educat ion and practice, adding informatics

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43 competencies related to evidence-bas ed practice. The research reported after 2000 is discusse d in depth below. Staggers, Gassert, and Curran (2002) created the first research-based master list of informatics competencies for nurses by level of practice: beginning nurses, experienced nurses, informatics nurse specialists, a nd informatics innovators. They extracted categories of computer skills, informatics knowledge and informatics skills from a literature search, and then added unique comp etencies, for a total of 305 competencies. One of the co-authors later published an arti cle (Curran, 2003) sta ting that advanced nurse practitioners need to have written professional competencies. Summary of common language and core competencies. Healthcare informatics is the specific change mechanism I am studyi ng to capture the transformational change processes. It is important in my research to clarify the definition of healthcare informatics and the corresponding competencies across th e three schools of nursing. Staggers and Bagley-Thompson (2002) reinforce a common language and corresponding competencies as an essential building block. The processes to reach a consensus involves key aspects of the change process as described by Eckel and Kezar (2003), such as a focus on the existing medical and nursing cu ltures, values, basic assump tions, and getting faculty to think differently. Health care professional oversight organiza tions are the key drivers to facilitate reaching a consensus across all health care professionals for common language and competencies. The benefits of a common langua ge and competencies include reduction of potential medical errors. Each health care professional would use the same language and

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44 similar core healthcare informatics skills; and would understand how to use informatics to manage knowledge, make decisions and communicate with one another. Some health care professional groups disagree with the IOM (2003) recommendations for a common language and competencies across the disciplines. For example, nursing argues that the application of informatics for management of data processing of information is closely tied to specific nursing professional practices versus medical practice. A healthcare informatics definition and the general informatics competencies are identified in the IOM (2003) report. In general, these competencies include word processing, use of external online databases and the Internet, security protections, and ethical issues re lating to informatics. The core competencies to be shared across the health care professionals include specific skills sets, knowledge, and shared expertise. Professional competencies are de fined as the routine and careful use of communication, knowledge, technical skills, c linical reasoning, em otions, values, and reflection in the profe ssional’s daily practices. The IOM (2003) identifies the process of the health care professions agreeing on a common language and corresponding competencies as a basic foundation to begin transforming the health professions edu cation. My knowledge of the IOM’s (2003) recommended strategies are important fo r any potential references made by the participants during th e interviews. For example, part icipant responses may reference broad-based versus discipline specific language and core competencies in the particular strategies being used, and why th ese strategies are being used. It is unclear in the literat ure if broad based competencies are the same as core competencies, and if discipline-specific co mpetencies are the same as professional

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45 competencies. I suggest that perhaps th ere should be both broad based or core competencies as well as discipline-specifi c professional competencies. At least one research-based master list of nursing informatics professional competencies exists inclusive of four levels of nursing expertise. Strategy Two: Integration of Core Co mpetencies into Oversight Processes Oversight processes defined The 2002 Education Summit participants recommended consistency in approach and coordination across oversight agencies for both private and public sector organizatio ns, stating this serves to enhance communication, integration and synergy w ithin and across the varying oversight agencies. The three major oversight pr ocesses are licensure certification, and accreditation (IOM, 2003). Licensure is the a ssessment of the gra duates’ understanding and mastering of their formal curricula at th e time of their entry into practice. Licensing exams should include healthcare informatic s competencies which assess graduates’ understanding and mastering of the formal cu rricula, a critical measurement of whether higher education meets accreditation standards. Accreditation serves as a leverage point for the inclusion of particular edu cational content in a curriculum. Nursing oversight agencies The majority of states require state nursing licensing board approval in the application for accr editation by one of the two nursing accrediting bodies the National League for Nursing Accreditation Commission [NLNAC] (2006) and the Commission on Collegiate Nursing Education [CCNE] (2002). Informatics competencies are not required by either (IOM, 2003). Certification seeks to ensure the licensed practitioner continue s to maintain competency throughout his/her career and ensures the testing is competency based.

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46 State nursing licensing laws. Geographical licensure and scope-of-practice acts have an effect on the integration of inform atics into practice and education (IOM, 2003). Licensure is implemented at the state le vel, with local board members permitting regulations to be tailored to meet local n eeds, resources and pub lic expectations. As a result, variations occur across states not only in who is licen sed, but also in the standards for licensure and practice. Nursing does not include informatics on its licensing exams in any state (IOM, 2003). The National Council of State Boards of Nursing, Inc. (NCSBN) has representatives from the boards of nursing in all states. Its purpose is to provide an organization through which boards of nursing act and counsel together on matters of common interest and concerns affecting the public health, sa fety and welfare, including development of nursing licensing examinations This council may serve a role in the promotion of uniformity in relationship to the regulation of nursing practice, dissemination of data regardi ng licensure of nurses, as we ll as a forum for information exchange across all states. Regulating the scope of practice The IOM (2003) report revealed none of the health professions’ licensure exams include informatics. Phillips, Harper, Wakefield, Green, and Fryer (2002) indicate health care is an environm ent in which responsibilities are increasingly overlapping, l eading to tremendous fricti on among the professions over practice control and compensation. As of June 2006, none of the licensing and accreditation bodies have demonstrated much progress. Inlander (2002) suggests a new look at regulating the scope of practice, which then might encourage focus on the direction in which professiona l education should proceed.

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47 Summary for integration into oversight processes. Licensure assesses the graduates’ understanding and mastery of the curricula at the time of their entry into practice. Since licensure is a critical measurement of wh ether higher education meets accreditation standards, the schools of nursi ng will be required to respond to the regulations established by the respective state licensing boards. As of June 2006, informatics is not required for licensure in any of the health care profe ssions in any state. The IOM (2003) recommends strategies whic h include the use of accreditation as a leverage point for the inclusion of informatics in the curriculum. Strategy Three: Motivation, Support fo r Leadership and Monitoring Progress A council of national educational leaders in academic and pr actice settings and leading consumer advocacy organizations should be convened by the (IOM, 2003). The purpose of this council would be to develop a joint agenda to lobby for funding for the council, as well as for leadership devel opment activities and pa rtnerships between academic and practice leaderships. The purpos e of the council would be trifold: 1) promotion of the overarching vision and need to reform health professions’ education on a l ong-term and continual basis, 2) evaluation of progress toward meeting the vision, and 3) communication of the progress of re form efforts, inclusive of 2002 Educational Summit participants’ commi tments, and of case presentations to sponsors. Supporting partnerships between academic and practice settings The AHRQ (2005), the nation’s lead research agency on he alth care quality, patient safety, efficiency and effectiveness, serves a critical oversigh t role in the adoption of health information

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48 technology. Its initiatives include contracts with five states and grants to more than 100 communities, hospitals, providers and health care systems examining healthcare informatics. The overall goals of AHRQ (2005) included identification of the most successful approaches and barri ers to implementation of th e electronic health record; development of patient care processes that ar e patient-care centered, safer, and of higher quality; and establishment of a cost-benef it analysis of healthcare informatics. AHRQ (2005) assembled the first annual jo int conference for Patient Safety and Health Information Technology in June, 2005. Res earchers, federal officials, health care providers, and corporate health care leadership examined accomplishments which created a high quality, safer health care system AHRQ (2005) awarded $139 million to a number of “real-world laborat ories.” Overall goals include development of statewide and regional networks to promote access to heal th information technology and encouraging the adoption of information technology. The University of Chicago (NORC) was awarded a multi-year contract by AHRQ (2005) to establish and operate the NRC. Th e NRC will work with providers to prepare and incorporate health inform ation technology into the health care system by serving as a repository for the research findings of AH RQ (2005) projects. The NRC will provide technical assistance and consulti ng services to those individual projects, with a particular focus on addressing challenges facing rura l and small community settings (AHRQ, 2005). Support provided by professional organizations. Various organizations already in existence are providing resources for nursing and healthcare informatics activities.

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49 1) The (American Medical Informatics Association [AMIA] 2004) is the organization representing the Unites St ates at the International Medical Informatics Association (IMIA) ( http://www.imia.org/ ). 2) The IMIA was founded in 1989 as a nonpo litical internati onal scientific organization ( http://www.imia.org/ ). 3) The Health care Information Management Society (HIMSS), founded in 1962 as a not-for-profit organization is dedicated to promoting a better understanding of health care info rmation and management systems ( http://www.imia.org/ ). 4) The (Nursing Informatics Collaborative Task Force [NICTF], 2005) was created as part of th e (AMIA, 2004) and HIMSS ( http://www.allianceni.org/ doc/min_20040726.pdf#search=’NICTF ’). 5) The Alliance for Nursing Informatics (ANI) is a committee created in February 2004 under the umbrella of (AMIA, 2004) and HIMSS. ANI r epresents more than 3,000 nurses an d 20 distinct nursing informatics groups in the United States which func tion separately at local, regional, national and international levels (Thede, 2003). Summary for motivation, support for leadership and monitoring progress. AHRQ (2005) is the national lead research agen cy on health care quality, patient safety, efficiency and effectiveness, and oversees the adoption of health information technology. A critical component of the agencies’ role is to support partnerships between academic and practice settings. Recent activities incl ude the award of a multi-year contract to University of Chicago to provide techni cal assistance and consulting services to

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50 individual projects, and the award of $130 m illion for the development of statewide and regional networks to promote access to health information technology. Members of the leadership and faculty at each school of nursing may be involved in various national and/or state professi onal organizations rela ting to healthcare informatics. Participants may identify strate gies used; and those strategies may include activities and/or consulting services funded directly or indirectly by AHRQ (2005). Strategy Four: Develop Evidence-based Curricula and Teaching Approaches Overview In the past it was assumed that hea lth professionals would be able to diagnose and treat ailments and evaluate new tests and procedures w ith training received through academic preparation and their ongoi ng practice experience. This assumption is no longer valid. Human memory is becoming in creasingly overloaded and unable to keep pace with an ever-expanding knowledge ba se. Prominent quality expert David Eddy, quoted in the IOM (2003) report, stated “The complexity of modern medicine exceeds the inherent limitations of the unaid ed human mind” (Millenson, 1998, p.75). According to Staggers, Gassert and Sk iba (2000), attendees at the AMIA 1999 spring conference validated these concerns. Stud ents are now expected to transcend rote learning, to formulate meaningful questions using information technology to answer them, to perform critical thinking about info rmation and technology, and to develop skills to filter and manage vital information. The linkages will provide the student with an emphasis on the way information and clinical care are intertwined. The groups suggested that informatics education be designed in the context of real-world applications and behaviors.

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51 The Tri-Council for Nursing (2000), an alliance comprised of the American Association of Colleges of Nursing [AACN] (2000), American Nurses Association (ANA), American Organization of Nurse Exec utives (AONE), and the National League for Nursing (NLN), responded to the IOM’ s (2003) recommendations. The response included the following statements: Technology has dramatically altere d practice, teaching, and learning environments in nursing, as well as th e way in which nurses, educators, and students communicate. While easier to acce ss, information is often harder to control because of the speed at which it is generated and communicated. Indeed, access to comprehensive and up-to-date data bases has increased both the speed of clinical decision-making and the responsibility of provide rs to ensure that such quick decisions are equally demonstra tively sound. Moreover, advances in technology have resulted in shortened hospi tal stays as less-invasive techniques are developed; and the portability of high technology has helped shift the focus of complex care for the acutely ill to sub-acute care centers, skilled nursing facilities, homes, and rehabilitation centers outside the hospital (AACN, 2000, 1). Across all health professions, demand has accelerated for creative thinking, pattern recognition and problem resolution. At the same time, burgeoning technological advances and incr eased access to information require health professionals who are knowledge workers that is, who are able to manage information and high technology on the one hand, and complicated clinical judgments on the other (AACN, 2000, 2).

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52 Some reformers advocate curriculum desi gn from a systems perspective, merging meaning, context, and connectedness among a ll concepts and components (Saba, 2001). Participants in the 2002 Educa tional Summit reinforced the cu rrently available research to employ evidence-based practice in the reform efforts to revise curriculum and teaching methods. They recommended a best-practice re view of universities integrating the five competencies into their curri cula, to understand what the universities are doing and how or why it is a best practice. Defining evidence-based curricula. The IOM (2003) report defines competencybased education but does not defi ne evidence-based curriculum per se Competencybased education is defined as educational programs designed to ensure that students achieve pre-specified levels of competency in a given field or trai ning activity, with a focus on making the learning outcomes for courses explicit, and on evaluating how well students have mastered these outcomes or competencies. (IOM, 2003, p. 24) Carraccio, Wolfsthal, Englander, Fere ntz and Martin (2002) and IOM (2003) suggest that these types of approaches have lead to improvement on licensing exams. There is, however, scant ev idence supporting this claim. The undergraduate curriculum Gaff, Ratcliff and Asso ciates (1997) defined undergraduate curriculum as the formal academic experience of a student’s pursuit of baccalaureate and lower degrees, formalized into courses or programs of study comprised of the purpose, design, conduct and evaluation pr ocesses of the intend ed experiences of undergraduate education. The undergraduate curr iculum consists of general or liberal

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53 studies, major specialization, minor specializa tion, and electives (L evine, 1978; Toombs, Fairweather, Amey, & Chen, 1989; Ga ff, Ratcliff & Associates, 1997). Professional education is defined as “a sy stem of formal education that prepares novices for highly skilled occupa tions through a combination of theory and practice, and that culminates with an aw ard of certification, licensure, or other formal credentials (Gaff, Ratcliff, & Associates, 1997, p. 342). Professional education emphasizes theory and the use of knowledge. Students need to “l earn the unique critical thinking skills of their future profession, the social context and values of that profe ssion and how as future professionals they may best communicate with clients, patients and colleagues” (p. 353). Major and minor specializations are pr escribed by the department or program i.e the health care professions of nursing, medici ne, pharmacy, and so forth, but often in compliance with state licensing agencies or professional boards. El ectives prescribed by the department major or minor may leave lim ited courses for the student to select. The curriculum is heavily influenced by discip linary values, educational philosophy, student population, and the social and in stitutional context. Faculty, working in interdisciplinary committees, must reconcile the conflicting forc es, the diverse needs of student learning, expectations of society and employers, polic y makers’ requirements, and the academic disciplines and applied fields of study in formulating, renewing or transforming the undergraduate curriculum. According to Gaff, Ratcliff and Associates (1997) “academic folklore tells us that it is harder to change the curriculum than it is to move a cemetery” (p. 6). The IOM (2003) report identified a hidden cu rriculum and faculty reward system as roadblocks to reform. The training envi ronment for students impacts the values and

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54 attitudes of future health professionals. Th e hidden curriculum is the observed behaviors, interactions, and overall norms of culture that often contradi ct what is taught in the classroom (Hafferty & Franks, 1998; Ferr ill, Norton, & Blalock, 1999; Maudsley, 2001; IOM, 2003). The faculty reward system pres ents a major barrier in many academic settings, with its heavy emphasis on research and often, little reward for teaching (IOM, 2003). Common barriers to informa tics curriculum development Barriers specific for integration of informatics into the he alth professions curriculum include: 1. lack of clear understanding of the informatics discipline 2. lack of clarity of healthcare informa tics in reference to its application to patient care or the informati on technology to delivery education 3. limited support for informatics education 4. lack of time and dollars to develop faculty informatics skills 5. lack of access to informatics experts. (IOM, 2003) Existing models for nursing informatics curriculum The Nursing Informatics Working Group of AMIA convened an educatio nal think tank in 2004. There is no single model for a nursing informatics curriculum only major variations across programs. Master’s degree programs averaged 40 credits, with a range from seven to 27 credits plus six to nine credits for clinical practicum. Half the programs had only one or two faculty appointments associated with an informatics specialty, something which is likely true for many other nursing sub-specialties as well. The Nursing Informatics Working Group of AMIA (now ANI) recommended a nursing informatics curriculum prototype, to include continued preparation of nursing

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55 informatics faculty, alliances to secure funding for graduate faculty preparation, encouragement for graduate credentialing, a nd inclusion of nursing informatics content across all education levels. Th e domain of nursing informatics requires differentiation from other disciplines such as business, management information and IT-focused programs. Nursing Informatics Working Gr oup (2004) suggested ANI should collaborate with the Education Working Group to develop a core curriculum across all disciplines, with a list of generic/core program outcomes. Collaborative partnerships. The IHI Health Professions Collaborative includes leaders of 16 schools of medicine, nursing a nd pharmacy that have been implementing school-wide quality curricula. Future arrangements with ot her health profession schools and partnerships with national organizatio ns such as the Accreditation Council for Graduate Medical Education (ACGME) and the Association of American Medical Colleges (AAMC) are planned. New approaches to the health professional’s education include vertically integrated undergradua te curricula, interprofessional learning, redesigned residency programs, developmen t of exemplary clinical settings where optimal patient care and e ducation take place in a seam less fashion, practice-based learning and improvement throughout the entire ty of one’s professional career, and the creation of an academic base to facilitate these goals (IOM, 2003). The projects in the participating institutions FY05 include: 1. interprofessional learning 2. vertically-integrated improvement curricula 3. exemplary learning sites 4. faculty development

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56 5. student initiated quality improvement 6. organizational infrastructure. The IHI Professional Collaborative, in which nursing is a member, includes Vanderbilt University and the Universities of Connecticut, Miami, Missouri, Minnesota, Oregon and UT Memphis (as of February, 2006). Evidence-based teaching approaches for informatics. Due to the lack of performance measures within higher education, at this time, teaching approaches relating to informatics are currently directed mostly at the oversight organi zation level. The IOM (2003) report strongly enc ourages a competency-based approach for all core competencies. Although evidence of the efficacy of various educatio nal approaches is slim, there is limited evidence which poi nts to improvements on licensing exams (Caraccio, Wolfsthal, Englander, Ferentz, Martin, 2002, IOM, 2003). Pedagogy refers to the methods of teaching and interaction by an instructor (Gaff, Ratcliff & Associates, 1997). Teaching appro aches such as active learning, problembased learning, service lear ning, and lifelong learning we re recommended by the 2002 Educational Summit particip ants. According to Armstrong and Barron (2002), a competency-based curriculum stimulates pe dagogical approaches of active learning and problem-based learning that encourage grea ter faculty-student interaction. Student learning groups are used to provide system atic feedback to faculty. Problem-based learning engenders more self-directed learni ng and does a better job of providing students with a process for integrating what has alr eady been learned (Ride out, et al., 2002; JuulDam, Brunner, Katzenellenboge n, Silverstein, & Christakis 2001; Krackov & Mennin, 1998; IOM, 2003). Service learning is another education appro ach which allows students

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57 to apply academic knowledge in a designate d practice environment within a relevant community service program or agency. This approach exposes students to cultural diversity and assists in developing and fostering inductive reasoning (Hales, 1997; Callister & Hobbins-Garbett, 2000; Schamess, Wallis, David, & Eiche, 2000; Davidson, 2002; IOM, 2003). Example of education efforts Bakken et al. (2004) desc ribes an informatics-based approach to nursing education for the promo tion of patient safety at the Columbia University of Nursing. This university designed PDA software to document clinical interventions and to retrieve patient safety info rmation at the point of care. This facilitates clinical documentation and analysis and provides instan t access to patient safety resources. The electronic st udent clinical log, with its related database and knowledge base, documents students’ cl inical encounters using sta ndardized nursing terminology. Faculty members review the reports to dete rmine whether appropriate experiences are occurring and to provide feedback to the st udents. The selected group of faculty uses a three-pronged approach to enhance competenci es: (a) small workshops and seminars, (b) consultation on appropriate assignments for sele cted competencies, and (c) guest lectures and co-teaching by informatics faculty members. Summary for evidence-based curricula and teaching approaches. The old assumption that health professionals woul d be able to provide ongoing safe quality patient care with the training received th rough academic preparation, practice experience and continuing education is no longer vali d. With the introducti on of computerized clinical systems, different c ognitive skill sets are required to filter massive data, manage critical information, formulate meaningful questions quickly, utilize information

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58 technology to answer them, and, at the same time, meet the needs of patients and their families. The undergraduate curriculum consists of general or liberal studies, major specializations, minor sp ecialization, and electives. Many inte rests must be considered in formulating, renewing or transforming the unde rgraduate curriculum. Academic folklore provides a clear description of the complexity of this process; it is harder to change the curriculum than it is to m ove a cemetery. The review of the literature describes recommendations by some of the interest groups. For example: 1) The Tri-Council for Nursing (2000) states the need for knowledge workers ; 2) Saba (2001) states some reformers advocate for a curriculum design fr om a systems perspective; 3) IOM (2003) uses two terms, competency-based education and evidence-based curriculum, to describe their recommendations; and 4) Bakken et al (2004) describe an informatics-based approach. The document reviews and participan t interviews may reveal a specific term used in the curriculum, and its corresponding definition as accepted by each school of nursing. Progress for healthcare informatics curriculu m to date includes research into the current status of health informatics curriculu m within nursing schools, perceived barriers to change, recommended curriculum cons tructs, steps toward creating a nursing informatics curriculum model(s), and collaborative partnerships. Several initiatives are occurring to transform the curriculum, and ot hers are being created daily. One example is the IHI Health Professions Collaborative, which includes leader s of 16 schools of medicine, nursing and pharmacy that have been implementing school-wide quality curricula.

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59 Pedagogy, methods of teaching, and interact ion between student and professor are impacted by the curriculum models used. Th e various pedagogical approaches cited in the IOM (2003) literature include active learning, problem-based learning, service learning, and lifelong learning to address competency-bas ed education and/or the evidence-based curriculum. Perceived barriers for employing healthca re informatics in nursing schools include lack of funds to purchase the co mputers and necessary software upgrades for students and faculty, funding for staff who are healthcare informatics experts, faculty training, faculty time to develop and revise the curriculum, and excessive emphasis on research with little reward for teaching. The barr iers specific to integration of informatics into the health professions curriculum in clude: lack of clear understanding of the informatics discipline, limited support for informatics education, lack of access to informatics experts, lack of time to develop faculty informatics skills, and the lack of clarity of healthcare informatics regarding its application to patient care versus to delivery education. Strategy Five: Developing Faculty as Teaching/Learning Experts Current status of faculty informatics competencies McNeil et al. (2003) r ate nursing faculty teaching information literacy skills at the novice or advanced beginner level in teaching informati on technology content and in using information technology tools. An online survey in July 2001 us ed a relatively small sample size of 132 participants to assess the perceptions of information technology competencies among nursing faculty, practicing nurses, and baccal aureate-and master’s-prepared students.

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60 Information literacy skills and computer liter acy skills taught by the faculty were not tied to clinical practice. Carty and Rosenfield (1998) surveyed program administrators in selected accredited diploma, associate, baccalaureat e, and master’s nursing programs using a stratified random sample of National League of Nursing ac credited nursing schools. The purpose of the study was to determine the stat us of computer and information technology in nursing education. The response rate was 55%, or 190 responses from the 347 schools selected. All nursing programs were proportionately represented. The survey revealed that fewer than 13 percent had written plan s and specific goals for teaching computer technology. The cost, lack of faculty time and technical support, and the need for faculty development were identified as key issues to be addressed. Th e group identifies three resources crucial for faculty: (a) faculty development, (b) faculty commitment to use technology and to acknowledge that it is perceived as a resource, and (c) faculty incentives (travel, merit increases, time) for to learn informatics skills. Mentoring is the primary method to guide informatics learni ng (Staggers, Gassert, Skiba, 2000, p. 558). A collaborative model. Connors, Weaver, Warren, and Miller (2002) describe a jointly funded partnership between the Univer sity of Kansas School of Nursing and the chairman/founder of the Cerner Corporation. The pilot program is designed so nursing students can use Cerner’s full clinical data repository, clin ician order entry, documentation, clinical decision support tools as well as PowerChart, the application tool for patient charting and order entry. The pr oject, called Simulated E-health Delivery System (SEEDS), is designed for patient care delivery with a clinical information system imbedded into the basic curriculum. A problem based learning strategy is employed as

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61 outlined by Chickering and Ehrmann (1996), using virtual patient case studies. The university employs a full-time, experienced clin ical informatician as the project manager who trains faculty and staff. Thirty-four out of 120 basic undergraduate students participated in the pilot group, which be gan in summer and fall 2001. Evaluations available at the time of publication include d the online survey in strument, a 15-item Likert-type scale of selected items from the Flashlight Prog ram Current Student Inventory, and two open-ended questions. Five major areas of learning were selected: critical thinking, student-stude nt interaction, rich rapid f eedback, time on task and realworld application. Nineteen of the 34 st udents responded to the online survey, a 54% response rate. Students reported having a greate r sense of collaborat ion with peers and faculty, enjoyed the opportunity to receive rapid feedback on their work, and found the assignments interesting. The students percei ved this process as a learning experience helping them understand the nursing process, clinical documentation and preparation for the real world. Faculty reported difficulty in becoming accustomed to new technology, having to adjust teaching techniques in order to allow for more data-driven case presentations, and the need to rework case studies and teaching strategies (Connors et al., 2002). McNeil et al. (2003) recommend analysis and replication across the U.S. of successful collaborative models such as the SEEDS project. The gap created by insufficient expertise with informatics tools in daily practice of faculty will transfer to students. Incentives to encourage faculty expertise. Shaping the Future for Health Academic Health Center (AHC): Leading change in the 21st century (July, 2003) outlines

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62 the critical role of Academic Health Cent ers in the higher educa tion reform process. Academic health centers (AHC) play an important part, since they train health professionals, conduct research that advances health and provide care to ill and poor populations. Financial support from Congress is required to support innovation in the education of health professionals, reforming methods, approaches, and settings used in clinical education. Summary for faculty development. Carty and Rosenfield (1998) survey revealed that fewer than 13 percent of the surveyed accredited diploma, associate, baccalaureate, and master’s nursing programs had written pl ans and specific goals for teaching computer technology. McNeil et al. (2003) r ate nursing faculty teaching information literacy skills at the novice or advanced beginner level in teaching information technology content and in using information technology tools. The analysis and replicati on of successful collaborative models such as the SEEDS project are highly recommended. The sc hools of nursing selected for my research may be a part of academic health centers an d/or collaborative models. One collaborative model described in the literat ure includes one school of nur sing selected for this study. The SEEDS project at the Univ ersity Of Kansas School Of Nursing is a problem-based learning strategy using virtua l patient case studies. Summary of Review of Related Literature Leaders engaged in clinical education of health care pr ofessionals are expected to transform clinical training, to shift faculty values and assumptions, and to encourage thinking and acting in new ways and across departmental boundaries. Health Professions Education: A Bridge to Quality (2003) describes some of th e long-standing issues to be

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63 considered, such as differing professional a nd personal perspectives and values; role competition; turf issues; lack of a co mmon language; variations in professional socialization processes; diffe ring accreditation and licensure regulatory bodies; different payment systems; and existing hierarchies that emphasize individua l responsibility for decision making. These changes involve infrastr ucture, cultural and at titudinal changes as described by Eckel and Kezar’s (2003) M obile Model for Transformational Change. My research questions focus on how each selected school of nursing is implementing widespread transformational chan ge, their particular strategies, and why these strategies are being used to address the core competency of healthcare informatics. Eckel and Kezar’s (2003) model provides five core change strategies and 15 supporting strategies. The interrelations hip among these strategies cove rs the significant roles of sense-making in the institutional culture, as we ll as other cultural, structural, attitudinal indicators of progress. The qualitative research methods selected allow me to be flexible and open, so the participants can relay their experiences and th e meanings they attach to strategies of significance duri ng their institution’s change processes, which may or may not be the same as those described by Eckel and Kezar. Healthcare informatics is the specific change mechanism I am studying to capture the transformational change processes. Healthcare informatics is a new core competency and is not required for licensure by any state boards in any of the health care professions. The IOM (2001, 2003) reports identify healthcare informatics as the most significant tool that can be used to improve patient safety. So me of the reasons cited, which are related to shift in values and assumptions and acti ng across department boundaries, include, for

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64 example, enhancing communication among the h ealth care teams and increasing effective coordination of patient care. The five cross-cutting strategies reco mmended by the IOM (2003) report serve as the framework for my literature review of the core competency of healthcare informatics. Some themes noted in the lite rature review may be brought up by participants during my interviews. Knowledge of these issues will a ssist me to ask probing questions during my interviews. For example, the debate between broad-ba sed versus discipline specific language, as described in the literature, involves d eeply embedded professional values, protection of specific interests, turf issues, and di ffering accreditation and licensure regulatory bodies between medicine and nursing. Any of my interview questions may elicit a participant response that directly or indire ctly identifies broad-ba sed versus discipline specific language and corresponding competen cies as a specific strategy (critical decision, improvement, and/or process). So me indirect responses may include for example, faculty are thinking di fferently about healthcare informatics, there is an increase in collaborative committee structures; new decision-making st ructures, and/or reallocation of existing funds. As I probe furt her as to why these strategies have been employed, the participants may reveal di ffering language and competencies between medicine and nursing are at th e core of these strategies. I intend for my study to provide practic al data about the change processes involved during the initial y ears after the IOM’s (2003) pub lished recommendation of the core competency of healthcare informatics. Once the Mobile Model of Transformational Leadership is applied to the three cases studi ed, I will be in a positi on to discuss how well

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65 the model works as a framework for analyzi ng transformational change and whether it maintains its value beyond the six cases studied by Eckel and Kezar.

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66 Chapter Three Methods The research questions focused on how each school of nursing is implementing widespread transformational change, what ar e their particular st rategies, and why the strategies were being used to address the core competency of healthcare informatics. The direct observations and interviews of the pa rticipants within th ree schools of nursing captured an independent account of forces and sources of change. Being on site allowed me to capture insider interpretations of ch ange activities and to see things that may routinely escape awaren ess of the people in the setting (Patton, 2002). The final research question asked: “Are these inst itutions approaching the shift to healthcare informatics as a broad and deep change in values, culture and structures that would characterize a transformational change?” Methods for Research Questions The case study method allowed insider desc riptions and interp retations regarding the ways in which the three schools are addressing healthcare informatics. Additional insight was obtained by identifying the core change strategies employed by college leadership and faculty. This included opportuniti es to discuss responsiveness to internal or external environments, involvement of organizational members, and planned or unplanned components of the change process.

