M1 Nursing Curriculum Reform and

Healthcare Information Technology

THE IMPACT OF HEALTHCARE INFORMATION TECHNOLOGY ON CURRENT

HEALTHCARE
Many years ago, healthcare teams used to bring a cart full of paper-based patient medical
records during rounds. Physicians and nurses often furiously documented to-do lists on
pieces of paper or in notebooks. Recent advancements of HIT and the national push for
using EHRs have revolutionized and impacted every aspect of healthcare delivery. For
instance, currently most patients gather a significant amount of health information about
their health online even before they meet with healthcare providers. When the patient goes
to a clinic or hospital, he/ she is admitted to a registration (or an admission) system before
the patient sees his/her care providers. The data in those systems then are forwarded to
other clinical systems including electronic health records, laboratory and pharmacy systems,
as well as other ancillary systems. Eventually the persons’ health data in those systems are
forwarded to finance systems and then sent to necessary insurance companies and other
regulatory organizations (Borycki, Kushniruk, Joe, Armstrong, Otto, Hoe, et al, 2009).
Clinicians in the current era make rounds with a portable workstation on wheels (WOW)
(a.k.a computers on wheels [COWs]), which is connected to the hospitals’ main EHR systems
using a wireless connection. They look for the most up-to-date evidence-based clinical
information needed for the patient right at the bedside using various portable systems (iPad,
tablet computers, personal digital assistant [PDA] devices). In addition, Meaningful Use (MU)
requires that eligible professionals and hospitals must meet the specific requirements for
using EHRs to receive incentives and avoid penalties from Medicare and Medicaid. The
current national HIT policies have had significant implications for healthcare providers, and
the use of HIT systems in healthcare settings will continue to increase at a rapid pace.
Current HIT has already transformed various aspects of healthcare delivery, including
regulations related to healthcare data and information. For instance, the 1996 Health
Insurance Portability and Accountability Act (HIPAA) was introduced to establish
mechanisms to secure data stored in servers as well as during transmission to the other
healthcare parties (Centers for Medicare and Medicaid Services, 2010; U.S. Department of
Health & Human Services, 2010). In recent years, much has changed in healthcare since
HIPAA was enacted over 15 years ago. Thus, the HIPAA Omnibus Rule was introduced in
2013 to protect patient privacy and safeguard patients’ health information in an ever-
expanding digital age (U.S. Department of Health & Human Services, 2013).
On the other hand, the demand for electronic health information exchange among care
providers and care settings is growing along with national emphasis on the quality, safety,
and efficiency of healthcare delivery (The Office of National Coordinator, n.d.-b). At the
systems’ level, healthcare providers must ensure the accuracy and completeness of data, as
well as appropriate interoperability between the systems. Implementation and maintenance
of HIT are complex and dynamic processes and increasing numbers of HIT experts and
clinicians are being involved in this process. An enormous challenge for both healthcare
organizations and educational institutions is the preparation of competent healthcare
informaticians and clinicians competent in the use of health information technologies. With
the national push, the adoption rates of these HIT technologies by clinicians and hospitals
have been accelerated. To achieve the successful adoption of HIT in healthcare, it is also
critical to ensure clinicians’ competency to use healthcare IT.
Nurses’ competency for using HIT is particularly important because they are the largest
group of direct healthcare providers in the United States, accounting for 19.6% of all
healthcare workers in 2008 (approximately 3 million) (U.S. Bureau of Labor Statistics, 2010;
U.S. DHHS Health Resources and Services Administration, 2010). In fact, nursing as a
healthcare discipline has been ahead in terms of educating healthcare professionals who are
specialized in healthcare IT. For instance, nursing informatics (NI) was created as an area of
graduate specialization at the University of Maryland School of Nursing (UM SON) in 1988,
and NI was officially recognized as a specialty practice area by the American Nurses
Association (ANA) in 1992 (Gassert, 2000).
Since then, informatics has become a core course for many baccalaureate programs, and
many nursing schools have offered graduate degree programs focusing on nursing and
healthcare informatics. Many nursing schools, however, struggle with the inclusion of
informatics competencies at all levels since many faculty members are unfamiliar with the
informatics content. The advancement of available information communication technologies
has also changed nursing education drastically. Nursing schools teach their students using
innovative technologies emphasizing evidence-based practice and problem-solving abilities.
Many nursing schools have high fidelity simulation labs allowing students more
opportunities to learn about critical components of practical cases from school. Stakeholders
expect nursing students to be competent in using HIT when they arrive in practice settings.
Nursing as a profession has recognized the major reform of nursing education, and
significant efforts are being made in many areas of the nursing domain, including revision of
essentials for all levels of nursing education (American Association of Colleges of Nursing
[AACN], 1994, 2008, 2011, 2014). With these changes, informatics is now essential for all
levels of nursing education. In addition to the reform in nursing education, the landmark
document, The Future of Nursing: Leading Change, Advancing Health, by the Institute of
Medicine examined the current nursing workforce and made critical recommendations to
transform the nursing profession in an effort to improve the health of the U.S. population
(Institute of Medicine, 2010).
Those recommendations are focused on four areas, including an informatics field:

• Nurses should practice to the full extent of their education and training.
• Nurses should achieve higher levels of education and training through an improved
educational system that promotes seamless academic progression.
• Nurses should be full partners, with physicians and other healthcare professionals, in
re-designing healthcare in the United States.
• Effective workforce planning and policy-making require better data collection and an
improved information infrastructure

EFFORTS IN NURSING CURRICULUM REVISIONS

Background
An increased awareness of patient safety and the use of HIT in healthcare called for changes
in the nursing curriculum. The IOM report, Health Professions Education: A Bridge to
Quality, is a result of a 2002 summit followed by the IOM’s report, Crossing the Quality
Chasm (Committee on Quality of Health Care in America & Institute of Medicine, 2001). This
inter-disciplinary summit was held to discuss reforming education for health professionals to
enhance quality and patient safety (Institute of Medicine Committee on Health Education
Profession Summit, 2002). The report proposed five core competencies for healthcare
professionals (Committee on Quality of Health Care in America & Institute of Medicine,
2001; Institute of Medicine Committee on Health Education Profession Summit, 2002): •
Provide patient-centered care – identify, respect and care about patients’ differences,
values, preferences, and expressed needs …. and continuously advocate disease prevention,
wellness, and promotion of healthy lifestyles, including a focus on population health.

• Work in interdisciplinary teams – cooperate, collaborate, communicate, and

integrate care in teams …. • Employ evidence-based practice – integrate best
research with clinical expertise and patient values for optimum care, and
participate in learning and research activities to the extent feasible.
• Apply quality improvement – identify errors and hazards in care; understand and
implement basic safety design principles … design and test interventions to
change processes and systems of care, with the objective of improving quality.
• Utilize informatics – communicate, manage knowledge, mitigate error, and
support decision making using information technology.

Since then, many efforts have been made by nursing professional organizations and the
AACN to revise the nursing curriculum to be aligned with the IOM competencies. Quality
and Safety Education for Nurses (QSEN) The overarching goal of the three phases of the
QSEN project, which was supported by the Robert Wood Johnson Foundation (RWJF), is to
address the competencies necessary to continuously improve the quality and safety of the
healthcare systems in which they work (Cronenwett et al., 2007;
Quality and Safety Education for Nurses [QSEN], 2010).
Phase I of the project identified six competencies that needed to be developed during pre-
licensure nursing education The group also proposed clarified competencies in the areas of
knowledge, skills, and attitudes (KSAs). Phase II work of QSEN was focused on
competencies for graduate and advanced practice nurses (APNs). The QSEN faculty
members collaborated with APNs who practiced in direct patient care and worked on the
development of standards of practice, accreditation of educational programs, and
certification (Cronenwett et al., 2009).
The workgroups that participated in Phase II generated KSAs for graduate-level education.
Additionally, in Phase III, the AACN worked on developing the capacity of faculty engaged in
pre-licensure nursing education to mentor their colleague faculty integration of the evidence
based content on the six QSEN competencies (QSEN, 2012). Phase IV supports Institute of
Medicine’s recommendation increasing number of nurses with advanced degree. These
efforts are being led by the Tri-Council for Nursing, consisting of the American Association
of Colleges of Nursing, National League for Nursing, American Nurses Association, and the
American Organization of Nurse Executives (AONE).
The IOM/QSEN competencies and the pre-licensure KSAs are embedded in the new AACN
Essentials for nursing education (Cronenwett, Sherwood, & Gelmon, 2009; Cronenwett et
al., 2009; Dycus & McKeon, 2009).
The American Association of Colleges of Nursing Essentials for Nursing
In response to the urgent calls to transform healthcare delivery and to better prepare
today’s nurses for professional practice, the AACN convened a task force on essential
patient safety competencies in 2006 (AACN, 2006b). The taskforce recommended specific
competencies that should be achieved by professional nurses to ensure high-quality and
safe patient care.
Those competencies were identified under the following areas:
(1) critical thinking;
(2) healthcare systems and policy;
(3) communication;
(4) Illness and Disease Management;
(5) ethics; and
(6) information and healthcare technologies.
Since then, the AACN revised the Essentials of Baccalaureate Education for Professional
Nursing Practice in 2008 (AACN, 2008).
In regard to the essentials for graduate programs, the AACN made a decision to migrate
advanced practice nursing programs (APNs) from the master’s level to the doctorate level
(doctor of nursing practice [DNP] program) by the year 2015 (AACN, 2014). Under this
decision, many master’s programs that prepare advanced practice registered nurses (APRNs)
have already transitioned or in the process of making transition. The Essentials of Doctoral
Education for Advanced Nursing Practice were developed in 2006 (AACN, 2006a) and the
informatics competency is one of the essentials for this education program. This has a major
impact on education at the graduate level. Some non-APRN master’s speciality programs
(e.g., informatics, healthcare leadership and administration, and community-health nursing)
still maintain master’s program. The essentials for master’s education were revised in 2011
(AACN, 2011). Among various changes regarding essentials in nursing education since 2001,
major emphasis has been on patient safety and healthcare IT. The major focus of this
chapter is to discuss nursing curriculum from the context of HIT.
Technology Informatics Guiding Educational Reform (TIGER) Initiative
The recent Technology Informatics Guiding Educational Reform (TIGER) Initiative epitomizes
nurses’ efforts to translate high-level initiatives on nursing education reform to a practice
level (Hebda & Calderone, 2010; TIGER, 2014a; TIGER, 2014b). TIGER’s aim is to fully
engage practicing nurses and nursing students in the electronic era of healthcare. TIGER’s
goal is to create and disseminate action plans that can be duplicated within nursing and
other multi-disciplinary healthcare training and workplace settings. In Phase I of the TIGER
summit, stakeholders from various fields, including nursing practice, education, vendors, and
government agencies, participated in the discussions, and the TIGER team developed a 10-
year vision and three-year action plan for transforming nursing practice and education
(TIGER, 2014a).
In Phase II, TIGER formalized cross-organizational activities/action steps into nine
collaborative TIGER teams (TIGER, 2009).

