Two years of German summer school of nursing informatics

International Journal of Medical Informatics 58–59 (2000) 307–317

Two years of German summer school of nursing informaticsDid we reach the goals?

T. Burkle a,*, U. Schrader b

a Institute of Medical Informatics, Uni6ersity of Gießen, Heinrich-Buff-Ring 44, 35392 Gießen, Germanyb Uni6ersity of Applied Sciences, Nibelungenplatz 1, D-60318 Frankfurt am Main, Germany

Received 20 December 1999; accepted 16 April 2000

Abstract

This paper describes a continuous effort to improve the knowledge of nursing informatics among German nurses.The authors have co-operated in the nursing informatics working group of the German Medical InformaticsAssociation GMDS. Besides, one of the authors has been active in the European summer school of nursinginformatics (Essoni) for several years. The authors have now established a national counterpart to the Essoniprogram, the German summer school of nursing informatics. This event in German language is centred aroundnursing informatics topics. Students may opt for one of the several study tracks to gain insight in topics such asnursing classifications and nursing terminologies, clinical information systems and their implementation or teachingrequirements in nursing informatics. They go through a 5-day curriculum consisting of plenary sessions, lectures andopportunities for self learning and self teaching. At the end they demonstrate to the fellow students from the othertracks what they have achieved in their own field of study. The German Summer School is open to interested nurses,nurse executives and nurse teachers. In this paper, we will describe the curriculum, talk about the participants andshow results of the questionnaire-based evaluation for the first two events in 1998 and 1999. © 2000 Elsevier ScienceIreland Ltd. All rights reserved.

Keywords: Nursing; Informatics; Education

www.elsevier.com/locate/ijmedinf

1. The dilemma of nursing informatics inGermany

Traditionally, nursing is a non academicprofession in Germany. Registered nurses

complete a 3 year undergraduate training at anursing school. Approximately 800 suchnursing schools exist in Germany, most ofthem are affiliated with a medium sized orlarge hospital. The nursing school curriculumis very much practice centred and pupilnurses spend much of their time working onthe wards of the affiliated hospital. Typically,they serve repeated terms on the ward (1–6

* Corresponding author. Tel.: +49-641-9941370; fax: +49-641-9941359.

E-mail address: [email protected] (T. Burkle).

1386-5056/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved.

PII: S1 386 -5056 (00 )00095 -2

T. Burkle, U. Schrader / International Journal of Medical Informatics 58–59 (2000) 307–317308

weeks), followed by an equivalent period innursing school. Thus, they rotate throughseveral departments of the hospital. Theyreceive a small, gradually increasing reim-bursement during their training. Contentand quality of the curriculum is largely de-pendent on the individual nursing school,only few German states (e.g. Hessen [1])define a mandatory nursing curriculum.Once a nurse has finished nursing school, heor she becomes a registered nurse and isexpected to collect several years of workingexperience. For those experienced registerednurses the nursing associations themselvesoffer further education, e.g. to become anintensive care nurse, a teaching nurse or anursing executive. Often these courses runparallel to his or her regular nursing job atthe hospital. They comprise several studyterms of weekly courses over a period of 2or more years.

Neither the nursing school curricula, northe additional education courses incorporatemuch information about computers or nurs-ing informatics. Occasionally, the use ofstandard software such as word processorsor spreadsheets is taught. Some nursingschools also teach the use of applicationsfound at the particular hospital they areaffiliated with. Here the educational con-tents depend directly on the informationtechnology infrastructure at the hospital.None of the few existing official state nurs-ing school curricula even mentions nursinginformatics [1]. In a study conducted atGießen University Hospital we found thatjust 6% of 106 nurses learned basic com-puter skills at nursing school [2], comparedwith 7% who did so at secondary schoollevel before becoming a nurse.