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67 Qualitative research methods allowed enough flexibility and openness that the participants relayed the experiences and the m eanings they attached to the inner workings of the change components. The participants presented core change strategies, including the interrelationships among the strategies, the role of sense ma king, and the importance of institutional culture. The emerging themes provided insight into whether the institutions are, in fact, a pproaching the shift to healthcar e informatics as the broad and deep change in values, cultures, and struct ures indicative of tran sformational change. This study meets Yin’s (1994) criteria fo r case study as one form of qualitative research. These criteria include the ‘how’ and ‘why’ questions being asked, as well as the limited control I, as the researcher, have ove r the plans and actions of Schools of Nursing as they address implementing Healthcare in formatics. Case studies are used in organizational and management studies to focus on a contemporary, a real-life phenomenon, which, in the context of this re search, examines how leaders and faculty members within three exemplary schools of nursing are implementing healthcare informatics. Selection of Case Studies Ronda G. Hughes, PhD, MHS, RN, Senior Health Scientist Administrator for the (AHRQ, 2005) provided me with names of four nursing informatics experts: Melinda Jenkins and Dr. Sue Bakken (Columbia University), Nancy Staggers (University of Utah), and Pat Brennan (University of Wi sconsin). These nursing informatics experts recommended seven experts (listed in Appendix C). I cont acted these experts and asked them to identify Nursing colleges doing exemplary work in implementing informatics. The schools most often mentioned were: University of Iowa; University of Kansas; St.

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68 Scholastica; and Case Western Reserve. Case Western Reserve did not respond to repeated efforts to contact them. University of Iowa did not meet the inclusion criteria. During my on-site visits, the University of Maryland and Large State University were mentioned as potential sites to study. I cont acted the Dean of University of Maryland who supported my doctoral dissertation rese arch; and Dr. Judy Ozbolt, the Program Director for Nursing Informatics, to discuss the specifics of my research. We determined that the University of Maryland did not meet the inclusion criteria for my study. I subsequently contacted the Dean of Large St ate University. The College of Nursing at Large State University met the in clusion criteria for this study. Characteristics of Case Study Sites All three schools of nur sing are accredited by the Commission on Collegiate Nursing Education and their resp ective state boards of nursing. The University of Kansas is a major public research and teachi ng facility with an overall 2005-06 student enrollment of 29,272. The baccalaureate nursing program enrolls some 300 students. The website notes th at the school is the first to incorporate healthcare informatics into its curriculum. It is ranked 21st in the nation among public nursing schools funded by the Natio nal Institutes of Health ( http://www2.kumc.edu/son/centennial.htm). St. Scholastica is a private college with an overall 2005-06 student enrollment of 3,249. The baccalaureate nursing program enro lls up to 112 students each fall semester. The main campus is located in Duluth, Minnesota ( http://www.css.edu/About _St_Scholastica.html ).)

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69 Large State University is a large coeduca tional public research university. There are many different schools and colleges, includi ng all the allied health professions and medical schools. It has more than a hundred nursing faculty members. In 2007, the college of nursing graduated more than 200 students (LSU reference 8). Gaining Access to the Study Sites I contacted the deans of nursing at each of the three schools of nursing by formal letter. The deans of nursing at University of Kansas, St. Scholastica, and Large State University gave me approval to conduct my research. Assuring Protection and A ddressing Ethical Issues I followed the University of South Flor ida Institutional Re view Board (IRB) policies and procedures. Confid entiality as a protection was extended to everyone in the study. The interviewees particip ated voluntarily and were info rmed of the nature of the study. The participants were not exposed to risk s that are greater than those they routinely face at work. I maintained my certification for Human Participant Protections Education For Research Teams (2007) through the U. S. Department of Health and Human Services National Institutes of Health and Collabor ative Institutional Training Initiative (20082009). A copy of the USF IRB approval letter (A ppendix D) and approved consent form is attached (Appendix E). Large State University college leaders’ requested institutional anonymity. All citations have been coded to pr otect the identification of the college. The Deans of Nursing at University of Kans as and St. Scholastica Schools of Nursing provided an approval letter for their schools to be identified (Appe ndix G). The Cerner Corporation provided an approva l letter to be identified in this research (Appendix H). The electronic health record company used by Large State University was not identified.

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70 Participant Selection According to Patton (2002), the purpose of in terviewing is to allow a researcher to enter into the study participant’ s perspective to “collect thei r stories and discover what is in and on someone else’s mind” (p. 341). Partic ipants in this study were nursing college leaders and faculty members who have the appropriate experience, are knowledgeable, and were able to explain what they know. The deans of nursing and/or their designees provided me with a list of the individuals m eeting these criteria. As I communicated with various leaders and faculty members about who was involved and contributed to the implementation processes, certain names we re repeated. According to Patton (2002), when this occurs, the repeated reference takes on special importance. The people who were mentioned the most often were included to my list of people fr om whom to request an interview. By agreeing to participate in the research study, the d eans of nursing consented to share documents related to the implementation of informatics and allowed me to arrange and conduct one site visit at my expense, including approximately one hour interview meetings with selected faculty and staff. Af ter I obtained IRB approval, I contacted each participant by e-mail and provided them the purpose of the study, an overview of process, assurance that the participants’ privacy and identities will be honored, and the approximate length of the interview (60 minut es). The dates/times of my on-site visit were listed, requesting each participant to select their interview time. Some background/demographic information was requeste d, such as, validation of name and title of the participant; role and position; length of time in current position; and formal or informal training in healthcare informatics.

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71 Data Collection and Storage Document review. Documents were requested prior to the on-site visit, and were requested during the interview and/or after the on-site vis it as circumstances dictated. Such items included curriculum change propos als, evaluation reports on the curriculum and informatics, accreditation self-study docum ents, and minutes of meetings. According to Patton (2002), these kinds of documents pr ovide information about many things that cannot be observed, for example, activities prio r to my on-site visit, private interchanges, and goals or decisions that might not be know n to the participant. Importantly, program documents can provide a behind the scenes l ook at the processes and how these processes came into being. Interviews. Patton (2002) identifies three basic approaches to collecting qualitative data: the informal, conversationa l interview; the general interview guide approach; and the standardized open-ended interview. I used a semi-structured interview approach, a combination of the latter tw o. I am aware of the importance of being comfortable with ambiguity and uncertainty in a process that is also semi structured (Lincoln & Guba, 1985; Patton, 2002; Yin, 1994; Rubin & Rubin, 2005; Bogdan & Biklen, 2003). I do have a genuine and abiding in terest in the perspectives of the leaders and faculty members of th ese schools of nursing. According to Patton (2002) control of data collec tion is facilitated by (a) knowing what it is you want to ascertain, (b ) asking focused questions to get answers relevant to the purpose of the research, (c) li stening attentively to assess the quality and relevance of responses, and (d) providing a ppropriate verbal and nonverbal feedback to the participant. Clarification questions were asked during the interview. Participants

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72 were informed of the possibility of a telephone inte rview for follow-up clarification questions. The interviews were scheduled for approximately 60 minutes; and I let participants know whether the purpose of the interview was being fulfilled, reinforcing high quality and relevant responses through feedback. If additional time was necessary to complete a well-informed interview, I sche duled another time to conclude the meeting. Design of Interview Questions Interview questions were thematically and dynamically focused, keeping in mind the later analysis, verification, and reporti ng of the interviews. Thematically, the questions related to the purpose of the research; and dynamicall y, they promoted a positive interaction, to keep the flow of c onversation going and motiv ate the participant to talk about experiences and feelings related to the research topic (Yin, 1994; Kvale, 1996; Patton, 2002). Opening questions. The first series of questions asked at the beginning of the interview initiated the process with topics pa rticipants were comfor table in answering. These include background questions regardi ng their position and tim e at the school of nursing; their participation on any committ ee relating to the core competency of informatics; and any formal or informal trai ning in healthcare informatics they may have received. Initial questions regarding healthcare informatics. The next set of questions turned the focus on healthcare informatics in the participants’ ow n experience. Issues included clarification of the common language used by the school to define informatics and the corresponding core competencies.

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73 First and second research questions Asking how each school of nursing is implementing informatics served as a lead question for the second research question. I anticipated that getting participants to identi fy particular strategi es (critical decisions, improvements, and/or processes) used to implement healthcare informatics would require open ended questions. Third research question. This is related to why a ny specific critical decisions, strategies, improvements, and/or processes were selected to address the core competency of healthcare informatics. Asking the participan t to share at least one example of a critical decision, strategy, improvement, and/or process highlighted some of the cultural progress markers identified by Eckel and Kezar (2003). Examples included attitudinal markers such as changes in the ways groups or indivi duals acted or interacted with one another, changes in language used to talk about th e change processes, changes in types of conversations among the faculty, and new relationships with stakeholders. If any of the top issues related to hea lthcare informatics were introduced by a participant, additional probing questions were asked. Such issues included broad-based versus discipline-specific common language an d core competencies; scope of practice issues in the professional disciplines; rewa rds for research, preparation for, and/or teaching of informatics; budgetary support fo r informatics; and/or any new decisionmaking structures to increase collaborative efforts. Fourth research question. The final research question focused on whether these institutions were approaching the shift to healthcare informatics as a broad and deep change in values, culture, and structures that would characterize a transformational change. Responses to the previous three research questions provided sufficient

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74 information for me to respond to this ques tion, so I addressed this question myself, without specific input or res ponses from the participants. Closing question. It is important in formal interviews to allow participants time to provide additional information on their own. According to Patton (2002), some of the richest data occurs in this phase of in terviewing. Examples offered by Patton (2002) include: “That covers the things I wanted to ask. Anything you care to add?” and “What should I have asked you that I didn’t ask?” (p. 379). Interview Guide Approach Use of an interview guide is advocat ed by Yin (1994), Kvale (1996), and Patton (2002). The semi-structured inte rview process allows the fl exibility and openness needed so the participant can introduce and emphasi ze the experiences and the meanings they attach to the inner workings of the change process. The interview guide served as a critical tool to ensure that I maintained sufficient structure and remained focused on gathering the answers the participants consider most important, and still remained relevant to my study. It also allowed me to concentrate on hearing, seeing, experiencing, and thinking about the critical observations during the interv iew; and reminded me of the key markers to be captured, i.e., setting, peopl e, actions, and convers ations. According to Kvale (1996), the recognition and applic ation of the knowledge gained from the interpersonal experience is what matters in a research interview. The interview guide also provided consistent questions for my collecti on of reflective data a bout the interpersonal experience following the interview. Tape recording of interviews Tape recording of the interviews is beneficial in data collection. I took field notes during th e interview, adding my own reflective

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75 comments immediately following the interview. If participants objected to the taping of the interview, my field notes were necessarily more comprehensive. The taped interviews and field notes were transcribed. I captured multiple perspectives using tape recordings, field notes, reflective notes and documents. I organized participant responses into a separate case record for each school of nursing. Field notes. Bogdan and Bilken (2003) defined fi eld notes as “the written account of what the researcher hears, sees, experience s and thinks in the course of collecting and reflecting on the data in a qualitative study” (p. 111). Field notes served to supplement the taped recordings by allowing me to documen t the participants’ facial expressions and verbal and non-verbal communi cation during the interview, li nking these behaviors to the question being asked and what the participants are discussing. The fi eld notes were added to the transcripts to document the facts and the intent of the data gathered. I also wrote a brief summary after the interview to relive th e events and conversations, and to revise, clarify, or capture my thoughts and perceptions ; and included this as an introduction to each transcription. The taped interviews we re transcribed using steps recommended by Bogdan and Bilken (2003). Protection of the participants ’ identities, responses and observations are critical in every step of any research process. An orga nized, confidential track ing system protected the identity of the participant. Each pa rticipant’s specific da ta, field notes, taped recordings and transcribed documents were co llected. Copies of the collected data were stored in a secure location to which only I have access.

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76 Data Analysis Computer-Assisted Qualitative Data Management and Analysis HyperResearch™ is the qualitative software package I chose to store, code, and retrieve the data. This software enhan ced the processes of grouping coded themes, grouping data into categories, and comparing pa ssages in the transc ripts from field notes and typed interviews. Logical Analysis I conducted an inductive analysis to disc over patterns, themes, and categories in my data. According to Patton (2002), findings would emerge through my interaction with the data. Inductive analysis began with an i nventory and definition of key phrases, terms, and practices unique to the participants in the study. Once some inductive dimensions (patterns, themes, categories) were identif ied, a cross-classified matrix was produced. This involved creating potential categories by crossing one dimension with another, working back and forth between the data a nd one’s logical constr uctions, completing the matrix, and searching for meaningful patter ns. I was careful to avoid manipulating the data by forcing it into categorie s to make the matrix work. Content Analysis Development of a classification or coding sche me is the critical first step of data analysis. I identified, labeled, and categorized the raw data, applying codes to specific pieces of text. The core content of inte rviews and observations was analyzed for significant research meaning. I referred to these core meanings as patterns, themes, pattern analysis, or theme analysis. Pattern is usually a descriptive finding, while theme connotes a more categorical or topical form (Patton, 2002).

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77 Convergence Convergence is determining which thi ngs fit together (Patton, 2002). Recurring regularities in the data were examined and sorted into categorie s based on internal homogeneity, or the extent to which the data in a certain category holds together in a meaningful way; and external heterogene ity, the extent to which differences among categories are bold and clear. When a large number of unassigned or overlapping data occurred, I worked back and forth between the data and the classification system to verify meaningfulness and accuracy of the categories. When different possible classification systems emerged, I established priorities to determine which were more important and illuminative. The establishment of priorities was accomplished, according to Patton (2002, p.466), “according to utility, salience, cred ibility, uniqueness, heuristic value, and the feasibility of the cl assification schemes.” Test for Completeness The set of categories were tested for completeness. Patton’s (2002, p. 466) four steps served as a guide to test for completeness. 1. Each set of categories was viewed for internal and external plausibility. When viewed internally, the individu al categories should appear to be consistent; viewed externally; they should be seen as comprising a complete picture. 2. Each set of categories was reasonably inclusive of the data and information collected. 3. The data was reviewed to ensure it was appropriate ly categorized. 4. The set of categories were credible to the individuals interviewed.

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78 Divergence Patton (2002) recommended ‘fleshi ng out’ the categories by building on information already known; making connect ions among different items, and proposing new information that ought to fit and verifyi ng its existence. Divergence includes careful and thoughtful examination of data that does no t seem to fit into the dominant identified patterns. Determining Substantive Significance I addressed the following questions in making an argument for substantive significance: 1. How solid, coherent, and consistent was the evidence in support of the findings? 2. To what extent and in what ways di d the findings increase and deepen my understanding of the topic? 3. To what extent were the findings consistent with other knowledge? 4. To what extent were th e findings useful for some intended purpose, such as contributing to transformational change processes? (Patton, 2002) Creative and critical judgment about what is significant and meaningful in the data is required. I relied on my own in telligence, experience, and judgment; I took seriously the responses of those who studied or who participated in the inquiry; and also considered potential responses and reactions of those who will read and review the results. Interviewing with open-ended ques tions in a familiar environment provided comfortable conditions for the participants, allowing the interviews to unfold naturally. Although the research design was pre-esta blished, components of the design were

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79 redirected to capture the dynamic real world environment that impacted or influenced processes, programs, or interventions over th e time period of the study (Lincoln & Guba, 1985; Patton, 2002; Yin, 1994; Rubin & Rubin, 2005; Bogdan & Biklen, 2003). Trustworthiness and Transferabili ty of Study Data and Findings Limitations, delimitations, and my persona l biases were addressed in Chapter 1. There I discussed steps taken to demonstrat e trustworthiness of data collection and subsequent analysis of the data. According to Firestone (1987), trustworthiness is about convincing the reader that pr ocedures have been faithfully followed and providing the reader with a depiction in su fficient detail to demonstrate that conclusions make sense. The data collection and analysis methods were designed to be consis tent and appropriate with my research questions. Patton (2002) listed four components of trustworthiness: dependability, authenticity, reflexivity, and triangulation. Th ese elements were demonstrated in my research as follows: Dependability relates to systematic data collection procedures (Lincoln & Guba, 1986). My taped interview recordings documente d the detailed responses to the questions asked of each participant. Th e recordings also captured participants’ answers to any clarifying questions during the interview, en suring that descriptions and context were accurate and complete. In as far as was possi ble, I clarified any statements that could imply multiple interpretations, and/or any contradictory statements made during the interview process. Member checking also occu rred after the interview when additional clarification questions were necessary. Each participant was given an opportunity to

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80 review and offer comments rega rding the written analysis of the summary for the case site. Authenticity, as described by Lincoln and Guba (1986), is being “balanced, fair and conscientious in taking into account multip le perspectives, multiple interests, and multiple realities” (Patton, 2002, p. 575). I a dopted a neutral stance, committed to understanding the change processes through stories shared, was open to multiple perspectives as they emerged, and was conscientious in reporting both positive and unfavorable information with regard to a ny conclusions reached as suggested by Patton (2002). Reflexivity involves recognizing that how one acts during data collection may affect the data collected (P atton, 2002). I wrote reflective notes immediately after the interview and included them with the fiel d notes. They captured possible effects my actions may have had on the data collected, a nd also my reflexive consciousness of my own perspective, thus encompassing my appr eciation for the perspe ctives of others during the interview. My research journal described my ow n thoughts during the data collection and analysis, indicating how I was thinking about the topic and how my analytic ideas were growing and merging. In this way I documented how I reached my conclusions and was ready to review my thought processes. Triangulation, capturing and respecting mu ltiple perspectives (Patton, 2002), provided diverse ways for me to look at the implementation of healthcare informatics, and offered greater illumination of various as pects of the change pr ocesses. Triangulation of data sources included comparing and cr oss-checking the observations with the

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81 interviews, comparing field notes with the other data collected, and using assembled research documents and other written eviden ce to augment the interviews. This process added credibility by strengthe ning confidence in the conclu sions that are drawn as suggested by Patton (2002). The transferability of the research findi ngs depends on the trustworthiness of data collection, as well as on the e xplanation of lessons learned and their potentia l application to those who will read the research findings at some future date. Those readers will have to make their own determinations as to the ex tent to which the findi ngs apply to their own circumstances (Merriam, 1998). Tying my da ta collection from specific sites to the broader literature of transformational change and to the mobile model enabled me to demonstrate larger lessons regarding change and the applicability of the theoretical considerations beyond the few cases studied he re. This demonstrated that my findings could be applied to other inst ances of transformational change in other institutions of higher education.

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82 Chapter Four Research Findings Findings at University of Kansas School of Nursing Introduction The University of Kansas is a comprehensive educational and research institution. It enrolls 30,644 students and employs near ly 2400 faculty members, including 79 nursing faculty. The School of Nursing is one of the 14 schools of the university. Programs are offered through the doctoral level. In 2007, the School of Nursing graduated 195 students: 145 at the undergraduate level, 43 at the graduate level, and seven at the doctoral level ( http://www2.kumc.edu/aa/ir/re ports/students/degreesAY06_07.html ). During my research into the transforma tion to informatics, I interviewed 11 individuals at the KU School of Nursing. Eight were PhD prep ared; one was a PhD candidate; one was masters’ prepared; and th e remaining individual was a staff member. Their longevity at the college ranged from one to 40 years; the majority had over six years. Only four of the 11 participants st ated they had received formal training in informatics; the rest received informal traini ng. To preserve confiden tiality, all leadership participants will be referred to as administra tors in this chapter, and faculty members will be referred to as just that. In describing the complexity of the transformation process, Eckel and Kezar (2003) employ a metaphor, a mobile with vari ous hanging parts to illustrate change

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83 processes. Their mobile model captures various interdependent strategies which, although they may be somewhat independent, are infl uencing one another either directly or indirectly. In this paper, I have organized participants’ independe nt accounts regarding the strategies used by the University of Kans as School of Nursing as they addressed the core competencies of healthcare informatics. First, I provide an overview of what is occurring in the undergraduate nursing curriculum, classroom, and laboratory settings. Second, I present participants’ perceptions of change proce sses regarding ‘what’ specific methods were used, and why these particular key strategies (critical deci sions, improvements, and/or processes) were selected. Third, I will present how I believe University of Kansas School of Nursing has approached its shift to healthcare informatic s as the broad and deep change in values, culture and structures that charact erize a transformational change. Research Question One: How is Healthcare Informatics Core Competency Addressed? University of Kansas School of Nursi ng used the electroni c health record developed by Cerner Corporation for sale and use in medical facilities, and specifically created an electronic record for educational purposes. University of Kansas School of Nursing reported major revisions to the nursing forms used by hospitals in the creation of the educational version of the electronic health record. They noted the electronic health record was somewhat lacking in the areas of terminology and definition of terms, forms to follow the nursing process, and evidence-base d information links behind the icons. As a result, forms were re-designe d to provide students with mo re clinical information than the electronic health record. In addition, these forms were or ganized to assist students in

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84 forming a cognitive structure in which to le arn and understand the information in the electronic health record. Established patient case scenarios, pr eviously used by undergraduate nursing faculty members, were loaded into the elec tronic health record. These case scenarios were enhanced to include more data and to follow a variety of t eaching and/or learning activities throughout the undergraduate curriculum. Facu lty members use the scenarios with all undergraduate nursing students – in the classroom, in clinical group seminars, and in a simulated virtual health care delivery laboratory. In the classroom, the electronic health r ecord is available for students to document and analyze clinical data in case studies. Faculty members are able to project the electronic health record with all student documentation onto a screen, allowing them to point out trends and discrepancies. They are thus able to offer immediate student feedback, facilitate classroom discussion, a nd assign data-driven teaching cases for online presentation and instruction. Since the elec tronic health record is accessible to both faculty and students through the internet at all times, students can submit patient care plans and other clinical course assignments on these electronic forms for faculty members to review on-line. Each undergraduate nursing program is requir ed to provide a nu mber of clinical practice hours, hours in which direct clinical care is provided to individuals, families, and populations, for students in clinical fieldw ork settings. These include acute hospital settings, clinics, health depa rtments, and other medical-su rgical environments. These guided experiences by faculty in selected settings are designe d to help students develop clinical nursing competencies.

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85 Nursing schools traditionally have used procedurally-based clinical simulation labs with mannequins to practi ce clinical skills before stude nts encounter live patients. University of Kansas School of Nursing has in tegrated the electronic health record into the simulation lab. Nursing students can use th e electronic health record to document the procedures, and can access the web for eviden ce based practice standards and answers to questions. During my on-site visit in April 2007, Un iversity of Kansas School of Nursing faculty and staff tested the electronic hea lth record with SimMan, the institution’s computerized human simulator. Such pati ent simulators are another technology linked with the capabilities of the el ectronic health record, along w ith internet access to reports of evidence based practices. Students are intr oduced to the clinical information system (CIS) through a virtual health care delivery environment such as an acute care hospital. They are given patient scenarios that ar e pre-programmed into the computerized simulator. Key strategies (critical decisions, improve ments, and/or processes) used by deans of nursing are the focus of the following section. Research Questions Two and Three: What St rategies Were Used, and Why They Were Selected? Culture of innovation An administrator indicated that many innovations at the university often starts in the school of nursing, and then migr ates into the medical school and allied health curricula. Several faculty members commented on the innovative reputation of the school of nursing:

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86 The world of healthcare is really one of the most exci ting places to be right now. Our school is wonderfully receptive for a school in the Midwest. I think we are definitely ahead of the curv e and I am pleased to be here. Most of [what we are doing] has never been done before, so you get to be on the cutting edge. Another faculty member added: “The d ean…has created a culture of innovation.…The School of Nursing adopts the newest technology first to figure it out, work[s] the bugs out and get[s] it to working before it goes a nywhere else on campus.” A faculty member described how the college leadership team entices faculty to be open to innovation. Our leadership team understands our cultur e, sets expectations and then provides us the necessary support to accomplish those expectations. The School of Nursing here has always been identified as be ing on the cutting edge. This school has been known for pushing things. In the la st few years it’s been about pushing technology. Between 1993 and 1998, the university r eceived five grants of $800,000 to $1 million each. With these grants University of Kansas School of Nursing had been the first school to offer nurse practitioner cla sses on compressed video, and this proficiency in long distance education was transformed ove r time into a state-of-the-art, web based program. During the initial stage of the pr ogram’s web-based education development, several faculty members were invited to create their own asynchronous, web-based courses, each paired with an individual sp ecializing in educational technology. This led to the creation of an educational technology department on the medical center campus. Remaining faculty members were able to mast er this technology themselves, rather than delegating it to a technology person. An admi nistrator spoke about the initial doubt:

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87 There was a lot of skepticism among the f aculty that this was not good, it wasn’t educationally sound and so forth; but once we started creating the asynchronous methodology, it became apparent that this wa s very attractive to the students. It allowed us to have a pretty far reaching outreach effort and increase our graduate student numbers. Faculty figured out pretty quickly that the quality could be there, and our students did very well on their ce rtification exams. I would say now that we have a hundred faculty members and almost every single person has taught on-line. Academic-business partnership. In 1999 University of Kansas School of Nursing began its journey to address the healthcare in formatics core competency when a school of nursing administrator and the CEO of Cerner Corporation, both involved in the IOM’s (2003) Health Professions Educational Summits, committed to exploring academic solutions together. Cerner, founded in 1979, is a leading U.S. s upplier of healthcare information technology solutions that op timize clinical and financial outcomes ( www.cerner.com/academic ). The School of Nursing was sel ected to take the lead on this front because of its reputation for innovati on and proven track record of success. Two years later, their collaboration resulted in the creation of an academic-business partnership involving the college s of nursing, allied health pr ofessions, and medicine. The university affiliated with Cerner to create an environment in which people from both academia and business could help in putting an educational product together. An administrator explai ned the relationship: Cerner provided a person, the technol ogy and tech support; the school provided the intellectual capital (a nurse informatics expert), as well as faculty time. Cerner

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88 owns the platform and runs and supports the hardware and soft ware through their remote hosting center. We (the School of Nursing and Allied Health and the Medical School) have the equipment and the software on campus. The system is live, which means we have the same electr onic health record in our School of Nursing that is used in the clinical environment, in the clinical laboratory, and other places. This live production environment provides us the latest software updates and latest releases to faculty and students. In January 2000, several events were happening simultaneously: First, the IOM report on medical errors was re leased. Discussions between the college administration and Cerner representative commenced, and Cern er Corporation hired a vice president of nursing. At the same time, the school of nursing was preparing to move into a new building and wanted the building to be wire d for technology. An administrator takes up the story: We invited their new VP of Nursing to tour our new building and to discuss our innovative activities in education at th e time. We began to brainstorm about educating students from the very start in terms of healthcare informatics. The first legal agreement was … in place … nine months following the initial discussions. Our first agreement with Cerner was to ne gotiate for the electronic health record system used in acute care settings. Our undergraduate nursing curriculum was closely aligned to the in-patient hospita l acute care setting, which the electronic health record format was developed to follow. An outpatient physician officebased electronic health record system wa s also available. We decided to launch the electronic health record system [fi rst] within the undergraduate nursing

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89 curriculum, with plans to extend to other health profession schools on the academic health campus. In order to extend the electronic health record within the School of Medicine, we would need to negotiate for the ‘PowerChart Office software, which is the name of the physicia n office-based electronic health record system. Another administrator continued: Doctors are their [Cerner Corporation’s] ‘bread and butter’ for their office product, so they wanted to figure out a way to reach out to medical students. We wanted to involve medicine, the vendor wanted to extend to the school of medicine, and the school of medicine wa nted it. The strategies include the launching of the project with the nursing curriculum and then expansion of the partnership to include other health prof essional specialty schools on the academic health center campus. We have 10 allied health professions on this campus. Cerner wanted exposure to future hea lth providers who might some day choose their product. Attention to academic culture. The school of nursing’s culture of innovation specifically their early master ing of web-based education enabled the school to respond quickly when the IOM (2003) called for the in tegration of clinical informatics into nursing curricula. The leadersh ip team made a conscious a nd purposeful selection of the person to lead the integration of healthcar e informatics core competencies into the nursing curriculum. A faculty member noted overall acceptance of the final choice: No one questioned the selection of our new Director of the Center of Informatics. She has solid academic credentials as a well-known nursing informatics expert,

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90 [an] academic published researcher. Medi cine [also] thought the selection was very appropriate. In addition, the leadership team gave c onsiderable thought to the characteristics needed in the lead project person, who would also serve as a connecting link between the college and the business partner, Cerner Cor poration. College administrators recognized the importance of integrating Cerner Corporation’s unfamiliar business-centered culture and the university’s established academic cultu re into the change process. The lead project person needed to have a high en ergy level and the ability to handle the unexpected without undue stress. Interpersonal and communicat ion skills were essential, as there would have to be considerable cons ultation with faculty a nd in communication of academic concepts to Cerner staff. An administrator remarked on this cultural issue: The academic-business partnership brings to gether two very different cultures that needed to be bridged to rec ognize equity and assure success. [The lead] had to be an RN with informatics competencies, e ligible for a faculty position, and have knowledge and expertise in how clinical information systems work in the real world. The lead faculty member played a signifi cant role in education and training of faculty members who had limited knowledge of healthcare informatics. This individual worked closely with the leadership team to establish realistic expectations for an ‘educationally designed’ electr onic health record with both the Cerner Corporation staff and faculty members. As part of this process, the lead ership team provided on-going administrative oversight and support. A critical component of support included addressing faculty resistance. A faculty member described faculty resistance:

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91 After the introduction of the nursing inform atics process, some faculty members chose to leave the school of nursing. Some of those who remained were still highly skeptical, and others seemed to i gnore the process. Leadership employed different training methodologies, invoked c onstant awareness of the newness of the technology, and found new ways to phase it in. Another faculty member explained how th e leadership team responded to faculty resistance: Leadership’s acknowledgment of the resi stance validated concerns and provided an opportunity to reiterate that change [i s] a vital component of the curriculum and must be accepted. Acknowledging resistance …and addressing ways of dealing with faculty negativity and resist ance was incorporated into the training. The role of sensemaking According to Eckel and Kezar (2003), “getting people to adopt new mind-sets is a cognitive and intellectual process spurred by a set of activities that can be intentionally designe d to leave behind old ideas, assumptions, and mental models” (p. 73). In the organizational behavior literature, th is process is known as organizational sensemaking (Gioia & Ch ittipeddi, 1991; March, 1994; Weick, 1995). My observations lead me to conclude that University of Kansas School of Nursing leadership team employed sensemaking in th eir change strategies The project leader served in a significant role as an informa tics mentor. In addition, the leadership team facilitated the explora tion of possible meanings of proposed changes for faculty work and pedagogies.