1. Standards and Interoperability

2. Healthcare IT National Agenda/HIT Policy
3. Informatics Competencies
4. Education and Faculty Development
 5. Staff Development/Continuing Education
6. Usability/Clinical Application Design
7. Virtual Demonstration Center
8. Leadership Development
9. Consumer Empowerment/Personal Health Record

Currently TIGER is working on Phase III that integrates the TIGER recommendations into the
nursing community as well as other disciplines across the continuum of care. Some of the
important activities include the development and implementation of a Virtual Learning
Environment Center (VLE) and developing another invitational summit (TIGER, 2014b). The
VLE is an interactive Web-based learning environment where the learners can develop
knowledge and skills in the area health information technology.
INFORMATICS COMPETENCIES FOR PRACTICING CLINICIANS
The essentials and competencies recommended by the IOM, AACN, QSEN, and TIGER
address essential competencies that need to be addressed in educational programs. A great
deal of effort also has been made in developing more executable competency lists that can
be used in practice settings. American Nurses Association Nursing Informatics. The Scope
and Standard of Practice (ANA, 2008) addressed an NI-specific domain.
As discussed earlier, nursing informatics is an essential component for any nurse.
The competencies contained in the NI Scope and Standards matrix were categorized into
three overall areas:
(1) computer literacy,
(2) information literacy, and
(3) professional development/leadership (ANA, 2008).
Computer literacy addresses competencies in the area of the psychomotor use of computers
and other technological equipment. Information literacy competencies are related to the
ability to identify a need for information as well as the ability to find, evaluate, organize, and
use the information effectively. Professional development and leadership competencies
address ethical, procedural, safety, and management issues for informatics solutions in
nursing practice, education, research, and administration The competency framework
includes all nurses with different levels of NI education (e.g., nurses with and without
graduate-level NI specialty education) and different NI functional areas (e.g., analysis,
consultation).
The categories of educational and functional roles within the competency matrix include:

• Beginning Nurse
• Experienced Nurse
• Informatics Specialist/Informatics Innovator
• Administration Analysis
• Compliance and Integrity Management
• Consultation
• Coordination
• Facilitation and Integration
• Development
• Educational and Professional Development
• Policy Development and Advocacy
• Research and Evaluation
 • Integrated Areas

The ANA’s Nursing Informatics Scope and Standards Revision Workgroup is working on the
revision of the current Nursing Informatics Scope and Standard of Practice (ANA, 2014). The
public comment period for the draft version closed on January 17, 2014.
TIGER Informatics Competencies Collaborative Recommendations
Upon extensive review of the literature, the TIGER Informatics Competency Collaborative
(TICC) recommends specific informatics competencies for all practicing nurses and
graduating nursing students (TIGER Informatics Competencies Collaborative, 2014c).
The TIGER NI competencies model consists of the following three areas:
(1) basic computer competencies;
(2) information literacy; and
(3) information management. For the basic computer competencies, the TICC adopted the
European Computer Driving License (ECDL) competencies and made its recommendations.
The European Computer Driving License (ECDL)/International Computer Driving License
(ICDL) is an internationally recognized Information and Communication Technology and
digital literacy certification (The European Computer Driving Licence Foundation Ltd.,
2014b). The ECDL certification program was developed through the Task Force of the
Council of European Professional Informatics Societies in 1995. The new ECDL training
program includes various modules and the certificate program is run worldwide through a
network of Accredited Test Centres (ATCs) (The European Computer Driving Licence
Foundation Ltd., 2014a).The specific recommendations made by the TICC were based on
the old ECDL/ICDL Syllabus 5.0.
eHealth Literacy
One area that needs further discussion in the competencies addressed by the AACN
(American Nurses Association, 2008) and the TICC (TIGER Informatics Competencies
Collaborative, 2014) is eHealth literacy. Norman and Skinner (2006a) defined eHealth
literacy as “the ability to seek, find, understand, and appraise health information from
electronic sources and apply the knowledge gained to addressing or solving a health
problem” eHealth therefore requires combined literacy skills in several domains. Norman and
Skinner (2006b) suggest six domains of eHealth literacy: traditional literacy, information
literacy, media literacy, health literacy, computer literacy, and scientific literacy. With the
rapid growth in the use of eHealth at the global level, the concept of eHealth literacy has
become more important than previous times (Chan & Kaufman, 2011; Norman & Skinner,
2006a).
eHealth literacy is often discussed at the consumers’ level because consumers in the current
age can access a large amount of health information online and many of them may not be
prepared to locate the information they need or evaluate the quality of the information
found from different sources (Chan & Kaufman, 2011; Norman & Skinner, 2006b; Norman,
2011).
Although nurses have much knowledge in general health than the public, eHealth literacy is
also a concern for them. Unlike many younger generations, nurses who did not grow up with
technologies may spend less time exploring online health information and may be less
familiar with search functions. Considering the nurse’s role as an educator for consumers
and the heightened emphasis on evidence-based practice, nurses must be properly prepared
to be eHealth literate.
NURSING INFORMATICS AS A SPECIALTY PROGRAM AT THE GRADUATE LEVEL
The ANA defines Nursing informatics (NI) as:
“a specialty that integrates nursing science, computer science, and information science to
manage and communicate data, information, knowledge and wisdom in nursing practice. NI
supports consumers, patients, nurses, and other providers in their decision-making in all roles
and settings. This support is accomplished through the use of information structures,
information processes, and information technology” (ANA, 2008)
The NI Scope and Standards of Practice clearly differentiate between informatics nurse
specialists (INSs) and informatics nurses (INs). The INSs are those formally prepared at the
graduate level in informatics and INs are generalists who have gained on-the-job training in
the field but do not have the educational preparation at the graduate level in an informatics-
related area (ANA, 2008). With the national emphasis on HIT education, various types of
informatics-related educational programs are available at the graduate level, such as nursing
informatics, healthcare informatics, bio-medical informatics, etc. Most informatics
educational programs are moving toward online programs and/or hybrid (mainly online with
some face-to-face classes) programs.
The curriculum and credits vary a great deal depending on the program. The nursing
informatics field also has unique characteristics. For instance, unlike other clinical nurses, the
majority of the colleagues of the INSs are from other disciplines, such as computer science,
information management, business (vendors), or administrators. The roles the INSs assume
also vary (Sensmeier, 2007).
In a 2009 Informatics Nurse Impact Survey (N = 432) conducted by the Healthcare
Information and Management Systems Society (HIMSS), participants were asked to indicate
the roles that nurses play with regard to IT (HIMSS, 2009).The findings showed the following
results: user education (93%), system implementation (89%), user support (86%), workflow
analysis (84%), getting buy-in from end users (80%), system design (79%),
selection/placement of devices (70%), quality initiatives (69%), system optimization (62%),
system selection (62%), database management/reporting (53%) (Note: only includes roles
with greater than a 50% response rate).
In a subsequent 2011 Nursing Informatics Workforce Survey (N = 660) (HIMSS, 2011), the
majority of informaticians reported that their primarily work involves the area of systems
implementation (57%) and systems development (53%), followed by Quality initiatives (31%).
Additionally, recent scientific discoveries in biomedical informatics and genomics, as well as
the rapid growth in mHealth and eHealth, have made a significant impact on healthcare
informatics and the roles of nursing informatics specialists. These changes led to the revision
of the ANA’s Nursing Informatics Scope and Standards of practice (ANA, 2014).
The revision also addresses other recent trends in technology, such as knowledge
representation, tools to manage public health concerns, and nanotechnologies. Considering
these varying roles and areas of practice, it is logical that each program may have a different
emphasis or strength. Assurance of quality standards of each program, however, is
particularly concerning considering that there is no regulatory body or specialty organization
that could set standards for educational programs in nursing informatics.
CERTIFICATION IN NURSING INFORMATICS AND RELATED HIT
Currently the American Nurses Credentialing Center (ANCC), an accredited agency, offers
the generalist nursing informatics certification (RN-BC) (ANCC, 2014b). The minimum
academic degree required to take the examination for this certification is a bachelor’s or
higher degree in nursing or a bachelor’s degree in a relevant field. The test content outline
for the nursing informatics certification examination can be found on ANCC’s Web site
(http:// www.nursecredentialing.org/InformaticsTCOs) (ANCC, 2014c).
The main content as of October 2014 includes:

1. Foundations of Practice (71 items, 47.33%), which includes the Scope and
Standards of Informatics Practice, ethics, privacy and confidentiality, regulation
and policy, management of data, healthcare industry trends, team building,
conflict management, computer science, information science, cognitive science,
nursing science, testing and evaluation methodologies, workflow processing, and
theories that support the NI practice.
2. System Design Life Cycle (SDLC) (39 items, 26.00%) which includes the phases
and tasks contained within the SDLC process along with the NI leadership role in
managing the process.
3. Data Management and Healthcare Technology (40 items, 26.67%), which includes
the current evidence about data to knowledge, data mining, and management. As
discussed previously, nursing informaticians’ primary responsibilities vary a great
deal and their work environments also differ (e.g., hospitals, vendors, consulting
firms).

Each job or setting may require a different certificate, such as project manager, information
administrator. Based on the 2011 HIMSS Nursing Informatics Workforce Survey, 19% of the
respondents reported having a certificate in nursing informatics offered through the ANCC
(HIMSS, 2011). Many survey participants reported having a certificate(s) in other areas such
as Certified Professional in Healthcare Information & Management System (CPHIMS)
offered by HIMSS (HIMSS, n.d.).
INFORMATICS COMPETENCIES FOR FACULTY MEMBERS
In the past few years, there have been significant changes in nursing education. (AACN,
2008, 2011). Informatics competency has been addressed as a vital component in those
changes. IOM’s Future of Nursing report also emphasized that efficient management of data
and a robust informatics infrastructure are components in transforming the nursing
profession (IOM, 2010).
Additionally, the current emphasis on meaningful use of EHR demands that nurses be
competent in managing health data and information. These changes also require nursing
faculty member be competent in healthcare informatics. The majority of current nursing
faculty members also face challenge in a way instruction is delivered. Previously, most
nursing education was delivered via classroom face-to-face settings. However, with the
exponentially growing information communication technologies, more instruction is being
delivered using online format.
Current popularity with social networking programs has added additional complexity to the
current online learning environment. To address these pressing needs, the National League
for Nursing Issues call for Faculty Development and Curricular Initiatives in Informatics
(National League for Nursing, 2008) The RWJ also supported QSEN Phase IV specifically
focusing on the goal of building capacity for nursing faculty members who are competent in
the six QSEN competencies and to serve as peer mentor for other faculty members (QSEN,
2012). The AACN also plays a major role in building this capacity. For example, in 2012,
AACN sponsored the QSEN Nursing Informatics Deep Dive Workshop (DDW) in San
Francisco Bay Area to build develop, pilot, and evaluate a curriculum to improve the
informatics knowledge and competencies of nursing faculty and health system educators
who provide informatics training (AACN, 2012). All materials are available for use in the
classroom through the QSEN Web site.
Simulation-Based Learning
Use of high-fidelity simulation has become the gold standard in current nursing education
(Burns, O’Donnell, & Artman, 2010; Schiavenato, 2009). The purpose of simulation in clinical
settings is to replicate the important aspects of a clinical situation where students or
clinicians can work to gain knowledge and experience (Jeffries & Rogers, 2007; Nehring,
2009). Most nursing schools have multiple high-tech simulation labs including high fidelity
simulators. Those labs provide students with various simulated clinical settings. For instance,
the University Of Maryland School Of Nursing has an entire simulated hospital in its school
consisting of 24 labs including an operating suite, a community/home healthcare lab, and a
diagnostic laboratory.
To augment the simulation environment, some schools use an academic version of the EHR
system (AllBusiness.com, 2009; Borycki et al., 2009; Joe et al., 2009; Otto & Kushniruk,
2009). Implementing the EHR in simulation labs allows students to have an opportunity to
develop competencies in using HIT before they go into the clinical setting. In addition, most
EHRs have decision support systems which could significantly augment students’ learning.
When schools implement these academic EHR systems, they must have a thorough plan and
a multitude of resources. For instance, the school must have network infrastructures that
can support the program, and have a designated project manager who is familiar with system
deployment.
There will be a great deal of work in developing use cases and building tables in the system,
which also requires the clinical faculty members’ participation. It will be necessary to
educate faculty members about the system since they must be competent to teach classes
using the EHR. Policies and procedures for using the system within the lab must be
developed and clearly communicated to the students before the system is deployed. The
project manager must also consider various human factors and ergonomic issues, as well as
system characteristics (Cacciabue & Cacciabue, 2004; Nielsen, 1993).
Inter-disciplinary Collaboration
As emphasized by the NIH Roadmap initiative, the advancement of science can be made
more effective by combining inter-disciplinary knowledge and skills (National Institutes of
Health -Office of Portfolio Analysis and Strategic Initiatives, 2006). The recent NIH Clinical
Translational Science Awards (CTSAs) have stimulated collaboration among disciplines and
impacted both the clinicians’ and researchers’ paradigm in approaching research, practice,
and education. Most of the changes have been mainly addressed in research and science
fields thus far (Chesla, 2008; Sampselle, Pienta, & Markel, 2010; Woods & Magyary, 2010).
However, nursing education must embrace this initiative and prepare both our students and
clinicians. One example of an approach could involve EHRs. EHRs can be an excellent
communication and collaboration tool among inter-professional care providers in healthcare
settings. Class projects and papers that incorporate data and information from EHRs can
provide students the opportunity to exercise skill sets required for inter-disciplinary
collaboration which is an important competency within informatics. When a HIT system is
implemented in a hospital setting, various professionals (e.g., IT professionals, clinicians,
administrators, vendors, lawyers) have to work together as a team for a prolonged period,
and the system often affects many departments and professionals concurrently. Upon the
completion of system deployment, the systems will continue to require management and
upgrades. Learning about inter-disciplinary collaboration is critical in nursing education, and
is becoming more important as technology becomes more advanced and as healthcare
becomes more complex.
Informatics Competencies for Faculty Members
Innovative technologies in teaching and learning can produce optimal outcomes only when
the instructors are competent in using those technologies. Previously we discussed the
essential educational components needed to ensure nursing students’ and practicing nurses’
competencies in using healthcare information technologies and managing information.
Current students who grow up with technologies often outpace their faculty members in
using technologies (Curran, Sheets, Kirkpatrick, & Bauldoff, 2007). When faculty members
need to teach online class, they also have to learn about not only using technology but also
re-orient themselves to a whole new way of teaching the content. For instance, the way that
online students respond may be different from the students who take face-to-face classes.
Faculty members must be properly supported to fully adopt the newest technologies
(Griffin-Sobel et al., 2010). Some continuing education modalities for faculty members
include half-day workshops, short refresher courses before the beginning of each semester,
or online self-learning modules. If the school offers many online classes, a sufficient number
of instructional design specialists should be a part of the staff. Faculty members who teach
informatics must have a specific expertise in the field. With the heightened awareness of IT
in healthcare technologies and the revised essentials for the baccalaureate and the DNP
curriculums, increasing numbers of informatics classes are being required as core courses in
nursing programs. The AACN’s decision to migrate the ANP programs to the DNP level
further accelerates this need. However, there is a significant shortage of faculty members
who have an expertise in healthcare informatics and who can teach students. More
doctorally prepared informatics faculty members with a proper education/training are
needed in NI education.