In order to bring nursing education inGermany up to the international standards,nursing is also being taught at the university

level since the beginning of the 1990s. Sev-eral universities of applied sciences and afew regular universities offer study trackssuch as nursing, nursing pedagogic, nursingresearch and nursing management [3]. Grad-uates receive a diploma, which can be posi-tioned someplace between a bachelor and amaster degree. To qualify for such a univer-sity-based course the participant must eitherbe graduated from secondary school, or heor she must be a registered nurse with pro-fessional experience [4]. Fortunately, insome universities curricula of nursing infor-matics or selected parts of it have been in-corporated besides an education in basiccomputer literacy [5,6]. Basic computerskills and standard software are generallytaught, e.g. to enable students to write termpapers. But no mandatory or optional nurs-ing informatics curriculum exists. Whentaught, nursing informatics education at thedifferent universities in Germany is quite di-verse. Most of the universities have no fac-ulty specific to this subject and employexternal lecturers. In these cases the con-tents depend on the understanding of thefaculty and the external lecturers. The Uni-versity of Applied Sciences in Frankfurt iscurrently the only place in Germany wherea full faculty position is dedicated to nurs-ing informatics education. The position isoccupied by one of the authors (USchrader) who is mainly responsible forteaching nursing informatics to nursing andnursing executive students.

Other German educational programs formedical informatics such as the HeidelbergUniversity course for medical informatics [7]or the undergraduate medical documentalistcourses [8] are only suitable for nurses whowish to leave their profession, e.g. becauseof health problems. A formal degree of anurse informatician or informatics nursedoes not exist in Germany.

T. Burkle, U. Schrader / International Journal of Medical Informatics 58–59 (2000) 307–317 309

2. Which needs exist for nursing informaticstraining in Germany?

In the first chapter we have looked at theeducational situation of German nurses andthe level of computer skills they can acquirethere. We found a non satisfactory situation.Before thinking about improvement, weshould however assess the actual computerand informatics knowledge of nurses. Thisassessment will always be time dependent,therefore, we will only look at a few recentstudies [2,6,9].

For Gießen University Hospital an inter-esting comparison exists on the developmentof computer knowledge among nurses be-tween 1994 and 1998 [9]. Based on question-naires and self assessment, in 1994 nearlythree-fourth (73%) of 37 nurses stated, thatthey had no computer knowledge [10]. Inanother questionnaire distributed 1998, only8% of 106 nurses said so. However, 57%rated themselves as beginners. Similar resultswere found in another study performed 1999among nursing executive students at theFrankfurt University of Applied Sciences [6].Around 7% stated no knowledge, 62.5% be-ginners knowledge and 31.2% advancedknowledge. We conclude that today despitean unsatisfactory educational situation a sig-nificant percentage of German nurses possessat least basic computer knowledge.

Several reasons, such as the availability ofinexpensive personal computers and the ad-vent of the internet can explain this improve-ment. However, German hospitals have alsorecognised the need to improve computerskills of their nursing employees. Whereas in1994 only a fifth of the queried nurses hadcompleted a computer course, and which wasdone mostly outside the hospital, a completechange could be observed in 1998. Then morethan half of the respondents had finishedsuch a training, most of them had done it

inside the hospital [9,10]. Today, computersare accepted tools for nurses in Germany.They are available in many institutions butmainly used for administrative and not pa-tient-related tasks. Few comprehensive nurs-ing information systems in use can be foundin German hospitals [11,12], but Germannurses are often confronted with a clinicalworkstation or a local computer application[12–15]. Besides, many nurses use standardsoftware like text processors and spreadsheets to organise their own working environ-ment. Large hospitals have recognised theresulting education needs and organise com-puter training for their employees to teachthem computer skills, respectively, the use oftheir specific computer applications. Com-puter knowledge is likely to improve evenmore when learning basic computer skillsbecomes a mandatory element of generalschool education. This is not yet the case inGermany, but many schools have built upcomputer labs and we noted in our study,that more nurses learned computer skills inregular school than in nursing school. Weconclude that further nursing education pro-grams should not only concentrate on com-puter knowledge.