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92 The following strategies employed at Univ ersity of Kansas School of Nursing provide additional examples of their co mmitment to academic culture and/or sensemaking. Academic template created prior to involving faculty. The electronic health record software provided by Cerner required the f aculty informatics expert and the business employees to work together to build a basic template that included academic terminology, forms and evidence based links. An administrator de scribed the initial development of the system: At the beginning, the electronic health record was pretty rudimentary. Cerner’s employees had prior experience creating systems used in practice, not in academia. They needed help to understand the educational process. Our nursing informatics expert and a representative from Cerner created system terminology and definition of terms; forms to follo w the nursing process; and evidence based information links behind the icons. The learning activities [were] structured to follow the novice to expert pathways; [t he forms were] kept simple, easy to follow, and grouped by learning concepts. Electronic health record desi gned as a teaching platform. Administration clearly articulated that the technology was to be view ed as a tool, a teaching platform transparent to the pedagogy, rather than the driver of the established curriculum. They wanted the system to follow the educational work flow and the competencies of the curriculum. An administrator explained that a formal curriculum revision was not considered: We had previously revised the curriculum in 1996 to include an outpatient focus, because at the time, patient care was moving to an outpatient arena. We wanted

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93 the electronic health record to be up and running quickly, and felt there was no real need to change the curriculum to ma ke that happen. We have always said technology should be transparent to the pe dagogy. I’m not sure faculty would like to have seen the technology being the driver of the curriculum. Students were not taught the specific functions of the Cerner system. Instead, they were taught how to use the electronic he alth record as a tool. A faculty member described the decision: From the very beginning, we decided not to teach the software to the students… We show them where to look and what to click on to go to the assessments; show them where to go to identify problems; and we link this up with the nursing process, which is what we’re trying to t each them to do. They learn conceptually where to go to look for things. …We have ‘cherry picked’ th ose functions that support the educational domai n, [and] defined an educational work flow instead of a clinical work flow. They come i mmediately into a seminar where they’re learning how to assess a patient and beginni ng to identify problems. The hospitals in town who are clients of Cerner are ecstatic we are using the same company. That makes me a little nervous because they are thinking we are teaching them all the bells and whistles of the system. We ar e not. We have adapted it to what the students really need. Existing case scenarios computerized. Existing patient cases were uploaded into electronic health record. The project manager used establis hed educational work flow processes and worked with faculty members to integrate the case scenarios into their courses, Faculty members then develope d case scenarios and created choices around

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94 them. Through assignments using these pati ent case scenarios, students were taught conceptually where to look for patient data in the electronic health record. A faculty member remembered discussions as these cases were uploaded into the electronic health record: Cases had [initially] been kept simple because faculty [wanted] to keep from overloading students with massive amounts of data; [however, faculty] observed that the simple case studies they had b een using did not translate well to the electronic system, [and] student s requested additional data. Another administrator described facu lty responses to these situations: Faculty found that secondand third-week students were seeking more data. This caused faculty some initial frustration. Ca ses that had been used for years without problems were now being viewed as inadequate. The new concerns were addressed in various ways. For example, one faculty member decided she would be the patient and provide th e data directly to students; another had one student be the patient and provide the needed data to the other; and a th ird returned to her office to amend the case study. Participants did not refer to any spec ific learning strategy they employed; however, in a published chapter by one of Un iversity of Kansas School of Nursing’s administrators in the book, Nursing and Informatics for the 21st Century: An International Look at Trends Cases and the Future (2006), she uses the phrase “problem based learning using virtual patient case stud ies” to describe th eir learning strategy employing virtual patient case studies.

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95 Pilot program began Fall, 2001. An administrator explained the initial plan was to launch the electronic health record in th e undergraduate nursing program. She reported the following: The initial implementation of the electronic health record as a teaching platform was… in three first semester clinical groups of about 10 students each. Thus, only one-third of the total class was part of the pilot study; the remaining two-thirds provided a control group for comparison. Us ing fewer students initially meant any implementation difficulties would aff ect a smaller population. The foundation course was chosen to introduce the elect ronic record concept from the beginning of the students’ training to eliminate a ny pre-conceived ideas on record keeping. The original plan was to conduct a two-y ear pilot program be ginning with the Fall 2001, junior students. During the first year faculty-student focus groups assessed the progress, and that plan was s oon changed. At the end of the 10-month pilot, the students recommended immediate extension of the pr ogram to all students. Faculty worked together to address the needed changes. In general, faculty reported that students seemed to appreciate that the electronic system allowed them to see an entire picture of the nursing process. Faculty observed that students demonstrated an increased ability to handle and utilize more data, decision making tools, and evidence based practice st andards in support of the nursing care process. Critical thinking skills were enhanced, and students showed a more comprehensive understanding of the overall nursi ng process. This was especially true in students with English as a second language, where feedback from these students was consistently positive. According to an administrator:

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96 At faculty meetings, we would discuss the changes and encourage faculty members to share their observations of student responses. Analysis of student behaviors was pointed out to faculty, su ch as the connection of critical thinking skills and particular student observations. We collected lots of data, [including] student observations, audio taped focused student groups, and surveys… sent out to students. This data was triangulat ed. We conducted a pow er analysis and discovered that if we had twice the sample size, we would have gotten significant findings. Since we do not enroll enough students, we needed to conduct a multisite site study and replicate the study. The remaining faculty worked steadily, though perhaps with differing degrees of comfort, to acquire the computer skills fo r the new program. Then, along with faculty from the pilot, they evaluated the process and moved to make the needed changes. One faculty member recalled the response to a suggestion: Initially, [not all] faculty members [had desktop] access to the electronic health record. We [felt] that faculty needed access in their own office in order to become comfortable with using the el ectronic health record. Th e suggestion was adopted. During the evaluation of the pilot project several faculty members pointed to a significant factor in the pilot’s success: “The ability for a faculty member to have quick response from an information technology reso urce person reduced faculty’s stress levels and negativity when faced with computer problems.” Once the initial learning pr ocess had been successfully implemented in the classroom and in clinical settings, faculty be gan requesting more func tionality. The flow sheet, a form which captures critical patient data and student deci sions, was one of the

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97 most useful aspects, enabling faculty to obser ve how all students were working with the same patient. At a glance, each student’s documentation of the same patient was evident, so data errors and documentation erro rs could be immediat ely corrected. While the faculty project manager and sta ff continued one-on-one interaction with faculty and responded immediately to ideas and suggestions, the system was so successful they soon found that priorities ne eded to be established for making changes and additions. Some requests could be in corporated while others proved unrealistic; however, all suggestions were given consider ation. Since students needed to have a variety of responses available, the coopera tion of several faculty members was required to provide the necessary data. In addition, th e complexity of course content required faculty members to assist the project manage r by providing the necessary clinical data to make the suggested changes. Although all suggestions were give n consideration, only some requests could be incorporated; others pr oved to be unrealistic. An administrator noted: “There was some initial confusion regarding automation of course content, “Faculty… did not understand when you automa te content [the system requires] …detailed and precise content.” Electronic health record combined with patient simulator The school of nursing combined three key components to create a virt ual health care world for all health care students: prior success in the use of videos, the financial investment in computerized patient simulators, and the electronic heal th record. A faculty member described the process: We created videos as a challenge exam a nd used [this] to evaluate how well the students performed. Now [t hat] we are using patient simulations with the

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98 electronic health record …w e are seeing positive results. The clinical scenarios are pre-established with diffe rent protocols; the student s work in pairs, and two faculty members watch from behind a window to evaluate and provide immediate feedback. A faculty member explained some of the ways in which the new system is beneficial for students: This process provides every student some continuity. It offers a better way to evaluate the effectiveness of the clinical inst ruction. As faculty member[s], we can assess the students’ needs at any time identify some learning needs… It also helps to determine what worked. Our st udents are better prepared when they interact face-to-face with patie nts on the clinical unit. Common language and core competencies. The literature review identified a significant academic cultural issue relating to a common language and core healthcare informatics competencies across all health pr ofessions. According to Masys et al. 2000; and IOM (2003), the debate re garding healthcare informatic s core competencies across all health professions hinders widespread pr ogress within health pr ofessions education; and the distinctions between broad-base d and discipline-specific language and competencies add to the problem. Medical informatics includes the medical decisionmaking process of physicians (Hogarth, 1997) Nursing argues the application of technology in nursing decision-m aking is different from that in medicine. Nursing management of data, information, and the proce ssing of the information is closely tied to specific nursing professional practices. As a consequence, informatics practice, education, competencies, and corresponding cu rriculum development for the health

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99 professions have proceeded slowly, and lack consensus regarding essential building blocks (Staggers & Bagley-Thompson, 2002). Pa rticipants at University of Kansas School of Nursing made no mention of any form al or informal proce sses used to reach a consensus of a common language for healthcare informatics. A description of how Univers ity of Kansas School of Nursing is addressing core (broad-based) and professional (discipline specific) healthcar e informatics competencies is found in Nursing and Informatics for the 21st Century: An international look at trends, cases and the future (2006) In general, the competencies recommended by the IOM (2003) are broad-based; and in clude word processing, use of external online databases and the internet, and security protections, as well as the ethical issues relating to informatics. Examples of the competencies ta ught within University of Kansas School of Nursing’s undergraduate program include an appreciation for the use of standardized clinical terminology; promo tion of the integrity of nursing information within an integrated electronic health r ecord; an understanding of the us e of networks for electronic communication; and the development of co mpetencies in information management, knowledge management, and evidence-based nur sing. The professional [nursing specific] informatics competencies for beginning nurses identified by Staggers, Gassert; & Curran (2001, 2002) are used for the undergraduate nursing program (Weaver, C., Delaney, C; Weber, R; & Carr, R (2006). A faculty member captured an insight in to the informatics language philosophy at University of Kansas School of Nursing: Healthcare informatics is the gathering a nd retrieving and analyzing of data for its use in decision-making and creating quali ty patient care. When you talk with

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100 anyone about our nomenclature, I think we’re pretty committed to using healthcare informatics as the rubric to describe al l the activities that would go on in our center around informatics. We rarely use the term nursing informatics as a distinction. We don’t really talk mu ch about medical informatics either. Another faculty member elaborated: Informatics as a specialty is a way of looking at knowledge representation in whatever technology you use, whether it is paper, a hand held device, or a computer… something a human can interact with that captures the knowledge and presents the knowledge to them for deci sion-making. So, it is …an algorithm of how we think and how we communicate. An administrator described some of the re luctance perceived toward using a common language for healthcare informatics: Nursing wants to hold onto its own vo cabulary because it defines us as a discipline. But it makes it very difficult in electronic formats if we are not all using the same words. I think nursing and medicine need to talk about patients in an integrated way. Center for Healthcare Informatics announced. The Center for Healthcare Informatics was established in 2004, with the four-fold purpose of advancing information technology, facilitating cultural changes towa rds this technology, attracting grants, and selling the educational electronic health record to other schools of nursing ( http://www2.kumc.edu/healthinformatics/ ). The center is an interdisciplinary structure involving nursing, medicine and allied health professions. An admini strator described the

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101 center’s role as that of providing both the financial resources a nd the new structure necessary to continue the ch ange processes related to h ealthcare informatics: Our Center for Healthcare Informatics is broader than the academic health center on campus. It offers many components, including continuing education; consultation and staff development workshops/seminars; development and integration of clinical care tools for all aspects of patient care, including inpatient, outpatient, public health, home health a nd extended care. In addition, it serves as an alpha and beta testing site for in formation technology companies and product development. Comments by administrators indicate an al truistic desire to promote the benefits of their educational model to other school s of nursing. One administrator described discussions with Cerner about their pricing structure: We rent the product and the outside school s buy platform time and contribute and build the product. We reminded the busine ss partner that their original driving force was to have a greater number of pr ofessionals using the electronic medical record, as well as to get both experienced and new health professionals familiar with the system. In our discussions, we insisted that [their] regular charging structure can’t be used with academic in stitutions, especially nursing schools. Nursing schools do not have that kind of money and most places do not have the interactive software platform.

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102 The financial status of th e center at the end of its third year provided positive reinforcement for this approach. Noted one administrator: In three years we were able to double the Center’s income through grants and contracts including agreements with other schools to support the Academic Education Solution. Admini strators of the center and faculty members are active in state and natio nal initiatives, which often provide additional financial support. In summary. The school of nursing’s culture of innovation and the financial support from Cerner Corporation enabled th e college leaders to respond quickly to address the core competency of health care informatics. The undergraduate nursing curriculum was aligned with Cerner Corporat ion’s in-patient electronic health record, making this an ideal platform from which to launch University of Kansas Healthcare informatics program. Their Center for Hea lthcare Informatics was established in 2004. The center is an interdisciplinary structure involving nursing, medicine and allied health professions. Cerner Corporation owns th e Academic Education Solution (AES) and markets it to other schools of nursing. The University of Kansas School of Nursing supports the implementation in the academic environment through an annual agreement for consultation and remote monitoring. The language and core competencies of healthcare informatics are both broa d-based and discipline specific. Cultural considerations were an integral part of the change processes employed by the leadership team members. The academic qua lifications and interpersonal skills of the lead faculty member were essential to su ccessful implementation within the academic culture as well as between the college and the business partner. The fa culty project leader

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103 and Cerner representatives fi rst created a fundamental education template using the Cerner’s hospital-based health care recor d. A group of undergraduate nursing faculty, along with the project leader, further devel oped this into a teaching platform for the undergraduate nursing program. Each faculty member worked with the lead faculty member to integrate the electronic records into their course. As part of this process, data driven patient case scenarios pr eviously used by faculty we re carefully supplemented to follow a variety of teaching and/or learning ac tivities. The electronic health record was clearly identified to serve as a tool and a teaching platform. The system was designed to follow the educational work flow and the co mpetencies of the curriculum. The learning strategy employs virtual patient case studies in a problem based learning environment. Activities are grouped by learning concepts, an d are structured to follow novice to expert pathways. The faculty lead person facil itated purposeful discussions at faculty staff meetings to encourage open sharing of experiences a nd observations of student responses with other faculty members. This process provide d opportunities for facu lty to explore the meaning of the proposed changes for both faculty work and pedagogies. In the following section, I will explain how st rategies used at University of Kansas School of Nursing coincide with elements of Eckel and Kezar’s (2003) Mobile Model for change. Core and Supporting Strategies Eckel and Kezar (2003) explained the interconnectedness of transformational strategies according to their m obile model. Core strategies te nd not be linked as often to one another; and some supporting strategies tend to cluster with specific core strategies.

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104 University of Kansas School of Nursing employe d all five core strategies with 14 of the 15 supporting strategies. I have organized Ecke l and Kezar’s five core strategies with their suggested supporting strategies accord ing to Eckel and Kezar (2003), and shown how this school of nursing incorporated the strategies in its change process. Core strategy: senior administrative support. Supporting strategies most often linked to this core strategy include: altering admi nistrative and governance processes; establishing support structures; providing financial resources; offering incentives; and using external factors. According to Eckel and Kezar (2003), administrative and governance processes are altered to support the changes, which re inforce the changes as a part of daily operations. Establishing a new center was considered by Eckel and Kezar as an administrative and governance process. In ad dition, these authors id entified the creation of new units such as a new center as a suppor tive structure. The point made by Eckel and Kezar is that “new positions, new centers, new offices served to send the message that the change was important enough to receive st aff, budgets, and office space” (p. 117). Eckel and Kezar (2003) observed that senior administrators in successful change situations established support structures to assist with the changes processes, and also provided new sources of revenue and/or re allocation of existing funds to support the changes processes. At University of Kans as, the Center for Healthcare Informatics exemplifies such approaches. It offers c ontinuing education, consultation and staff development workshops, and generates and integr ates clinical care tool s for all aspects of patient care, thereby providi ng both financial resources and the new structure necessary to continue the change processes related to he althcare informatics. Cerner provided staff,

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105 technology and technician suppor t; the school provided the in tellectual capital (a nurse informatics expert and an app lication analyst), as well as fa culty time. Cerner’s support for the project is provided through the software applications as well as the administration and technical support. Eckel and Kezar (2003) also noted that college leaders provided financial resources to support the transformational proc esses. University of Kansas School of Nursing leaders found new sources of reve nue through the partnership with Cerner Corporation and in the marketing of their pr oduct, the AES, to other schools of nursing. Faculty and staff are provided financial s upport to attend confer ences. In addition, the Center for Healthcare Informatics provided additional funding fo r faculty and staff involved in consultation and staff development workshops/seminars for other schools. Eckel and Kezar (2003) identified anot her supporting strategy of senior administrative support, the offering of incentives to facilitate the change processes. Faculty described the reward processes under the cu rrent administrative leadership at the School of Nursing. One faculty member compar ed current and previous administration: Our previous administration did not va lue clinical faculty. There was an acceptance of high turnover and an attit ude that clinical faculty are easily replaceable; [that] anyone can serve in these positions. Now we are using Boyer’s model, a clinical and a tenure track process. This model recognizes teaching as being one of the four areas of scholarship: research, synthesis, practice, and teaching. Most of us who teach in the undergraduate program are on the clin ical track. The activities I am involved in with the elec tronic health record is considered scholarship.

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106 For example, I am involved in the creation of the family case studies, coordinating classroom learning activities, linking to other courses throughout the curriculum. These act ivities would not have been considered scholarship in the tradi tional model. The Boyer model makes me feel proud to be in th e clinical teaching track. This faculty member referred to Ernest Boyer (1990), who described a model of scholarship consisting of teaching, integrati on of knowledge, application, and discovery. Boyer argued for equal consideration of all f our forms of scholarship in promotion and tenure decisions. Eddy (2007) described Boye r’s model as one th at celebrates the richness in scholarship demands that teaching, integration, and application be embraced in the same manner as the scholarship of discovery. Eddy summarized Boyer’s model as follows: The controversy around teaching as sc holarship is not so much about whether teaching matters as it is abou t how much it matters. The work of educators matters if it is communicated to others, and if teaching inspires lifelong learning (p. 78). Several faculty members noted that they [faculty] are appreciated, recognized and rewarded for their efforts in curriculum innovation; and that involvement with the electronic health record academic soluti on is considered scholarship-related. Another faculty member described faculty recognition in curriculum innovation: “The project director and faculty find a variety of opportunities for scholar ship [presentations and publications] which result in recognition and rewards in terms of merit increases

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107 based on scholarly productivity.” An admini strator explained release time as another faculty reward: For example, they may not have a clinical group or [may] have one less class to teach. They have a chunk of time at work where they could [work on] developing the new technology. That to me, is showing appreciation for the development, and I like that approach. Eckel and Kezar (2003) define external factors as those events and activities outside the institution used internally by lead ers to promote change; and I noted examples of college leaders using exte rnal factors: The IOM’s (2003 ) recommendations and their subsequent reports have influenced Univ ersity of Kansas School of Nursing. The academic-business partnership with Cerner, and later the creation of the Center for Healthcare Informatics are additional exampl es of University of Kansas School of Nursing’s leadership team usi ng external factors to promote change at the University of Kansas. In summary The core strategy of senior ad ministrative support and all of the Eckel and Kezar (2003) supporting sub-strategies were employed by the leadership team. Core strategy: collaborative leadership. Eckel and Kezar (2003) explained that collaboration entails a set of strategi es focused on the human dynamic. Supporting strategies for this core strategy include: inviting participation; providing opportunities to influence results; establishing support stru ctures; encouraging ne w interactions; and facilitating communication. Establishing s upport structure was previously addressed under the senior administrative support core strategy.

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108 The leadership team invited faculty invol vement and worked to create diverse opportunities for involvement. According to pa rticipant responses, administrators at University of Kansas School of Nursing be gan the electronic h ealth record change process with challenging questions. They took into account the college culture as strategies were developed, cr eated collaborative processes, and clearly articulated the processes of change. One administrator viewed he r leadership role as that of a facilitator, prompting open discussion of innovative id eas and motivating individual faculty members to take the lead. Another admini strator shared her approach to requesting faculty involvement: Faculty knew we were a little ahead of the times, making this [informatics] challenge an unusual le ap of faith. I think our innovative faculty, especially, could see the va lue of it. If faculty members are challenged to think about what they need, they come up with a realistic plan to make it happen. I acknowledged this probably will not work smoothly from the beginning, [and] asked the faculty, “what is it you need to develop this unique system, someth ing no one else has tried? We know this isn’t going to be easy; we want to provide support for your great ideas.” In the case of healthcare informatics, the nursing informatics expert and information technology staff pr ovided one-on-one support for faculty members as they implemented the electronic he alth record for each course A small group of faculty piloted creative concepts, revising processes as needed and then sharing results with other faculty. Purposeful faculty discussions id entified advantages and disadvantages, new

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109 ideas, and components that would be needed to ensure success of these emerging ideas. A faculty member commented on the leadership team’s style and fac ilitation of faculty group discussions as a critical component of success: [College leaders] held dynamic c onversations, listening actively and patiently to all ideas; then leadership made the final decision. This process worked because faculty members perceived leadership as open-minded, nonjudgmental and fair. Another faculty member continued: Our administrator is patient, and list ens while faculty process ideas. Some people are very process orient ed and … engage everybody. The conversations are fairly dynamic, but at some point … she chooses a direction. The faculty accepts her decision because she is very openminded, nonjudgmental, and extremely fa ir. She always picks those kinds of people who are willing to take risk s, look at change and modify fairly quickly when it’s not working. I think it was her leadership and her vision, and the way she explains things. She makes sense. In summary Participants consistently identifi ed the collaborative approach of college leaders and the faculty informatics lead person as critical to the transformational change processes. Each faculty member was provided one-on-one support by the information technology staff and/or the faculty project leader as the electronic health record was introduced in their course. College leaders held purposeful discussions with faculty members about the change processes, listened to their ideas, and openly discussed the key processes needed for success. A sm all group of faculty members piloted the

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110 creative ideas and shared the re sults with other facu lty. If the leadership team needed to make a decision to move the project forward, faculty accepted the de cision because of the consistently open-minded, fair, and nonjudgmen tal approach to the change project. Core strategy: staff development. This core strategy was linked to the supporting strategies of tapping outsid e perspectives, facilitati ng communication, finding and creating connections and synergy. The suppor t strategy of facilitating communication overlaps with the collaborative leadership core strategy and has been previously addressed. Tapping outsiders’ perspectives helped to advance change at the campus level by providing opportunities to expl ore ideas and assumptions, by developing new ways of thinking, and by surfacing unexplored assumptions and beliefs. Inviting outsiders can, in many instances, allow for questions that ma y be difficult for campus leaders to raise (Eckel & Kezar, 2003). An example is provided by an administrator: One speaker defined healthcare informatic s as the entire adoption of information technology within the American healthcare delivery system and practice. Some faculty members were not aware of this differentiation. They thought instructional technology like Angel, Blackboard or WebC T, or on-line course s, was healthcare informatics. …[S]essions with outside experts discussing the national agenda [in order] for the electronic health record to be fully implemented by 2010 made the faculty realize this is not just an internal issue. Visits to other institutions by faculty and administration, and their attendance at national and regional meetings and conferences, is another example of how University of Kansas School of Nursing tapped into outside perspectives. This also demonstrates the

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111 leadership team’s commitment to involving faculty in development and implementation activities. Cross-departmental teams and common ta sks charged to a particular group created connections (Eckel & Kezar, 2003). Cr eating and sustaining energy is necessary for successful transformation. The support stra tegy of ‘finding and creating connections and synergy’ arose from various on and off cam pus activities. The activities at University of Kansas School of Nursing created new en ergy because multiple projects led to new connections among individuals from differe nt parts of the institution. These new connections also served to reassure peopl e they were not working in isolation. The interdisciplinary approach to health care informatics extended across allied health, nursing, and medicine, and beyond, to other schools of nursing, created vibrant connections and synergies on campus. The re lationship between the nursing school and the information technology department is anot her example of internal cross-departmental teams and common tasks which created and su stained energy and promoted synergy. A faculty member remarked about the significance of the IT department: Our information technology staff at th e school of nursing and Center for Healthcare Informatics has been very f acilitative in terms of getting us to attend educational se ssions to make sure that we stay updated. We’re usually on the top in terms of our comput ers, [and] all of those things help keep us modernized so our students are technologically updated. Additional on-campus examples involved the role of the project leader, who worked with individual faculty to address specific pedagogi cal issues rela ting to their individual course. Faculty discussions took place to ‘make sense’ of what faculty

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112 members were seeing in their classrooms. St aff meetings included discussions of what the system could provide, how critical thin king skills were connected, and what faculty members were encountering in the classroom Observations were documented through video and audio tapes of focus groups and scored surveys sent to students; and these were then discussed during faculty meetings. Faculty observed that students demonstrat ed an increased ability to handle and use more data, decision making tools, and evid ence based practice standards in support of the nursing care process. Critical thinking skil ls were enhanced, a nd students showed a more comprehensive understanding of the ove rall nursing process. This was especially true in students with Englis h as a second language, where feedback from these students was consistently positive. In summary The core strategy of staff de velopment and the supporting substrategies were employed by the leadership team at University of Kansas School of Nursing to facilitate including healthcare informatics core comp etencies in the curricula. College leaders purposefully c onnected faculty and staff from other departments within the university as well as tapping outside pe rspectives. The faculty project leader addressed educational needs of each faculty as their course and pedagogical issues were being developed and facilitated open discussion related to faculty-student interactions and analysis of student observations. Core strategy: flexible vision. Supporting strategies linked most often to Eckel and Kezar’s (2003) core strategy of flexible vision include: tapping outside perspectives, promoting long-term orientation, facili tating communication, sustaining momentum, setting expectations and holding people accountable, making connections, and putting

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113 issues in a broader context. Many of thes e strategies are interconnected. There was no evidence that the leadership team publicly communicated objectives to be accomplished and established frameworks to hold indivi duals accountable. Howe ver, participants described other support strategies linked to flexible vision in various aspects of their interviews. Examples of tapping outside pers pectives and facilitating communication and connections have already been addressed. The following support strategies were used at University of Kansas School of Nursing: en couraging a long-term orientation, sustaining momentum, and putting issues in a broader context. The support strategy of encouraging a long-term orientation involves the leadership team’s approach to change pro cesses as long-term endeavors, while at the same time employing strategies that captu re and hold the orga nizational members’ collective attention. The school of nursing’s reputation for a culture of innovation specifically it’s early masteri ng of web-based education in the nineties enabled the school to respond quickly when the IOM (2003) called for the integration of clinical informatics into the curricula of health professions. The commitment to create a national academic solution was discussed initially in 1999, and the first nursing undergraduate pilot began in 2001. An administrator summarizes her hope fo r a long-term orientation in healthcare informatics competencies: My hope is that we graduate student s…who are well-versed in clinical information as a basis for decision making in patient care, [who have] the compassion that we want to have our students use with patients and

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114 families; [and who] can translate clinical information into the best possible, safe patient quality of care. At the time of my visit in April 2007, all nursing undergraduate courses except community health and the senior practicum ha d incorporated the electronic health record. A faculty member described another impetus, remarking that the celebration of the university’s 100th year provided an opportunity for faculty to assess their legacy and consider the directions in which they wanted to build the university’s future. According to Eckel and Kezar (2003) su staining momentum during the change processes is another supporting strategy relati ng to flexible vision. Too much change too quickly can overwhelm and exhaust member s of the organizati on, while too little progress can stall the change processes. Mode rating the pace of cha nge is a significant strategy used within organizations under going transformational change processes. Participants at University of Kansas School of Nursing appr oached leadership regarding their concerns over the pace of change: We have a faculty retreat in May. Last year, administration began the retreat by discussing some of the “stu mbling blocks to change.” A major stumbling block was fatigue. When administration openly shared their own personal stories of the impact of change, faculty members began sharing … their own struggles. A majo r focus of our retreat was about taking care of ourselves, using technology to work smarter. We agreed that we do not have to have everything perfect for all of our classes. We celebrated our incredible informa tion technology department and were encouraged to use their expertise.

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115 Another faculty member is more succinct: “Last year the f aculty said to the leadership, could we slow down a bit? That was heard loud and clear.” Putting issues in a broader c ontext is related to the core strategy of flexible vision. An example of this is revealed in one faculty member’s comment: We are very fortunate to have leadership who has a very broad perspective, one that looks outsi de the university and appreciates nationally as well as globally what is occurring in health care. In summary. The core strategy of flexible visi on and all but one of the supporting sub-strategies were employed by the leadership team at University of Kansas School of Nursing to implement the healthcare informatics core competency. College leaders addressed faculty resistance as part of the expected processes of change. Educational sessions included acknowledging re sistance, identifying ways to deal with it, and taking the time to actively listen to faculty. Faculty and college leaders’ interactions at the annual retreat included acknowledging fatigue le vel as a major stumbling block to the change processes. Personal impacts of the changes processes were linked to the broader context of the realization of what was bei ng accomplished. College leadership celebrated the success to date and connected the accomplis hments to the legacy currently being built for a sustainable future. The support strategy of publicly communicating expectations and holding faculty members accountable was not evid ent at University of Kansas School of Nursing. Core strategy: visible action. Eckel and Kezar (2003) link visible action to support strategies such as establishing s upportive structures, enc ouraging communication, setting expectations and holding people accountable, facilitating connections and

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116 synergy, providing financial resources, and in centives. All of these supporting strategies have been discussed. Taking visible action by college leadership moved the change processes forward. Participants connected th eir acceptance of leadership decision making to the consistent collaborative approach of leaders. Demonstrating Balance Eckel and Kezar (2003) identified the impor tance of striking numerous balances between the five core and 15 supporting strate gies and the long-term orientation to the change processes at a deep and pervasive leve l. Moderating the pace of change required leaders to balance speed of the change with patience. In addition, other types of balance were critical to transformational change. Some of the types of bala nce identified by Eckel and Kezar (2003) were apparent in Universi ty of Kansas School of Nursing’s change processes, for example, balancing participa tion of various faculty members and staff, non-tenured and tenured faculty, f aculty from different discipli nes, faculty and staff, and leadership and faculty. The leadership team was aware of the need for balance between internal and external perspectives and i nvolvement. Although they wanted the change processes to move faster, they acknowledged that faculty needed time to try out the new technology, to ‘play’ with it and have some persona l successes before moving on to additional change. Finding ways to create short-term gains while laying the foundation for longterm needs was necessary. They engaged in periodic retreats and a range of new pedagogies that generated the de sired student learning outcomes.