M2 The TIGER Initiative

THE DECADE OF HEALTHCARE TECHNOLOGY (2004)

National HIT Agenda
In early 2004, U.S. President George W. Bush declared the Decade for Health Information
Technology and created the Office of the National Coordinator of Health Information
Technology. In May 2004, Secretary of Health and Human Services, Tommy Thompson,
appointed Dr. David Brailer as the first National Health Information Technology
Coordinator. This was an exciting time for health professions committed to the
transformational role health information could play in substantial improvements in safety,
efficiency, and other health reform efforts. In July 2004, Brailer convened the first national
health information technology summit in Washington, DC, and launched the strategy to give
U.S. citizens the benefits of an electronic health record within a 10-year timeframe.
Where Is Nursing?
A very important observation was made at this first Office of the National Coordinator
(ONC) event. The nation’s 3 million nurses who comprise up to 55% of the workforce were
not represented and/or clearly identified as an important integral part of achieving the ONC
vision and strategy. It left many begging the question, “Where is nursing?” There was also a
keen awareness that without nursing engagement not only was the National HIT Agenda at
risk, but nursing would be at risk by not acting on a wonderful opportunity to significantly
advance the agenda to transform practice and education with evidence and informatics. In
his books, Leading Change (Kotter, 1996) and A sense of urgency (Kotter, 2008), the author
describes the impact that having a true sense of urgency can have on large-scale effective
change. When the sense of urgency is as high as possible and among as many people as
possible, the greater the successes of leading transformational change efforts will be.
Leaders in nursing realized the sense of urgency to begin a grassroots effort following this
initial HIT summit and moved to birth a movement that would assure nursing was at the
table and were key stakeholders/advocates as health information technologies were
integrated into the nation’s healthcare delivery systems and academic programs.
THE BIRTH OF THE TIGER INITIATIVE (2005)
Challenges and Opportunities Facing Nursing
The grassroots leadership efforts began to take action and network with others to determine
first steps and gather key individuals to attend the first TIGER meeting. The first official
TIGER gathering was held on January 14, 2005, hosted by Johns Hopkins University School
of Nursing. A diverse group of nursing leaders across the country engaged in conversation
about the skills and knowledge needed by the healthcare provider/nurse in the twenty-first
Century.
Trends and patterns on topics such as basic skills, critical thinking, change management,
evidence-based practice, knowledge-workers, curriculum integration, professional practice,
inter-disciplinary collaborative practice, leadership, global military systems, national
standards, clinical documentation, public policy, and more emerged as current challenges
and opportunities facing nurses during this informatics revolution.
It was identified that the opportunity was more than just tackling “informatics”—the focus
needed to be more on quality care and evidence-based care. There was a unique window of
opportunity for TIGER to build on the successes of informatics and to connect more key
stakeholders in an effort to move a bigger whole forward in guiding true transformation.
Lastly, TIGER needed to tap the power of the 3 million nurses in the workforce by finding
ways of getting many of them engaged to move the TIGER agenda forward. It was decided,
at that time, to hold an invitational summit in an effort to bring together a diverse group of
stakeholders (professional organizations, governmental organizations, technology vendors,
informatics specialists, etc.) to further advance the sense of urgency and action needed to
assure that nurses were able to provide safe, efficient, and patient-centered care to all.
At that time, questions were raised concerning whether or not the summit should include all
disciplines to help meet the IOM aims and competencies. While this was recognized as being
very important, there was consensus that it was critical to begin with moving the nursing
workforce forward first and then to expand out as recommendations were made from the
summit.
Setting the Vision for TIGER
The following vision statement and expected outcomes were developed to guide the early
stages of the TIGER Initiative:
TIGER Vision

• Allow informatics tools, principles, theories, and practices to be used by nurses to

make healthcare safer, effective, efficient, patient-centered, timely, and equitable.
• Interweave enabling technologies transparently into nursing practice and
education, making information technology the stethoscope for the twenty-first
century.

TIGER Expected Outcomes

• Publish a Summit report, including Summit findings and exemplars of excellence.

• Establish guidelines for organizations to follow as they integrate informatics
knowledge, skills, and abilities into academic and practice settings.
• Set an agenda whereby the nursing organizations specify what they plan to do to
bridge the quality chasm via information technology strategies.

THE TIGER SUMMT (2006)

The Invitational Summit
To prepare for the invitational summit, a program committee was formed that planned for
over a year for the event. A fundraising committee was also formed to secure funds to
support the TIGER Summit and expected outcomes. Over 25 diverse sponsors made
contributions to the summit and grants were received from the Agency for Healthcare
Research and Quality (AHRQ), Robert Wood Johnson Foundation (RWJF), and the National
Library of Medicine (NLM). The invitational summit was held at the end of October in 2006
and was hosted by the Uniformed Services University of the Health Sciences in Bethesda,
MD. Over 100 leaders from the nation’s nursing administration, practice, education,
informatics, technology organizations, governmental agencies, and other key stakeholders
participated in the very interactive two-day summit.
External facilitators from Bonfire Communications created an open-space experience that
included small and large group dialogs; unique graphic art to capture the vision, outcomes of
the dialogs and action plans; and the use of an audience response system (ARS) to capture
current realities as well as gain consensus. To stimulate imagination and thinking, a Gallery
Walk experience was done on Day One in which participants were able to “walk through”
and review cuttingedge technology and clinical decision support systems being utilized in
healthcare environments today. The TIGER Executive and Program Committee felt that it
was important to build on some national exemplars in practice and education today. A total
of seven national exemplars were shared with time for questions and answers from
participants.
10-Year Vision and Three-Year Action Steps
The entire summit was focused on creating movement toward consensus on a 10-year
vision and a three-year action plan. The 10-year vision was more clearly evolved by doing
collective work around seven pillars and then content streaming the patterns and most
salient points. With the seven pillars and rich content as its framework, a three-year action
plan was identified to achieve the 10-year vision of evidence and informatics transforming
practice and education. This required intense group work and collaboration amongst the
participants.
The last Call for Action before participants left the summit was for each leader of a
participating organization to identify definable action plan goals that they could take back to
their organization. Each participant signed the “TIGER Commitment Wall” to show their
commitment to the TIGER Vision and Action Plans as well as to continue to promote and
engage others in the TIGER Initiative. Following the TIGER Summit a Web site was
established to record the several events and actions to the TIGER Summit as well as to post
new information.
In addition, the summit report Evidence and Informatics Transforming Nursing: 3-Year
Action Steps toward a 10-Year Vision (2007) was developed and widely distributed via a
published report as well as via a pdf download from the Web site (Technology Informatics
Guiding Education Reform, 2007). The report provided a summary of the summit as well as
recommendations for specific stakeholder groups: Professional Nursing Organizations,
Academic Institutions, Information Technology, Government and Policy Makers, Healthcare
Delivery Organizations, Health Information Management Professionals/Health Science
Libraries. Leaders from five major nursing organizations including the American Colleges of
Nursing, American Nurses Association, American Organization of Nurse Executives, National
League for Nursing, and Sigma Theta Tau International affirmed their commitment and need
for the profession to continue to support the TIGER Initiative.
THE TIGER COLLABORATIVE WORKGROUPS (2007–2008)
Several months after the summit, and after several follow-up meetings with the TIGER
Executive Steering Committee, it was decided to move into phase II of TIGER. Building off
the summit pillar and action plans, nine key collaboratives were identified to dig deeper and
tap a broader engagement from the nursing community to address the recommendations
made at the summit. Each collaborative was assigned co-leaders to facilitate the workgroup
as well as write a final report and share the workgroup final findings and recommendations.
THE TIGER INITIATIVE TODAY (2009–2014)
The TIGER Initiative Foundation
The past five years have continued to demonstrate continuous momentum toward the 10-
year vision. The years 2009–2010 kept critical TIGER leader volunteers busy with sharing
the collaborative reports as well as seeking new opportunities for further TIGER
engagements with key stakeholder, nursing, and other inter-disciplinary professional
organizations. During this time the foundation was being laid for building out a Virtual
Learning Environment (VLE) including collaborating partners such as the National Library of
Medicine and the Uniform Services University of the Health Sciences.
In July 2011, the TIGER Initiative Foundation was formed as a 501(c) (3) organization
operating for charitable, educational, and scientific purposes. This was a significant
milestone for TIGER as it provided a structure to strategically grow TIGER including having a
dedicated Senior Director and full Board of Directors. A new TIGER Web site, www.
thetigerinitiative.org, was established that has been a central hub for connecting TIGERs and
sharing the many TIGER activities that occur with the more than 1500 volunteers that have
been engaged with the TIGER Initiative. Refreshed TIGER Vision and Mission The first
priority of the new Board of Directors was to re-evaluate the TIGER vision and mission.
The new TIGER Vision is to enable nurses and interprofessional colleagues to use
informatics and emerging technologies to make healthcare safer, more effective, efficient,
patient-centered, timely and equitable by interweaving evidence and technology seamlessly
into practice, education and research fostering a learning healthcare system and the new
TIGER Mission statement is Advancing the integration of health informatics to transform
practice, education and consumer engagement. The board also focused on a strategic
priority to launch the TIGER VLE.
Committees were also formed to focus on Education, Foundation Development, and Inter-
disciplinary & Consumer Engagement. Virtual Learning Environment (VLE) In February 2012,
the TIGER Initiative Foundation VLE was officially launched. The VLE provides an interactive
Web-based learning opportunity which includes information about HIT and related topics
for healthcare professionals and consumers (Schlak, 2013). The Web-based format provides
dynamic and real-time information on topics such as electronic health records, usability,
clinical decision support, health information exchange, care coordination, meaningful use,
standards and interoperability, consumer health information, mobile health, privacy and
security, health IT and nursing practice, and many other related topics. It also provides the
opportunity for sponsors to share their contributions of integrating health informatics to
transform practice, education, and consumer engagement via white papers, demonstrations,
videos, and other educational assets.
The VLE enables users to download information into a virtual briefcase as well as utilize
social media and chat rooms to engage with other TIGERs. Currently there are over 400
individuals across multiple countries that have active TIGER VLE memberships and two
universities are using the VLE to augment classroom curriculum. There is great opportunity
for interprofessional teams in practice and academia to leverage the TIGER VLE to learn and
develop knowledge and skills regarding technology and informatics to better integrate into
their daily work. A good case has been made for why faculty need access to the VLE (Skiba,
2013) with examples of how to find valuable resources and ways to engage with students
using the Web-based platform.
A new component being added to the Faculty Development Learning Community is a series
of curriculum guides (Skiba, 2013) that tie Outcome Competencies, Content, Learning
Activities/Resources, and Teaching Strategies for specific topics such as Use of Technology
to Support Safety and Quality Care Delivery, Clinical Decisionmaking, Communication and
documentation of interprofessional care, and Consumer Engagement. The last one is related
to Involvement with Systems Development Life Cycle. All of the curriculum guides are
crosswalked to the AACN’s Essentials of Baccalaureate Education for Professional Nursing,
TIGER Competencies, QSEN, and the Canadian’s Nursing Informatics Entry-into-Practice
Competencies for Registered Nurses. The TIGER VLE can be accessed via the Web site
www.thetigerinitiative. com to become a member and get access to the plethora of great
learning materials and interactive learning venues.
International and Interprofessional
Expansion Two strategic priorities the TIGER Initiative Foundation is focused on for the next
few years is in increasing the TIGER vision/mission across international borders and to
engage interprofessional colleagues in education and practice. The first step at international
expansion was at the NI2012 Conference in Montreal, Canada, where the International
Committee was officially launched with five countries including Brazil, United Kingdom,
Taiwan, Germany, and Canada.
The TIGER International Committee led a TIGER session at MedInfo 2013 in Copenhagen
which generated much interest from other countries to become engaged. Recently 28 new
countries have been invited to join the TIGER International Committee to share learning
needs, synergies and engage in the VLE. There is a growing momentum in healthcare today
on creating true interprofessional education and practice environments (Christopherson &
Troseth, 2013) and it is critical that leaders in informatics to be aware of this momentum.
The TIGER Initiative Foundation has committed to transitioning to an Interprofessional
Board of Directors in the future and to include other healthcare professions in TIGER
activities and the TIGER VLE learning environment.
The Leadership Imperative Report
At the writing of this chapter, The TIGER Initiative Foundation is preparing to launch
another Collaborative Report. It was recognized at the TIGER Summit the significance of
leadership to be engaged and support the vision and mission of TIGER which resulted in the
TIGER Revolutionary Leadership Report. The new leadership collaborative report The
Leadership Imperative: TIGER’s Recommendations for Integrating Technology to Transform
Practice and Education (2014) resulted from the continued recognition of how critical
leadership is to fulfill the TIGER vision and mission and to lead the way by providing
transformational leadership that drives and executes the transformation of healthcare
(Technology Informatics Guiding Education Reform, 2014). The report addresses the need to
focus on both practice and technology as well as provides valuable information, tools, and
resources for leaders to access and utilize as they integrate technology into practice and
education. The report will be launched at the TIGER Institute at HIMSS 2014 and will be
available on the TIGER Web site.
ONCE A TIGER ALWAYS A TIGER
The sign of significant changes to come was palpable back in 2004 as our nation began to
address healthcare reform by announcing this would be the decade for healthcare
technology. A great sense of urgency to set a vision and course of action for nurses to lead
and, in turn, engage all nurses was the beginning of Technology Informatics Guiding
Education Reform; The TIGER acronym was perfect as hundreds of nurses launched into
action. The grass roots effort took root and emerged into an innovative social disruption that
continues to grow. Many TIGERs have shared that the sense of collaboration and teamwork
has been an amazing experience. The number of volunteer hours has been simply
astounding! Today TIGER has also expanded its presence on social media with a TIGER
Facebook and TIGER Twitter@AboutTIGER.
The timing of TIGER is even more significant now with the passing of the 2009 American
Recovery and Reinvestment Act (ARRA) and the phased mandate for “Meaningful Use” of
the electronic health records. The development of the TIGER Initiative Foundation has
provided a solid home for TIGER that has resulted in the launching of an exciting TIGER VLE
that helps provide tools and resources that are support many of the ANA Certification topics
such as human factors, information technology, information management, professional
practice, models and theories, and management and leadership. Expanding TIGER beyond
international boundaries and interprofessional silos will also help spread the vision and take
the actions necessary to integrate evidence and technology informatics into our daily work
to make healthcare safer, effective, efficient, patient-centered, timely, and equitable.