Obviously, nursing informatics is morethan just computer literacy. The most recentdefinitions of the term ‘nursing informatics’stems from the special interest group on nurs-ing informatics (IMIA-SIG nursing) of theInternational Medical Informatics Associa-tion. They defined in 1998 [16]:

Nursing informatics is the integration ofnursing, its information, and informationmanagement with information processingand communication technology, to supportthe health of people worldwide.

In this process it is essential that nursespronounce their requirements, that they are


able to influence information system designand that they can contribute to system intro-duction and information management. Thisrequires considerable knowledge.

When thinking about the summer school,we asked ourselves which educational needswould exist among German nurses. First ofall, they would need a learning opportunitywhere they could participate besides a regularnursing job. Second, we would have to ad-dress their real information needs. Potentialeducation contents have been depicted a cou-ple of years ago by an informatics workinggroup of one of the German nursing associa-tions [17]. This group has drawn up a modu-lar curriculum with basic modules for allnurses, such as information infrastructure inhospitals, functionality of a hospital informa-tion system, data protection etc. and spe-cialised modules for nurse executives or nurseteachers. Sadly, this concept has never beenformally incorporated into German nursingcurricula.

We found another alternative in the shapeof the European summer school of nursinginformatics (Essoni). This event which hasbeen earlier sponsored from the Erasmusprogram exists for over 9 years and rotatesthrough various European countries. In 1999it was held in Horn near Vienna in Austria.The European summer school has the objec-tive to advance nursing informatics as a re-search, education and practice baseddiscipline [18]. It is a 1 week full-time coursein mid-summer and splits up in three or fourdifferent tracks with specified topics whichchange every year. Each student has to decidefor one of these tracks. In the tracks, theparticipants work together with a tutor whois called facilitator. His task is not onlyteaching, but mainly to facilitate the betterunderstanding of the track topic. Thus at theend of each summer school the studentsthemselves have to present to their colleagues

what they learned in their term. Essoni hasbeen a success every year for the participants.This model was well known to the authorssince one of them has himself participated asa student there for several years and eventu-ally became a member of the organisingcommittee.

However, despite its recognised success,Essoni has not really succeeded in attractingGerman nurses due to the language barrier.German participants, if any, mostly camefrom the medical informatics scene whereEnglish language is usually not a problem. Inthis situation we considered a German lan-guage summer school to promote nursinginformatics for German nurses. Our idea wasthat for them a German language event, rea-sonably prized, near to their home and heldoutside regular work periods, might be morepopular.

3. The German nursing informatics summerschool

We started the German summer school ofnursing informatics in summer 1998 [19,20].The first task was to find an appropriatesetting for this event. Fortunately, the Uni-versity of Gießen, where one of the authors(T. Burkle) works, operates a remote retreatand conference site, the castle Rauisch-holzhausen (Fig. 1), situated 30 km fromGießen in a rural area. This castle gave asplendid setting for the 1998 and 1999 Ger-man summer school and will also host theyear 2000 event. It has not only variousmeeting rooms of different sizes, but can hostmany guests in 38 double and 2 single rooms.It is operated in a hostel like manner, there-fore, we could organise the complete event allinclusive for a low fee. On this occasion wewould like to mention that the tutors agreedto receive only cost reimbursement and nosalary.


Printed invitations for the participationwere distributed during special nursingevents. The summer school was announcedwith the help of the German nursing associa-tion DBfK and a website was established.

When designing the German summerschool of nursing informatics, we adoptedmany features of the European event such asthe track structure, the tutor/facilitator con-cept and the final presentations by summerschool students. For 1998 and 1999, we keptroughly the same tracks and tutors, while theinvited plenary speakers have changed.1. Nursing classifications (G. Nielsen).2. Nursing informatics and education (W.