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117 Research Question Four Is University of Kansas School of Nursing approaching the shift to healthcare informatics as the broad and deep change in values, culture and structures that would characterize a transformational change? Eckel and Kezar (2003) define transf ormational change as both deep and pervasive. Depth of change affects th ose underlying assumptions the organization acknowledges: what is important; what to do, why, and how; and what to produce. Such pervasiveness suggests that transformation is a collective, institution-wide phenomenon (p. 33). In addition, Eckel and Kezar’s (2003) resear ch noted that transformational change takes time to reach fruition. University of Kansas School of Nursing began addressing healthcare informatics in 2001, two years prior to IOM’s (2003) Health Professions Education: A Bridge to Quality publication, and six years pr ior to the time of this research. Transformational change is associated w ith particular strategies and activities directed toward implementation of new pro cesses inclusive of structural, cultural and attitudinal markers of progress. The structural evidence markers are familiar concrete measurements that can be counted and compared to baseline sets of data. The additional evidence of attitudinal and cultu ral shifts suggests more dept h to the change (Eckel and Kezar, 2003). Eckel and Kezar (2003) refer to new depa rtments, institutional structures, and new decision-making structures as structural evidence markers. At University of Kansas School of Nursing, creation of the new Center for Healthcare Informatics confirms the

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118 presence of this marker. Creation of the cen ter as a link between ot her schools and as a unit to support the project is a structural change. I presented change processes identified by the participants and source documents regarding what specific methods were used, a nd why those particular key strategies were selected. I observed a number of Eckel and K ezar’s (2003) structural evidence markers of change in the University of Kansas School of Nursing program. These markers include changes in pedagogies, in stude nt learning and assessment pract ices, in policies, budgets, new departments, and in both institutional st ructures and new decision-making structures. Funding of the project manager, and late r additional staff to support the project manager’s mentoring of faculty to change pedagogy, demonstrate changes in budget. Successful partnerships resulted in the cr eation of this interd isciplinary center, and in business arrangements to offer the product to other schools of nursing. Faculty from other schools of nursing across the count ry are involved in revisions of the academic electronic health record, evidence-bas ed practice reviews, forms, and reports to measure student learning activities. The part nership of University of Kansas School of Nursing and Cerner provided an established sy stem for shared use. In 2001, the School of Nursing and Allied Health and School of Medicine created a position as the project manager to explore an interd isciplinary approach to the integration of electronic technology into their respective curricula. Th e following year the undergraduate nursing program conducted a nine-month pilot program us ing the electronic health record in the foundations course. Working with select undergraduate nursing faculty, additional courses were introduced one at a time. Rather than shifting the tota l structure of course requirements, the school of nursing chose to change class activities and teaching methods

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119 within the curriculum structure. Faculty members designed educational experiences for their students, using the electr onic record as a teaching platform in the classroom and in the simulation lab. The problem-based learni ng strategy used patient cases previously developed by faculty. Eckel and Kezar (2003) found that in additi on to structural evidence, another set of evidence was needed to id entify the cultural impact of transformation. These cultural indicators signaled a ttitudinal and cultural shifts that suggested the institution had developed new capacities and a new set of be liefs and assumptions about the changes. Their examples include changes in the patter ns of interactions between individuals or groups, changes in the campus self-image, changes in the ty pes of conversations, and in new attitudes and beliefs. The most significan t strategy that has served to change the patterns of interactions between the health professions was an interdisciplinary approach to the change processes. One of the IOM (2003) recommendations includes use of a common language with corresponding core competencies. Chapte r Two, review of the literature, discussed the debate concerning the use of broad-based versus discip line specific language, which is part of the national conversation about the electronic health record. The debate involves deeply embedded professional valu es, protection of speci fic interests, turf issues, and differing accreditation and licensu re regulatory bodies in medicine and nursing. In general, University of Kansas School of Nursing participants referred to healthcare informatics as an automated proce ss to capture, store, and represent patient data in the same way clinicians think a nd communicate across disciplines. The specific process (formal or informal) used here to reach a consensus was not mentioned in the

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120 interviews; however, individual participants di d share their own beliefs, values, or basic assumptions relating to the definition of healthcare informatics. As a group, these reinforce the need for both a common vocabul ary (broad-based) a nd profession-specific competencies. University of Kansas School of Nursing participants c onsidered healthcare informatics an algorithm of how health care professionals th ink and how they communicate with each other. They consider ed it simply a platform that captures knowledge and presents it for clinical decisi on making. The other different behavior I see is that teaching is much more problem cente red and interactive a nd focused on critical thinking and the use of in formation resources. Finally, I suggest that Univ ersity of Kansas School of Nursing has approached a shift to healthcare informatics as the broa d and deep change in values, culture and structures that would charact erize a transformational change Change at this school of nursing has affected underlying assumptions, as faculty are now thinking and acting differently. Faculty members are designing a di fferent kind of educational experience for students. Use of the electroni c record is much more extensive, and the educational alternatives and opportunities it provides require more t houghtful planning and design. Faculty members work with the healthcare in formatics project manager to integrate case scenarios into their courses, using establis hed educational work flow processes. The process takes extensive design and faculty expertise. As one administrator explained “when you automate content, that co ntent must be detailed and precise”.

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121 Findings at Large State Uni versity College of Nursing Introduction Large State University is a large coeduca tional public research university. There are allied health professional schools and a medical school on campus. It has more than a hundred nursing faculty members. In 2007, the college of nursing graduated more than 200 students (Large State University reference 2). My research interviews included 11 partic ipants, from administration, staff, and faculty: six who were PhD prepared, and five masters’ prepared. I talked to members of the administration and faculty who had longevi ty of between two to 15 years. Three of the 11 participants stated they had received formal training in informatics; the rest received only informal training. To preserve confidentiality, all lead ership participants will be referred to as administrators for the duration of this chapter while faculty members will be referred to as such. I have organized participants’ independent accounts regarding the strategies used by the college of nursing to address the core competencies of healthcare informatics. First, as with University of Kansas School of Nursing, I provide an overview of what is occurring in the Large State University unde rgraduate nursing curriculum, classroom, and laboratory settings. Second, I present participants’ accounts of change processes regarding what specific methods were used, a nd why these particular key strategies were selected. Third, I will present the reasons I believe Large State University College of Nursing has not yet approached its shift to healthcare informatics as the broad and deep change in values, culture and structures th at characterize a transformational change. Large State University College of Nursing be gan its processes of change five years ago

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122 from a adaptive perspective, when the d ean of nursing hired a part-time PhD nursing informatics expert shared with the medical center’s Department of Nursing. The major impetus to move the integration of nursing informatics into the undergraduate nursing curricula did not occur until a grant was awarde d. The grant was awarded for a three year period, which had ended approximately three mo nths prior to my on-site visit. The change is deep but it is limited to the medi cal-surgical and critical care clinical nursing faculty members. There was evidence of a sh ift in values and assumptions in that the small group of faculty members did appear to be thinking and ac ting differently. Research Question One: How is Healthcare Informatics Core Competency Addressed? The Large State University College of Nu rsing used an electronic health record developed by a national electr onic health record (EHR) company for sale and use in hospitals, and based on this, created an el ectronic health record specifically for educational purposes. Although the electronic he alth record is loaded on all of the computers in the college of nursing, its use in the classroom is limited. The use of the personal digital assistant (PDA), another technology employed at this Large State University College of Nursing was described by participants as being used frequently in the classroom. A PhD prepared nursing informatics project leader and a small group of undergraduate clinical nursing faculty enhanced patient case scenario s previously used by nursing faculty and loaded them into the elect ronic health record. These patient cases were enhanced with additiona l clinical data pulled from pre-identified cases in the medical center’s data warehouse, internet, or in a textbook. Faculty members use these patient case scenarios in the medical-surgica l and critical care clinical simulation

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123 laboratory. In addition, they created for co mparison, a “gold standard” case, in which everything in the patient’s electr onic health record is accurate. According to Large State University refe rence 3, the simulation skills laboratory is a structured experience which simula tes patients encountered in a hospital environment. These patients, referred to as a virtual community of patients, are woven into the medical-surgical and cri tical care course content. Stud ents draw on these as they consider multiple types and sources of patient information on which to base their clinical decisions and rapid critical thinking during pa tient simulations. As a result of designed course content and assignments, students master at minimum the beginning level of nursing informatics competencies as describe d by Staggers, Gassert, and Curran (2002). Patient data such as laboratory results a nd medication orders can be accessed remotely through the use of personal dig ital assistants (PDAs) (Large State University reference 4). According to Large State University refe rence 5, there are several examples of student performance in the simulation laborat ory. Sophomore students gain experience using the electronic health r ecord as they perform procedur es in the simulation clinical lab with low fidelity mannequins. In their junior year, students are given patient scenarios pre-programmed in the high-fidelity comput erized human simulator as they use the electronic health record to manage a single pa tient. Students can use their PDAs to access the web for evidence based practice standard s and answers to questions. During their senior year, students in clin ical leadership roles are assigned a group of electronic patients. For example, one may be assigned a quality improvement exercise involving an eight-patient unit. In this scenario, the stude nt develops a tracking tool to complete the

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124 audit, analyze patient charts, and make recommendations on how to improve nursing practice and patient care to th e mock nursing unit manager. Key strategies at this college of nursing’ s are the focus of th e following section. I will include intentional strategies by college leaders employed to get faculty members to think differently about their daily work and consideration of the institutional culture in their change strategies. Research Questions Two and Three: What Strategies Were Used, and Why They Were Selected? Nursing informatics expert recruited. The dean of the college of nursing and the chief nursing officer at the Large State Un iversity Hospital Medical Center jointly recruited a nursing informatics expert in 2002. An administrator de scribed her initial strategy to employ informatics within the undergraduate nursing curriculum: The department of nursing at the hospita l medical center and I jointly recruited a PhD prepared nursing informatics expert. Bo th organizations agreed to fund joint positions, one as associate professor in the college of nursing, and the other as director of nursing informatics and resear ch at the medical Center. We wanted a major change agent. The person we recruite d preferred the medical center clinical informatics environment [rather than] a teaching one. Our college of nursing needed expertise for our students, our faculty, and [for] identification of the informatics competencies needed here. The leadership team at Large State Univ ersity College of Nursing decided to employ the nursing informatics expert to se rve as a ‘change agent’ to implement

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125 healthcare informatics within the college of nursing. An administrator stated her philosophy of change processes and the role of change agents: I believe it is critical th at the person in a leadership role be a champion of the change process. I have observed that successful academic projects have a point person to lead the change effort with a small group of faculty to create the idea. Once the group is successful, then you intr oduce the project to other faculty who can react to the project. College of Nursing receives federal grant The nursing informatics project leader wrote a grant for funding implementation of an electronic health record in the College of Nursing Technology Learning Simulation skills lab. Large State University College of Nursing received a federal grant of approximately one million dollars (Large State University reference 6). An administrator explained: “We we re funded [by] a federal grant on resubmission. This grant was the major impetus to move us forward towards our plans to implement informatics.” She further stated: At the time, our faculty members did not have a good understa nding of healthcare informatics. The grant project would help to increase the knowledge of informatics among the faculty. We needed faculty members who understand informatics and were excited about it to promote to other faculty members who were not as interested. A faculty member supported this: “Mos t faculty members have no idea what healthcare informatics is about. In fact, most of the faculty members do not even want to know what [informatics] is truly about.”

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126 The college of nursing already had the Technology Learning Simulation skills lab and, through other funding sources, update d the lab with co mputerized human mannequins. The same small group of faculty w ho were involved with laboratory skills simulation in the Technology Learning Cent er was chosen to implement the core competency of informatics. One member wa s selected specifically because of her experience with the computerized manne quin. According to a faculty member: [This] person was hired to work exclus ively with simulation. She [already knew] how to program the mannequins, and worked with faculty to develop and program scenarios. When we decided to implemen t the electronic health record into the undergraduate nursing curriculum, this la b setting was alread y successful and [was] an easy fit for any nursing informatics tools. Beginning in 2002, the nursing informatics ch ange agent worked part-time at the hospital and part-time within the college of nursing. She wrote a federal grant for which, in 2004, the state University College of Nurs ing was awarded approximately one million dollars. Faculty response to healthcare informatics initiative Leadership team members described faculty members within the co llege as lacking cl ear understanding of healthcare informatics. College leaders re ported communicating the application for the grant to faculty members. However, accord ing to faculty members, the informatics initiative was introduced to faculty after the grant dollars were awarded. One faculty member stated: “it [the informatics grant] was announced one day in a meeting that this [the grant objectives] is what we’re going to do and it [electronic health record] will be applied in the undergraduate curriculum.” The grant application process was not a part of

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127 the faculty governance structure. One facu lty member described how these ‘cultural breaches’ led to significant pr oblems in the beginning: We have a faculty governance structure th at drives the curric ulum. The grant had no faculty involvement in its creation. F aculty felt it should have been discussed with them, since [implementing the gr ant had] a major impact on faculty workload. The majority of faculty, even those not teaching in the undergraduate program, was dead set against the project. [In] the first two y ears, there was not good buy-in. The three faculty members involv ed began to buy in [only after they had learned] about the programs, pro cesses, and discussions surrounding the implementation. Several Large State University nursing f aculty commented on the cultural clashes in the implementation of healthcare informa tics core competencies. For example, one faculty member said her perception was that the resistance originated from the grant project leader’s initial, unsatisfa ctory presentation of the project: The project leader was not a full-time me mber of the faculty. Her style, her approach, was counter to academia. Buy-in was [only] sought after the fact, [and was presented as] her project, her priorities. She did not to lerate any questions or dissention, [although the] grant must be everyone’s priority. Another described faculty members as de tailed oriented and expecting mutual respect and appreciation of their academic role and workload from the informatics project leader. Neither faculty members nor the projec t leader were willing to negotiate to reach a mutual understanding. She continued:

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128 Our faculty is renowned for being able to wallow themselves in the minutia. We had an immovable force against a rock, a nd neither one was going to give. I think more faculty members would ha ve bought in earlier, if [t he director or informatics expert] had sought their input and placated a little, or at least recognize the increased workload and showed some appreciation for the faculty. Another faculty member admitted that some resistance still exists: We are at our fourth year of the project, and [some] are still resistant. There are some faculty members who have embraced it and really gone up a level in their ability to use these tools to more effectively convey concepts. There are other faculty who are still very computer shy a nd have not spent time to really get to know the system. It’s like pulling teeth to get them to put [the system] into their curriculum. [Acceptance] vari es all across the spectrum. According to Kezar (2001), the existing st ructures such as shared governance in higher education should always be considere d. Change must be recognized as a human process, and inclusion of organizational me mbers must be encouraged. At Large State University, nursing faculty members reported they were not initially invited to participate in the writing of the grant proposal. Once facu lty members were included in the grant activities, they perceived the project leader as disrespectful of their academic role, and the project as an addition to their workloa d. Faculty members were expected to approve the grant application through their academic shared gove rnance model. Even though the project leader met major resistance from faculty members, she continued to work exclusively with the small gr oup of faculty members selected to implement the grant objectives.

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129 Next, I will present how the role of sensemaking, or getting people to think differently, was employed at the large state university College of Nursing. The role of sensemaking According to Eckel and Kezar (2003), “getting people to adopt new mind-sets is a cognitive and intelle ctual process spurred by a set of activities that can be intentionally designed to leav e behind old ideas, assumptions, and mental models” (p. 73). In organizational behavior literature, this process is known as organizational sensemaking (Gioia & Chittipeddi, 1991; March, 1994; Weick, 1995). There was evidence that the informatics projec t leader attempted to explore the meanings of proposed changes for faculty work and pe dagogy. Those attempts were, however, met with resistance from faculty members. An administrator described faculty responses: The lead faculty member presented the electronic health record as a tool to help them. Faculty who were not involved in this process dug in their heels. They said this process was too complicated and time consuming [even though it was emphasized that] it does not drive conten t, [that] it is a device to help communicate content and critical thinking. In an effort to make sense of their pe rsonal journey, several faculty members and administrative staff reflected upon the resist ance to the nursing informatics change processes. According to one faculty me mber, faculty resisted any new technology. “Faculty work loads are heavy and there is n’t much time to learn new technology, which takes a lot of energy and time.” Another faculty member who admitted her in itial resistance noted that after some exposure, she was glad she was involved, ev en though she was appointed rather than invited.

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130 I didn’t have a choice about being involved with the gran t process. At first, I didn’t know anything about informatics, and this [grant] was extra work for me. It seemed like a monstrous project. Now, it makes sense that I was a part of the project. I am glad I wasn’t left out. It has been very exciting and motivating. An administrator shared her belief about resistance from tenured faculty: Some of the tenured faculty members seemed to have the attitude that, even though the small group was doing a good job, they [tenured faculty] “didn’t want a darn thing to do with” the nursing informatics processes of change. She continued: There are two things happening. One, those faculty members who love [the electronic health record] are moving it forward and have their core members involved. They are presenting at conferen ces, publishing and getting recognition. Other faculty members, especially new faculty, are slowly entering this group. Second, there is a strong group of facu lty members who will be against any technology. Technology is not thei r ‘thing’ and they do not want to be pushed to use it. Some faculty members are holding out for retirement. In the next section, I will cover the pr ocesses of change employed by the Large State University College of Nursing healthcar e informatics project leader and her small group as they worked toward implementing healthcare informatics. I will list the strategies implemented in each year of the gr ant, and include any act ivities that supported the adoption of new ideas and assumptions abou t faculty work and pedagogies as a result of implementation of the el ectronic health record.

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131 Grant Year One The infrastructure to support the proj ect was established during 2005, the first year of the grant. Critical decisions include d selection of the electronic health record provider and subsequent clini cal decisions supporting its use, and establishment of the committee structure to oversee grant activities. Electronic health record provider chosen. In its quest to develop an educational version of the electron ic health record, the Large Stat e University College of Nursing selected a national electronic health reco rd company, the same vendor used by the university’s medical center. Th is electronic health record company is a privately held corporation that creates clinician documenta tion and electronic medical record solutions for hospitals, integrated delivery networks, academic medical centers, and other acute care providers (Large State University reference 6). The Large State University College of Nursing chose to operate its own educatio nal version of the EHR company electronic medical record independent of the hospital sy stem. Since the medical center must comply with patient privacy requirements, the educati onal version is on a separate server (Large State University reference 7). Structure to oversee grant activities According to an administrator, separate committees were established to supervise diffe rent divisions of the grant activities. A steering committee directed planning and fis cal activities, while an academic committee focused on clinical information and academic content. Another administrator further explained the role of the steering committee:

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132 They discussed the types of equipment needed and how the nursing informatics project would interf ace with other initiatives, and [planned] faculty development based on the programs selected. Our IT department was involved in this group. During my visit in 2007, a faculty member expressed regret on the apparent demise of the clinical information and academic content committee: “Our last meeting was June 2007, and the members did not want to disband the committee. They wanted this committee to oversee the next phase of the nursing informatics initiative.” These committee members were instrumental in driving the change processes of nursing informatics. Grant Year Two During 2006, the committees decided to implement healthcare informatics in the following ways: 1) informatics content and technology would be implemented in the medical-surgical and critical care [high acuity] courses; 2) patient case scenarios previously used by faculty members would be lo aded into the electronic health record; 3) nursing informatics competencies would be extracted from the Staggers, Gassert, and Curran (2002) master list of informatics comp etencies for nurses; and 4) faculty members would be taught the informatics knowledge and skills necessary as th e electronic health record was implemented in their courses. I will now describe the specifics of how these decisions were enacted. Informatics content and technology implemen ted in medical-surgical and critical care courses. An administrator noted that the entir e curriculum had been revised in 1998 based on the AACN Essentials documents (2000); and another total revision is planned to begin in 2008/2009. The Large State University College of Nursing opted not to revise

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133 the entire curriculum, instead revising each course as the corresponding nursing informatics core competencies were introdu ced. A faculty member explained one reason: We decided to embed [informatics] cont ent into the individual courses and not revise the curriculum [because] if you ch ange course objectives, [or] change curriculum, you have to get it approved. We preferred to revise our course syllabi without a major change to objectives [since] changing th e objectives is a major struggle within our university. Patient case scenarios loaded in to the electronic health record Faculty members crafted data-driven patient case scenarios based on those already being used in the classroom. A faculty member described the process: We reviewed the cases and mapped them on a grid, [examining] the concept that faculty [wanted] to teach in each of the scenarios. Interestingly, between [the cases submitted], we had nine CVA (str oke) cases. Each was unaware that other faculty had created these cases. Another faculty member continued: We built 15 core cases, [and a separate] gold standard case, where everything in the patient’s electronic health record is accurate so faculty can show students a case that is a good example. Cases created on paper are not as data rich; electronic health record cases have much more in formation. For example, vital signs for a three-day period have to be loaded into the system, social service notes are added, respiratory therapy notes, rehab notes, etc. This additional data was pulled from pre-identified cases [in] the medical cente r’s data warehouse, [in] cases published on the internet, or in a textbook.

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134 A faculty member noted that enhancing existing cases was popular with faculty, since they could integrate nursing informatics competencies without having to rewrite the scenarios or develop new ones. She continued: What makes an expert nurse is getting to know the patient over time, getting to interpret information in context within the continuity of care. By building the cases, standardizing the cases within the CIS, we were able to [include] all of the educational principles we set out to accomplish. Students are assigned the same person across different levels of their curriculum. This way, students get to know their patients across a continuum. For exam ple, in their sophomore year, they may [meet] a young patient in a routine histor y and physical exam; then again as a senior, [meet the same] patient [who] is admitted with an illness. Students learn the value of baseline data and making clinical decisions, [and] get to know patients over time throu ghout the curriculum. Nursing informatics competencies established. The Large State University College of Nursing informatics project team extracted its competencies from Staggers, Gassert, and Curran’s (2002) master list of in formatics competencies for nurses by level of practice. The team review ed the categories of computer skills, informatics knowledge, and informatics skills, then added their own unique competencies. A total of 305 competencies were established by this team A faculty member explained the process: [First, we] had to understand the vari ous levels of nursing informatics competencies, how to measure the competencies, and how to implement the changes. Then we began to review each c ourse syllabi to integrate the levels of informatics competencies as appropriate.

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135 Another faculty member continued: Faculty teaching the medical-surgical cour ses selected those competencies they thought BSN graduate nurses should possess by the end of thei r curriculum. The responses were combined and charted on a grid. If 80% of the faculty agreed, the competency was automatically included. If there was less than 80% agreement, the [involved] faculty had [to explain] w hy [they] viewed the competency as an important. We identified the rest of the co mpetencies by consensus, then selected those competencies we wanted to be prerequisites. We identified the competencies currently being taught and determined how those competencies not being taught would be integr ated into the curriculum. We chose the specific courses [in which] the competencies [would be] introduced. Together, [we] developed a homework assignment or [class] exercise -whatev er it took to put that content into the curriculum -then l ooked at whether students were actually getting the content. Faculty education and development Educational sessions were provided for faculty members involved in the project. A faculty member described how informatics competencies were introduced to faculty: [One] strategy [used was on] faculty deve lopment days, generally once a quarter. We focused on different informatics competen cies that we were trying to achieve. For example, we did presentations on how you evaluate web sites. We brought in outside speakers for the hand held devi ces, [talked about] how they were being used in other colleges, and gave them time to play [with the devices]. We [had] faculty talk about how [each was] using it in different as pects of the courses, so

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136 they could share and learn from each ot her. There were times when we would observe a faculty member teaching a cour se and [then] we were coached through the next time [as we taught it]. Educational opportunities were provided fo r any faculty member who wanted to attend. In addition, a faculty member stated, “We have six instructional technology staff, a clinical project leader, staff from a national EHR company, who have provided education as part of their role and as part of the grant.” The nursing informatics project leader provided on-going education for the faculty. Several faculty members specifi cally acknowledged the College of Nursing Information Technology staff as being critical to their education and development. The six individuals within this department were cited by faculty members as service oriented and always eager to assist them immediately with their needs. Grant Year Three By 2007, the conclusion of the grant pe riod, nursing informatics competencies were fully integrated in the medical-surgical a nd critical care clini cal courses. A faculty member outlined the next phases: “The plan is to bring up the obs tetrics course this coming year [2008], the pediatrics course th e following year [2009], and the psychiatric course in the third year [2010].” Medical-surgical and critic al care clinical faculty members had begun using the electronic health record in the technology center, the simu lation labs, and in student assignments, and an assessment of the proj ect’s effectiveness was needed. A faculty member described how she measured students’ critical thinking skills using preand postmeasurements, and what this revealed:

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137 [When] I used the Health Science Reas oning Test (HSRT), [I found] a significant increase in critical thinking skills for the sophomore and junior students, but not [in] senior students. Seniors were give n the test two weeks before graduation [and] feedback from [them indicated] they did not take the test seriously, since they were [already] graduating. Pedagogy. Some participants were uncertain as to the type of pedagogical practices being used. The descriptions of methods of teaching and learning were problem based and active learning pedagogies. One facu lty member stated: “In the past, we tried problem based learning in its purest form, wh ich is very inefficient. I believe we abandoned [it].” Another faculty member suppor ted this statement th at the college of nursing was not using problem-based learni ng. One faculty member described their process as ‘participative.’ No other refere nce to pedagogical practices was mentioned during the interviews. Student learning and assessment practices According to Armstrong and Barron (2002), a competency-based curriculum stim ulates pedagogical approaches of active learning and problem-based learning that enc ourage greater faculty-s tudent interaction. Student learning groups are used to provide a systematic f eedback to faculty. Problembased learning engenders more self-directed learning and does a be tter job of providing students with a process for integrating what has already been lear ned (Rideout, 2002; et al., 2002; Juul-Dam et al., 2001; Krackov & Mennin (1998); IOM, 2003). Student learning and assessment practices used in th e clinical simulation laboratories included student learning groups, self-dir ected learning, and various pr ocesses to integrate what students were learning. A faculty member desc ribed student learning groups and student

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138 roles during a simulation: “We usually have five students in a hi gh-fidelity simulation. Student play various roles, a charge nurse; a recorder, an observer, a primary nurse, and a family member. These learning groups also included laboratory RN staff and clinical faculty members. According to a faculty me mber, “We have two RN staff members [in the clinical simulation laborator y]. One works with the medical record to send orders and results across the electronic health record [and] the other runs the hi gh-fidelity simulator. Self learning opportunities are provided as students demonstr ate their knowledge and skills as a member of the pre-programmed simulation team. One faculty member would facilitate student interactions within their assigned roles, and also facilitate feedback between students. Another facu lty member explained, “Once the students completed the simulation, we [faculty members] debriefed with the students about [their] responses to the pre-programmed patient simu lation. Then, we repeated the simulation so students could apply wh at was discussed.” A faculty member said that her observati on indicated that clinical information systems enhance student education: “Clinical information systems such as the electronic health record provide students with much rich er and deeper data about patients. Students have greater context and knowledge about th e patient, [allowing them] to make more informed decisions.” Faculty members provided other observati ons relating to student learning and assessment practices, which they believed wa s linked directly to the simulation lab experiences and immediate faculty feedback to students. One shar ed discussions with colleagues:

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139 Faculty members have [noticed] student benefits from the implementation of nursing informatics competencies in the simulation skill labs. We have observed enhanced critical thinking, impr oved organizational delegation, and communication skills. Students are able to a ssimilate the clinical picture in a more comprehensive and integrated way. We us ed to see students get a good clinical picture and comfort level in w eek nine; now it is in week five or six. I think it is a combination of the role playing that occu rs in the simulation labs and immediate feedback between clinical instructors and students. In summary In 2002, the Large State Universi ty Hospital Medical Center’s Department of Nursing and the College of Nu rsing partnered to recruit a PhD prepared nursing informatics expert to be the ‘champ ion of change’ in implementing the core competencies of informatics. In 2004, the co llege of nursing received a federal grant of approximately one million dollars. The small group of clinical undergraduate nursing faculty already involved in the developm ent of the Technology Learning Simulation [skills lab] was selected to implement nursing informatics in the medical-surgical and critical care course simulation lab. Faculty members were unhappy with the ad ministration’s decision to implement the healthcare informatics core competencies within a small group of faculty and later, to introduce the findings to other faculty members. According to some faculty members, the faculty governance structure that drives the cu rriculum was not included as a part of the change process for the approval of the grant, and this also was met with resistance. The project leader was not a full-time faculty me mber, and her personal approach was counter to the existing academic culture. Once faculty members outside the initial pilot group of

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140 undergraduate nursing faculty did become invol ved, neither they nor the project leader were willing to compromise in negotiati ng resolutions to problems. This conflict continues to impact the implementation of nursing informatics at the Large State University College of Nursing, with one facu lty remarking that “[acceptance] varies all across the spectrum.” The nursing informatics project leader and the small group of faculty did, however, consider academic cultural issues, and encouraged the adoption of new ideas about faculty work and pedagogies as they implemented nursing informatics in the medical-surgical and critical care courses simulation skills lab. Examples included the examination of teaching and learning con cepts faculty members wanted in their respective courses. Each cour se was further reviewed fo r specific nursing informatics competency and for methods to imbed this content into the curriculum. The small group of undergraduate faculty members on the academic committee and the nursing informatics expert used the St aggers, Gassert, and Cu rran’s (2002) list of informatics competencies for nurses by level of practice: beginning nurses, experienced nurses, informatics nurse specialist, and info rmatics innovators. This group reviewed all of the healthcare informatics competencies at the prerequisite level, as well as those competencies currently being taught or not being taught to the undergraduate nursing students. They reviewed each medical-sur gical and critical care course for the appropriate introduction of healthcare info rmatics competencies, and devised homework assignments to introduce the content into the cu rriculum. By the third year of the grant, the electronic health record was fully integrated into sk ills lab in the Technology Learning Simulation Center.