M3 Initiation and Management of

Accessible, Effective Online Learning
Initiation and Management of
Accessible, Effective Online Learning
THE HISTORICAL EVOLUTION
This type of education has always experienced bumps and surges of acceptance. Even the
term distance education denotes remoteness or isolation to call attention to the differences
from the traditional classroom education. While distance education has been available in the
United States since before the turn of the nineteenth century, schools and educators have
often required a reason to develop and conduct education for students beyond the
traditional classroom setting. Initial development centered primarily on vocational training.
Historically, educational regulatory agencies have not been very supportive; approval for
off-campus or extension sites was needed when the sites were separated from the
originating school or when geographical barriers existed, even when the same faculty were
teaching both types of courses. Some states even defined the number of miles for approval.
Another approach to distance education, depending on the school’s technological resources,
could also mean that the faculty drove “the distance” to the off-campus sites, then provided
face-to-face (F2F) instruction.
Use of Technology
The advent of print, audio, television, and the computer has assisted distance education
strategies, and eventually led to online learning. In the United States, the distance education
movement began with the Boston-based Society to Encourage Studies at Home in 1873,
followed in 1885 by the University of Wisconsin developing “short courses” and Farmer’s
Institutes. By 1920, a Pennsylvania commercial school for correspondence studies had
enrollments of more than 2,000,000. Unfortunately, dropout rates averaged around 65%. In
1919, radio was the first technology used for distance education, later followed by
telephone service. Wisconsin again became a pioneer by using audio conferencing
equipment with telephone handsets, speaker phones, and an audio bridge to connect
multiple phone lines for the first two-way interactive distance education for physicians and
nurses (Armstrong, 2003; Schlosser & Anderson, 1994).
Next came television, so that complex and abstract concepts could be illustrated through
motion and visual simulation. Satellite technology for distance education in the United
States was implemented in the early 1980s. As these methodologies grew in sophistication
and complexity, distance education students began to experience greater transparency of
the technology, which enhanced the educational experience. Computer technology came
slowly to the forefront of distance education with computer-based education (CBE),
computer-assisted instruction (CAI), and computermanaged instruction, and then its use
exploded. Yet, it has been the combination of the various interactive Webbased
technologies that have really provided the force for creative educational strategies, as well
as innovative ideas from faculty that have provided the momentum and impact of online
education.
EXAMINING TECHNOLOGIES USED IN ONLINE LEARNING
A number of technologies are employed in the delivery of online learning, yet not all online
programs use all of the technologies described.
Learning Management Systems
A Learning Management System (LMS) is a software product that was first designed for
corporate and government training divisions as a tool to assess workers’ skills for job
positions, and then provide specific training, either individually or in groups. Learning
management systems are also commonly used for K–12 education and the higher education
level to track student achievement in outcomesbased educational programs (Waterhouse,
2005). Another term for LMS that is used more frequently in academic settings is Course
Management System (e.g., Blackboard and Desire2Learn). They provide the same
functionality as an LMS. The general functions for LMS software includes distribution of
course content, communication among the users, interaction with course resources, testing,
grading, and tracking records. LMS becomes significantly more powerful by incorporating
third-party applications such as Turnitin, Respondus, Lockdown Browser, and provides an
array of sophisticated features.
Content Management Systems
A content management system is a database of learning objects, which may include many
items developed for instructional use. A content management system allows course
developers to develop learning objects such as videos, modules, assessments, or any other
materials used for online learning. It provides version tracking so that changes to these
learning objects can be implemented without losing previous versions of the items. Another
benefit to such systems is the ability of developers to share learning objects. They can be
used as previously developed or modified to fit the need of the current course. Finally,
content management systems are designed to integrate with course management systems.
This allows the development of materials to take place outside the course itself. Then,
building the course becomes as simple as selecting learning objects and placing them into
the course. Course management systems such as Blackboard offer a content management
system that is designed to fully integrate with their system.
Emergence of Massive Open Online Courses
A massive open online course (MOOC) is a model for delivering free learning content. Many
MOOCs do not require pre-requisites other than Internet access and interest. Recently,
MOOCs are beginning to offer academic credit. The concept of MOOCs originated in 2008
among the open educational resources (OER) movement. MOOCs provide participants with
course materials that are normally used in a conventional education setting—such as
examples, lectures, videos, study materials, and problem sets. MOOCs are typically provided
by higher education institutions, often in partnership with “organizers” such as Coursera,
edX, and Udacity, though some MOOCs are being offered directly by a college or university.
MOBILE COMPUTING
The rapid changes in new technologies and access to content anywhere and anytime allow
learners to experience learning in a variety of settings and not just in schools (Prensky,
2004). Mobile computing devices are playing an increasingly important role in our personal,
professional, and educational life. There are many different mobile devices including
personal digital assistants (PDAs), smart phones, tablet PCs, and laptop computers. The
recent advances in mobile devices make online learning possible through the powerful
computing capability built into their conveniently small sizes, Internet connectivity, and the
availability of many types of mobile software applications (apps) (Johnson, Levine, Smith, &
Stone, 2010). Because of the mobility and strong Internet connectivity, learning becomes
ubiquitous and seamless (Liu, Tan, & Chu, 2009). Learners who are taking online courses can
use mobile devices anywhere to access the course content, complete learning activities,
communicate with classmates, and work on group projects.
Mobile devices become usable and functional enough to produce an impact on the
education software industry, including LMS software. The number of applications for mobile
devices has increased dramatically. For example, Google Docs for mobile allows accessing,
editing, and sharing documents. Books have also gone digital and for many people e-books
are now more desirable than books. Readers have the freedom to read e-books using e-
raiders like Kindle or Nook, tablets, and smart phones. Although the integration of functional
mobile computing devices is no longer the real challenge, the focus becomes mainly on how
this technology should be used to fulfil the core mission of learning (Cain, Bird, & Jones,
2008). Swan, Hooft, and Kratcoski (2005) found that the effective use of the mobile device
increases the quality and quantity of student work.
FACULTY SUPPORT
With the number of online courses increasing, the American Association of State Colleges
and Universities emphasizes the critical need for faculty well experienced in teaching online
(Orr, Williams, & Pennington, 2009). In order to assist in successful online education, faculty
must receive appropriate support, technical expertise, and online infrastructure. The role of
the online instructor has developed into that of a facilitator rather than a knowledge
distributor. This is achieved by monitoring and guiding students to learn critical concepts,
principles, and to develop skills, rather than just lecture material (Easton, 2003).
Faculty Development
Faculty development is a critical component to the success of any online education,
especially as colleges and universities are using numerous Adjunct Faculty to assist with the
increased student enrollments and teaching responsibilities (Allen, Arnold, & Armstrong,
2006). Academic institutions are taking a proactive approach to faculty support. Numerous
workshops and one-to-one support in course development and technical issues are the most
common types of training faculty receive. The faculty development activities are designed to
assist and improve faculty teaching at all levels of the educational programs. Workshops,
seminars, Webinars, and peer coaching are among services available for faculty
development. The focus of these services should not be limited to technical skills
development, but must include pedagogical issues. For example, strategies to create active
learning activities, engage online learners, or motivate online students are topics that, if
explored in depth, would help faculty be more effective online teachers (Lahaie, 2007).
Disaggregated Faculty According to Allen, Keough, and Armstrong (2013) a new
disaggregated model for faculty content delivery has emerged and is designed for
consistency of content delivery as programs respond to large numbers of students. This
model segregates design, teaching, and assessment of student learning into a team approach
to course delivery (Rosenbloom, 2011). Robison (2013) indicates the disaggregated model
helps build a network of student support while the student is learning. This model also
provides access to a variety of perspectives due to the availability of different faculty in
areas of knowledge providing learning enhancement (Robison, 2013).
Support for Course Development
Developing and delivering an effective online course requires pedagogical and technological
expertise. Instructors new to online teaching are not likely to have such skills. An example
used at our university is the Jumpstart Program. Hixon (2007) defined Jumpstart as a series
of workshops that may take more than a week. These workshops include a team of support
professionals, including instructional designers, librarians, and media production specialists,
who help faculty increase their knowledge, productivity, and teaching experience with
technology. Evaluation findings document that this Jumpstart program significantly
influences the faculty members in their online course development process. Allen, Bakrim,
Lacy, Boyd, and Armstrong (2006) note that online course development requires a team
involving instructional designers, technical support staff, and content experts.
The content expert offers an outline of topics that should be covered. The instructional
designer provides help in course structure organization and functionality, and the technical
support provides assistance with integration of technology tools. This model of team course
development is common in most non-academic settings and has been adopted by a number
of academic organizations. However, course development carried out by the instructors who
will be teaching the course is still a common practice in many colleges and universities that
offer online learning. Technological tools for online learning are constantly being developed
and improved, with the aim to make online learning more interesting and more effective
(Moar, 2003). Regardless of faculty teaching experience, technology support is critical in
online teaching. Appropriate training on using new technologies, routine technical support,
and instructional guidance are the common support that faculty receive (Gopalakrishnan,
2006).
Faculty Workload
Faculty workload refers to the number of courses taught by an instructor (Boyer, Butner, &
Smith, 2007). The allocation of faculty time in Higher Education usually includes teaching,
scholarship activities, and community service. Because teaching online is thought to require
more time and effort compared with traditional face-to-face teaching, workload adjustment
is usually used by institutions to promote faculty involvement in non-teaching activities.
Actual research into the assumption of increased development time has been limited.
Freeman’s (2008) research findings suggest that the time spent with online course
development seems to be proportional to classroom teaching. As with traditional classroom
development, usually the extra time devoted to making the course effective and applicable
then produces a significant reduction of faculty time after first-time delivery.
Freeman (2008) offers four Lessons for Distance Education Administration:

1. “Make sure faculty understand that they are starting something new.”
2. “Teach your faculty to think about their course in a different way, to be ready to
do things differently.”
3. “Use your instructional designers. As the faculty member is developing the course
with the instructional designer, the designer should be on the lookout for time-
consuming approaches.”
4. “The more an administrator knows about the process of course development, the
better he/she can manage [the faculty workload issue].” (para. 9)

COURSE DEVELOPMENT
The use of the Web for courses can be divided into three categories: hybrid courses, Web-
enhanced face-to-face courses, and fully online courses. The selection of approach depends
on the needs of the organization, the nature of the content.
Learner Assessment in Online Courses
Assessment is an important aspect in the learning process. Assessment is defined as a means
to test and evaluate student performance and ensure that students meet the outcomes
designed for the course (Waterhouse, 2005). The assessment may take different forms, such
as:
 • Online quizzes and exams.
• Self-assessment: Students assess their own learning as they progress through the
course.
• Online discussion: Students respond to questions, reply to peers messages, and
discuss course materials.
• Papers: Students submit research papers, or essays. Posting papers to the online
discussion forum can spark discussion. Rubrics provide guidelines and a method
for self-evaluation.
• Individual or collaborative projects: Students develop a project individually or as
members of a group by using clear directions and guidelines.
• Presentations: Synchronous communication systems can be used to make
presentations or even have debates. A student can use a whiteboard or show a
Web site they would like everyone to view while holding a live discussion.
• ePortfolio: It is an online application for collecting the student’s work that
demonstrates meaningful documentation of individual abilities. Electronic
portfolios can serve as a means to assess student’s ability over time, and if the
student has met each objective or learning outcome as determined by the
instructor or the academic program.

STUDENT SUPPORT
One of the most critical factors in a student’s success with online learning is student
support. Moore and Kearsley (2005) noted that the absence of student support could
drastically affect student retention, and tends to increase student frustration and feelings of
inadequacy, which in turn leads to the student dropping out of the program. Several
investigators have proposed a wide range of student support services that should help
students be successful. These services include precourse orientation (Nash, 2005), free
tutoring services (Raphael, 2006), and online technical support (Moore & Kearsley, 2002).
These academic services allow students to be familiar with the technology and improve
student-to-instructor and student-to-student communication.
The main goal is to increase students’ ease with the cyber environment and encourage
constant connection with their peers. In addition to academic support, services that focus on
students’ affairs are also important to success and retention. Services such as online library
resources (Gaide, 2004; Raphael, 2006), online advising (Herbert, 2006; Osika, 2006), and a
common course management system (Osika, 2006) could be part of an integrated student
support system aimed at making online learning exciting and successful.
Orientation to the Online Environment
Orientation programs designed to introduce new students to the online environment are
crucial to assure a smooth transition, especially for students without prior experience in
online learning. The goals of orientations and tutorials are to ensure that students are
familiar with the online environment and are aware of expectations. Free tutorials are also
helpful, especially with difficult or challenging tasks such as navigating the Web course
space, using new software packages and/or equipment, or performing technical procedures
(e.g., uploading a file to a Web site).
Communication and Flexibility
There are two basic types of Web-based communication:

• Asynchronous communication tools such as e-mail, discussion boards, and blogs.

Course participants use these tools when they are online; however, the person to
 whom they communicate may not be online. They serve as a messaging interface
between communicators.
• Synchronous communication tools require participants to be online to
communicate at the same time. These tools include chat, whiteboard, desktop
conferencing, and video conferencing such as Skype.

To ensure effective communication, instructors must select the most appropriate tool for
the class. This will depend on accessibility to the technology and the levels of students’ skills.
Communication is strongly affected by course flexibility (due dates and/or assignment
submission). Building flexibility in the course structure allows the faculty to compensate for
unexpected technological problems, as well as provides opportunities to respond to student
feedback.
Accessibility in Online Learning
To avoid creating barriers in online learning, federal and state laws, and local guidelines and
policies for online learning such as Americans with Disabilities Act (ADA) and Rehabilitation
Act, require that the online learning should be accessible to the broadest range of possible
learners. Accessibility of content becomes a legal requirement in many situations. It is
important to present instructional content in a format that accommodates the diverse needs
and learning styles.
Some elements for accessibility include alternative text for images, appropriate color and
contrast, accessible and consistent navigation, closed captioning for audio/video materials.
Accessibility also applies to online testing. Students with disabilities can have many different
types of limitations that affect their abilities to take tests. These individuals who are
protected by disability legislation can ask for alternative format and extra time to take tests.
Students must apply for an “accommodation” through the university’s student services for
accommodations to be made by the school.
LEGAL, ETHICAL, AND COPYRIGHT ISSUES
The faculty is accountable for educational content they teach. However, accountability is
even more at the forefront of education at this time. Eaton (2011) defines accountability as
the “how and the extent to which higher education and accreditation accept responsibility
for the quality and results of their work and are openly responsive to constituents and the
public” (p. 8). The Higher Education Act, reauthorized in 2008, made additional demands on
accreditors to be more accountable and subsequent creation of rules during 2009 and 2010
expanding accountability expectations even more (Eaton, 2011). Legal concerns relate to
established laws associated with telecommunication technologies, whereas ethical concerns
relate to the rights and wrongs stemming from the values and beliefs of the various users of
the distance education system. Three major areas that are of concern regarding legal issues
include copyright protection, interstate commerce, and intellectual property. Privacy,
confidentiality, censorship, freedom of speech, and concern for control of personal
information continue to be as relevant today as in 1998 when Bachman and Panzarine
(1998) identified these cyber ethical issues.
Copyright Protection
Copyright is a category of intellectual property and refers to creations of the mind (World
Intellectual Property Organization, n.d.). According to the World Intellectual Property
Organization (WIPO) Web site (www.wipo.int/ policy/ed/sccr/)
The Standing Committee on Copyright and Related Rights (SCCR) is currently engaged in
discussion of:
 • Limitations and Exceptions
• Broadcasting Organizations

This protection for Copyright is based on the Copyright Act of 1976, and was last amended
November, 1995 (World Intellectual Property Organization, n.d.). Copyright law protects
“works of authorship,” giving developers and publishers the right to control unauthorized
exploitation of their work (Radcliff & Brinson, 1999). Although there have been no new
federal laws since 1976 to address educational multimedia concerns, the Consortium of
College and University Media Centers has published the Fair Use Guidelines for Educational
Multimedia (Dalziel, 1996). When combining content such as text, music, graphics,
illustrations, photographs, and software it is important to avoid copyright infringement
(Radcliff & Brinson, 1999). Additionally, the Digital Millennium Copyright Act was passed in
October 1998. The UCLA Online Institute for Cyberspace Law and Policy lists the highlights
of the Digital Millennium Copyright Act at gseis.ucla.edu/iclp/ dmca1.htm and the U.S.
Copyright Office Summary can be located at www.copyright.gov/legislation/dmca.pdf. As
noted by the dates of citations here, regulations and legislative guidance seem to lag from
the technological changes incorporated within the online educational arena.
Intellectual Property
A common question by faculty is, “Who owns the course?” According to Kranch (2008) there
is a great deal of controversy over who owns academic coursework materials U.S. copyright
law is intended to provide ownership and control of what an individual has produced.
However, its relationship to faculty-produced work is not as clear. Although faculty may
own the materials they have developed for use in their online courses, it is always good to
have a memo of understanding documenting the specific use of the materials as well as the
accrued benefits (Billings & Halstead, 2009).
The issue of “work made for hire” is the point of controversy. According to the 2003 U.S.
Copyright Office document, as indicated by Kranch (2008), a “work made for hire” is defined
in the following ways:

1. A work prepared by an employee within the scope of his or her employment

2. A work specially ordered or commissioned for use as a contribution to a collective
work

The bottom line of this section is that faculty should know their employer’s policy pertaining
to intellectual property rights. Over the last several years, universities, government, and
private organizations have noted the need to clearly delineate their policies in this area. For
example, our school has an established university-wide committee providing advisory
opinions to the Provost on matters related to patentable discoveries and inventions, and/or
copyrightable material, which had been developed by University employees. MIT Open
Courseware (2010) is a free and open digital publication of educational material (http://
ocw.mit.edu/index.htm). However, there are specific guidelines and requirements for the
use of Open Courseware. Although Open Courseware is available to anyone, material used
in education from any Open Courseware participant is consistent with materials from any
university and/or faculty. Additional information on Open Courseware can be found at
http:// ocw.mit.edu/help/.
Extensive resources on intellectual property law and rights can be found at the following
sites:

• Indiana University Information Policy Office (informationpolicy.iu.edu)

 • Office of Technology Transfer and Intellectual Property at Texas Tech University
Copyright (www.ttuhsc.edu/HSC/OP/OP57/op5702.pdf); Intellectual Property
(www.ttuhsc.edu/hsc/op/ op52/op5206.pdf)
• Legislative initiatives regulating intellectual property and copyright are found in
the Technology, Education and Copyright (TEACH) Act (www.arl.
org/pp/ppcopyright/index.shtml)
• The Berkeley Digital Library at Sunsite is an excellent resource for national
perspectives on intellectual property (sunsite.berkeley.edu/ Copyright)
• The Creative Commons Web site (creativecom mons.org/about/what-is-cc) is a
non-profit organization that works to increase the amount of creativity in the
body of work available to the public for free and legal sharing, use, repurposing,
and remixing.

