Handheld technology and nursing education

Handheld Technology and Nursing Education:
Utilization of Handheld Technology in Development of
Clinical Decision-making in Undergraduate Nursing Students
A Thesis
Submitted to the Faculty
of
Drexel University
by
Frances Haider Cornelius
in partial fulfillment of the
requirements for the degree
of
Doctor of Philosophy
May 2005
ii
DEDICATIONS
I dedicate this dissertation to my family, whom I love dearly. To my husband,
John, who was my anchor and sounding board throughout this endeavor. To my children,
Ryan and Janis, who provided inspiration and a strong desire to be a good role model. To
my mom who was always there, quietly in the background doing whatever it took to
instill some semblance of order in our chaotic lives. To my sister, Gabe, who provided
much needed mini mental health breaks by sending me humorous emails as well as
inspirational messages. Finally to my dad who taught me early on that one should always
aim high and there is nothing you cannot achieve through hard work and perseverance.
Thank you all. Without you, this would not have been possible.
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ACKNOWLEDGMENTS
The pursuit of this doctoral degree has been an adventurous journey. It has been an
experience that has opened my eyes. I would like to express my gratitude to those
individuals who contributed to my learning in so many ways. First, a special thank you
to my chair, Dr. Elizabeth L. Haslam, who was wonderful to work with and provided me
with considerable encouragement and guidance. Second, I wish to thank to my
committee members, Drs. Mary Ellen Smith Glasgow, Alice M. Stein, Sheila Vaidya and
Wesley Shumar for the time and feedback you provided me throughout this process.
Your thought provoking questions have caused me to think in new and exciting ways. It
is difficult to express, in this limited space, the impact you have had on my personal and
professional growth. Dr. Elizebeth Smythe (2004) articulates my feelings best in her
statement:
The very nature of being human means that we cannot not-think. Every person
sitting in a classroom will be thinking about something (what others are wearing,
how long till lunch, what happened yesterday). Thoughts will always run around
our minds, infuse our emotions, and provoke our bodies. We seek thoughts and
thoughts seek us. There will be excitement, concern, bewilderment and clarity,
perhaps all in the same experience. The charge is not to ‘make thinking happen’
for that is beyond our abilities. The teacher, however, has the chance to capture
the focus of thinking, and invest the thinking time in a quest worthy of thought.
Thinking can infuse everything with fresh passion, with bold questions, with
radical insights. And it can be as simple as stopping to listen, as simple as asking
the right question at the right time. (p. 331)
Thank you all, for asking the right questions. I hope that I can do the same.
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TABLE OF CONTENTS
LIST OF TABLES ………………………………………………………….…………… ix
LIST OF FIGURES …….........………………………………………………………....... x
ABSTRACT …………………………………………………………………………….. xi
1.
2.
INTRODUCTION AND OVERVIEW…………………………………..………… 1
1.1
Introduction…………………………………………………………………… 1
1.2
Background…………………………………………………………………… 2
1.3
Purpose ………………………………………………………………………. 6
1.4
Research Questions…………………………………………………………... 9
1.5
Significance ……………………………………………………………..….. 10
1.6
Definition of Terms ……………………………………………………..….. 11
1.7
Limitations ……………………………………………………………….… 12
1.8
Delimitations …………………………………………………………….…. 12
1.9
Summary ……………………………………………………………….…… 13
REVIEW OF RELATED LITERATURE ……………………………………..…. 14
2.1 Introduction ………………………………………………………….……… 14
2.2
EPSS as a Model for Nursing Education ………………………………..….. 15
2.3
Situated Learning ……………………………………………..…………….. 18
2.4
Grounded Theory …………………………………………………..……….. 19
2.5
Complex Thinking ……………………………………………………..…… 21
2.6
Clinical Decision Making ………………………………………………..…. 23
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2.7
PDAs in Education ……………………………………………………..……28
2.7.1 Introduction …………………………………………………………… 28
2.7.2 PDAs in K-12 Education ………………………………………………28
2.7.3 PDAs in Higher Education …………………………………………….30
2.7.4 PDAs in Medical Education ………………………………………….. 32
2.7.5 PDAs in Nursing ……………………………………………………… 34
2.7.6 PDAs in Nursing Education ………………………………………… 36
2.6 Summary ……………………………………………………………………… 38
3.