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141 Large State University faculty used a different EHR company to create an educational electronic health record. Case s cenarios previously created by faculty were reviewed and mapped on a concept grid. Th is process of mapping case scenarios to teaching/learning concepts provided an opportunity for the faculty to revisit the concepts of each class. Because the electronic health record requires more data than is found in paper medical records, the nursing informatic s expert to pulled information from preidentified cases in either the medical cen ter’s data warehouse, published cases, or textbook cases. Large State University College of Nursing has addressed the core competencies of healthcare informatics as nursing specific. The nursing competencies implemented with the undergraduate nursing program (with the exce ption of obstetrics and pediatrics which will be introduced in coming years) follow the competencies for beginning nurses identified by Staggers, Gassert, and Curra n (2001). Based on their approach to implementing nursing informatics competencies within the undergraduate medicalsurgical and critical care c ourses, as well as on faculty members’ descriptions of the simulation laboratory experiences I conclude that Large St ate University College of Nursing is employing a competency-based ap proach, and using problem-based and active learning pedagogical practices. Student learning assessment practices we re observed by some participants as changing within the simulation laboratory. Faculty members described self-directed learning, student learning groups and debriefi ng sessions which included a repeat of the simulation. This process helped students to integrate what they learned. The small groups

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142 of faculty members within the simulation la b were having conversat ions regarding their observations of student learni ng and assessment practices. In the following section, I will explain how strategies used by Large State University coincide with elements of th e Eckel and Kezar’s (2003) Mobile Model for change. Core and Supporting Strategies As previously with the University of Ka nsas School of Nursing, I have organized the core strategies with the supporting strate gies suggested by Eckel and Kezar (2003). In their model, some supporting strategies ar e linked to more than one core strategy. Four of the five core strategies for th e implementation of nursing informatics were evident at state university’s college of nursi ng. The exception was use of collaborative leadership strategies. Only seven of the 15 supporting strategies were evident. I will provide examples identified as present at th e Large State University College of Nursing, and will comment on those strategies which were not employed. Core strategy: senior administrative support. The five supporting strategies most frequently linked to this core strategy were in evidence. These strategies include altering administrative and governance processes, es tablishing support structures, providing financial resources, offering incen tives, and using various extern al events and activities to promote internal change. According to Eckel and Kezar (2003), the supporting strategy of altering administrative and governance processes is inte nded to ensure that the desired changes ultimately become part of daily operations. These authors identified the creation of new positions and new units as both a supportive stru cture and a financial resource. This sends

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143 a message that “the change was important enough to receive staff, budgets, and office space” (p. 117). They believe that support struct ures are designed to assist with change processes by providing new sour ces of revenue and/or real locating existing funds to support them. This strategy was evident at the Large State University College of Nursing in their partnership with the Department of Nursing at the Large State University Hospital Medical Center, through which they join tly funded an informatics expert to lead the change processes. Initial funding of the national EHR company platform came from the grant, and the College of Nursing has continued to fund both this expense and an information technology support person after gr ant monies were exhausted. In addition, the College of Nursing has six IT staff av ailable for faculty members. Grant monies allowed for some incentives in addition to the funding of faculty to work on the project. A faculty member noted the core faculty group were “presenting at conferences, publishing their work, [and] getting recognition they well deserve.” External factors are those events and activities outside the institution used internally by leaders to promote change. Ex ternal factors cited by participants at the Large State University College of Nursing incl uded the use of outside speakers to educate faculty about healthcare info rmatics. (IOM, 2003) reports and a seminal work on nursing informatics core competencies were also mentioned. In summary The core strategy of senior administrative support was employed by the Large State University College of Nursing, along with all five of the most often cited supporting strategies. Core strategy: collaborative leadership. This core strategy is about developing extensive internal plans to facilitate co mmunication, inviting part icipation and providing

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144 opportunities to influence results, and bringing together people in new ways to foster communication and encourage new interactio ns. Establishing support structures was previously addressed under the senior admi nistrative support core strategy and was evident at the Large State Univ ersity College of Nursing. Collaborative activities such as invited participati on, opportunity to influence results, and facilitating comm unication between the grant proj ect leader and the faculty members at large were not part of the cha nge process at the Large State University College of Nursing. Faculty members reported not being informed of the grant until after it was awarded and the application was not submitted through the faculty governance structure. The informatics project leader expected faculty members to make the grant their priority and was not open to their suggestions. However, there was evidence of these support strategies being employed within the core group of undergraduate faculty charged with implementing nursing informatics within the medical-surgical and critical care clinical courses. Acco rding to a faculty member: There were two separate committees which supervised grant activities. One oversaw the day-to-day grant activitie s while the other (academic) committee focused on clinical information and academic content. The academic committee determined philosophical issues relating to the design of the electronic health record format, such as types of nursing notes and plans of nur sing care used; the patient case scenarios to be loaded into the electronic health record system; nursing informatics competencies fo r the beginning undergraduate nursing student; and homework assignments for each course.

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145 Another of the supporting strategies of Eckel and Kezar’s (2003) model, encouraging new positive interactions was not evident here as part of addressing the core competency of healthcare informatics. As previously noted, faculty members were not involved in the grant application, and they desc ribed the change agent as being outside of academia and difficult to work with. There was no evidence of any extensive internal communication plan with a range of strategies to communicate the activities of the pilot group to faculty at large. In summary Establishing support structures wa s previously addressed under the senior administrative support core strategy, a nd was evident at the La rge State University College of Nursing. The remaining support stra tegies relating to this core strategy were not evident. According to Eckel and Kezar (2003 ), the intent of this core strategy is to instill a sense of trust, to clarify misundersta ndings and rumors, and ultimately to foster a sense of community across the campus. The f aculty’s shared governance process was not included in writing the grant ap plication. Faculty member pe rceived the opportunity to influence results of the informatics gr ant initiative as ‘after the fact.’ Core strategy: staff development. Eckel and Kezar’s (20003) linked this strategy to the support strategies of tapping outsid e perspectives, facil itating communication, and identifying and creating linkages among vari ous campus activities. The supporting strategy of facilitating communi cations has already been addr essed and was not evident at the Large State University College of Nursing. Inviting outsiders can, in many instances, al low for questions that may be difficult for campus leaders to raise (Eckel and Kezar, 2003). Tapping outside perspectives helps to advance change at the college level by providing opportunities to explore ideas and

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146 assumptions, by developing new ways of thinking, and in surfacing unexplored assumptions and beliefs. At the Large State University, the nursing informatics leader initiated faculty development days on a quarter ly basis, focusing on different informatics competencies such as the use of the hand held device (PDA). Outside speakers were often used during this time, and the nationa l EHR company staff presented the electronic health record system to faculty. In summary Only one of the supporting strate gies, specifically, the tapping of outside perspectives, was evident for the core strategy of staff development. Eckel and Kezar (2003) identify the importance of co mmunicating the multiple projects and the connections among change activit ies to reassure organizational members they are a part of a community and are not working in isol ation. There was no evidence that college leaders attempted to facilitate communicati on among faculty members at large, or to identify and create connections linking various activities. Core strategy: flexible vision. Supporting strategies linked most often to the core strategy of flexible vision include several of the supporting strategi es already discussed, such as, tapping outside perspectives (evide nt), facilitating communi cation (not evident), and making connections (not evid ent). I will discuss the remaining support strategies of promoting long-term orientation, sustaining momentum, setting expectations and holding people accountable, and putting i ssues in a broader context. The commitment to nursing informatics core competencies to be integrated into the curricula began in 2002, five years pr ior to my on-site visit. Leadership representatives of the colle ge of nursing demonstrated continued administrative commitment to the project in their decisi on to continue funding the national EHR

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147 company CIS platform and an IT support pers on for this system. It was evident that the leadership team communicated a long term commitment to the faculty members with plans to select another nursing informatics e xpert lead to replace the original expert, who resigned. According to Eckel and Kezar (2003), su staining momentum during the change process is a strategy relating to flexible vision. Too much change can exhaust members within an organization while t oo little progress can stall the change processes. There was concern about the sense of urgency regarding actions taken to sustain the progress. For example, one faculty member remarked that “we may be okay [in waiting to select the next informatics project lead er] one or [even] two semest ers, but not any longer.” The core strategy of setting expectations and holding people accountable was noted only within the core faculty group. The structure of grant awards requi res documentation of objectives and regular reporting of activi ties accomplished; however, there was no evidence of this being employed by the leadersh ip team for the faculty members at large. Eckel and Kezar’s (2003) model suggested tw o types of expectations that should be publicly communicated by leadership: how th e objectives are to be accomplished and how the campus will be different and improved. Part of this change strategy includes addressing campus behavior and priorities These are developed through extensive consultation and listening to change lead ers, faculty, and various campus subgroups, ensuring that faculty members believe they are part of something critical. Most of the supporting strategies discussed by Eckel and Ke zar (2003) under this core strategy were not applied in the Large State University Co llege case study. There was evidence of only two, tapping outside perspectives and promoting a long-term orientation.

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148 There was no evidence that the leadersh ip team framed the implementation of nursing informatics in a broader context by extending the issues beyond Large State University College of Nursing. This s upport strategy, according to Eckel and Kezar (2003), helps leaders to raise the level of importance of the processes of change, makes the local challenges more reasonable when compared to state-wide or national happenings, and helps to depersonalize the i ssues for the individual faculty members. In summary Three of the seven supporting stra tegies for the core strategy of flexible vision had already been previously addressed. Tapping outside perspectives and promoting long-term orientation were the s upporting strategies evid ent at Large sState University College of Nursing. There was no evidence of sustaining momentum (yet), setting expectations and holding people acc ountable, or putting i ssues in a broader context. Core strategy: visible action. All supporting strategies linked to Eckel and Kezar’s core strategy of vi sible action have been disc ussed. The evident supporting strategies include: establishi ng supportive structures, provid ing financial resources, and offering incentives. The supporting strategies not evident include: encouraging communication, setting expectations and hol ding people accountab le, and facilitating connections and synergy. There were some substantial (but incomplete) efforts by college leaders to demonstrate visible action during the change process at the Large State University College of Nursing. In summary Seven of the 15 supporting stra tegies were employed during implementation of the electronic health reco rd at the Large State University. These supporting strategies were: 1) altering administrative struct ures; 2) establishing support

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149 structures; 3) offering incentives ; 4) using external events to promote change internally; 5) providing financial resour ces; 6) tapping outsider persp ectives; and 7) promoting a long-term orientation to the change processe s. Other supporting strategies were employed only within a small group of undergraduate nurs ing faculty. I chose not to include these supporting strategies since they were eviden t only in the pilot group but not throughout the college. Demonstrating Balance Eckel and Kezar (2003) identified the impor tance of striking numerous balances between the five core and 15 supporting strate gies and the long-term orientation to the change processes at a deep and pervasive le vel. Moderating the pace of change required leaders to balance speed of the change with patience. Faculty members expressed dissatisfaction in not being involved in the grant application and not being invited to discuss the amount of work that would be need ed to implement the grant. As discussed in the core strategy of flexible vision, sust aining momentum was a concern mentioned by faculty. I also did not observe additional t ypes of balance identified by Eckel and Kezar (2003), for example, balancing participation of various faculty members and staff, nontenured and tenured faculty, faculty from diff erent disciplines, faculty and staff, and leadership and faculty. There was a concern by faculty members that too little change was occurring after the grant was completed and there was not a named person to lead nursing informatics. The use of only seven of the fifteen supporti ng strategies, also demonstrate a lack of balance by employment of too few of the supporting strategies. Four of the eight neglected supporting strategies included the core strategy of colla borative leadership.

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150 Demonstrating balance by college leaders includes the balance of faculty participation between junior and seasoned faculty, and f aculty members from different disciplines, which was not evident here. There was evid ence of a long-term approach to nursing informatics by college leaders in their on-going financial support of the electronic health record usage costs. Research Question Four Is the Large State University approaching the shift to healthca re informatics as the broad and deep change in values, culture, and structures that would characterize a transformational change? Eckel and Kezar’s (2003) research confir med transformational change takes time to reach fruition. The Large State University College of Nursing began to address the core competency of healthcare informatics in 2002, with the hiring of a part-time nursing informatics expert. However, the major im petus to move the integration of nursing informatics into the simulation lab and parts of the curricula occurred only after the grant was awarded. The grant was awarded for a three year period, which had ended approximately three months prior to my on-site visit. I have presented the processes of change employed at the Large State University College of Nursing, along with the evidence or lack of evidence that the key aspects of the Mobile Model were or we re not employed at the Large State University College of Nursing. These included the role of sense-ma king, the attention to the academic culture, and the interrelationships among core and supporting strategies. There was no evidence that the leadersh ip team engaged faculty in intentional conversations designed to leave behind old id eas, assumptions and mental models about

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151 nursing informatics. However, I did find eviden ce that the small group of clinical faculty and the nursing informatics project leader engaged in sensemaking. There was only limited evidence the leadership team had paid close attention to the academic culture. For example, some faculty stated that the shared governance stru cture within the college of nursing was not included in the grant applicati on process. They said that faculty members were not informed of the grant until the grant was actually awarded. Participation by faculty members outside of the core group involved in the grant has been spotty. In reviewing the interrelationships among Eckel and Kezar’s (2003) core and supporting strategies, I determined the major core strategy evident at the Large State University College of Nursing was support fr om senior administra tion. I also found evidence of the supporting strategi es most often linked with th is core strategy. Financial support was provided, administrative structures were altered, support structures were established, outside events and activities to promote internal change were employed, and incentives were offered to the faculty member s involved in the grant project. The core strategy of staff development and flexib le vision included the tapping of outside perspectives. In addition, th ere was evidence of a long-term orientation and commitment to continue the change processes related to nursing informatics. The core strategies of collaborative leadership, staff development, flexible vision and visible action all focus upon the breadth of the change. For example, th e core strategy of collaborative leadership focuses on developing extensive internal commun ication plans, inviting participation, and providing opportunities to influence results to instill a sense of community. Staff development also relates to facilitating communication between the multiple projects and establishing connections among activities to r eassure members they are not working in

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152 isolation. Flexible vision included sust aining momentum, setti ng expectations and holding people accountable, or putting issues in a broader cont ext. Visible action included such behaviors as extensive consultatio n with and listening to faculty members. Participants mentioned none of thes e activities during my interviews. The importance of striking numerous balances between the five core and 15 supporting strategies and the long -term orientation to the cha nge processes at a deep and pervasive level is seminal to transformati onal change; and these types of balance, identified by Eckel and Kezar (2003), were also not observed. For example, there was no evidence of leadership team’s consideration of balancing par ticipation of various faculty members and staff, non-tenured and tenured faculty, faculty fr om different disciplines, faculty and staff, and leadership and faculty. Eckel and Kezar (2003) also suggest structural and cultural evidence markers of change to determine the depth of change pro cesses within an organization. Such markers are concrete measurements that can be counted and compared to baseline sets of data, for example, changes in curriculum, in peda gogies, in student learning and assessment practices, policies, budgets, new departments, and in both inst itutional structures and new decision-making structures. I did find evid ence of budgetary changes within the Large State University College of Nursing, such as the part-time PhD nursing informatics expert, first funded in 2002. The leadership team supported the grant project and has continued to support the nati onal EHR company information system and the nursing IT specialist for this system. There were st ructural evidence markers of change in pedagogies and in student learning and a ssessment practices. The nursing informatics expert and the small group of faculty me mbers accomplished the integration of the

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153 competencies for beginning nurses as identifi ed by Staggers, Gassert, and Curran (2001) in the medical-surgical and critical care cour ses and the clinical high-fidelity simulation labs. Based on faculty members’ descriptions of the simulation laboratory experiences, I conclude that this Large State University College of Nursing is involving a nursing competency-based approach, problem-based and active learning pedagogical practices. Faculty responses, however, were not clear as to any formal description of these processes. The participants observed student learning asse ssment practices as changing within the simulation laboratory. Structural evidence by itse lf did not necessari ly suggest transformational change. There is a need for an additional set of evidence to identify the cultural impact of the transformation. These cultural indicators signaled attitudinal and cultural shifts that suggested the institution had developed new capacities and a new set of beliefs and assumptions about the changes. The exampl es of these indicato rs at Large State University College of Nursing were only obs erved within the small group of clinical nursing faculty. In conclusion. Large State University College of Nursing leaders did not approach nursing informatics as a transf ormative change, but as an adaptation. According to Eckel and Kezar (2003) adaptation is described as a deliberate modification or adjustment by the organizati on or its units in response to the external environment. Adaptation is systemic; it is comprised of in terdependent relationshi ps with the external environment which can be at the individual un it level versus organizational-wide; and can allow subunits to adapt to cha nge without widespread organiz a tional disequilibrium. A loosely coupled system can, however, evince lack of coordination, difficulty responding

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154 to change in an unified manner, and communi cation that is inconsistent. Adaptation is similar to transformational change in th at both are ongoing processes and not single events. Both include responding to environm ental changes. Transformation is also distinct from adaptation in that adaptation l acks the breadth of tran sformational change. Eckel and Kezar (2003) note two characteristi cs that differentiate transformational change from adjustment, isolated cha nge, and far-reaching change -depth and pervasiveness. My research demonstrates th at the Large State University College of Nursing did not experience a shif t in healthcare informatics as the broad and deep change in values, cultures and structures that char acterize a transformati onal change. Based on Eckel and Kezar’s definition, I conclude the Large State University College of Nursing did experience deep change; however, it is limite d in to the medical-surgical and critical care clinical nursing f aculty members who were also involved in the computerized simulation lab. There was evidence of a shift in values and assumptions in that the small group of faculty members did appear to be thinking and acting differently. I also documented intentional convers ations relating to the dail y work environment of the faculty members and the nursi ng informatics expert. The Large State University College of Nu rsing's experience of high depth and low breadth as identified by Eckel and Kezar's ( 2003) model is in line with the leadership team's initial strategies to introduce nursing informatics into the curriculum. In 2002, they employed a nursing informatics expert to serve as a change agent to provide expertise for faculty members and to identify nursing competen cies to be integrated into the simulation lab and medical, surgical and cr itical care course content. In 2004, the award of a grant was a major impetus to move the processes of change forward, at least within the small

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155 group of faculty members who were involved in the computerized human simulation lab. During my on-site visit, these faculty member s expressed excitement at their successful integration of nursing informatics into the curricula. They now have a good understanding of nursing informatics and are promoting their experiences and conveying their enthusiasm to other faculty members. Findings at St. Scholas tica School of Nursing Introduction St. Scholastica is a private college compri sed of a main campus and four extended sites. Total college enrollment exceeds 3,000 students. The School of Nursing, one of seven schools of the college, has an underg raduate nursing faculty of 19. The school of nursing offers programs through the doctoral level, and graduates approximately 112 baccalaureate trained nurses each year. Within the college, the School of Health Sciences has students in physical therapy, occupational therapy, social work, exercise physiology, and health information management ( http://www.css.edu/About_St_Scholastica.html ). Seven participants were interviewed: f our were PhD or EdD prepared, and three were MA or MS prepared. Participants incl uded both administrators and faculty, with longevity of three to 26 years: Three had been with the instit ution in excess of 17 years; four had been there four years or less. Three of the seven participants received formal training in informatics; the re st received only informal trai ning. To preserve anonymity, all participants in this chapter will be referre d to as an administrator or faculty member. I have organized participants’ independent accounts regarding the strategies used by their school of nursing to address the core competencies of healthcare informatics in the same format for all three cases. First I will provide an overview of what is occurring

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156 in the undergraduate nursing curriculum, cla ssroom, and laboratory settings. Second, I present participants’ perceptions of change processes regarding what specific methods were used, and why these particular key st rategies (critical de cisions, improvements, and/or processes) were select ed. Third, I will present the reasons I believe St. Scholastica School of Nursing has not yet approached its sh ift to healthcare informatics as the deep change in values, culture and structures characterizing a transformational change as defined by Eckel and Kezar (2003). As of 2007, St. Scholastica has addressed healthcare informatics in an interdisciplinary approac h. Breadth of the change was limited to a small group of undergraduate nursing faculty members who made important changes in their ways of thinking and teaching. Research Question: How is the Healthcare Informatics Core Competency Addressed? St. Scholastica College of Nursing used th e electronic health record developed by Cerner Corporation for sale and use in medi cal facilities, and loaded college alumni medical records (personal identifiers erased) into the electronic record for educational purposes. These electronic health record case studies are categorized to conform to the nation’s top 10 disease prototypes. Facu lty members can use the scenarios with undergraduate nursing students in the clas sroom, homework assignments, and in a simulation laboratory ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Advance_March_2004.html ). In the classroom, the electronic health r ecord is available for students to document and analyze clinical data in case studies w ith the disease prototypes. Faculty members have automated capability to project all st udent documentation onto a screen, allowing

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157 them to point out trends and discrepancies. They are thus able to offer immediate student feedback and facilitate classroom discussions. A faculty member expl ains the use of case scenarios in the classroom: “The learning pr ocess is one of discovery. Patient cases can be reviewed in the classroom across time pe riods to evaluate [skills such as] nursing interventions, actions and assessment.” An administrator observed changes in homework assignments following implementation of the electronic health r ecord: “Student homework assignments are carefully planned with questions that en courage students to think, and to discover answers as they discuss with other students in the classroom.” Since the electronic health record is accessible through the Internet at any time, students can access clinical course assignments for faculty members to review on-line. A faculty member explained that even those faculty members who do not like the electronic health record in the classroom accept its use in the simulation lab. Nursing schools have traditionally used procedural -based clinical simulation labs with mannequins to practice clinical skills before students en counter live patients. St. Scholastica purchased high-fide lity computerized human si mulators in academic year 2005-2006, and the electronic health record has b een integrated into the simulation lab. Nursing students can use the electronic hea lth record to document the procedures, and can access the Web at the point-of-care fo r evidence based practice standards and answers to questions. Students are also assigned to follow specific patients in the highfidelity simulation lab ( http://www.css.edu/resources.css.edu /athensproject/Images/Frontpage.ppt ).

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158 Students are introduced to the clinical in formation system (CIS) through a virtual health care delivery environment such as an acute care hospital. Students are given patient scenarios that have b een pre-programmed into the com puterized simulator. As the student progresses through hi s/her coursework, the simula tion lab experience becomes more sophisticated. Faculty members are obs erving students’ interactions with the mannequin (patient) and with each other. Stude nt learning groups are used to provide a systematic feedback to faculty. A faculty member described laboratory simulation: Simulation is a critical piece of our teaching methodology because it is active learning. A computerized simulator, wh ich is programmed by the top ten diagnoses, responds like a human being. St udents are given patient scenarios to demonstrate nursing procedures, interd isciplinary communication, and critical thinking within a controlled, virtual clin ical environment. The electronic health record provides necessary patient data and web-based clinical resources on the select diagnosis. The simulation lab promotes active learning and provides a controlled environment that guarantees the clinical experience of a sele ct disease according to the semester syllabus. A faculty member adde d: “We guarantee students will experience select patient scenarios in the simulation lab. In an [actual] clinical setting, there can be no such guarantee.” Another faculty member reported feedback from hospital staff concerning their students who have used the computerized simulation setting: The hospital staff has reported that our student s ask better questions and interact with other members of the health care team in a more confident manner. I attribute the enhanced professionalism to our computer ized simulation lab, which also has an

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159 electronic health record at the bedside. The simulation requires our students to interact face to face and give cons tructive feedback to each other. Next, I will discuss the ke y strategies (critical deci sions, improvements, and/or processes of change) used at St Scholastica to address the core competency of healthcare informatics. Research Questions Two and Three: What Strategies Were Used, and Why They Were Selected? College leaders had general co ncerns with enrollment a nd financial strength that are common to most private colleges. Th e school of nursing was also concerned about the passing rate of its gr aduates on the nursing exams. These concerns led college leadership to undertake two re lated but distinct change pr ocesses— one incorporating informatics and another reforming the undergra duate curriculum. St. Scholastica School of Nursing began its change processes from a strategic perspective, using faculty subgroups that worked simultaneously on both change projects. The subgroups began merging their strategies in academic year 2004-2005. I will discuss the overall objectives of, then the specific change processes implemented by each group, by academic year. Faculty subgroup one: revision of th e undergraduate nursing curriculum. A small group of faculty members began revising the undergraduate nursing curriculum in 2002. A faculty member explained their objectives : “We revised the curricula for the following reasons: to create a new curriculum, to decreas e clinical faculty time in hospital setting [because we had] limited clinical faculty, and to enhance student preparation for clinical experiences.” Additional objec tives of the curricula facu lty subgroup were identified when an outside consultant was engaged in 2004 to assist this faculty subgroup to

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160 enhance pedagogical practices and increase student pass rates on the National Council License Examination-Registered Nurse (NCLEX) exam. Faculty subgroup two: implementation of healthcare informa tics competencies. Based on the recommendation of a member of the Health Information Management (HIM) department, an administrator from th e school of nursing ag reed to explore the concept of employing healthcare informatic s within the nursing and allied health professions programs. Several college represen tatives visited the Cerner Corporation to view their electronic health reco rd and, later, to discuss a pa rtnership as part of a grant application. An administrator desc ribed the selection process: A member of the Healthcare Informatic s and Information Management [HIIM], who had professional contacts among health information management professionals employed by the Cerner Corporation, convinced other college representatives they needed to learn more about the electronic health record. I was absolutely wowed…. My whole focus was using this system to teach the health professions. Cerner Corporation was willi ng to partner with us to create an electronic health record designed [s pecifically] for educational purposes. In 2001, St. Scholastica, through a partnershi p with the Cerner Corporation based on an Application Service Pr ovider (ASP) model, received a $1.8M Title III grant from the U.S. Department of Educa tion. Title III-A grants are awar ded to eligible institutions of higher education to increase self-sufficiency and to strengthen their capacity to make a substantial contributi on to the nation’s educational resources (http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_

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161 Room/Annual_Report_2004-2005.html) An administrator described the thought processes behind th e application: The Title III grant is used to help institu tions that are vulnerable, and [we] made the case that enhancing our curricula with progressive technology content such as the electronic health record would contri bute to increased enrollments in these programs and to increased financial stabi lity for the college. A small group of faculty engaged in the vision that we coul d be distinctive in the market by using our HIIM department and our relationship with Cerner Corporation to implement the electronic health reco rd in our curricula. A small group of faculty members representa tive of each of the health professions programs were selected to address the Title II I healthcare informatics grant award. Their overall objective was to integrate the electr onic health record in to the allied health professions and undergraduate nursing curricu lum. The results expected from this objective were to increase enrollment in all health professions, enhance financial stability, and increase academic quality ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Annual_Report_2004-2005.html ). Attention to academic culture The Title III-A grant application included all health professions and nursing with a repres entative of the Healthcare Informatics and Information Management department to serve as the lead healthcare informatics person. This lead healthcare informatics indivi dual, a technology person, a health profession administrator, and one lead faculty member fr om each of the health professions served as the faculty subgroup to plan and implem ent the healthcare informatics grant

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162 http://www.css.edu/Academics/Special_Acad emic_Programs/ATHENS_Project/News_R oom/Dr_Brailer_press_release.html ). The reputation of the HIIM Department provided a cultura l foundation on which to base the facilitative lead for healthcare in formatics core competency across the health professions. Faculty members respected th ese professionals, who already had an established degree of trust prio r to the introduction of healthcare informatics. The HIIM department was a natural fit for St. Scholastica’s culture as the leader for healthcare informatics core competencies. According to a faculty member, the Healthcare Informatics and Information Management depa rtment is nationally recognized for their innovation. “They have a long hi story of providing outstanding professional services and always ready to assist the faculty with wh atever we need.” St. Scholastica’s website described the department’s reputation: The Health Information Management (HIM) profession was ‘born’ at CSS in 1934 when the college established the firs t baccalaureate program in the nation in this discipline, then known as “medical record science.” For decades this program has sustained a national reputation for leadership and innovation among the HIM education community ( http://www.css.edu/Academics/School_of _Health_Sciences/Health_Information _Management.html ) A faculty member spoke about St. Schol astica’s model to address change processes: “The leadership team selected a combination of early adopters and steady, well respected faculty who are open to new ideas, [but who] give due consideration before taking action.” An administrator adde d that, in her mind, lead faculty are the ones

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163 “who bring the vision [healthcare inform atics] to life.” She continued: Faculty must have a sense of ownershi p. The strategy was to select opinion leaders whom the faculty respects and [w ho] could convince othe rs to be involved with the change processes. We communi cated the change challenge to identify ways to use the electronic health record in a more creative and robust way. We asked questions: Would you? Could you? What do you think? Why not? Then we got out of the way. We woul d meet with the lead faculty members periodically with ideas and motivate, encourage, ch eerlead, and bring enthusiasm to the change processes. According to the website, St. Scholastica ha d eight lead faculty members– at least one designee from each academic program – who served as the “point persons” for project related initiatives in their de partment and two IT project staff ( http://www.css.edu/resources.css.edu /athensproject/Images/Frontpage.ppt ). An administrator explained the caref ul selection of lead faculty: We have 19 undergraduate faculty members with diverse opinions. Faculty members align with different faculty, [s o] we chose two nursing faculty members to serve as project leads. We identified faculty members who demonstrated energy and enthusiasm for the vision [of healthcare informatics]. One member’s strengths included respect, credibility, and longevity among faculty. The other was an energetic adopter of i nnovation and was very creative. In the next section, I discuss the stra tegies employed by each faculty subgroup. The following table 1 lists the processes of change by academic year for each faculty subgroup.