Ethical behavior in the nursing profession has been established by groups such as the
American Nurses Association (ANA) in the Code of Ethics (ANA, 2001) and the American
Association of Colleges of Nursing’s (AACN, 2008) competencies for baccalaureate nursing
education. These nursing values and ethics are fundamental in practice decisions and are just
as applicable in nursing education, whether education be face to face or online. Mpofu (n.d.)
regards ethical considerations in online teaching as performing your work within the context
of professional practice and the confines of institutional regulations. However, over and
above professional and institutional ethics, nurse educators must contend with legal and
ethical issues that take on a new dimension when applied to online education. While issues
such as copyright, privacy, licensing, fair and acceptable use, and plagiarism are certainly not
unique to online education, they assume new dimensions and different proportions. Another
source for consideration with ethics issues can be found in Best Practice Strategies to
Promote Academic Integrity in Online Education (Version 2.0, June 2009)
(wiche.edu/attachment_library/Student_Authentication/ BestPractices.pdf).
EFFECTIVENESS OF ONLINE EDUCATION
Online learning for nursing courses is exploding. Advertisements about “new online
education for working professionals” certainly have appeal, capturing the attention of many
people seeking to fit further education into their busy schedules. Yet, there are still some
traditional students who do not pay attention to online education, there are still some
faculty who avoid the concept by raising questions of quality rather than exploring the
educational principles used in online learning, and there are still some who believe the only
“gold standard” of education continues to be the traditional classroom setting (Allen, Arnold,
& Armstrong, 2006).
Additionally, questions emerge concerning the validity of the courses: Is it really possible to
earn a degree while at home or in the work setting without driving long distances and sitting
in tedious lecture classes? Is the interaction with the faculty equal to the same interaction
that occurs in the classroom? Is this really applicable to clinical nursing? Overall, market-
driven demands of educational reform and creative, visionary faculty have moved online
learning, transforming both academic and continuing nursing education, by capturing new
types of educational experiences and innovative kinds of pedagogy (Allen & Seaman, 2010;
Allen, Arnold, & Armstrong, 2006).
The outcomes have been an empowerment of the nursing student and working professional
to have numerous important educational choices. Now, in addition to quality, the
educational decisions are often based on accessibility and the amount of time needed to
complete the course or program. Online learning offers more alternatives to accommodate
individual circumstances and educational needs. Now, it is becoming a commonly accepted
instructional method in higher education institutions, and the numbers of online courses are
constantly increasing to accommodate the large number of students enrolling. For the past
six years, online enrollment has grown at a greater rate than the total higher education
enrollment (Allen & Seaman, 2010). According to the Sloan Consortium Report (2013),
overall online enrollment increased to 7.1 million in 2013, with the majority of doctoral-
granting universities (80%) offering online courses or programs. In order to purport quality,
educational outcomes must be similar for both the on-campus and online learning students;
countless studies over at least three decades have documented this (Dede, 1990; Mahan &
Armstrong, 2003; Schlosser & Anderson, 1994).
Findings reflect that regardless of the delivery method, online learning students receive the
same grades or do better than those students receiving traditional instruction. Overall,
student evaluations are good to very good following online education activities. In essence,
good online education theory and good education theory are actually the same; the
education just transcends the barriers of time and space.
PROGRAM EVALUATION AND ACCREDITATION
Program evaluation is an ongoing process in online education and requires a framework for
evaluation to be adopted by the faculty, standards, and outcomes to be defined, as well as a
timeline for measurement of outcomes. Program evaluation focuses on review and
improvement. The need for curriculum revision, resources, and faculty and staff may
become apparent during this ongoing review process. Program evaluation allows educators
to facilitate meaningful change, while providing feedback. All program evaluation gathers
evidence for measurement against predetermined outcomes. The framework will provide
the steps to outcome attainment. With systematic program evaluation, revision decisions are
based on the evidence from findings rather than assumptions.
To obtain this evaluative data, program surveys by faculty, students, and administrators
should be completed and analyzed annually. Additionally, course surveys should be
completed by students at the end of each course. Regional accreditation agencies assist in
guiding programs for maintaining standards in program delivery, and regional credentials are
sought after by major colleges and universities. Regional accreditation is a continuous
improvement process involving the entire university or college. Many of the regional
accrediting agencies, such as the Southern Association of Colleges and Schools (SACS),
engage the college or university to pursue a continuous improvement process of self-
evaluation, reflection, and improvement for not only face-to-face learning but distance
learning as well (Southern Association of Colleges and Schools, 2010).
Other regional accrediting agencies providing excellent resources for online program
assessment and evaluation include Western Interstate Commission on Higher Education
(WICHE) and WICHE Cooperative for Educational Technologies (WCET), a division of
WICHE, providing good practices and policies to ensure the effective adoption and
appropriate use of technologies in teaching and learning online (wcet.wiche. edu/advance).
Accreditation agencies require that each facet of the online program be critically and
logically appraised to reflect the quality of the programmatic goals and outcomes designated
within the program. There is no one type of accreditation applied to online education. In
fact, there are several types of accreditations for different institutional statuses, and they
are categorized into regional, national, and professional accreditations (see Table 44.3).
STANDARDS FOR QUALITY IN ONLINE EDUCATION
To ensure the quality of online education, various organizations (Table 44.4) have recently
developed standards for this type of education. The main purpose of these standards is to
guide the development and evaluation of online learning programs offered through colleges
and universities.
FUTURE TRENDS
The future trends in online learning will be defined by student empowerment and
technological advancements. The population and student enrollments have grown
extensively during the last six years (Allen & Seaman, 2010) and it is anticipated that the
field of online education will witness a tremendous growth both in terms of quantity as well
as quality.
For example, Hodgins (2007) predicts that learning content will be customized for each
learner, rather than mass produced. In the future, data analytics will be used to identify
individual student learning needs and the role of faculty as mentors will be strengthened
(Johnson et al., 2013). Huge data sets will allow advisors to see academic risks in real time
and intervene with the student. By focusing on processes of actual cognitive development
Stanford University is researching new forms of assessment in order to measure twenty-first
century skills (Skiba, 2013). Additionally, immersive virtual learning environments tailored to
the learner’s desired competency set will emerge. Here the student will enter an immersive
virtual environment which transcend real world time and there be paired with virtual
teammates designed to enable the student to meet identified competencies (Dede, 2013).
The next apparent trend changing online learning is the advancement of technologies.
Gaming, learning analytics, and mobile applications are now the norm as well as tablet
computing and use of ebooks (Skiba, 2013). We now expect are tools to have geo-
everything and gesturebased computing through a tap or a swipe, but the future may bring
technology that allows computing through subtle body gestures with wearable computing
(Skiba, 2013). Along with the wearable technology, 3D printing will become commonplace
(Hidalgo, 2013). Futurists have been predicting the rise of the ubiquitous computing device
for years (Bull & Garofalo, 2006; Swan, Van ‘T Hooft, Kratcoski, & Schenker, 2007; Weiser,
1991). A ubiquitous device is one to which users have become so accustomed, they no
longer notice the device itself when they are using it. Instead, users tend to focus on what
they get from the device. One example of this in our life is the refrigerator.
We may open the door of the refrigerator, but often are thinking of the food we get from
the device, rather than the device itself. Some authors go even farther, defining the
ubiquitous device as a single device or service that takes care of all of our computing needs
(Pendyala & Shim, 2009). These computing devices will continue to be part of an exciting
new world for online learning opportunities. The 2013 Horizon Report by the New Media
Consortium described six technologies that universities will likely mainstream within the
next five years. One of these technologies is gesture-based computing, which is also called
Gesture Recognition. This refers to technology that recognizes and interprets the motions
and movements of its users. Instead of using the mouse or keyboard, the users employ
natural body movements to control the device, such as shaking, rotating, tilting, touching, or
moving the device in space. It is expected that in four to five years this type of technology
will emerge in educational settings and have a considerable impact on teaching and learning
(www.nmc.org/horizon (Links to an external site.)).
There will be more technologies that offer live interactive instruction. With all the growth in
online education, the need for effective course management systems will be ever more
crucial. Furthermore, technological advancements will also increase the need for developing
effective teaching strategies that exploit the capabilities of technology. Massively Open
Online Courses (MOOCs) will continue to explode as noted in the latest NMC Horizon
Report (Johnson et al., 2013).
And the movement on the horizon is for MOOCs to determine mechanisms for awarding
credit (Kolowich, 2013). Skiba (2014) recently noted students of the future will use mobile
devices more, but will also still value a mix of online and face-to-face learning environments
and although technology will enhance achievement of their learning goals students will
continue to value privacy. There is a limit to connectivity and students will continue to keep
academic and social lives in separate silos (Skiba, 2014).

M4 Social Media in the Connected

Age: Impact on Healthcare Education
and Practice

INTRODUCTION
The Internet has revolutionized the computer and communications world like nothing
before. The Internet is at once a world-wide broadcasting capability, a mechanism for
information dissemination, and a medium for collaboration and interaction between
individuals and their computers without regard for geographic location (Leiner et al., 1997, p.
102). There is no doubt the Internet provided the necessary infrastructure to revolutionize
the way scientists and researchers from the worlds of academia, business, and government
could share data, interact, and collaborate with each other. But it was not until the
introduction of the World Wide Web that “everyday people” without computer
programming skills were enabled to reap the benefits of this revolution.

The Web not only changed how governments and businesses operate, it has impacted every
facet of society—how we work, learn, play, and now, even how we manage our health. In
this chapter, there is a brief history of the evolution of the Internet to the Web and now to
the Connected Age. There is a specific focus on the use of social media digital tools, and its
impact on healthcare and education. This is particularly true as we evolve from the Web 2.0
era to the Connected Age where it is not only access and interactions but about establishing
relationships. As Sarasohn-Kahn (2008, p. 2) noted, “the use of social media on the Internet
are empowering, engaging and educating consumers and providers in healthcare.” In the
Connected Age, everything and everyone is interconnected that ultimately will have an
impact on how we learn as well as how we receive healthcare. The benefits and challenges
related to the growing use of these tools are also discussed.

HISTORICAL PERSPECTIVE
Internet
As early as the 1960s, computer scientists began to write about the creation of a network of
interconnected computers where scientists could share and analyze data by interacting
across the network (Leiner et al., 1997). According to Cerf (1995), “the name ‘Internet’ refers
to the global seamless interconnection of networks made possible by the protocols devised
in the 1970s through DARPA-sponsored research.” The Internet is defined as “a computer
network consisting of a worldwide network of computer networks that use the TCP/IP
network protocols to facilitate data transmission and exchange” (http://
wordnetweb.princeton.edu/perl/webwn).

Over the next decade, various government agencies and companies conducted considerable
research to support the advancement of the Internet. It was not until 1985 that a broader
community, in particular the academic community beyond the computer scientists, was
given access to the Internet.

NSF funding for the Internet continued for almost a decade before the Internet was
redistributed to regional networks with the eventual move toward interconnecting networks
across the globe. As the Internet came to expand, Tim Berners-Lee wrote his seminal paper
Information Management: A proposal that circulated throughout the European Council for
Nuclear Research (CERN) organization. The paper explicated his ideas that using a hypertext
system that would allow for storage and retrieval of information in a “web of notes with links
(like references) between them is far more useful than a fixed hierarchical system” (Berners-
Lee, 1989).

In 1990, Berners-Lee’s paper was recirculated and he began development of a global

hypertext system that would eventually become the World Wide Web (WWW). As the
WWW concept evolved, Marc Andreessen and Eric Bina at the University of Illinois
developed a browser called Mosaic that provided a graphical interface for users. This
browser is credited with popularizing the Web.

World Wide Web

It is important to note that although many use the terms Internet and Web synonymously,
there are differences between them. Whereas the Internet is the network of interconnected
computers across globe, the Web is an application that supports a system of interlinked,
hypertexted documents. One uses the Internet to connect to the Web. A Web browser
allows the user to view Web pages that contain text, images, and other multimedia.

Web 1.0
The Web in its first iteration (Web 1.0) allowed users to access information and knowledge
housed on Web pages complete with text, images, and even some multimedia. It was
considered a dissemination vehicle that democratized access to information and knowledge.
Many in the field designate the time period between 1991 and 2004 as Web 1.0.
This was an important era and, as noted by Friedman (2005), the world suddenly became
flat—his metaphor for the leveling of the global playing field. The convergence of the
personal computer with the world of the Internet and all its services facilitated the
flattening. The flattening was particularly powerful in the world of commerce but also
exploded in higher education, making it easier for students to access knowledge beyond
their own academic campus. For healthcare, it was a time when consumers could now have
access to health information and knowledge that was not locked in an academic library or in
a distant place.

Web 2.0
O’Reilly and Doughtery introduced the term Web 2.0 at a 2004 conference brainstorming
session (http://oreilly.com/web2/archive/what-is-web-20.html) about the failures of the
dot-com industry. It was apparent that despite the demise of the dot-com industry, “the web
was more important than ever, with exciting new applications and sites popping up with
surprising regularity” (O’Reilly, 2005).

There were several key concepts that formed the definition of Web 2.0. First, the Web is
viewed as a platform rather than an application. Second, the power of the Web is achieved
by harnessing the collective intelligence of the users. A third important principle was that
the Web provided rich user experiences. The introduction of Web 2.0 embodies the long
history of community spirit of the Internet conceived by its originators.

As Leiner and colleagues (1997, p. 206) noted, “the Internet is as much a collection of
communities as a collection of technologies, and its success is largely attributable to
satisfying basic community needs as well as utilizing the community effectively to push the
infrastructure forward.” The transition from an information dissemination platform to an
engaging, customizable, social and media-rich environment epitomizes this next generation
of the Web. As Downes (2005) stated, “the Web was shifting from being a medium, in which
information was transmitted and consumed, into being a platform, in which content was
created, shared, remixed, repurposed, and passed along.”

Another important feature was the idea of users interacting and sharing information, ideas,
and content. Owen, Grant, Sayers, and Facer (2006) aptly described the transition of the
Web, “we have witnessed a renaissance of this idea in the emergence of tools, resources and
practices that are seen by many as returning the web to its early potential to facilitate
collaboration and social interaction.” Although some have predicted (Berners-Lee, Hendler,
& Lassila, 2001) that there will be Web 3.0, known as the Semantic Web, this never
materialized as projected. There have been more recent references to such terms as the
Internet of Things (IOT) and the Connected Age. Both are fairly similar but there are some
distinctions. Ashton (2009) first described the IOT as “describe a system where the Internet
is connected to the physical world via ubiquitous sensors.”