DESIGN AND METHODOLOGY ………………………………………………. 39
3.1 Overall Approach and Rationale ……………………………………………… 39
3.2 Site Selection …………………………………………………………………. 43
3.3 GRIP – A PDA-Based Patient Assessment Tool ……………………………... 45
3.4 Reliability and Validity of the Tool …………………………………………... 47
3.5 Population Sample ……………………………………………………………. 48
3.6 The Student Experience – Traditional vs. New Method ……………………… 49
3.7 Methods ………………………………………………………………………..50
3.8 Reliability and Validity ……………………………………………………..… 51
3.9 Data Collection ……………………………………………………………….. 51
3.10 Field Observations …………………………………………………………... 53
3.11 Role of the Researcher ………………………………………………………. 55
3.12 In-Depth Interviews …………………………………………………………. 56
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3.13 Data Analysis ………………………………………………………………... 57
3.14 Verification of Data Collected ………………………………………………. 58
3.15 Protection of Human Subjects ………………………………………………. 60
4. RESULTS …………………………………………………………………………… 61
4.1 Overview of the Study ………………………………………………........... 61
4.2 Subject Demographics………………………………………………………. 61
4.3 Research Question One……………………………………………………... 62
4.3.1 Comparison of Faculty and Researcher
Identified Patient Care Priorities …………………………………62
4.3.2 Comparison of Student and Faculty Identified
Patient Care Priorities …………………………………………..... 64
4.3.3 Comparison of Student and Faculty Identified
Patient Care Priorities over Time………………………………….. 65
4.3.4 Comparison of Students and Faculty Identified
Patient Care Priorities by Clinical Site …………………………….66
4.4 Research Question Two …………………………………………………….. 67
4.4.1 Observational Data ...………………………………………………68
4.4.1.1 Tool functionality and design issues………………..…. 69
4.4.1.2 Patient related issues…………………………………… 69
4.4.1.3 Student related issues………………………………….. 71
4.4.2 In-Depth Interviews ………………………………………………. 72
4.4.2.1 Student Interviews ……………………………………….72
4.4.2.1.1 Question 1 - What stood out for you
during this project?............................................ 72
4.4.2.1.2 Question 2 - What should be done
differently in the future? .....................................75
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4.4.2.1.3 Question 3 – What were the unexpected
outcomes or changes that occurred as a
result of the GRIP tool? ................................... 78
4.4.2.1.4 Question 4 – How did you feel using the
GRIP tool? ......................................................... 82
4.4.2.1.5 Question 5 – Did the GRIP tool help or
hinder your decision-making? ………….…….. 84
4.4.2.1.6 Question 6 – Give examples of how you
used the GRIP tool ……………….…………… 86
4.4.2.2 Faculty Interviews ……………………………………….87
4.4.2.2.1 Question 1 – What stood out for you
during this project? …………………………….88
4.4.2.2.2 Question 2 - What should be done
differently in the future? ……………………… 88
4.4.2.2.3 Question 3 – What were the unexpected
outcomes or changes that occurred as a
result of the GRIP tool?..............................……88
4.4.2.2.4 Question 4 – Did the GRIP tool help or
hinder students’ decision-making? …………… 89
4.4.2.2.5 Question 5 – Give examples of how
students used the GRIP tool ………………….. 90
5. SUMMARY AND IMPLICATIONS FOR FUTURE RESEARCH ………………... 91
5. 1 Overview of Study ………………………………………………………….... 91
5.2 Conclusions …………………………………………………………………. 92
5.3 Limitations of Study ………………………………………………………….104
5.4 Summary and Recommendations for Future Research ……………………… 105
LIST OF REFERENCES …………………………………………………………........ 108
APPENDIX A: BENNER’S STAGES OF CLINICAL COMPETENCE …….…….....118
APPENDIX B: FIELD OBSERVATIONS ………………………………………….…120
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APPENDIX C: IN-DEPTH INTERVIEWS …………….……………….………..…... 122
APPENDIX D: PROGRAM CURRICULUM …………………………………………123