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164 Table 1 St. Scholastica Timeline by Year of St rategies of Two Separate Faculty Groups Year Healthcare Informatics Undergraduate Nursing Curriculum 20022003 Established infrastructure Orga nized to revise undergraduate nursing curricula 20032004 Selected lead faculty and trained them on the electronic health record system, created electronic documentation templates for allied health professions Engaged outside consultant, began active learning pedagogy approach to curricula revision 20042005 Requested undergraduate nursing curricula faculty group to use the electronic health reco rd in one course, requested patient cases to be loaded into electronic health record, and established a Center for Leadership and Innovations in Health Care Selected a ‘generalist curricula’ approach using nation’s top ten disease prototypes 20052006 Loaded alumni personal health records into electronic health record, signed first contract for the ATHENS subscription service Linked electronic health record, computerized mannequins, problembased curricula approach and active learning pedagogy 20062007 Integrated two technologies, accomplished Title III-A grant objectives Began phasing in the new undergraduate nursing curricula

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165 Strategies Employed in Academic Year 2002-2003 Healthcare Informatics Infrastructure established The first year of implementation of the Title III-A grant objectives required the es tablishment of infrastructure. This infrastructure included development of the project website for intern al and external communi cation of activities; a project evaluation plan, including data co llection, tools and sources needed for the project; and fund raising effort s to support curriculum development projects. The project was named Advancing Technology and Health Education Now at St. Scholastica [ATHENS] ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Annual_Report_2004-2005.html ). Undergraduate Nursing Curriculum Review of undergraduate nursing curricula. Several participants disclosed that revision of the undergraduate nursing curriculu m, which began in 2002, took five years to complete. However, the review of the mi nutes did not document any meeting minutes until 2004. Strategies Employed in Academic Year 2003-2004 Healthcare Informatics Faculty lead selected and trained. During this time, the lead faculty was trained on Cerner’s computer information systems applic ations for nursing and for the five health science professions. The lead faculty memb ers were from exercise physiology, health informatics and information management occupational therapy, physical therapy, nursing, and social work

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166 ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Annual_Report_2004-2005.html ). Electronic documentation tools crea ted for allied health professions The healthcare informatics grant project leader met with each faculty member from the allied health professions colleges to create basic documentation templates in the Cerner electronic health record. Since the gran t objective was “to provide students the opportunity to use the electroni c health record as a legitim ate professional practice tool” ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Annual_Report_2004-2005.html ), a faculty member noted the critical role of HIM staff in this area: “A huge amount of work was required for physical and occupational therapy, [since] the existing el ectronic health record had ve ry little [in the way of templates, data, and forms] designed for these health professions.” Undergraduate Nursing Curriculum Outside consultant engaged An administrator reported the college paid for “an outside consultant [who] was engaged to di scuss faculty teaching and student learning practices.” She elaborated on the consultant’s role: The consultant assisted faculty member s in prioritizing the changes and the processes of revising the undergraduate curriculum, [and] assisted us with pedagogies, test writing, a nd student evaluation processes. Our NCLEX scores were low the year before the consultant was engaged. Active learning pedagogy approach to curricula revision begun. According to a faculty member, “Our focus was integr ation of active learning throughout the undergraduate nursing curricula.” Accordi ng to Bonwell and Eison (1991), active

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167 learning pedagogies are methods of teaching and interaction whereby an instructor allows students to learn in the classr oom and/or laboratory with the help of the instructor and other students. The student is actively involve d in the learning process, rather than a passive listener to the professor. Strategies Employed in Academic Year 2004-2005 Healthcare Informatics Electronic health record used in one course. The healthcare informatics faculty subgroup asked the undergraduate nursing faculty to introduce electronic health record in one of their courses ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Project_Update_Spring_2006.html ). According to the Ma rch, 2004, junior course syllabi faculty meeting minutes, application of the electronic health record project was to be incorporated into a single undergradua te nursing course in fall 2004, and was scheduled for a second nursing course in spring 2005. A faculty member recalled the discussion: The grant required faculty to choose a course in the undergraduate nursing program, [so] at first we felt like we had to implement the electronic health record into the undergraduate curriculum [only] because of the grant. We were changing the curriculum at the time, so we decided to use the electronic health record in the health assessment class. According to an administ rative representative: The nursing faculty selected the health a ssessment course because it is the first course at the sophomore level in the undergraduate nursing program. The course

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168 focuses on clinical assessment skills, and seemed to be the right place to begin the student’s introduction to the electronic h ealth record as a teaching and learning tool. Cerner’s electronic health record had basic templates already built into its structure for use in acute care hospitals. The introduction of the electronic health record in the health assessment class was not successful. A faculty member described the students’ negative reaction: We allotted three hours for students to use the electronic health record. This class did not go very well because of Internet connectivity glitches between our college and Cerner Corporation. The system didn’ t work right and st udents didn’t know how to use hand-held computers. Students want to get as much as they can from a class and [were] frustrated by sitting at computers when they experienced the connectivity glitches. The next semester those students didn’t want to use the electronic health record. [This] caused some difficulty, but we persisted. The electronic health record pr oject started [the following semester] with some bad publicity because of the glit ches during the first semest er. [But,] by the time we moved it into more courses, students who ha d been in the [original] classes were gone. Request to load case scenarios into electronic health record received Once several faculty members used the electronic health record in one undergraduate nursing course, nursing faculty members asked that pa tient case scenarios be loaded into the system. An administrator explains: “Nursi ng faculty [wanted] patient case scenarios loaded into the system. Nursing used the el ectronic health record in a more creative,

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169 robust way than the other health professions which used it [only] as a documentation system.” Center for Leadership and Innovat ion in Healthcare established. As previously stated, in academic year 2002-2003 the healthcar e informatics project at St. Scholastica was named ATHENS. In March 2005, a separate structure within the college was created to be the organizational home for the subscrip tions services for othe r schools to purchase the Cerner EHR. The integrating of the EHR into other schools and classes remain within academia. It was named the Center for Leadership and Innovation in Healthcare. ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Year_5_Annual_Report_.html The center’s strategic theme is to be entrepre neurial and proactive in executing efficient and effective ways to improve health care ed ucation. The goal of the center is to be a revenue-generating organization that identifies trends within both health sciences education and the healthcare industry, and uses expertise and innovative approaches to help address these trends ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Annual_Report_2004-2005.html ). An administrator shared her perspectives about the Center: The center provides a business structure to experiment, innovate and create new ideas to address quality issues with the health care delivery system and the educational preparation of h ealthcare professionals. Th e business structure allows us to capture revenue as well [serving] as a structure which is outside the day-today academic processes. The electronic health record is one of the major

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170 technological tools to change the future of healthcare. Academia must be a part of innovative approaches to create new processes to enhance that future. The center offers a subscription service to other colleges and universities, which includes the academic version of the electronic health record for a fraction of the time and cost they would incur in developing a nd maintaining a similar program on their own. Ongoing technical support and immediate acces s to all system upgrades are packaged with the service. Other schools can purchase additional services, such as consulting faculty to help with designing course integration activities and creating specialized forms for the client school ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Annual_Report_2004-2005.html ). An administrator offered an update on the Cerner relationship: We continue to have a contractual rela tionship with Cerner that involves an established, on-going annual licensing fee for the continued use of their electronic health record platform for College of St Scholastica [as well as for the] other colleges/universities that ar e partnering with us. This contractual relationship is administered by the Center for Leadersh ip and Innovation in Healthcare. Undergraduate Nursing Curriculum Generalist curricular approach selected. According to junior course syllabi faculty meeting minutes (2004, March), facu lty made plans to introduce case studies representing prototypes of l eading US health issues into the course content. These prototypical cases were to be threaded throughout clinical co urses in order of increasing complexity.

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171 Strategies Employed in Academic Year 2005-2006 Healthcare Informatics Alumni health records loaded into the electronic health record. The HIIM Department responded to nursing faculty’s requ est to incorporate act ual patient case data into the electronic health record. Alumni we re asked to authorize use of their medical records to abstract clinical case data so the electronic he alth record could be populated with current, relevant cases. At least 25 su ch cases were added to the system over the summer of 2005 ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Project_Update_Spring_2006.html ). According to an administrator: We received over 50 cases from our alum ni, and selected 25. [After] patient identifiers were erased, we ha d data rich day-to-day reco rds of all kinds of health problems from these donated records. The sample electronic health records have day-to-day notes and therapie s provided. We decided to call these ‘pristine cases,’ rich with information. [We loaded them] in to the system and selected cases that related to our curriculum. This process was a motivator for faculty, since they didn’t have to develop their own cases. Faculty could use these cases, modify them and create assignments from real live patient scenarios. A clinical data abstractor was hired on a temporary basis to support the clinical case building. This person assisted the HIIM Department in loading alumni medical records into the electronic h ealth record. The position wa s funded through grant monies ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Project_Update_Spring_2005.html ).

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172 First contract for ATHENS subscription service signed. The College of St. Scholastica initiated its first ATHENS Subscr iption Service to two clients in Minnesota and in Arizona in spring, 2006 ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Project_Update_Spring_2006.html ). Undergraduate Nursing Curricula Electronic health record and other components linked. At this point, the undergraduate nursing faculty subgroup was ev aluating use of the electronic health record in a second course, and developing pr oblem-based curricula with active learning pedagogies. As discussed in the liter ature review in Chapter 2, problem-based learning engenders more self-directed learning and does a better job of providing students with a process for integrating what has already b een learned. This faculty group was working on a robust family of case scenarios by diseas e prototypes with the electronic health record when another technology caught their attention. The group realized the new highfidelity simulation mannequins in their si mulation lab should be included. A faculty member recalled: “A group of faculty a ttended a national co nference about active learning, [and] discovered simulation lends it self to active learning.” Another faculty member summed it up, remarking that “it all just seemed to come together.” She continued: We were asked by the healthcare informa tics subgroup and leadership team to incorporate the electronic health record in one of our courses. We were designing our

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173 ‘generalists’ curriculum as problem-based, pr oblem-driven, with the use of case studies based on the nation’s top ten disease protot ypes. Our focus was in tegration of active learning throughout the curricula. ATHENS gave us the idea that we could have this robust family of problem-based case scenario s by disease prototype. This is when we realized the electronic health record could be the tool to run our laboratory simulations with the disease prototypes. The undergraduate nursing faculty subgr oup began to notice the complimentary aspects of the generalist curricu la approach using the nation’ s top ten disease prototypes and high-fidelity simulation to active learning pedagogy. The School of Nursing purchased computerized patie nt simulation equipment and linked that technology with the electronic health record to promote active learning. An administrator supported the integration of high-fidelity mannequins in their simulation laboratory. “Lab simulation needed to be integrated into our curric ulum in a different way, and we knew the electronic health record by its elf wouldn’t get us where we wanted to be.” Nursing faculty began using the highfidelity simulator with students using the ATHENS electronic health record ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Project_Update_Fall_2005.html ). Strategies Employed in 2006-2007 Healthcare Informatics Two technologies integrated. The healthcare informatics subgroup responded to the curricula faculty subgroup, assisting w ith the integration of two technologies

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174 supporting nursing education: th e electronic health record as a tool to run the clinical simulations with the computerized human mannequins. Now, students and faculty members can access the electronic health reco rd at the bedside of the simulation case using wireless laptop devices connected to a web-based, remote-hosted service. ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Year_5_Annual_Report_.html ) The electronic health reco rd began in the nursing program in conjunction with high-fidelity simulator http://www.css.edu/Academics/Special_Acad emic_Programs/ATHENS_Project/News_R oom/Project_Update_Spring_2006.html Title III-A grant objectives accomplished. According to St. Scholastica’s website ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Annual_Report_2004-2005.html ), “The purposes of the grant were to increase student capacity; to increase self-sufficien cy [of the college]; to increase financial stability [of the college] and to strengthen capacity [of the college] to make a substantial contribution to the nation’s educational resources.” According to the Title III third year grant report: Nursing enrollment increased over 50% by e nd of year 3 [2005]. By leading to the development of a new model for health professions education, this program allows the college to make a substa ntial contribution to higher education resources of the nation. Our students gain competencies in using the electronic health record as a legitimate professional practice tool ( http://www.css.edu/Academics/Special _Academic_Programs/ATHENS_Project/ News_Room/Project_Update_Spring_2006.html ).

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175 This report also included a status report on the goal to incr ease the financial stability of the college: [The] ATHENS Project funded by this gran t served as the impetus for seeking resources for two additional projects: an Electronic Health Record (EHR) Implementation Best Practices research effort, and a Personal Health Record (PHR) Implementation effort. Both pr oposals received funding in late 2004, and the projects were implemented in 2005. The EHR project was funded by a local foundation (Blandin Foundation), and th e PHR project by a state foundation (Minnesota Community Foundation). The out comes of these two projects are also fueling new discussions re lated to improving the elec tronic health information infrastructure on campus. Over the past year, the Title III grant has clearly contributed to bringing additional resources to the college by raising the visibility of the organization throughout the stat e and the region and by stimulating new ideas and the energy to pursue them among college faculty and staff. ( http://www.css.edu/Academics/Special _Academic_Programs/ATHENS_Project/ News_Room/Year_5_Annual_Report_.html ). Undergraduate Nursing Curricula New undergraduate nursing curricula phased in. The undergraduate nursing curriculum group began planning for the re vision of the undergraduate nursing curriculum in 2002, and began a phasing-in process in academic year 2007-2008. A faculty member described the new curriculum: Our students are prepared as ‘generalists.’ Students no longer spend a semester in specialty areas. For example, [current] students may spend [only] one day on the

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176 obstetrics unit in their clinical rotation. Our new curriculum is built on prototypes. Each course has six prototypes, and si x faculty members teach in an active learning environment. This was accompanied by a reduction of c linical time in a hospital nursing unit. As a faculty member explained, “Students ar e spending one day per week [instead of] a day and a half in clinical setti ngs such as the hospital. The ot her four clinical hours are in the lab.” Another faculty member describe d decreased clinical faculty time in the hospital setting: A portion of the requisite clinical hour s are now observed in a virtual hospital environment, where the clinical instructor /student ratio is 1: 14 versus 1:8 on an actual clinical unit or site. There are three credit hours fo r the clinical course and one credit hour for the simulation laboratory. The electronic health record stores a number of prototyp ical patient cases that are available to faculty for planning lessons and assignments, and to students for homework and laboratory exercises. These cases, whic h include the cases donated by alumni, are threaded throughout clinical c ourses in order of increasi ng complexity. Since the new undergraduate curriculum was implemented so recently, there has not been enough time to determine how the strategies affect the graduate’s NCLEX scores The NCLEX scores was one of the goals set by the faculty and administrative teams. According to the Minnesota Board of Nursi ng Education Annual Report, College of St. Scholastica NCLEX-RN first-time success rate percentages, do point to a positive trend, starting in 2004 at seventy-seven percent, and increasing to eighty-five percent in 2005, eighty-three percent in 2006, and eighty-nin e percent in 2007. Several pa rticipants suggested student

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177 improvement had occurred based on thei r own observations and/or on comments by faculty members or hospital clinical staff. In summary Two small groups of faculty me mbers began their journey to accomplish their strategic objectives during academic year 2002-2003. In academic year 2004-2005, the two separate groups of faculty worked separately, then together, responding to the others’ requests. For example, the healthcare informatics interdisciplinary faculty group requested that the undergradu ate nursing faculty introduce the electronic health record in one of their courses. The undergraduate curricula faculty group responded tentatively; however, as they began integrating active learning pedagogies into the generalist nursing curri cula approach, they began to realize the educational benefits of the el ectronic health record. The HIIM Department began loading patient case scenarios donated by college alum ni into the system following the top ten disease prototypes. Later, as the integrati on of high-fidelity co mputerized mannequins into the simulation lab in conjunction with the electronic health record progressed, their ideas became reality. An administrator expl ained the synergistic results of the two faculty groups: We wish we could say we had a grand scheme and knew what our vision was for our nursing program. One word we would us e to describe our change processes is synergy. The combined efforts of the tw o faculty groups have resulted in an impressive undergraduate nur sing curriculum. We were i nvolved in major change processes, the holistic re vision of the undergraduate nursing curriculum, and integration of the electronic health reco rd and then the high-fidelity simulation. Our accomplishments thus far have been great serendipitous events.

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178 The contractual relationship with Cerner Corporation is administered through the Center for Leadership and Innovation in Healthcare. The center administers a subscription service to other colleges and uni versities which includes an established ongoing annual licensing fee for the use of the elec tronic health record. Consulting services are provided to other college and univers ities, which is a revenue source for St. Scholastica. These consulting services provi ded opportunities for St. Scholastica faculty members to interact with othe r faculty members. The cente r also promotes a long-term orientation to the processes of change related to healthcare informatics. In the next section, I provide examples of discussions among faculty members which demonstrate sensemaking activities am ong the two faculty subgroups. Then, I discuss the core strategies and the support strategies employed by St. Scholastica School of Nursing leadership. The Role of Sensemaking According to Eckel and Kezar (2003) “Get ting people to adopt new mind-sets is a cognitive and intellectual proces s spurred by a set of activitie s that can be intentionally designed to leave behind old ideas, assump tions, and mental models” (p. 73). This process is known in organiza tional behavior literature as organizational sensemaking (Gioia & Chittipeddi, 1991; March, 1994; We ick, 1995). Leaders at the transforming colleges and universities inten tionally explored the meani ngs of proposed changes for faculty work and pedagogies, creating a personal reality for college faculty and staff by continually negotiating meanings and reaching consistent new understandings within the shifting work environment. Eckel and K ezar (2003) found that during significant transformational change periods, this proce ss occurs more frequently. The need for a

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179 fresh understanding of the impact of the pr oposed change on individuals becomes more important as they attempt to fathom the shifting terrain of their world. Nursing college leaders were supporting the processes of ch ange ‘behind the scenes’ to motivate and encourage the lead faculty members within the two faculty subgroups. There were reports of sensemak ing within the two f aculty subgroups, and between these faculty members as they e xplored the combination of active learning, pedagogy, and the electronic health record as a tool within the computerized simulation lab. I found evidence that th e health care info rmatics faculty subgroup engaged in sensemaking in conversations relating to the impact on the daily work environment of the people involved. An administrator spoke about the dynamics among the lead faculty: These two faculty members have taken th e electronic health record innovative concept and driven it through the curriculum processes. They learned how to use the electronic health record, its possibilitie s, problem solved together, and worked as members of an inte rdisciplinary team. There was additional evidence of th e undergraduate nursing faculty subgroup engaging in conversations relating to the imp act of the curricula changes on faculty and students. The engagement of an outside consulta nt to assist this faculty group to prioritize the curricula changes was one example of inte ntional discussions to adopt new mindsets, such as active learning pedagogy. An administra tor reflected: “She [the consultant] may have opened a little bit of a door in some pe ople’s minds to doing things a different way, because we [hadn’t been achieving] the results we wanted.”

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180 There was also evidence of sensemak ing among faculty as they used the simulation lab. One faculty member explained: We have a full-time RN simulation lab coor dinator. She’s always there to help faculty set up the lab, and supports them with various learning strategies. She serves as a faculty mentor and helps them to see the common threads and linkages [between classroom and lab simulation]. My review of documents from the undergraduate nursing curricula faculty subgroup identified some discussions regarding student performance as a result of the computerized simulation lab. Student impr ovement in the second year was documented in the February, 2007, traditional (entry -level professional nursing practice) undergraduate nursing faculty committee meeting minutes: [They] students were much better pr epared. For example, students in the gerontology class have demons trated higher levels of critical thinking. Faculty members attribute this improvement to the clinical skills and simulation lab experience using the SimMan and electronic health record. Several faculty members described obse rvations of student performance in discussions among themselves. A faculty memb er stated: “Clinical instructors have reported the junior class students are bette r prepared to handle their first complex medical-surgical patient. The students’ proble m solving and critical thinking skills are noticeably improved.” In summary. The faculty subgroups engaged in sensemaking activities as they implemented various strategies with new understandings and the building capability to use the electronic health record and simulati on pedagogies to teach in a different way.

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181 There was limited evidence of college leadersh ip personal involvement in getting faculty to think differently. Next, I discuss the fi ve core strategies em ployed by St. Scholastica School of Nursing leadership and the eviden ce or lack of evidence of the fifteen supporting strategies. Core and Supporting Strategies St. Scholastica School of Nursing leader ship employed all five of the core strategies which support sensemaking activitie s. Eckel and Kezar (2003) defined core strategies as "intentional mechanisms, proce sses, and tools available for campus leaders to effect major change that is deep, pervasiv e, and cultural, and that occurs over time" (p. 75). The underlying connection between the five core strategies, acco rding to Eckel and Kezar (2003, p. 78) is that they are intende d to assist people to think and to act differently. These strategies include: 1) senior administ rative support; 2) collaborative leadership; 3) staff development; 4) flexible vision; and 5) visi ble action. Eckel and Kezar (2003, p. 109) found a need for additiona l strategies to augment the five core strategies in their Mobile M odel. These 15 additional strate gies occur less frequently, and play smaller, but still important, roles in facilitating transformational change. Some supporting strategies are linked to more than one core strategy. A ll five of the core strategies, and 13 of the 15 s upporting strategies, were eviden t at St. Scholastica School of Nursing during their implementa tion of healthcare informatics. Core strategy: senior administrative support. The five supporting strategies most frequently linked to this core strategy were in evidence. These strategies include altering administrative and governance processes, es tablishing support structures, providing

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182 financial resources, offering incen tives, and using various extern al events and activities to promote internal change. According to Eckel and Kezar (2003), the supporting strategy of altering administrative and governance processes is inte nded to ensure that the desired changes ultimately become part of daily operations. These authors identified the creation of new positions and new units as both a supportive stru cture and a financial resource. This sends a message that “the change was important enough to receive staff, budgets, and office space” (p. 117). They believe that support stru ctures are designed to assist change processes by providing new sour ces of revenue or reallocatin g existing funds to support them. The Center for Leadership and Innova tion in Healthcare, previously discussed under strategies implemented in academic year 2004-2005, is an example of altering administrative and governance processes. St. Scholastica college leaders found new sources of revenue through the partnership wi th Cerner Corporation and in the marketing of their ATHENS product to other schools of nursing. St. Scholastica moved the business aspects of the health care informatics reve nue producing functions outside the academic structure. The website cited critical pro cess themes for the center, which include leveraging of existing college assets and resources, mainta ining a business sense for all center initiatives, and providing the necessary structure to make decisions at a rapid pace. The center provides both financ ial resources and the new stru cture necessary to continue the long-term orientation of change pro cesses related to he alth care innovation ( http://www.css.edu/Academics/Special_A cademic_Programs/ATHENS_Project/News_ Room/Annual_Report_2004-2005.html ). A faculty member noted:

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183 We just signed two contracts, [so] th e center provides the college with a new source of revenue. This is an opportunity for faculty to apply their expertise and parlay this knowledge into other venues that will provi de revenue. It’s a Research and Development arm [of our college]. Eckel and Kezar (2003) identified anot her supporting strategy of senior administrative support, the offering of incentives to facilitate the ch ange processes. The grant did provide some stipends for facu lty members and several faculty members mentioned St. Scholastica’s School of Nursing tenure and clinical tr ack processes. One faculty member acknowledged the college’s posit ion that scholarship includes projects such as the implementation of healthcare informatics: We have a tenure track and a clinical track. Scholarship is looked at in a variety of ways, not just publishing, but also contribution to pract ice and presentations. If people are out for tenure, they’re expected to meet a variety of [criteria]. Being involved in projects like the electronic health record is respected. Another faculty member added: “We have a five-year rolling clinical track. The ATHENS project, revising the curriculum, in tegrating active learning and the simulation lab are all consider ed scholarship.” External factors are those events and activities outside the institution used internally by leaders to promote change The annual updates required for the grant provided status reports of progress made with in the health sciences and nursing schools. These updates cited the (IOM, 2003) recomm endations on numerous occasions. The partnership with Cerner influenced the impl ementation of the health care competency of

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184 informatics within the School of Nursing. Representatives of Cerner Corporation provided ongoing education to the faculty. In summary The core strategy of senior administrative support was employed by the St. Scholstica School of Nursing, along w ith all five of the most often cited supporting strategies of alteri ng changes in administrative and governance processes; establishing support structures; providing financial resources; offering incentives; and using external events and activities outside th e organization to promote change internally. Core strategy: collaborative leadership. This core strategy is about developing extensive internal plans to facilitate co mmunication, inviting part icipation, providing opportunities to influence results, bringing together people in new ways to foster communication and encouraging new interact ions. Collaborative activities such as invited participation, opport unity to influence results, and facilitati ng communication between the two project groups was evident. School of nur sing leaders fostered an interdisciplinary approach in the implementatio n of the electronic heal th record, with lead faculty members from each of the health profe ssions participating in this group of faculty. There was evidence of internal communi cation within the health informatics subgroup, announcement of accomplishments by th e faculty group, and references to the planned actions for the next semester. Th ese documents were cited on the ATHENS project website and in announ cements in the college’s in ternal newsletters. Four faculty members described the pr ocesses of communication with faculty regarding activities within the two faculty s ubgroups. Faculty members at large were kept abreast of changes in individual sessions or small group discussions during which the two lead faculty members gave presentations. Th e lead faculty members also worked with

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185 individual faculty to demonstr ate ways in which ATHENS coul d be beneficial to faculty and students. One faculty member recalled day-long faculty meetings where ATHENS’ pedagogy, active learning, and interactive teach ing were discussed: “At one faculty meeting, there was a lengthy discussion about how to evaluate activ e learning.” Another faculty member noted that the size of the facu lty made it easy to have individual or small faculty group meetings to discuss the concer ns, to teach, or to demonstrate ATHENS. “These types of discussions, whether at a luncheon or an open [meetings] are becoming more intentional,” a faculty member remarked. Another of the supporting strategies in Ec kel and Kezar’s (2003) model, that of encouraging new positive interactions, was evident here as part of addressing the core competency of healthcare informatics. In academic year 2004-2005, the health informatics faculty group began to interact with the undergraduate nursing curricula group when it was time for nursing to select a course to implement the electronic health record. The health informatics subgroup res ponded to the undergra duate nursing faculty group’s request to load patient case scenarios into the el ectronic health record. In addition, the outside consultant for the unde rgraduate nursing curricula group, who was assisting with enhancing the curricula and introduci ng active learning pedagogies, stimulated additional ideas such as a generalist approach to curricula and use of top ten disease prototypes. All of these concepts en couraged new interactions and discussions regarding use of the high-fidelity simulation laborator y, and how the electronic health record could become a critical tool to integrate all these learning processes. In summary Establishing support structures wa s previously addressed under the senior administrative support core strategy, and was evident at St. Scholastica School of

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186 Nursing. The remaining support strategies rela ting to collaborative leadership include developing extensive internal plans to fac ilitate communication; inviting participation and providing opportunities to influence results; and bringi ng together people in new ways to foster communication and encourage new interaction. All were part of the change process at St. Scholastica. According to Eckel and Kezar (2003), the intent of this core strategy is to instill a sense of trust, to clarify misunderstandings and rumors, and ultimately to foster a sense of community across the campus. The ATHENS Project web site provided ongoing communication regard ing the activities of the healthcare informatics faculty subgroup ( http://www.css.edu/resources.css.e du/athensproject/Images/Frontpage .ppt). Core strategy: staff development. Eckel and Kezar (2003) linked this strategy to the support strategies of tappi ng outside perspectives, f acilitating communication, and identifying and creating linkages among various campus activities. Th e support strategy of facilitating communication overlaps the collaborative leadership core strategy and has been addressed previously. The engagement of an outside consultant, discussed earlier under strategies employed in academic year 2003-2004, demonstrates the support strategy of tapping outside perspectives, in which faculty members explored different pedagogical practices and engage d in several sensemaking activities. Faculty members discovered the linkage between high-fidelity si mulation and the electronic health record while attending a national conference on active learning pedagogies and the simulation lab. Nursing faculty engaged in intentional conversations re lating to the impact of the curricula changes on faculty and students. An administrator reflected: “She [the

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187 consultant] may have opened a little bit of a door in some people’s minds to doing things a different way, because we [hadn’t been achieving] the results we wanted.” At St. Scholastica, the lead person with in the HIIM department provided on-going classes for faculty members. Documentation of numerous on-site classes was evident on the ATHENS website and in the grant activ ities report. Throughout the healthcare informatics implementation process, the HIIM department provided the faculty with both a hands-on, one-on-one orientation to the electronic health record and additional technological courses when needed ( http://www.css.edu ). A faculty member commented on the critical role of HIIM staff: “The HIIM staff provided classes, one-on-one mentoring and responded rapidly when we n eeded assistance. They helped faculty integrate the electronic health r ecord and course assignments.” Creating and sustaining energy is nece ssary for transformation, according to Eckel and Kezar (2003), who describe th e support strategy of finding and creating connections and synergy as including activit ies both on and off campus. New energy was created at St. Scholastica because the multiple projects brought toge ther individuals from different parts of the institution. Cross-depa rtmental teams and common tasks charged to a particular group created new connections. Th ese connections also served to reassure people they were not working in isolation. There was evidence of the faculty subgroups requesting assistance from one another. On e administrator felt her role was to be a ‘cheerleader,’ working with the faculty lead s to encourage and mo tivate them during the processes of change. She believed it was the role of the lead faculty to ‘own’ the change processes and convince other faculty member s to get involved. A faculty member observed:

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188 We celebrated each successful activity, and quickly gathered together to problem solve whenever that was necessary. Pr oject staff and lead faculty members consciously make an effort to interact with each other in positiv e ways – to create a “we are in it together” attit ude from beginning to end. Another example of finding and crea ting connections and synergy at St. Scholastica is its interdisciplinary appro ach, which addresses healthcare informatics across the health professions and nursing. Faculty members have engaged in webinar sessions with faculty from other colleges and universities in Wisconsin and Minnesota as they began using the ATHENS system. In this way St. Scholastica is advancing the quality of the nation’s educational res ources by extending the model for curricular innovation in health professions’ education into the broader academic community. Faculty members presented at six c onferences, published two ATHENS-related articles in nursing journals, and collaborat ed on a textbook to support the introduction of electronic health records in curricula for a ssociate degree level allied health programs. The first article, Innovative Strategies for Nursing Education: Enhancing Curriculum with the Electronic Health Record (2008) was written by Donahue and Thiede. The second article, CIN Plus: An Academic Industry Pa rtnership for Advancing Technology in Health Science Education (2008) was written by Fauchald and Thiede. The book, Using the Electronic Health Record in the Healthcare Provider Practice was written by Eichenwald Maki, and Petterson. College leaders also encouraged faculty members to mentor other staff. According to an administrator, “we encour aged faculty who have experienced success and feel good about ATHENS to mentor othe r staff.” According to a faculty member,