Goossen).3. Information systems in nursing and their

introduction (T. Burkle/U. Schrader).The nursing classifications track dealt with

taxonomies and classifications in nursingsuch as NANDA, OMAHA, UNLS andICNP. The vocabularies have been comparedand semantic relationships have been exam-ined. Cross mappings between the differentnursing terminologies have been demon-strated and performed.

Track 2 was meant as a broad introductionto nursing informatics and its possible inte-gration into the nursing curriculum. Teachingstrategies have been compared and discussed,culminating for example in the design of acomplete nursing informatics workshop,which might be needed when a hospital intro-duces a nursing information system.

Track 3 dealt with nursing requirementsfor a clinical workstation and the problemswhich arise when computer applications areintroduced in hospitals. Issues such as re-quirements analysis, system selection, systemintroduction and system operation have beendiscussed. Checklists with selection criteriafor nursing information systems have beenpresented and methods of system assessmenthave been tried.

Besides, the 5-day program comprised ple-nary sessions and invited lectures. Invitedlectures dealt with new and interesting topicssuch as evidence based care and internet fornurses and nursing minimum data sets. Theother plenaries were given by the tutors andintended to keep all the students up to dateon the contents of all three tracks. Like the

Fig. 1. Castle Rauischholzhausen, hosting the 1998, 1999 and 2000 German summer school of nursing informatics.


Fig. 2. Curriculum of the first German nursing informatics summer school.

European event, the final plenary presenta-tions were given by members of each track.An exemplary timetable can be seen in Fig. 2

The afternoon was split in two regularsessions and if requested an optional latenight session after dinner. The track sessionsstarted with an introduction of a specificproblem, given by the respective tutor, andcontinued with tasks for the participants tosolve this problem. Appropriate learning ma-terial has been supplied to promote co-oper-ation among the participants and to enablethem for continuous self teaching. Occa-sional late night sessions have been usedfor software introduction and practice, e.g.with Microsoft Powerpoint for the final pre-sentations. For this task a small computerlab was established with seven portable com-puters.

4. The result

When we announced the first Germansummer school of nursing informatics, wehad intended to find around 25 participants.

However, we had soon to close admission,having exhausted our room contingent with35 students. So far, two summer schools with35, respectively, 42 students from Germany,Switzerland and Austria have taken place.Both times the number of requests for partic-ipation exceeded the number of availableplaces. According to the zip codes partici-pants of the second event came nearlyequally from all over Germany (Fig. 3).

In 1998 the students’ background could bedistinguished in three partitions of almostequal size; the first consisted of nurses al-ready engaged in the area of data processing,a second of nurses and a third partitionworking as teachers or in management. In1999 the picture had changed. Nearly half ofthe participants came from a nursing man-agement background, respectively, academicnursing curricula and from nurse teaching.‘Normal’ nurses made up for a third, theremainder being from data processing andcompanies (Fig. 4).

These different backgrounds had an effectupon the level of knowledge and the infor-mational needs of the students. In general,


Fig. 3. Distribution of the students of the second Ger-man nursing informatics summer school.

Fig. 5. Change in preference of different track topicsfrom 1998 to 1999.

tracks, which has been shown in Fig. 5; fortrack 1 (nursing classifications) the requestsremained on the same level, but track 2(nursing informatics) and track 3 (imple-mentation issues) switched position com-pletely in preferences. In 1998 most studentsopted for track 3, in 1999 for track 2.

In the first summer school we had a highpercentage of nurses working as data pro-cessing co-ordinators in hospitals. Conse-quently they asked for implementation andinstallation information. It seems that stu-dents with a nursing management back-ground have lower information needsregarding these issues. They rather want toknow how to organise and how to teachinformatics knowledge or how nursing in-

all the tutors noted that the second summerschool achieved a higher educational levelthan the first one did. This effect wasmarkedly visible in the final presentations,on comparison of the two events. Some ofthe final presentations of the second eventcame up to the conference level.