In the 2012 Horizon Report (Johnson, Adams, & Cummins, 2012, p. 30), IOT “is the latest
evolution of network-aware smart objects that connect the physical world with
information.” Skiba (2013, p. 63) noted, “Several attributes are associated with these smart
objects; they are small, easy to attach and unobtrusive, contain a unique identifier and data
or information, and can connect with an external device on demand (e.g., your smartphone
or tablet).”

CONNECTED AGE
More recently, Oblinger (2013) introduced the concept of the Connected Age in higher
education. Abel, Brown, and Suess (2013) describe the Connected Age as an environment
that “offers new ways to connect things that were previously considered disparate and ‘un-
connectable’: people, resources, experiences, diverse content, and communities, as well as
experts and novices, formal and informal modes, mentors and advisors.” Oblinger (2013, p.
4) further noted, “Connecting is about reaching out and bringing in, about building synergies
to create a whole that is greater than the sum of its parts. Connecting is a powerful
metaphor.

Everyone and everything—people, resources, data, ideas— are interconnected: linked and
tagged, tweeted and texted, followed and friended. Anyone can participate.” As noted by
Skiba (2014, p. 63), “In higher education, we can think of these as learning pathways, created
by the individual or guided by other students or faculty. The bottom line is that learning
pathways are about connecting the dots—in the classroom, online, or even with people and
places outside the traditional academic environment.”

In healthcare, Caulfield & Donnelly (2013) offered a model of Connected Health that
“encompasses terms such as wireless, digital, electronic, mobile, and tele-health and refers to
a conceptual model for health management where devices, services or interventions are
designed around the patient’s needs, and health related data is shared, in such a way that
the patient can receive care in the most proactive and efficient manner possible. In this
model, patients, caretakers, and providers are ‘connected’ by means of timely sharing and
presentation of accurate and pertinent information regarding patient status through smarter
use of data, devices, communication platforms and people.” Iglehart (2014, p. 2) concurred
that Connected health is “an umbrella term to lessen the confusion over definitions of
telemedicine, telehealth and mHealth.” Iglehart (2014) as considered connected health as an
emerging disruptive technologies that has the potential to transform the healthcare delivery
system. Although both terms, IOT and Connected Age, speak to connections to everything
and everyone, IOT focuses on those connections with physical objects whereas the
Connected Age refers to more virtual connections especially with people, resources, and
ideas.

It is within the context of the Connected Age, that we examine the digital tools being used
to transform education and healthcare practice. In the Connected Age, digital tools are
primarily associated within the broad context of social media and mobile applications. The
Pew Research Internet Project has witnessed three technology revolutions since it began
studying the Internet. The three revolutions include broadband, mobile connectivity, and the
rise in social media and social networking in everyday life (http://www.pewinter
net.org/three-technology-revolutions/). The three revolutions are primary driving forces
behind the Connected Age. According to Fox and Rainie (2014), the World Wide Web
turned 25 on March 14, 2014, and has reached 87% penetration in terms of adult usage in
the United States. There is also considerable growth of cell phones from 53% in 2000 to
now 90% and also smartphones has increased to 58%.
When participants were asked about the impact on their lives, 90% claimed the Internet was
a positive influence. Users noted that being online was essential for not only job-related
responsibilities but for a many other facets of their lives such as learning, health, politics,
family, friends, and community interactions. It is interesting to note that 67% of users
indicated that online communications were positive and strengthened relationships with
family and friends. Facebook In a 2013 update specific to social media, Duggan and Smith
(2013) found that although 73% use social networking sites, Facebook being the most
prevalent, there are 42% who are also exploring other social networking platforms. On a
daily basis, most users check both their Facebook and their instagram accounts.

There is a growing use of Pinterest, LinkedIn, and Twitter. In terms of mobile devices, the
Pew Internet Research Mobile Fact Sheet (http://www.pewinternet.org/fact-sheets/
mobile-technology-fact-sheet/) indicated as of January 2014, 90% of American adults have
cell phones of which 78% have smart phones (Pew Internet Research Mobile Fact Sheet,
2014). There are also 52% of American adults with tablet computer devices and 32% with e-
reader devices. It is also interesting to note that 70% of teens (13 to 17 years old) and 79%
of young adults (aged 18–24) are owners of smart phones (Nielsen Corporation, 2013).
According to Nielsen’s Digital Consumer Report (Nielsen Corporation, 2014), social media is
well integrated into the fabric of everyday life. The Digital Consumer Report documented
that 64% of social media users log in at least once a day and almost 50% log into their social
network on their smart phone on a daily basis. “Mobile devices are certainly driving the
growth in social media, as social media app usage increased 37 percent in 2013 compared to
last year” (http://www.nielsen.com/us/en/newswire/2014/ whats-empowering-the-new-
digital-consumer.html).

DIGITAL TOOLS IN EDUCATION AND PRACTICE

To better understand the tools being used in the Connected Age, it is important to define
social media. In some cases, social media is used as the broad category that encompasses all
of the Web 2.0 tools. Anthony Bradley (2010) in his blog
(blogs.gartner.com/anthony_bradley/2010/01/07/ a-new-definition-of-social-media)
offered a new definition, “social media is a set of technologies and channels targeted at
forming and enabling a potentially massive community of participants to productively
collaborate…. enable collaboration on a much grander scale and support tapping the power
of the collective in ways previously unachievable.”

According to Bradley (2010), there are six defining characteristics that distinguish social
media from other collaboration and communication IT tools. These characteristics are
Participation, Collective, Transparency, Independence, Persistence, and Emergence.
Participation echoes the “wisdom of the crowds” concept, but note that there is no wisdom
if the crowd does not participate. The term collective refers to the idea that people collect or
congregate around content to contribute, rather than the way individuals create and
distribute content in the Web 1.0 world. Transparency refers to the fact that everyone can
see who is contributing and what contributions are made. Independence refers to the
anytime, anyplace concept; people can participate regardless of geography or time.
Persistence refers to the notion that information or content being exchanged is captured
and not lost as in a synchronous chat room. Lastly, “the emergence principle embodies the
recognition that you can’t predict, model, design and control all human collaborative
interactions and optimize them as you would a fixed business process” (Bradley, 2010).

Taken together these characteristics define the new world of social media. Blogs In the
Connected Age, social writing and communication are important concepts for sharing
resources and ideas as well as for making connections with people similar to you. Social
writing can take many forms and include, but are not limited to, wikis, blogs, and
microblogging. Blogs, short for Web logs, are considered to be personal Web sites where
content is displayed for visitors to review and comment upon (Adams, 2008). A top listing of
healthrelated blogs is available at the following Web site: http:// labs.ebuzzing.com/top-
blogs/health. The Health Care Social Media List, maintained by the Mayo Clinic’s Social
Media Health Network, documents the types of social media being used by hospitals across
the United States. There statistics demonstrate although blogs were once very popular,
there are fewer blogs being maintained by hospitals. Of the 1544 hospitals
(http://network.socialmedia.mayoclinic.org/hcsml-grid/0), only 209 have blogs. Wikis are
coined after the Hawaiian work for fast, and are a means to establish an easily and quickly
accessed consumer-driven knowledge base (Meister, 2008); they are essentially
collaborative tools that are “based on social regulation rather than technical safeguards”
(Digital Library Federation, 2008). Wikis, as a form of social writing, are also prevalent in
healthcare. CliniWiki (www.informatics-review. com/wiki/index.php/Main_Page) is a popular
wiki targeted toward clinical informatics topics. This wiki contains information on a variety
of topics in such areas as clinical decision support systems, unintended consequences of
technology, federal initiatives, and usability. Professional organizations, such as HIMSS, also
maintain a Decision Support Wiki (http://himssclinicaldecisionsupportwiki.pbworks.com/w/
page/18288587/FrontPage). An interesting educational Web site in informatics is the
University of Edinburgh’s Informatics wiki
(https://www.wiki.ed.ac.uk/display/Informatics/Home) that is focused primarily on
educational opportunities, student projects, discussions, and resources. Another important
wiki is of course the ever-popular Wikipedia (http:// en.wikipedia.org/wiki/Main_Page) that
maintains over 4 million articles. Microblogging, the combination of texting and blogging,
adds a new dimension to communication a writing and is growing in popularity. Historically,
electronic mail (e-mail), instant messaging, and text messaging have been less public forms of
communication. These forms have been seen as one-to-one communication. Microblogging,
using such tools like Twitter, now allows consumers to post content to a Web site, which
then automatically distributes the content to others who have “subscribed” to the
individual’s site; this creates short bursts of communication among any number of
individuals (Hawn, 2009). These microblogging sites allow social communication to come
directly to consumers, rather than requiring that consumers go and seek it out themselves.
These short bursts of communication, known as Tweets, are limited to a specific number of
characters (140). In education, twitter is being used in various ways. One example is when
conference participants tweet information being presented at the conferences to their
students (McKendrick, Cumming, & Lee, 2012). Educators are also using Twitter in the
classroom to encourage student engagement. In healthcare, there is a rise in the use of
microblogging especially in the public health arena. According to Eysenbach (2009),
“Infodemiology can be defined as the science of distribution and determinants of
information in an electronic medium, specifically the Internet, or in a population, with the
ultimate aim to inform public health and public policy.”

The electronic medium can be supply driven, such as the information being published in
blogs, microblogs, and discussion groups, or it can be demand driven that includes Web
searching and navigation. Some examples of the use of Twitter include its use in tracking
trends in health behaviors: physical activity (Zhang et al., 2013); dietary (Hingle et al., 2013);
smoking (Myslín, Zhu, Chapman, & Conway, 2013); and prescription drug abuse (Hanson,
Cannon, Burton, & Giraud-Carrier, 2013). Other uses include dissemination of vital
information during disasters and documentation of the extent of crisis such as the H1N1 or
SARS viruses.

SOCIAL NETWORKING
Social networking embraces many of the defining characteristics of the Connected Age and
is a major component of connected learning and connected health. First, participation and
collaboration were two of the principal themes in Web 2.0 (Eysenbach, 2008) and are the
driving forces behind the social media movement with continued relevance in the
Connected Age.

Eysenbach (2008) further noted,

“Social networking …involves the explicit modeling of connections between people, forming
a complex network of relations, which in turn enables and facilitates collaboration and
collaborative filtering processes.”

Another aspect of social networking is the ability to share user-generated content in the
form of videos, stories, or photographs. In addition to adding and viewing content,
consumers can also post comments to media someone else has contributed, thus adding
another level of communication to these sites (Skiba, 2007).

Of the available digital tools, social networking offers the most opportunity for peer support
and consumer engagement. Users can make connections with people that they already know
in person or may connect with others through associations that they create (Boyd & Ellison,
2007). Essentially, the social networking site serves as a powerful tool to engage and
motivate consumers to share personal information, establish relationships, and communicate
with others. This is definitively exemplified in the phenomenal growth of social networks
such as Facebook.

Facebook celebrated its tenth anniversary in 2014 and is considered the dominant social
networking site where 57% of adults and 73 % of teens (12–17 years old) used Facebook.
According to a recent Pew Research Center study, despite the growing number of adults
using Facebook on a daily basis, the younger generation “are not abandoning the site”
(Smith, 2014). Here are some additional facts about Facebook. Although users dislike some
aspects of Facebook (sharing too much personal information and posting photos without
permission), the users do not want to miss out on social activities. Second, 47% like the
ability to share photos and videos with friends as well as sharing with many people at the
same time. They also like updates from their friends and humorous content.

Third, 50% of adult users have over 200 friends on Facebook. Fourth, younger rather than
older users have “unfriended” a person. Fifth, although most users do not change their status
on Facebook, they do like to comment on friend’s postings. Lastly, those that do not use
Facebook are still familiar with Facebook through their family members. Higher education,
including healthcare professional education, is taking full advantage of the collaborative
features of social networks and mobile access to create dynamic and collaborative learning
experiences.

The dynamic nature of collaboration via the Internet offers learners the opportunities to
share working knowledge, provide professional support, and create communities of learning.
Social media complements and supports e-learning opportunities where students are able to
have more control over the pace, sequence, and timing of their learning experience (Ruiz,
Mintzer, & Leipzig, 2006). These new digital learning environments aim at deepening the
level of engagement for the student experience (Boulos, Maramba, & Wheeler, 2006) and
also allows students to connect to a vast array of accessible resources knowledge, expertise,
and social connections (Alliance for Excellent Education, 2014).