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189 “our nursing leaders expected all faculty members to utilize simulation in the undergraduate program, since it is a teaching method which encourages active learning pedagogy.” An administrator expl ained some of the reluctance: “For some, it is an issue that [they are] expected to use ATHENS. We have encouraged faculty members to give ATHENS a try to see if it [electronic health record] fits in their course.” In summary The core strategy of staff developm ent and its five related supporting strategies were evident at St. Scholastica School of Nursing as they addressed the healthcare informatics core competencies Eckel and Kezar (2003) identify the importance of communicating the multiple pr ojects and the connections among change activities to reassure organizational members they are a part of a community and are not working in isolation. There was evidence of faculty members communicating between the two faculty subgroups: healthcare informatics a nd the undergraduate nursing curriculum. The ATHENS project update s were posted on the college website to communicate the activities of the grant obj ectives, which include d the undergraduate nursing curriculum project. Core strategy: flexible vision. According to Eckel and Kezar (2003) a flexible vision by college leaders is one that has a ta rgeted direction, yet allows variations to emerge. Supporting strategies linked most often to the core strategy of flexible vision include several of the su pporting strategies already discussed, tapping outside perspectives, facilitating co mmunication, and making connections, all of which were evident at St. Scholastica. Promoting a long-te rm orientation to the change processes is included under this core strategy. The Center for Leadership and Innovation in

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190 Healthcare was renamed The Center for H ealthcare Innovation. The center promotes long-term orientation to the change processes. I will discuss the remaining support strate gies of moderating momentum, setting expectations and holding peopl e accountable, and putting issu es in a broader context. According to Eckel and Kezar (2003), moderating momentum during the change process is a strategy relating to flexible vision. Too much change can exhaust members within an organization, and too little progress can st all the change processes. While Eckel and Kezar identify leadership’s role of inten tionally moderating the pace of change, at St. Scholastica, participants repor ted feeling overwhelmed and exhausted or described other faculty members as such. A faculty memb er remarked that faculty leaders and administration should allow adequate time to prepare the framework for new technology, noting that “[projects] always ta ke at least twice as long as originally planned.” Another faculty member added, “Just as important is adequate time for the faculty learning curve associated with the new technology. The intr oduction of [any] new technology requires a period of time for facu lty to adjust.” Vacancies in nursing faculty further comp licated implementation of the processes of change. A faculty member commented on th e four vacant nursing faculty positions at the time of my interview: “Several faculty members are carrying extra workloads due to faculty vacancies.” In add ition, there are only two lead healthcare informatics nursing faculty members working with individual nur sing faculty. Another faculty member commented on the pace of change observed with the undergraduate faculty members: The undergraduate faculty have been a dding a lot of things and running two curricula. They need a break, a period of time where they do not have to do

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191 anything new. They need to stop for a while and [have time to] make the changes common practice, and then look at where they need to go. Another faculty member agreed: Adequate time is needed for faculty me mbers to experience success with the change process. When faculty members ar e not able to meet the ultimate vision, they begin to feel guilty. When the seme ster doesn’t go as planned, faculty often feel a sense of failure and want to throw in the towel. Eckel and Kezar’s (2003) model suggested two types of expectations that should be publicly communicated by leadership: how the objectives are to be accomplished, and how the campus will be different and improved. Part of this change strategy includes addressing campus behavior and priorities These are developed through extensive consultation and listening to change leaders, faculty, a nd various campus subgroups and by ensuring that faculty members believe they are part of something critical. As I explained previously, there was an issue regarding public communication by college leadership. Several particip ants reported that nursing leadership did not communicate their expectations as to when individual f aculty members should be gin using ATHENS or mentor other faculty; neither did they es tablish any sort of monitoring process. Participants noted that college leadership expected faculty to engage in active learning pedagogies and, at minimum, to use the electronic health record in the simulation laboratory. However, neither participants nor related documents mentioned a process to hold faculty members accountable to this expectation. A faculty member noted: “Unless there’s a struct ure [to hold individuals acc ountable], change processes really won’t move beyond the tw o lead faculty members. This is what has happened

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192 here.” However, the Title III grant included a complete set of objec tives and expectations and timetables. The communication of the grant activities is readily available by semester and year-end on the ATHENS website. Resu lts of the requests by the undergraduate nursing curricula subgroup are also docume nted on this website. For example, the progress by semester of the alumni donated pe rsonal medical records into the electronic health record and the integration of the high-fidelity mannequins in the simulation laboratory are cited. These regular reports of grant activities served as an accountability tracking of the healthcare informatics goals and the progress towards meeting these expectations. In summary The presence of three of the seve n supporting strategies for the core strategy of flexible vision had already b een previously addressed: tapping outside perspectives, facilitating co mmunication, and making connections. Promoting long-term orientation and putting issues in a broader context were also evident. The supporting strategies of college leader s moderating momentum, and se tting expectations and holding people accountable were not evident. Although the supporting strategy of setting expectations and holding peopl e accountable relate to the grant written progress reports, some participants perceived a need for college leadership to communicate the expectations and a structur e for holding individual facu lty accountable to use the electronic health reco rd, mentor other faculty members, and learn the pedagogy linked to the ATHENS project. St. Scholastica part icipants reported feeling overwhelmed or described other faculty members as such. Partic ipants perceived colleg e leadership’s role in moderating the pace of change as limited or not evident.

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193 Core strategy: visible action. Eckel and Kezar (2003) link visible action to support strategies such as establishing s upportive structures, enc ouraging communication, setting expectations and holding people accountable, facilitating connections and synergy, providing financial resources, and in centives. All supporting strategies linked to the core strategy of visible action have been discussed previously and were evident with the exception of setting expectations and holdi ng people accountable. In summary The leadership team at St. Schol astica School of Nursing understood the way their institutional cu lture shapes their change processes. Innovative and respected faculty members were selected for both the healthcare informatics lead person as well as the lead faculty members for each health profession. The leadership team’s role was to empower, encourage and motiv ate the members of the subgroup throughout the change processes. Together, the administrator explained, “we fostered interdisciplinary meetings among all the health care professions.” I found evidence that the healthcare informatics faculty subgroup engaged in sensemaking in intentional conversations relating to the impact of change on the daily work environment of the people involved. All five of the core strategies and 13 of the 15 supporting strategies were evident in both faculty subgroups at St. Scholastica Sc hool of Nursing. The grant project reports provided definite objectives for each repor t period, along with reports of faculty progression. The grant provided the frame work for accountability, but it is more a report for an external funder than a driving intern al change mechanism. College leaders did communicate their expectation that indi vidual faculty members try ATHENS to determine if it fit in their courses, and, at minimum, to use it in the simulation lab.

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194 However, several participants perceive d the communication of a time frame or accountability processes as inadequate. As these five core and 15 supporting strategies are employed, Eckel and Kezar (2003) found that leaders that experienced transformational change within their organizations, consciously considered the im pact of these strategies on the faculty members. They refer to this process as college leaders “demonstrating balance. Demonstrating Balance College leaders need to balance particip ation in many ways, realizing too much change too fast can overwhelm the members of the organization and on the other hand, too little change can stall the processes of ch ange (Eckel and Kezar, 2003). First, college leaders need to balance the implementation of the five and 15 supporting strategies. St. Scholastica Schools of Nursing implemented all fi ve of the core strategies and 13 of the supporting strategies. The faculty members at St. Scholastica School of Nursing reported being overwhelmed with the change proce sses. Only a few faculty members were leading the change processes and the lack of an accountability process to hold other faculty members to greater participation ove rwhelmed those faculty members involved. In addition, this college was experiencing f aculty vacancies which placed greater demand on faculty. A diverse group of faculty members were car efully selected by college leaders at St. Scholastica School of Nursing in the health care informatics change initiative. These leaders balanced faculty participation betw een junior and seasoned faculty, and faculty members from different discip lines. Second, there was evidence of attempts to strike “workable balances between internal and ex ternal perspectives and involvement” (p.

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195 126). The healthcare faculty subgroup presente d to other faculty members the electronic health record, the patient cas e scenarios and methods of teaching. In addition, Cerner Corporation staff provided on-si te training and preparation of faculty members. Third, Eckel and Kezar (2003) identified the importance of creating short-term gains at the same time laying a foundation for long-term objectiv es. The healthcare informatics grant initiatives provided regular reports of the objec tives met, as well as the plans for the next steps of implementation of healthcare informatics at St. Scholastica. Finally, Eckel and Kezar (2003) observed that transformational change may be perceived as overwhelming, inciting fears th e changes might resu lt in a completely different institution, perhaps losing the characte ristics that made the institution unique. They recommend balancing the new change processes with established goals and traditions. At St. Scholastica this was eviden t on the college website, which celebrated the new changes along with those aspects fo r which the college was already noted. Research Question Four Is St. Scholastica School of Nursing approaching the shi ft to healthcare informatics as the broad and deep change in values, culture, and structures that would characterize a transformational change? I have presented the processes of cha nge employed at St. Scholastica School of Nursing, and the evidence or l ack of evidence of the key as pects of the Mobile Model that were or were not employed. These include d the attention to the academic culture, the role of sensemaking, and the interrelations hips among core and supporting strategies. In this section, I will discuss Ec kel and Kezar’s (2003) struct ural and cultural evidence markers of change used to determine th e depth of change pr ocesses within an

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196 organization. Such markers are concrete meas urements that can be counted or compared to baseline sets of data. For example, cha nges in curriculum, in pedagogies, in student learning and assessment practices, policies, budgets, new departments, and in both institutional structures and new decision-ma king structures. Attitudinal and/or cultural evidence includes changes in patterns of interact ions between individuals or groups, changes in the campus self-image, changes in the types of convers ations, and in new attitudes and beliefs. Structural evidence markers St. Scholastica completely revised its undergraduate nursing curriculum, a process that took at le ast five years to complete. An outside consultant was employed to assist faculty leaders in changing pedagogical practices, creating new student learning and assessment practices, and engaging in active learning strategies. This project did not originally include healthcare informatics. However, in 2004, faculty leaders decided to integrate active learning and the simulation lab with the electronic health record as the tool to run simulations using the automated SimManTM. A new Center for Healthcare I nnovation was established in 200 5. Creation of the Center for Health Care Innovation demonstrates the long-term orient ation to healthcare informatics already discussed. The goal of the center is to be a revenue-generating organization which identifies trends within both health sciences education and the healthcare industry and to us e expertise and innovative a pproaches to address these trends. The purchase of automated patient simulators (SimMan), and two additional staff for the simulation labs demonstrates budgetary commitment. Attitudinal and cultural evidence markers Eckel and Kezar (2003) note that structural evidence markers do not, by them selves, suggest transformational change.

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197 Since transformational change is about cha nging cultures, such at titudinal and cultural evidence markers are needed to identify th e cultural impact with in the organization. There was evidence the two faculty subgroups experienced change s in patterns of interactions between themselves, in the types of their conversations, and in new attitudes and beliefs. The strategies to implement the core comp etencies of healthcare informatics were interdisciplinary. However, each allied health profession created its own electronic health record templates and nursing used the Ce rner system documentation templates. The addition of the patient care scenarios provided a platform all health professions could utilize. One of the (IOM, 2003) recommendations addresses the use of a broad-based language for healthcare informatics with corr esponding core competencies. In general, St. Scholastica participants referred to healthcare informatics as the application of computers to manage information supporting the entire spectrum of us ers of health care information. Their shared concepts of hea lthcare informatics support the broad-based language; however, healthcare informatics core competencies as such were not defined. In Conclusion The initial approach to healthcare informatics was strategic in nature, based on general concerns of the college regarding enrollment and fina ncial strength, and specific concerns of the school of nursing leaders in re ference to the lower than desired pass rate on nursing exams, and a shortage of clinical nursing faculty. These concerns led college leadership to undertake two di stinct but related change pr ocesses: Introduction of healthcare informatics and revision of th e undergraduate nursing curriculum. St. Scholastica School of Nursing embarked on thes e two major change processes in 2002.

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198 As the lead faculty members and select faculty involved in implementation of the projects worked together, they discussed the different ways in whic h faculty could use the electronic health reco rd with their students. Using the same technology and the same program created many occasions for conversatio ns between disciplines. Changes in the two projects (healthcare informatics and a new curriculum based on active learning pedagogies and problem based pedagogies) occurred in pockets, with people committed to each change participating on a voluntary basis. The nursing program at St. Scholastica chos e to address healthcare informatics in an interdisciplinary approach involving ot her allied health professions. There was evidence that change in the healthcare in formatics subgroup extended beyond the nursing program into the allied health professions, how ever, the change at this time is limited in its breadth. Although the nursi ng faculty requested alumni medical records that were loaded into the electronic h ealth record, the full understand ing of pedagogical practices of this approach was, as of 2007, limited to the subset of the most involved faculty members. Based upon these findings, I classify St. Sc holastica processes of change as deep however, breadth of the changes is, as of my on-site visit, limited to only a few faculty members. According to Eckel and Kezar’s (2003) Mobile Model of Transformational Change the college leadership must comm it to long-term transformational change processes within the school of nursing. Th is will require college leaders’ to act to develop intentional strategies that will influe nce deep levels of or ganizational behavior across the nursing school.

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199 Chapter Five Conclusions and Discussion This study provides empirical data on the processes of change at three baccalaureate level nursing programs as they implemented the core competency of healthcare informatics. The sites I chose were considered exemplary as perceived by nursing informatics experts in 2006. Since quali tative findings are hi ghly contextual and case dependent, caution must be exercised regarding application of assumptions and generalizations to ot her nursing programs. Tying my data collection from the three nursing programs to the broader literature of transformational change a nd to the mobile model enabled me to demonstrate larger lessons regarding change and the applicability of the theoretical considerations beyond the few cases studied here. The data collecti on and analysis methods are designed to be appropriate to and consistent with my four research questions. To ensure rigor, I followed the qualitative research strategies outlined in Chapter 3. I used multiple sources of evidence to create converging lines of inquiry ; constructed a database of information for each case, and linked the analysis to specifi c instances in the cas e database and the research questions. I sought to mainta in all of Patton’s (2002) components of trustworthiness: dependab ility, authenticity, reflexivity, and triangulation.

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200 Transformational Shift to Healthcare Informatics After reviewing the data collected at the three research sites, I concluded that University of Kansas School of Nursing e xperienced transformational change based on the components of the Eckel & Kezar’s (2003) Mobile Model for Transformational Change, and that the other two nursing programs at the time of my site visits, had not. In arriving at these conclusions, I used Eckel & Kezar’s (2003) template to determine the extent to which St. Scholastica and Large State University are progressing towards transformation. These authors suggest th at institutions are well on their way to transformation when most, if not all, of the structural and cultural evidence markers are easily recognizable. The evidence markers have to be aligned, mutually reinforcing, and reflective of progress in a common direction. Eckel and Kezar (2003) identified seven structural change indicators in the Mobile Model for Transformational Change. These markers cover 1) changes to the curriculum, 2) changes in pedagogies, 3) changes in student learning and assessment practices, 4) changes in policies, 5) ch anges in budgets, 6) the presence of new departments and institutional structures, and 7) new decision-making structures. Presence of the structural evidence by itself, however, does not necessarily mean transformational change has taken place. An additional set of evid ence is needed to establish the cultural impact of the transfor mation. The presence of attitudinal and cultural shifts suggests greater depth to the ch ange. They indicate that an institution has developed new capacities and a new set of be liefs and assumptions. Attitudinal and cultural markers are: 1) changes in the ways faculty members interact with one another; 2) changes in the campus image, the language used to describe the organization; 3)

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201 changes in the types of conve rsations with different play ers from inside the institution and new partners from without; 4) willingn ess to abandon old arguments; and 5) new relationships with current stakeholders and with nontraditional stakeholders. Research Findings University of Kansas School of Nursing di splayed all of the structural and cultural evidence markers six years after the colle ge leaders began to address healthcare informatics core competencies. The evid ence markers were aligned and mutually reinforced, and reflected progress toward the creation of an educational version of the electronic health record designed to enhance pedagogi cal practices within the undergraduate nursing curriculum and to expand to the allied health and medical schools. At St. Scholastica School of Nursing, ther e was evidence of structural markers within the healthcare informatics faculty subgroup, in ch anges in policies and budgets, in the creation of a new center, and in new d ecision-making structures. The remaining structural markers, change s to the curriculum, pedagogi es, and student learning and assessment practices, were evident in the computerized human simulation lab. Each faculty subgroup began its pr ocesses of change in 2002; however, they did not merge their activities into a combined focus until academic year 2004/2005. At that point, the two faculty subgroups began to integrate their activ ities, learning pedagogies, patient case scenarios, the electronic hea lth record, and the computeri zed human mannequins in the simulation labs. There was evidence of th e cultural and attitudinal evidence markers between and among the two faculty subgroups. The introduction of the new curriculum, with all of the above changes was scheduled to begin in academic year 2007-2008. At the time of this study, St. Scholastica School of Nursing had not as yet applied the

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202 changes broadly enough within the nursing sc hool to be considered transformational. The alignment of these evidence markers was not a reality at St. Scholastica School of Nursing after five years. College leaders’ recognition of the progr ess of changes by both faculty subgroups convinced them to ali gn, mutually reinforce, and communicate a common direction toward transformational change. At Large State University School of Nu rsing, there was evidence of structural markers in changes in policies and budgets, in pedagogies, and in student learning and assessment practices. There was no evidence of new departments or new institutional or decision-making structures. There was some ev idence of cultural and attitudinal change markers signaling shifts that suggested a ne w set of assumptions among the small subset faculty members involved. Alignment and mutual reinforcement of the evidence markers was initially aimed in 2004 toward educating the small group of faculty members involved in the computerized simulation la b about nursing informatics, and toward integrating nursing informatics competencies within their respective courses. By 2007, these faculty members were positioned to ex tend their new knowledge and experience to other faculty members, but the understandings and behaviors were not broadly enough distributed in the college for the change to be considered transformational. Implication of Findings Examining structural, cultural and attitudi nal markers and their alignment, mutual reinforcement, and reflection of progress in a common direction, as discussed by Eckel and Kezar, proved to be an applicable and practical way to determine the depth and breadth of change and to distinguish differe nt levels of transformation in colleges and universities.

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203 Eckel and Kezar (2003) say that transfor mational change takes longer than five years, even with intentional strategies by college leadership to address both the breadth and depth of change within their organizati on. The results of this research support the fact that transformational change takes a cons iderable amount of time. As with the case for University of Kansas School of Nursing, these college leaders a ddressed the processes of change in a pervasive and d eep way. This school of nursi ng was in its sixth year and all nursing undergraduate cour ses except community health a nd the senior practicum had incorporated the electronic health record. St. Scholastica was in its fifth year of addressing healthcare informatics and the new curriculum was not scheduled to be fully implemented until fall 2007. Large State Un iversity began their implementation of nursing informatics core competencies three years prior to this study. Suggestions for Further Research My study offers one case that experienced transformational change and two others where change processes have led to knowledge and behaviors that have the potential for transformational change. Kezar’s (2001) analys is of the conceptual models of cultural, social-cognition, and political ch ange notes that in most inst itutions of higher education, incremental adjustments are more likely than transformational change. All three nursing programs did begin with incremental adjustment s, that is, with pilot groups designed to modify existing practices. Faculty members began altering existing practices, leading to changes in thinking and actions. Implementa tion of these incremental adjustments to faculty members at large was a challenge ev en at University of Kansas School of Nursing, where transformational change took pl ace. I suggest further research relating to

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204 incremental adjustments, such as pilot group and grant activ ities, and what it takes for these activities to result in transformational change. The Mobile Model offers practical strategies for institution-wide change as systemic, concurrent, and interdependent. Using conceptual frameworks that illustrate the dynamism, like this model, that occurs within and among organi zational phenomena can be powerful (Eckel & Kezar, 2003). Based on my own professional experience as a healthcare leader, healthcare systems have attempted to us e various types of continuous quality improvement (CQI), processes that have proved inadequate for the desired effects. I agree with Mintzb erg (1994, p. 13) that “organiz ational [change] strategies cannot be created by the logi c used to assemble automobiles.” The Mobile Model provides a theoretically-based model on which to build a transformational change model for healthcare systems. I suggest further re search of the processe s of change within hospitals, again using the Eckel & Kezar (2003) Mobile Model for Transformational Change for both informatics change and othe r types of change, modifying its components to reflect institutional purpose and culture. Research Question One: Teaching Methods, Assignments and Labs In this section, I discuss wh at is happening within the classroom, with homework assignments, and in the computerized human simulation laboratories at the three nursing programs. Research Findings All three nursing schools used patient case sc enarios loaded into electronic health records in their respective classrooms a nd homework assignments, and in their computerized human simulation laboratories. In the classroom, faculty members are able

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205 to project the electronic hea lth record with student documen tation onto a screen, allowing them to point out trends and discrepancies. Th ey are thus able to offer immediate student feedback, facilitate classroom discussi on, and assign data-driven teaching cases. University of Kansas School of Nursing made greater use of the electronic health record in the classroom than did the other two nursing programs, where only a small group of faculty used the elect ronic health record in the classroom. In homework assignments, faculty had the option of using the electronic health record to grade care plans and assess stude nt progress online. I determined that University of Kansas School of Nursing also made the most use of the electronic health record for this purpose. Again, at Large St ate University and St. Scholastica schools of nursing, this use of the electroni c health record was limited to a small group of faculty. Use of simulation labs is not new to nurs ing schools. The elect ronic health record and computerized human mannequins do offer new technologies; and all three nursing programs used them to create computerized si mulation labs. As addressed in Chapter 2, participants at all three nu rsing programs reported incr eased use of the pedagogical approaches of active learning and problem-based learning in these simulation labs. These approaches encourage greater faculty-student and student-tostudent interaction, engender more self-directed learning, and do a better j ob of providing students with a process for integrating previous learning. Implication of Findings The data suggests that implementation of healthcare informatics requires new ways of teaching, which, if implemen ted broadly and deeply, could produce transformational change within traditiona l nursing education. The combined

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206 technologies of the electronic health record and the comput erized human simulator have created “new ways to package, explain, and deliver information and new avenues to communicate between instructor and st udents” (Eckel & Kezar, 2003, p. 7). Combination of the electronic health reco rd with the patient case scenarios and the computerized human simulator has create d a more robust educational environment at all three schools. These si mulation laboratories allow faculty members to guarantee that students will experience real pati ent experiences that replicate clinical settings in a safe, interactive manner. Simulation techniques can be repeated and altered to enhance educational value. The elec tronic health record provides opportunities for students to document, review patient clinical reports, co mmunicate with other he alth care providers, and access the internet for additional informa tion. Proper preparation and application of skills and knowledge in a virtual health care environment that includes healthcare informatics core competencies allows student s to enter an actual hospital setting with greater poise and confidence. Suggestions for Further Research The findings of this study provide seve ral opportunities to expand research in pedagogical practices relating to the integra tion of healthcare in formatics within the undergraduate nursing curriculum. Further rese arch into the impact of the pedagogical practices of using the electron ic health record with patient case scenarios in conjunction with the computerized human si mulator may be beneficial. I suggest a study of graduates from the schools of nursing using the computer ized human simulation labs versus those graduates who experience the trad itional clinical setting expe ctations. The increased use of the EHR in the classroom provides a furthe r opportunity for faculty to offer immediate

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207 student feedback, facilitate cl assroom discussion, and assign data-driven teaching cases. What is required to be in the EHR in order for faculty members to enhance active learning pedagogies in the cl assroom? I suggest a study of the potential use of the computerized human simulation labs within th e healthcare systems for orientation of new employees and continuing education. Research Questions Two and Three: Strategies Used and Why In this section, I describe the critical d ecisions employed by colle ge leaders at three baccalaureate nursing programs as they addressed healthcare informatics. I present the research findings, the implicati ons of those findings, and sugge stions for further research to answer research questions two and three. First, I discuss what led college leaders to embark on major change; select ion of faculty members to lead the healthcare informatics implementation; resources to fund informatic s, and three of the five cross-cutting strategies recommended by the IOM (2003). Thes e IOM (2003) strategies include: 1) healthcare informatics core competencies; 2) development of competency-based curricula and teaching approaches; and 3) faculty de velopment. Next, I discuss the use of strategies that correspond to Eckel & Kezar’s (2003) core and supporting strategies; and the attention college leaders gave to cultural issues and balance. Research Findings Why College Leaders Embarked on Major Change College leaders at the University of Kans as School of Nursing wanted to create an electronic health record designed for educati onal purposes. Their plan was to test the educational version of the EHR first in th e undergraduate nursing program, then to extend to the School of Medicine and the 10 al lied health professions on campus. The

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208 undergraduate nursing curriculum was aligned with Cerner Corporation’s in-patient electronic health record, making this an id eal platform from which to launch the University of Kansas Healthcare informatics program. Similar to their previous successful processes of change, nursing college leaders chose a sma ll group of innovative faculty members who could see the value of an academic electronic health record. The University of Kansas School of Nursing’s cu lture of innovation and the financial support from Cerner Corporation enabled the college leaders to respond quickly to address the core competency of healthcare informatics. Transformational change was not reported as college leaders’ intent in th e beginning of the change; howev er, their approaches to the change processes targeted both the depth and breadth needed for transformational change. These college leaders generated purposeful and desirable outcomes with conscious decisions to act, and purposefully ch ose the direction of those actions. Leaders at St. Scholastica School of Nurs ing approached their change processes as a strategic response to enhance the sc hool’s position. They wanted to become distinctive in the market by enhancing th e undergraduate nursing curriculum with the electronic health record, whic h would contribute to increased student enrollments and to increased financial stability for the college. Leaders were also concerned with its graduates’ passing rate on nursing exams. They undertook two related but distinct change processes: one focused on incorporati ng informatics, and the other on revising the undergraduate nursing curriculum. The intentionality of the change processes did not meet Eckel and Kezar’s (2003) Mobile Mode l for transformational change. The two faculty subgroups were not intended to work together and to reinforce each others’ activities and those activities were described in interviews as serendipitous events.

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209 Large State University college leaders pur sued an adaptive approach, a deliberate modification by the organization in response to the external environment. College leaders and the university’s hospital personne l jointly recruited a nursing informatics expert. This expert served as a change agent for the college of nursing, introducing nursing informatics to the small group of unde rgraduate nursing facu lty involved in the computerized simulation labs. The expe rt and the faculty group designed the competencies they wanted the undergraduate nursing students to attain. Large State University School of Nursing met Eckel and Kezar’s (2003) description of intentional change. Intentional change, according to Ec kel and Kezar (2003, p. 30) is undertaken to “generate purposeful and desirable outcomes ; not changes that are serendipitous or unintended.” These college leaders however, did not aim for or create transformational change. Selection of Change Leaders Two of the schools (University of Kansas and Large State University) chose a Ph.D. prepared nursing informatics expert to lead the implementation of healthcare informatics within the undergraduate nursi ng curriculum. St. Scholastica chose its change leader from the Health Inform atics and Information Management (HIIM) Department. The project leaders from Univer sity of Kansas and St. Scholastica Schools of Nursing were well respected and accepted by faculty members, supporting the concept that people can lead from different positions and places in an organization. However, the leader for Large State University met with f aculty resistance, which impacted the breadth of the changes.

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210 It was obvious at all three schools of nursing that college leaders’ careful selection of pilot groups provided credibility and stability for the project resulting in depth to the change processe s within these groups. The MIS staff involved was also noted as highly significant to the successful implementation of change processes at all three nursing schools. Sources of Funding Both Large State University and St. Schol astica schools of nursing received grants to implement the healthcare informatics comp etencies. Large State University received grant dollars to implement nursing informatic s competencies within the undergraduate nursing program. St. Scholastica received its grant from the U.S. Department of Education to implement healthcare informatic s within the nursing and allied health professions. This grant included a contractua l relationship with th e Cerner Corporation based on an Application Service Provider (A SP) model. The University of Kansas School of Nursing college leaders chose to partner with Cerner Corporation in an exchange of resources. Cerner funded a staff position, the technology and tech support; the school provided the intellectual capital (a nurse informatics expert), as well as faculty time. Large State University College of Nursi ng selected a different electronic health record company, and instead of partnering with them, pays an annual fee for use of its system. Both St. Scholastica and Univers ity of Kansas School of Nursing have a contractual relationship with the Cerner Co rporation, which involves an established, ongoing annual licensing fee for the continued us e of Cerner’s electr onic health record platform.