Between 1998 and 1999 there has been aconsiderable shift in interest for the three

Fig. 4. Members of the German summer school of nursing informatics in 1998 and 1999.


formatics might solve their specific problems.Classification and nursing termino-logies have found a constant interest in boththe summer schools.

5. The evaluation

A questionnaire was distributed on thelast day of every summer school to evaluatethe participants’ response. Here we presenta few highlights of the questionnaire.

How did you find out about the summer school?

1999199859�I read the paper leaflet

9�I found it on the internet 1412 10�I heard about it from other

persons�Others 65

35Total answers 35

In both the events we could note that upto 40% of our students found informationabout the summer school on the internet.This is yet again a hint that computer skillsexist and that internet access is possible formany German nurses.

How did you pay for the summer school?

199919982225�My employer paid

3�I have paid myself 121�Others (e.g. partial subsistence) 2

3530Total answers

For many participants the employer paidthe summer school. Another indicator thatGerman hospitals have recognised the needof improved informatics education of theiremployees.

How would you rate the summer school?

19991998�Excellent 23 16

6�Good 1621�Satisfying0�Sufficient 000�Insufficient

Total answers 30 34

Both summer school events have beenrated pretty high. We note that students ofthe second summer school were not quite asenthusiastic. It is possible that the differentbackground of the second summer schoolparticipants has contributed to this result.

How would you rate the summer school plenary

sessions?

1998 199918�Excellent 26165�Good

0�Satisfying 01�Sufficient 000�Insufficient

Total answers 3531

The summer school plenaries have beenwell accepted and will certainly constitutean essential part of the curriculum of futuresummer school events. Again we note thatstudents of the second summer school werenot quite as enthusiastic in general.

Would you recommend the summer school to your

colleagues?

199919983130�Yes, I would

1�I would partially 40�No, I would not 0

3531Total answers


This is probably the most essential outcomeof all the German summer school events. Thehigh amount of recommendations is to us anindicator, that a real need for such educationexists and that an educational event of sum-mer school type might be able to replenish atleast part of the information needs regardingnursing informatics, which obviously existamong German nurses.

We have asked more questions to evaluateeach single track, however, this would exceedthe space allowed for this paper and couldpossibly detract from the essential outcomewhich has been made clear with the resultsquoted above.

6. Discussion

In this paper we have first described theeducational situation for German nurses andlooked at the amount and depth of computerskills and nursing informatics knowledge theyare likely to receive during their education. Weare faced with a situation where more nurseslearn computer skills at regular schools thanat nursing schools. However, this does notautomatically imply that most German nursesare computer illiterates. In the second chapterwe have looked at a set of recent study results,indicating, that up to 92% of the Germannurses possess basic computer knowledge.Such results are confirmed by our observationthat it is possible to promote educationalevents for nurses on the internet.

Taking those observations as a baseline wehave now examined which educational needsregarding informatics exist among Germannurses. We came to the conclusion, that edu-cation should cover nursing informatics in thesense of the IMIA definition as a means forintegration of nursing, and its informationmanagement with information processingtechnology. Nurses would need learning op-

portunities which they could visit besides theirregular jobs and they might be attracted by ascholar type event which teaches them to helpthemselves. However, such an event should beheld in German language and should notrequire too much travel effort. With theseideas in mind and taking main topics as wellfrom a formerly proposed German nursinginformatics curriculum and from the Essoni,we have started a German summer school ofnursing informatics. Our goal was to establishnursing informatics training not only for per-sons enrolled in academic nursing programs,but also for ordinary nurses besides theirnormal professional activities. Today, aftertwo successful German events we would liketo repeat our earlier statements [20].1. There is a need for nursing informatics

training among German nurses.2. The training must be extended beyond pure

computer knowledge.3. The training must enable nurses to partici-

pate acti6ely in decision groups and taskforces concerned with the introduction ofcomputer applications in healthcare. Theymust :

-be able to select systems and adaptthem to nursing requirements;-be able to prepare nursing standardsand use nursing terminologies;-be able to organise computer trainingand education for their colleagues.