In the field of informatics, Skiba & Barton (2009) described the use of social networking
tools at the University of Colorado College of Nursing. In this graduate program, they have
embraced the use of social media to engage and retain online learners but also to attract
potential students to the program. The program incorporates various social media, such as
social networking and virtual worlds, as part of the online learning environment. Another
example is the University of Oregon Biomedical Informatics program that includes the use of
blogs to connect students and faculty within their programs. More recent applications of
social networks are appearing as universities and specific programs form LinkedIn groups of
their graduates or current students.

In nursing education, one of the best known social networks was Meet Stella Bellman (Skiba,
2010), a mannequin in a simulation lab at Mesa Community College (https://www.facebook.
com/stella.bellman) and was used to connect and communicate with nursing students.
Healthcare institutions and consumers have already begun to capitalize on the limitless
utility of social networking. Numerous hospitals and healthcare-related organizations have
social networking sites where patients and visitors can explore details about the facility,
learn more about available services, and find information about diseases and/or treatments
(Sarasohn-Kahn, 2008). Of the available social networking sites, Facebook stands out as one
of the more popular, as it has proven useful for resource sharing, communication, and
collaboration (Mazman & Usluel, 2010). According to the Mayo Clinic’s Center for Social
Media List, of the 1544 hospitals using social media, there are 1292 hospitals that have
Facebook social networks and 651 that have LinkedIn groups.

To learn more about the top hospitals that are social media friendly, you can visit the
rankings of hospitals conducted by MHdegree.org (http://mhadegree.org/ top-50-most-
social-media-friendly-hospitals-2013/). At the top of the list are Mayo Clinic, Cleveland
Clinic, University of Texas MD Anderson Cancer Center, Mt Sinai Medical Center, and the
University of Michigan Hospitals and Health Centers.

Social Network
One of the first social networks in healthcare was Matthew Zackery’s i2y social network (I
am too young for this Cancer Foundation). At one of the first Health 2.0 conferences,
Zackery presented his experiences in creating the social network targeted for young adults
with cancer. To learn more, you can visit the following Web site: http:// stupidcancer.org/
The Centers for Disease Control (CDC) has embraced the use of social media and was used
extensively in their H1N1 campaign. The CDC site (www.cdc.gov/h1n1flu) not only
connects people to the CDC, but also to other social networks such as Facebook, My Space,
and Daily Strength.

It provides videos, podcasts, e-cards, widgets, RSS feeds, and the ability to get text messages
and join their Twitter subscription. Their Web site (http://www. cdc.gov/socialmedia/)
contains a variety of resources that are used such as current campaigns as well as a Social
Media Toolkit to help people create their own social media campaigns. Perhaps one of the
most interesting and well-researched social networking sites is PatientsLikeMe
(www.patients likeme.com). Through this social network, patients from all over the world
convene and share their experiences while dealing with chronic conditions such as Multiple
Sclerosis (Sarasohn-Kahn, 2008). The creators’ brother, who was living with amyotrophic
lateral sclerosis (ALS), was the inspiration for the network.

Two brothers and a friend, all Massachusetts Institute of Technology engineers, created this
network with the following goals in mind:
(1) share health data,
(2) find patients with similar conditions, and
(3) learn from each other.
Patients are asked to share data in the hope of improving the lives of all diagnosed with that
particular disease. The site currently supports over 250,000 members, over 2000 health
conditions, over 40 published research studies, and over 1 million treatment and symptom
reports (http://www.patientslikeme.com/). The site does not have any fees and is kept free
from advertising through revenues stemming from research awareness programs, market
surveys, and the sale of processed anonymized data (Brownstein, Brownstein, Williams,
Wicks, & Heywood, 2009). Members use aliases rather than real names and can openly
share details about their healthcare experiences, drug regimens, and treatment side effects
(Hansen, Neal, Frost, & Massagli, 2008; Sarasohn-Kahn, 2008). The primary motives behind
such sharing are to ask or offer advice and to build a relationship with others in similar
situations (Hansen et al., 2008). “Rather than disseminating medical advice, PatientslikeMe
serves as a platform for peers to interact with one another in a data-driven context”
(Brownstein et al., 2009, p. 889).

Patients have actually taken information they have learned from PatientsLikeMe to their
own healthcare providers to request to be put on specific treatments (Goetz, 2008). More
recently, PatientsLikeMe has launched a Data for the Good Campaign to encourage patients
to share their health data to advance healthcare research (http://
news.patientslikeme.com/press-release/patientslikemelaunches-data-good-campaign-
encourage-health-datasharing-advance-medic).
A recent report by the eHealth Initiative with funding from the California Healthcare
Foundation examined the use of social media to prevent behavioral risk factors associated
with chronic disease. According to this report (eHealth Initiative Report, 2014, p. 7), “By
seeking and sharing information online, health consumers (or “ePatients”) are using social
media to become more equipped, enabled, empowered, and engaged in managing their
health, care, and wellness.” Although healthcare providers continue to play a primary role in
the provision of health information, “more Americans than ever value social networks (e.g.
friends, family members, and fellow patients) for emotional support and advice on everyday
health issues” (eHealth Initiative Report, 2014, p. 7). Healthcare is in essence becoming more
social (SarasohnKahn, 2008; Fox & Jones, 2009, HIMSS Social Media Work Group, 2012).

Fox (2011) summarized it as “Peer-to-peer health care is a way for people to do what they
have always done – lend a hand, lend an ear, lend advice – but at internet speed and at
internet scale.” The eHealth Initiative Report (2014) developed a specific taxonomy to
classify social media tools for chronic diseases. This taxonomy includes such tools as Internet
support groups, media sharing, messaging boards/discussions, microblogs, social networking
general and specific to a particular disease, Weblogs, and social games and challenges.
Grajales, Sheps, Ho, Novak-Lauscher, & Eysenbach (2014) conducted a narrative review of
social media and its use in healthcare. They reviewed 76 articles, 44 Web sites, and 11 policy
reports to derive 10 categories of social media: blogs, microblogs, social networking sites,
professional networking sites, thematic networking sites, wikis, mashups, collaborative
filtering sites, media sharing sites, and virtual worlds. They found that social media was fairly
extensive, there was a need to begin to address challenges related to governance, ethics,
professionalism, privacy, confidentiality, and information quality.

BENEFITS OF SOCIAL MEDIA

To understand the benefits of social media, it is important to examine the growing number
of studies over time. In the past, most studies were descriptive. In a review by Skiba,
Guillory, and Dickson (2014), there are three general areas of research in social media. The
first focused primarily on the content being shared on social media, in particular social
networks and Twitter. The second area was the specific use of social media by patient
populations such as diabetics or cancer patients. The final area was related to the use of
social media for recruitment of patients for research studies and the collection of data from
social media could be used as an additional form of research data. Some interesting findings
were that Facebook, YouTube, and Twitter were the most common social media platform
and PatientsLikeMe was the most studied network to date (Skiba et al., 2014). More
recently, there have many more research studies, including clinical trials that have examined
the impact of social media tools on patient care.

The growth of these studies has generated several systematic reviews to provide evidence
for the use of these tools in promoting and managing various patient populations. Here is a
sampling of some systematics studies. Moorhead et al. (2013) completed a systematic
review to examine the uses, benefits, and limitations of social media for health
communications. Capurro et al. (2014) conducted a systematic review of social networking
sites for Public Health practice and research. Chang, Chopra, Zhang, and Woolford (2013)
analyzed studies in the role of social media in online weight management. Maher et al.
(2014) conducted a systematic review of the effectiveness of behavior change interventions
through social networks. Most found promising results but there was a need for additional
studies.
The eHealth Initiative Report (2014) concluded that social media provides a multitude of
benefits to patients by “enabling health education and enhancing behavior by:

• Breaking down the walls of patient-provider communication

• Improving access to health information
• Providing a new channel for peer-to-peer communications
• Developing meaningful relationships
• Establishing communities of patients, caregivers, and family members
• Engaging and empowering people”

The development and continuing research in the use of social media will expand and more
studies will continue to provide additional evidence of their effectiveness. There is little
doubt that the social life of healthcare (Fox & Jones, 2009) will continue. Despite their
prospects, digital tools in the Connected Age do not come without certain limitations and
risks. Like any element of our digital environment, they pose concerns for privacy, security,
and legal issues.

CHALLENGES OF SOCIAL MEDIA

According to the eHealth Initiative Report (2014), there are several key challenges affecting
the widespread adoption of social media in healthcare. First, there are concerns about
privacy and HIPAA compliance. There are also concerns about the balance of transparency
and anonymity associated with the sharing of personal information online. The quality,
validity, reliability, and authenticity of information are an issue especially when there is user-
generated information. There is also the challenge of the digital divide specifically with
differing populations such as the elderly, minorities, the disabled, those living in rural areas,
and those in poor or undeserved areas without access to broadband. The final challenge in
this report also mentions the lack of theoretical and evaluation models for social media given
the paucity of effectiveness data. Grajales et al. (2014) also echo many of the same
challenges, “The potential violation of ethical standards, patient privacy, confidentiality, and
professional codes of practice, along with the misrepresentation of information, are the most
common contributors to individual and institutional fear against the use of social media in
medicine and health care.” The Connected Age places unique circumstances around the
sharing of protected health information, as it is generally patient, student, or consumer
driven. That is, the consumer voluntarily divulges his or her information. In such cases the
HIPAA regulations do not apply, however, healthcare institutions’ attempts to abide by the
law may hinder their adoption of Web 2.0 applications (Hawn, 2009).

The sharing of personal information is also an issue with the use of social media by students.
It is not just the sharing by healthcare professional students of their own information in
social networks but also the potential of them sharing personal health information of their
patients on social networks. Such was the case of nursing students posting a picture of a
patient’s placenta (Skiba, 2011). There are also concerns about privacy and confidentiality.
Their concerns are not unfounded since the rates of identity theft are on the rise and
Internet security cannot ever be fully ensured (Acoca, 2008; LaRose & Rifon, 2006). Social
media applications promote information sharing and the open display of personal
information, such as age, gender, and location.
Posting this and other content creates digital footprints or lingering information that can be
connected back to the consumer who provided it (Madden, Fox, Smith, & Vitak, 2007); these
bits of information can then be found and coalesced to form a more complete picture of the
individual, thus negating the apparent transparency supposed by Web 2.0 applications
(Madden et al., 2007). A recent study conducted by Grajales et al. (2013) found there are
worries about sharing data, many U.S. adults (94%) are willing to share their health data to
improve care and believe that data sharing can help other patients as well as themselves.
Users of social media are at risk for social threats as well (Nosko, Wood, & Molema, 2010).
Characterized as stigmatizing and bullying, social threats can pose significant dangers to
consumers and those with whom they are affiliated (Nosko et al., 2010). In addition, there
may be legal issues related to risk management and liabilities. It has long been known that
Internet content is not regulated and may be unreliable (Eysenbach & Diepgen, 1998; Powel,
Darvell, & Gray, 2003). Healthcare and educational organizations in the Connected Age must
also be cognizant of the legal implications. Not only will they have to monitor the content
being shared on their site for appropriateness, reliability, and quality of their information,
they will also need to be sure there are no copyright infringements (Lawry, 2001).
Healthcare practice licenses are also an issue considering that in the Connected Age, there
are no real geographic boundaries (Grajales et al., 2014). The digital divide, or gap in
usability, exists for some consumers who either lack physical access to the Internet or do not
have knowledge or skills to navigate the myriad information on the Internet safely and
effectively (Baur & Kanaan, 2006; Cashen, Dykes, & Gerber, 2004).

Physical access limitations can be described as lack of resources to obtain the hardware or
software to utilize these tools (Baur & Kanaan, 2006; Cashen et al., 2004). Lack of
experience describes the knowledge and skill deficit that hinders a consumer’s ability to
navigate tools effectively and safely. Some have also found that ethnic disparities do exist in
regard to Internet access but, surprisingly, not in regard to social media use (Chou, Hunt,
Beckjord, Moser, & Hesse, 2009). As with most innovations, these challenges can be partially
addressed through the development and implementation of social media policies by
organizations, including user-generated networks. This is particularly important given that
most healthcare agencies are risk adverse regarding patient care. Professional organizations,
such as American Nurses Association, American Medical Association, and the National
Council of State Boards of Nursing, have provided guidance and social media policies (Skiba
et al., 2014). Barton and Skiba (2012) also present social media policy recommendations for
educational institutions. The Mayo Clinic Center for Social Media provides resources related
to social media policies (http:// network.socialmedia.mayoclinic.org/)