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211 In this study there are two examples of academic-business partnerships with Cerner Corporation. St Schol astica and University of Kansas Schools of nursing rent the electronic health record from Cerner Corporation. Other schools can buy platform time at a lesser fee than purchasing alone. The schools of nursing provide consulting services to other schools to assist with their inte gration of the EHR into their curricula. Healthcare Informatics Core Competencies This study offers two examples of an inte rdisciplinary approach with the allied health professions. University of Kansas included its medical sc hool. St. Scholastica does not have a medical school, so their interd isciplinary approach was, by necessity, somewhat limited. Although Large State Univer sity has a medical sc hool and a school of allied health professions on campus, the college opted to address healthcare informatics using a nursing-specific method. The inte rdisciplinary appro ach to healthcare informatics affected the overall pervasiveness of the change processes at University of Kansas School of Nursing. Although St. Schol astica School of Nursing also employed an interdisciplinary approach, pervasiveness of the implementation of healthcare informatics was limited among the undergraduate nursing faculty. Development of Competency-based Curricula and Teaching Approaches Two of the nursing programs (University of Kansas and Large State University) chose to modify individual course activiti es and teaching methods within the existing curriculum structure. A faculty subgroup at St Scholastica, separate from the healthcare informatics implementation group, revised the cu rriculum to a generalist approach with enhanced use of active learning pedagogies. St. Scholstica did not identify specific healthcare informatics core competencies; how ever, its approach to use the EHR as a

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212 documentation tool for students to gain compet encies implied broad-based competencies. Both University of Kansas and Large State University used the Staggers, Gassert and Curran (2001) research-based master lis t of nursing competencies. Large State University School of Nursing employed nursing informatics competencies. University of Kansas also used nursing informatics core co mpetencies as well as a broad-based set of core competencies. All three nursing programs employed a probl em-based approach using the patient case scenarios loaded into the EHR. Thes e patient case scenarios were a significant component in the processes of change at all three nursing schools. University of Kansas and Large State University used cases scenar ios created by faculty members for their preEHR courses. Additional data were need ed to enhance these cases since the EHR provides students with deeper and much richer data than the traditional written patient scenarios used by faculty members. St. Scholastica School of Nursing used donated alumni medical records for their electronic health record, and di d not report needing additional data. Students are able to make be tter decisions about thei r patients due to the enhanced knowledge and context provided by the enhanced patient case scenarios. At all three nursing schools, students can be assigne d the same patient, or a family member, throughout different levels of their curricu lum. This enables students to become acquainted with patients across a period of time allowing them to interpret information in a broader context. All three nursing schools reported enhanced student performance, especially in the simulation labs. Faculty observed that students demonstrated an increased ability to handle and use more data, decision making tool s, and evidence base d practice standards

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213 in the nursing care process. Critical thinki ng skills were improved, and students showed a more comprehensive understanding of the overall nursing process. Improved organizational and delegation skills, and co mmunication skills were also reported. Faculty Development Faculty at the three nursing programs identi fied one-on-one mentoring as critical to their successful mastery of healthcare informatics core competencies. This supports Staggers, Gassert, Skiba’s (2000) research. Satisfaction among facu lty members was also engendered by quick response to use of th e EHR by information technology staff. Faculty admitted the technology was challengi ng, even fearful at times. Technological glitches occurring in the presence of stude nts were an area of great concern, and resolution of these issues improved faculty l earning curve and comfort level. Adequate resources and allotment of time for faculty members to learn to use the electronic health record also proved necessary. All three nursing schools selected a sma ll group of undergraduate nursing faculty to pilot the electronic health r ecord in their courses and/or co mputerized simulations labs. Involvement in projects such as healthcare informatics was, therefore, respected and supported for those faculty memb ers on the clinical track. Core and Supporting Strategies The Mobile Model (See Appendix A) consists of five core change strategies and an additional 15 supporting strategies, which do not occur as frequently as the five core strategies. These change strategi es are connected directly or i ndirectly to one another. In this section, I compare the ways the three schoo ls of nursing used the core strategies and supporting strategies.

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214 University of Kansas and St. Scholastica Schools of Nursing used all five of the core strategies. Large State University Sc hool of Nursing did not employ collaborative leadership strategies, which limited breadth of th e change processes. This core strategy is about developing extensive plan s to facilitate persuasive and effective communication, inviting participation and pr oviding opportunities to influe nce results, and bringing together people in new ways to foster co mmunication and encourage new interactions. When used by college leaders, this strate gy instills a sense of trust, clarifies misunderstandings and rumors, and fosters a se nse of community. La rge State University School of Nursing did not employ eight of th e 15 supporting strategi es. Four of these eight related to colla borative leadership. Table 2 provides the supporting strategies and a brief explanation of the impact on the breadth of change processes for each school.

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215 Table 2 Supporting Strategies Evident in the Three Cases KUMCSS LSU Impact on Breadth of Change Processes Changes in administrative and governance processes X X X Ensures change becomes part of daily operations, provides support for groups to work faster Supportive structures X X X Provides structures to facilitate change Financial resources X X X Supports change with new funds Incentives X X X Motivates key faculty to commit time and energy to change Long term orientation X X X Captures and holds campus-wide attention External factors X X X Provides legitimacy, confirms beliefs, p rovides needed funds Outside perspectives X X X Taps out siders’ perspectives that advance change Setting expectations and holding people accountable Addresses campus behavior and priorities, uses frameworks to hold people accountable Moderated momentum X Prevents overwhelming members or stalling change processes Persuasive and effective communication X X Requires extensive and intentional communication plans Invited participation X X Involves faculty and creates diverse opportunities to meet the interests of various individuals Opportunities to influence results X X Recognizes participation, reinforces flexibility to changes N ew interactions X X Sparks creative thinking and approaches, fosters communication across campus Connections and synergy X X Creates new energy, reassures people are not working in isolation Putting issues in broader context X X Demonstrates proposed changes are not an attack on a particular campus subgroup 14 13 7

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216 University of Kansas School of Nursi ng used 14 of the 15 supporting strategies and St. Scholastica School of Nursing used 13 of the 15. None of the schools employed the setting of expectations and holding indivi dual faculty members accountable to the processes of change. The grants received by St. Scholastica and Large State University did contain specific objectives as well as accountability fo r those objectives. One important supporting strategy, modera tion of the pace of change, was an issue neither St. Scholastica nor Large State University addressed. Only two nursing faculty members at St. Scholastica were involved in the change processes, and they were the same faculty who taught the classes to other faculty members. Faculty members who were taught to use the EHR were not held acc ountable in using the system. Leadership encouraged faculty to try the EHR, but there was no monitoring to see if this took place. At Large State University, there were c oncerns about sustaining the momentum of change after the lead nursing informa tics expert left the college. Another contributing factor to the lack of breadth at Large State University was that college leaders failed to make conn ections and synergies linking the various activities across the campus; and did not put the issues in a broader context. New connections among individuals from different parts of the organization can spark new energy and serve to reassure people that they are not working in is olation. Framing the issues in a broader context helps college leaders to elevate the importance of the processes of change. This makes local chal lenges more reasonable when compared to external happenings, and helps to depers onalize the issues fo r individual faculty members.

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217 Attention to Culture and Sensemaking The underlying connection between the five core strategies, according to Eckel & Kezar (2003) is that they are intended to en courage people to think and act in new and different ways. According to Weick (1995), the opportunity for faculty to discuss, debate, reframe, and make sense of the proposed change s allows for creative re sults. Change as a result of cognitive dissonance pays greater atte ntion to individual learning and individual sense-making, and alters indivi dual beliefs and construction of reality. Social cognition models emphasize discussion and learning among the participants. As individual discussions and learning occu r, new ideas are created and acceptance of at least some aspects of the processes of change began to create incremental adjustment within the organization. As faculty members become more knowledgeable and gain experience with the modifications of existing practices, new ideas are created. Another major difference between the th ree schools of nursing was college leaders’ approach to culture and planned se nsemaking. Limited consideration by college leaders to these strategies resulted in limite d pervasiveness of the change processes at both St. Scholastica and Large State University Schools of Nursing. College leaders at University of Kans as engaged in purposeful sensemaking activities with groups of faculty members, encouraging open discussion of conflict and the impact of healthcare informatics on daily work responsibilities. The project leader played a significant role as an informatics mentor, facilita ting exploration of impacts of the proposed changes for faculty work and pedagogy. These discussions reinforced the adoption of new mind-sets in a cognitiv e and intellectual process among faculty members. The leadership team at University of Kansas made a conscious and purposeful

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218 selection of the person to lead the integrati on of healthcare informatics core competencies into its nursing curriculum. They gave cons iderable thought to the characteristics needed in the lead project person, si nce this individual would al so serve as a connecting link between the college and the business partner. Interpersonal and communication skills were seen as essential, as there would have to be considerable consultation with faculty and communication of academic concepts to Ce rner staff. The leader’s knowledge and experience within both academia and the busine ss culture was vital in her role as an interpreter and a facilitator between the two distinct cultures. College leaders at University of Kansas School of Nursing played a significant role in the processes of change. They pla nned for faculty resistance, scheduling meetings and educational sessions to a ddress any issues and/or confli ct with faculty regarding the processes of change. They al so took into account the probabl e responses of faculty to the change processes, and planned for sensemak ing discussions with faculty members to clear the air. The lead informatics pers on discussed linkages between the changes and students’ reactions to those changes during faculty meetings. Analyses of student behaviors, such as the connection of critic al thinking skills a nd particular student observations were presented. These observat ions by faculty members were discussed with peers and became a way to think about and reinforce the change processes. The discussions fed into the success of the proces ses of change in important ways, providing a reason for staying with the changes and broa dening interest in the changes among other faculty members. There were components of cultural cons ideration by college leaders at St. Scholastica in their initial se lection of the faculty member s, but evidence of any on-going

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219 consideration was limited. Sensemaking discussions occurred among the faculty; however, there was no evidence that college leaders encouraged faculty members to discuss the impact of the change processes on their daily work activities. St. Scholastica’s informatics lead was a representative of th e Health Information Management Department who was respected by faculty members. In addition, college leaders carefully chose two nursing faculty to work with the interdis ciplinary team. One was a well-respected tenured faculty member, and the other a faculty member who was an innovative thinker. College leaders at St. Scholastica worked behind the scenes with faculty members involved in the healthcare informatics and cu rriculum faculty subgroups. They hired an outside consultant to work with curric ulum subgroup to integrate active learning pedagogies within the curriculum. I did not find that college leaders here became personally involved in implementing the cha nge processes or in addressing faculty resistance to change. There was evidence of sensemaking discussions within and between the two faculty subgroups, but no evidence that college leaders were involved in these discussions. Although St. Scholas tica School of Nursing used five core strategies and 13 of the supporting strategies, this did not resu lt in transformational change. Subgroups of faculty members were driving different change s independently of one another in the first years of the change efforts, and leadersh ip oversight of thes e core and supporting strategies was limited. These strategies were not implemented sufficiently for transformational change to occur. Large State University college leader s made a thoughtful selection of those clinical faculty members invol ved in the computerized simu lation lab who were to work with the lead informatics person. Leaders here were to be the ‘champions’ of change, but

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220 not involved in day-to-day change activities They nominated a point person who led the change efforts in a small group of faculty. Once this group was successful, the changes were to be introduced to the faculty at la rge. The aim here was to implement nursing informatics within the specific courses and the computerized human simulation lab. Participants indicated the expert, a part-tim e employee of the college, was perceived as an outsider who did not understand the academic culture. Perceptions of college leaders and faculty member differed in the initial ap proach to including faculty participation in the grant proposal. Faculty felt the faculty govern ance structure was not being included in the grant process, and that their partic ipation was sought only after the grant was awarded. Collaborative activit ies such as invited particip ation, opportunity to influence results, and facilitating comm unication between the grant proj ect leader and the faculty members at large were not part of the cha nge process at the Large State University College of Nursing. The project leader wa s not a full-time faculty member, and her personal approach was perceived by faculty members as autocratic and demanding, and unappreciative of their academic position. The project leader expected faculty members to make the grant their priority, and was not open to their suggestions. Once faculty members outside the initial p ilot group did become involved, neither they nor the project leader was willing to compromise in negotia ting resolutions to problems. This conflict continued to impact the implementation of nursing informatics at the Large State University College of Nursing at the time of my visit, with one faculty remarking that “[acceptance] varies all acro ss the spectrum.” Evidence of sensemaking discussions and cultural considerations by college leaders was not apparent. Faculty members were

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221 reported as being opposed to usi ng the electronic health reco rd within the classroom or choosing to ignore the processe s of change altogether. Next, I compare the ways in which the th ree nursing college leaders demonstrated balance to the change processes employed. Attention to Balance Attention to balance means college le aders must consider the momentum of change, making certain people are not overwhelmed or stall the processes of change. College leaders must also cons ider the critical components identified by Eckel and Kezar (2003) to balance the mu ltiple strategies being employed, and also to personally demonstrate their use. The results of this research validate the importance of these actions. University of Kansas School of Nursing College leaders at University of Kansas School of Nursing demonstrated balance in pushing the processes of change forward, while at the same time listening and observing for any signs the processes of change needed to be slow ed. Although they would have liked the change processes to move faster, they acknowledged that faculty needed time to get used to the new technology, to ‘pla y’ with it and have some personal successes before moving on to the next phase. At University of Kansas School of Nursing, 14 of the 15 supporting strategies were employed, along with all of the types of ba lance identified by Eckel and Kezar (2003). College leaders’ careful balance of participation of various faculty members tenured and non-te nured faculty, faculty from different disciplines, leadership, and staff contri buted to the breadth of the change

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222 processes. The leadership team was aware of the need for balance between internal and external pe rspectives and involvement and putting issues in a broader context. A retreat was held annua lly to celebrate their successes and to pay tribute to these accomplishments for future generations. Faculty and college leaders’ interactions at these retreats included acknowledging fatigue levels as a major stumbling block to the change processes. The personal impact of the changes processes was linked to the broade r context of the reality of what was being accomplished. Behavior-changing act ivities were offered, using technology as a highway to greater efficiency, and l eaders encouraged faculty to accept that they did not always have to be perfect. College lead ership celebrated the success to date and connected the accomplishments to the legacy currently being built for a sustainable future. St. Scholastica School of Nursing St. Scholastica used all five core strategies and 13 of the 15 supporting st rategies; however they were mostly employed within the subgroups leading healthcare informatics and undergraduate curriculum revision. College leaders at th is school worked behind the scenes to support the lead faculty, and did not dem onstrate careful attention to the bigger picture of the processes of cha nge and the institutional impact. Faculty members at St. Scholastica School of Nursing reported being overwhelmed with the change processes. On ly a few faculty members were leading the change processes, and the lack of an accountability process to hold other faculty members to greater participation frustrated those f aculty members involved. Leaders balanced faculty participation between junior and seasoned faculty, and faculty members from

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223 different disciplines in their interdisciplin ary approach. The mini mal number of nursing faculty involved resulted in less pervasivene ss within the undergraduate nursing program. There was evidence of attempts to reach workab le balances between internal and external perspectives and involvement among the two faculty subgroups. The healthcare informatics grant initiatives provided regular re ports on the objectives as they were met, and on the plans for the next steps of implem entation and the other health professions. These reports noted short-term gains towa rds meeting their long-term objectives. Large State University College of Nursing Faculty members here were concerned that too little change was occurri ng after the grant peri od ended and there was no specific individual appointed to lead the processes of change for nursing informatics. The use of only seven of the 15 supporting strategi es also demonstrated a lack of balance. Demonstrating balance by college leaders includes the balance of faculty participation between junior and seasoned faculty, and f aculty members from different disciplines, neither of which were evident in this case. There was evidence of a long-term approach to nursing informatics by co llege leaders in their ongoing financial support of the electronic health reco rd usage fees. Implications of Findings College leaders do not have to target bot h the depth and breadth at the beginning of the change processes in order for transforma tional change to occur. The results of this study suggest, however, that co llege leaders must, at some point, make a careful and purposeful choice to address the breadth of th e change if transforma tional change is to occur.

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224 College leaders at all three nursing programs employed pilot groups that addressed the depth of the pr ocesses of change. Pilot pr ocess using a small group of innovative faculty willing to create and test new ideas can be an effective path for implementing change within higher education. Such pilot groups, with careful design and selection of participants serve as a mechanism to encourage members within an organization to modify their own practices, a nd then to explore their findings with the larger group of members in that organization. In this study, the credibility of those selected for the pilot groups was critical to the acceptance of f aculty members, and by extension, to the overall success. Also notew orthy was the realizat ion that leaders can come from different positions and places in an organization, as was the case at St. Scholastica. The use of the pilot groups to implement healthcare informatics course by course attained positive results in all thr ee nursing programs; however, course by course curriculum changes is clearly not sufficient to promote transformational change. The faculty members involved in the pilo t groups at all thr ee nursing programs also identified and selected the healthcare info rmatics core competencies. University of Kansas School of Nursing chose both broad-ba sed core competencies, applicable to all the health professions, and nursing-speci fic informatics competencies. This interdisciplinary approach had a positive effect on the overall breadth of the change processes. Both University of Kansas and Large State University, where nursing-specific informatics was the sole approach, used the Staggers, Gassert and Curran (2001) research-based master list of nursing competenci es to redesign their courses. My study suggests this master list of co mpetencies can be be neficial for the other health professions implementing a broad-based approach to healthcare informatics.

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225 Although St. Scholastica and Large State University used pilot small-group programs, it appears they did not focus intently on expanding the change and conversation beyond the small group. The resulting change, while obvious and commendable, failed to achieve transformationa l status. As noted in this study, college leaders’ meticulous attention to cultural asp ects of the organization was critical to the successful transformational change at University of Kansas. The core strategy of collaborative leadersh ip was demonstrated at St. Scholastica School of Nursing, but lack of involvement by college leaders adversely impacted the breadth of the processes of change. Faculty resistance at this nursi ng school appeared to be more covert. Large State University co llege leaders did not employ the core strategy of collaborative leadership, a nd faculty resistance there wa s overt, with open conflict between the lead informatics person and some faculty members. College leaders at University of Kansas School of Nursing planned for faculty resistance by scheduling educational sessions to discuss change and mee ting with faculty to listen to their issues and ideas. Participants here reported their nursing college leaders intervened to make decisions needed to advance the processes of change. I found that transformational change does not necessarily require college leaders to establish formal structures for holding i ndividual faculty members accountable to the processes of change. University of Kansas School of Nursing experienced transformational change without use of this strategy. Thei r success without using this strategy may be related to the tradition of innovation in the college which would contribute to the willingness of faculty to engage in new act ivities. At colleges without

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226 the reputation for innovation and change, the need to establish expectations and hold people accountable for them could be a more important change strategy. This research suggests moderating the pace of change is an important factor in transformational change processes. The lim ited number of faculty members involved with change processes at St Scholastica was overwhelmed w ith the scope and pace of the change. Large State University School of Nursing participants, in contrast, were concerned that too little progress was being made. The need for college leaders to demonstrat e balance, attend to culture, and engage sensemaking discussions is critical to su ccessful transformational change. College leaders must frequently monitor the proce sses of change to determine the overall institution-wide impact on faculty members. One major difference between University Kansas School of Nursing and the other tw o nursing programs was the attention college leaders gave to the change processes. Co llege leaders and faculty members engaged faculty in sensemaking discussions with genuine collaborative intent, providing opportunities to be ‘in touch’ with the impact of change on organizational members. They observed and participated in sensemaki ng discussions to offer linkages between the changes or activities; provided educati onal opportunities, and took immediate action when needed. Opportunities for sensemaking, that is helping faculty members to think differently about their daily work activities were common as faculty members prepared to implement the electronic health record. Purposeful sensemaking activities in faculty group meetings served to enhance the transfor mational change processes at University of Kansas School of Nursing. This was especi ally true in planne d discussions linking

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227 observations about student progr ess with the processes of change. These discussions incorporated cultural aspects, such as the e xploration of impact of the proposed changes for faculty work and pedagogy, and linkages to the observations of enhanced learning by students. These types of discussions also provide an impetus for staying with the changes, and for broadening interest in the change. Finally, this research implies that school s of nursing will need to seek additional funding to implement healthcare informatics an d/or to tap into the type of existing academic-business partnership model explor ed in this study. The academic-business partnership assisted college leaders in offsetti ng the cost of the electronic health record system, and enabled them to offer a more economical EHR to sma ller colleges unable to afford the system at commercial rates. Suggestions for Further Research I would suggest further study of how tr ansformational change occurs within organization where the processes of transforma tion become intentional later, but were not necessarily intended from the start. As ch anges occur within an organization and begin to cascade and build on one another, ideas ma y begin to coalesce into a larger purpose. Further research of case study si tes that have ‘backed’ into transformational change may provide greater insight into what methods may result in al tering the intention or direction in the processes of change. Linking m odifications of existing practices with transformational change processes may reveal that transformational change is actually taking place with greater frequency than recent literature in higher education suggests. Research into the role of college leader s where pilot groups are used to impact organizations in a transformational way shoul d also be useful. All three nursing schools

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228 used innovative faculty pilot groups to in tegrate healthcare info rmatics into their respective courses, and all expe rienced major modifications to existing practices that had faculty thinking and acting differently. Since University of Kansas School of Nursing has embarked on a transformational change journey with nursing, allied health, and medi cine, a study of the critical decisions required and strategies employed to accomplish this interdisciplinary approach to health professions education would be beneficial. Implications for Theory I have addressed the theoretical implicat ions for Eckel and Kezar’s (2003) Mobile Model of Transformational Change under each research question. I now provide a summary of these implications, focusing on how the Mobile Model offers an effective method for evaluating transformational change efforts. In addition, I present several suggestions for enhancing the model. Eckel and Kezar (2003) use the analogy of a mobile to illustrate the interconnectedness of the change strategies, providing a useful way to visualize the complexity of transformational change. Demonstrating balance, participating in sensemaking, and paying close attention to the institutional culture were significant strategies that resulted in transformational change for University of Kansas School of Nursing. College leaders’ use of the supporting strategies is essent ial for the breadth of the change processes. If only a few intere sted people engage deeply in the changing processes, other members of the institution ma y not feel the need to follow, as was the case at Large State University College of Nursing. University of Kansas and Large State University Schools of Nursing demonstrated resu lts that substantiate the viability of the

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229 model: One school used almost all the sugge sted methods and achieved transformation; the other, which used some of th e methods, was not transformed. St. Scholastica School of Nursing is an exception and suggests areas in which the model could be further developed. All of th e structural and cultural markers of change were present, but the school did not experience transforma tional change. St. Scholastica School of Nursing leaders actually employe d many of the strategies; however, the intensity seemed to be limited to those facu lty members in the subgroups. I suggest the model would benefit from specific ways of det ecting the breadth in th e application of the change markers and from the addition of strate gies for creating a bread th of intensity. My research indicates that all markers can be present, but the institution may have focused too narrowly for transformational cha nge to have occurred. This leads me to suggest that the components of the model relating to the stru ctural and cultural markers of change need to be further develope d to focus on the breadth of change. Finally, I suggest the Mob ile Model needs greater emphasis on and clarification of the role and nature of inte ntionality in the change proce ss, as well as a greater focus on the relationship between the core strategies, support strategies and the breadth of change. The intent of college leaders is important, in part because without it the breadth of change required for transformational change is not likely to be achieved. Conclusion Through this research experience, I have gained a deeper, wider, and more complex understanding of tran sformational change within higher education, and of the processes of change as used to implemen t the core competencies of healthcare informatics In Chapter One, I stated a personal bi as toward supporting a combination of

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230 several change models to enhance th e understanding of the complexity of transformational change. I feel the Mobile Model for Tran sformational Change provides a model for changing a college or university in the deep and broad way that is necessary for changes as important as implementing health care informatics and new modes of teaching in a nursing school. My anticipat ion that none of the undergraduate nursing programs would experience the transformationa l change of high dept h and pervasiveness was a second bias. I was pleasantly surp rised and motivated when I experienced firsthand observation of a nursing progr am undergoing successful transformational change.

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242 Maudsley, G. (2001). What issues are raised by evaluating problem-based undergraduate medical curricula? Making health co nnections across the literature. Journal of Evaluation in Clinical Practice, 7 (3), 311-24. Mavrinac, M.A. (2005). Transformational leader ship: Peer mentoring as a values-based learning process. Libraries and the academy, 5 (3), 391-404. McNeil, B. J., Elfrink, V. L., Bickford, C.J., Pier ce, S. T., Beyea, S. C., Averill, C., et al. (2003, August). Nursing Informati on technology knowledge, skills, and preparation of student nurses, nursing f aculty, and clinicians: An U.S. survey. Journal of Nursing Education, 42 (8), 341-349. Merrian, S. B. (1998). Qualitative research and case study applications in education. San Francisco, CA: Jossey-Bass. Millenson, M. L. (1998). 3 forces for change. Hospitals and Health Networks, 72 (4), 4449. Morgan, G. (1986). Images of Organization Newbury Park, CA: SAGE Publications. Morris, L.V. (2005, Spring). Transforming the Academy. On-Line Journal Innovative Higher Education, 29 (3), 177-179. National Advisory Council on Nurse E ducation and Practice (NACNEP). (1997). Report to the Secretary of the Department of Health and Human Services: A national informatics agenda for nursing education and policy. Retrieved December 18, 2005, from ftp://ftp.hrsa.gov//bhpr/nur sing/nireport/NIFull.pdf National Council of State Boards of Nursing. About NCSBN Retrieved December, 15, 2005, from National Council of State Boards of Nursing Website: http://www.ncsbn.org/res ources/publications.asp

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246 University of Chicago, National Resource Cent er for Research at the. (2005, June 6-10). AHRQ 2005 Annual patient safety and hea lth information tech nology conference: Making the health care system safe r through implementation and innovation Retrieved February 9, 2009 from http://www.ahrq.gov/qual/p tsconf3/ptsconf3a.htm University of Kansas, Kansas City. (n.d.). KU Center for Health Informatics Retrieved February 3, 2009, from The KU Center for H ealth Informatics: The University of Kansas School of Nursing Web site: ( http://www2.kumc.edu /healthinformatics/ University of Kansas, Kansas City. (2006). KU School of Nursing ce lebrates centennial in 2006 Retrieved August 22, 2006, from The KU Medical Center: The University of Kansas School of Nursing Web site: http://www2.kumc.edu/son/centennial.htm University of Kansas, Kansas City. (n.d.). Reports, Student Degrees AY 2006/2007 Retrieved December 20, 2007 from, KU Medi cal Center: The University of Kansas Center for Health Informatics Web site: http://www2.kumc.edu/aa/ir/re ports/students/degreesAY06_07.html University of South Florida, Tampa, Office of Research Compliance, Research Involving Human Subjects Retrieved February 3, 2009, from http://health.usf.edu/research/com pliance/humansubject_general.html Van de Ven, A. H., & Poole, M.S. (1995). Explaining development and change in organizations. Academy of Management Review, 20 (3), 510-540.

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247 Weaver, C. A., Delaney, C., Weber, R., & Carr, R. (2006). Transforming the nursing curriculum: Going paperless. In Nursing and Informatics for the 21st century: An International look at practic e, trends, and the future. Chicago, IL: Healthcare Information and Management Systems Society (HIMSS). Weick, K. E. (1995). Sensemaking in organizations Thousand Oaks, CA: SAGE Yin, R. K. (1994). Case study research: Design and methods. Applied Social Research Methods. Thousand Oaks, CA: SAGE.

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248 Appendices

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249 Appendix A Eckel and Kezar’s (2003) Mobile Model for Transformational Change

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250 Appendix B Eckel and Kezar’s (2003)Typology of Change Top

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251 Appendix C Nursing Informatics Experts Recommended Ronda G. Hughes, PhD, MHS, RN, Senior Health Scientist Administrator for the (AHRQ, 2005) provided me with names of four nursing informatics experts: 1. Melinda Jenkins (Columbia University) 2. Sue Bakken (Columbia University) 3. Nancy Staggers (University of Utah) 4. Pat Brennan (University of Wisconsin) These nursing informatics experts recommended seven experts: 1. Helen Connors, Dean of University of Kansas 2. Patti Abbot, Johns Hopkins University 3. Susan Newbold, NLN representative 4. Diane Skiba, UCDHSC 5. Ramona Nelson, HIMSS and Slippery Rock University 6. Angela Lewis, Manager, Informatics, HIMSS 7. Connie Delaney, Professor at University of Minnesota

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252 Appendix D USF IRB Approval Letter

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253

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254 Appendix E USF IRB Approved Consent Form

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257 Appendix F Interview Guide 1. Can you share with me how you became involved with implementation of informatics at your school of nursing? 2. Can you tell me your reasons to be involved? 3. Who do you see as being involved and contributing to the implementation process? 4. Can you describe how your school of nursing has addressed informatics A. Infrastructure related 1. New policies 2. New departments 3. New decision-making structures 4. Reallocation of existing funds 5. Curriculum revision 6. New student learning an d assessment practices 7. Faculty education B. Cultural and attitudinal 1. Explore the meaning of the info rmatics change has upon faculty 2. Negotiating of new understandings within the shifting work environment of those involved 5. Why do you think these part icular strategies and/or decision were selected? 6. How have the changes impacted your daily work? A. Interactions with ot her individuals or groups have changed B. Interaction with students is different C. Shift in values and assumptions D. People are thinking and acting differently E. Greater involvement with other departments and/or programs F. Teaching mode differences 7. Please share with me some of the barri ers experienced during the informatics change processes? A. Existing professional cult ures (differing values) B. Role competition C. Turf issues (protection of speci fic specialties’ or interests) D. Lack of a common language ; core competencies

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258 E. Internal hierarchies F. Time involved 8. How were these specific barriers addressed? 9. In your opinion, what has been campus leadership involvement in the change processes? 10. What has been the greatest lesson(s) learned during the implementation of informatics changes processes? 11. In your opinion, what should be the next steps towards implementation of the informatics core competency? How and why?

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259 Appendix G Deans of Nursing Approval Letter to Identify Institution

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260

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261 Appendix H: Cerner Corporation Approval Letter to Identify Company

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About the Author Revonda Leota Cornell received a Bachel or of Science in Nursing from University of North Carolina at Greensboro in 1978 and a Master’s of Science Degree in 1983. I entered the Ed.D. program for Higher Education in Leadership Development at University of South Florida in 2000. Revonda has worked as a Chief Executive O fficer/Chief Operation Officer and as a Chief Nurse Executive in medium to large size healthcare systems. During the past several years, she has worked as an executive and clinical healthcare consultant.


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ABSTRACT: The Health Professions Education: A Bridge to Quality (IOM, 2003) proposed strategies for higher education leaders and faculty to transform their institutions in ways that address the healthcare problems. This study provides higher education leaders and faculty with empirical data about the processes of change involved to implement the core competency of healthcare informatics. I chose the core competency of health care informatics as a base from which to conduct semi-structured interviews with faculty and college leaders at three schools of nursing intending to capture their stories about how healthcare informatics has been implemented, what strategies were used, and why they were selected. All three nursing schools used patient case scenarios loaded into electronic health records in their computerized human simulation laboratories.Participants' at all three nursing programs reported increased use of the pedagogical approaches of active learning and problem-based learning in these simulation labs. These approaches encourage greater faculty-student and student-to-student interaction, engender more self-directed learning, and do a better job of providing students with a process for integrating previous learning. University of Kansas and Large State University Schools of Nursing demonstrated results that substantiate the viability of the Mobile Model for Transformational Change. One school used almost all the suggested methods and achieved transformation; the other, which used some of the methods, was not transformed. I suggest the model would benefit from specific ways of detecting the breadth in the application of the change markers and from the addition of strategies for creating a breadth of intensity to the change processes.The components of the model relating to the structural and cultural markers of change need to be further developed to focus on the breadth of change. Finally, I suggest the Mobile Model needs greater emphasis on and clarification of the role and nature of intentionality in the change process, as well as a greater focus on the relationship between the core strategies, support strategies, and the breadth of change. The intent of college leaders is important, in part because without it the breadth of change required for transformational change is not likely to be achieved.
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