4. A condensed summer school program mightoffer nurses an introduction to the aspectsof informatics.

5. The German summer school curriculum metthe interest of the participants.

Between the two summer school events, wecould notice a fascinating change in the back-ground of our students. While in the firstevent we found besides ‘normal’ nursesmainly nurses who had resumed positions indata processing in their hospitals, the secondsummer school attracted a large number ofnursing management members and students


of nursing management with university back-ground. This shift in the background of ourstudents led not only to a higher educationallevel in the second event, but also obviouslyto changing preferences and informationneeds. In the second summer school systemimplementation and system introduction wasof less priority compared with organisationalteaching issues and an introduction in nurs-ing informatics. Only requests for classifica-tion and nursing language knowledgeremained the same.

The summer school students rated the sec-ond summer school marginally lower thanthe first event, but most of them would rec-ommend the event to their colleagues. For us,those results add up to the impression, thatnot only ‘ordinary’ nurses, the group we hadoriginally in mind when we established theGerman summer school, may draw advan-tage from such an event. It seems that evennursing executives and students enrolled inone of the few academic courses might profitfrom an additional educational offer to learnabout nursing informatics. They will havesomewhat different information needs whichwe must consider for the future, but thegeneral concept seems appealing to them. Itis a positive sign that employers accept thesummer school concept as a valuable tool forcontinuous education and that they acceptfor a good part the responsibility to traintheir staff in nursing informatics. We notethat this is in sharp contrast to the situationat nursing schools, where obviously comput-ers are still seen as something not belongingto the nurses working environment.

Despite such a positive echo, much work isstill needed to establish computer support asa valuable tool for information processing innursing. Not only must the primary educa-tion at nursing schools be improved. We alsonote, that there is no formal degree of a nurseinformatician or informatics nurse in Ger-

many, despite the fact, that many hospitalsappoint nurses to be responsible for dataprocessing issues. This situation should beimproved in the near future, by defining ofrequired knowledge and background for suchpositions and by installing suitable educa-tional courses to acquire such knowledge.Here, the summer school could play a role aspart of the required qualification. Fortu-nately, now we do have courses for nursing atthe university level. However, it seems thateven there nursing informatics knowledge canstill be improved and information needs doexist. Here, it could be an opportunity for theGerman nursing informatics summer schoolto become institutionalised as part of theregular curriculum if it continues to be assuccessful in the future. Today it is still tooearly to define the role of a nursing informat-ics summer school in the German nursingeducation scene. We think that we have atleast achieved our primary goal, that is toestablish nursing informatics training notonly for persons enrolled in academic nursingprograms, but also for ordinary nurses be-sides their normal professional activities.

The curriculum of the summer school didcover important aspects of nursing or healthinformatics that should be taught to healthprofessionals as recommended by the Educ-tra [21] and Nightingale [22] project of theEuropean Union. But the limited time ofonly 5 days did not allow us to cover everyaspect. The design of the summer school withthe different tracks is a very good way toexplore one aspect in its depth. So there isstill a need for other educational opportuni-ties to comprehensively cover every topic toits full extent. Further, summer schools withchanging curricula might serve this purpose.

The rising interest of nurse educators innursing informatics topics as experienced bythe increased number of educators in the1999 summer school might hopefully indicate


that nursing informatics aspects will be incor-porated into the different nursing curricula inGermany in the near future. So the summerschool might also have the important strate-gic task of ‘teaching the teacher’.

Acknowledgements

The authors especially thank WilliamGoossen and Gunnar Nielsen for their activi-ties in the German summer school. The eventhas been supported by the German MedicalInformatics Association GMDS.

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Two years of German summer school of nursing informatics

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