APPENDIX E: CLINICAL EVALUATION CRITERIA ………………………...……124
APPENDIX F: GRIP SCREENSHOTS ………………………………………..……..127
APPENDIX G: GRIP CONTENT EXPERTS ……………………………………....... 130
APPENDIX H: PILOT STUDY RESULTS…………………………………………... 132
APPENDIX I: FLYER ……………………………………………………………….. 135
APPENDIX J: EMAIL SENT TO STUDENTS ………………………………………136
APPENDIX K: CLINICAL PREP SHEET ………………………………………...... 137
APPENDIX L: GRIP TUTORIAL ……………………………………………..…….. 144
VITA ………………………………………………………………………………….. 155
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LIST OF TABLES
1. Traditional Clinical Decision Making Models Used in Nursing Practice………….. 24
2. Study Sequence……………………………………………………………..….….... 40
3. GRIP Assessment Modules………………………………………………..…......…. 46
4. Project Timeline………………………………………………………….….…..….. 52
5. Evaluation Matrix……………………………………………………….……………53
6. Assignment Sheet………………………………………………………………….…54
7. Comparison of Faculty and Researcher Identified Patient Care Priorities .………… 64
8. Comparison of Student and Faculty Identified Patient Care Priorities ……………... 64
9. Comparison of Student and Faculty Identified Patient Care Priorities over Time ......65
10. Comparison of Student and Faculty Identified Patient Care Priorities by
Clinical Site .………………………………………………………………………... 66
11. Study Sequence……………………………………………………………..……..… 67
12. Question 1: What stood out for you during this project? …........................................ 75
13. Question 2: What should be done differently in the future? ....................................... 78
14. Question 3: What were the unexpected outcomes that resulted from this study? .......81
15. Question 4: How did you feel using the GRIP tool? ...................................................84
16. Question 5: Did the GRIP tool help or hinder your decision-making?........................85
17. Question 6: Give examples of how you used the GRIP tool………………….…..… 87
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LIST OF FIGURES
1. Complex Iterative Clinical Decision-Making Process …………..……………….... 25
2. Complex Thinking and Clinical Decision Making Process …………………….…. 26
3. The Iterative Nature of Clinical Decision Making from Novice to Expert………… 27
4. Screen Shot of Self-Concept Pattern Question ……………………………….….… 70
5. The Iterative Nature of Clinical Decision Making from Novice to Expert ………... 95
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ABSTRACT
Handheld Technology and Nursing Education:
Utilization of Handheld Technology in Development of
Clinical Decision-making in Undergraduate Nursing Students
Frances Haider Cornelius
Elizabeth L. Haslam, PhD
This study investigated the benefits of introducing handheld computer technology
into undergraduate nursing education as a means to enhance the development of clinical
decision-making skills in undergraduate nursing students. It explored how handheld
technology can be used in nursing education to develop clinical decision-making skills
and evaluated the effectiveness of using the Gerontological Reasoning Informatics
Project (GRIP), a PDA-based assessment tool, to accomplish this goal. This case study
used qualitative and quantitative methods, including field observations, ‘on-the-spot’
informal interviews and a follow-up phase of in-depth interviews. During phase one,
clinical faculty identified and recorded the top three nursing care priorities of all patients
prior to giving student assignments. Students conducted assessments for assigned
patients utilizing the GRIP tool and also identified the top three nursing care priorities.
The researcher conducted assessments, also recording the top three nursing care
priorities. This data was analyzed to identify similarities between the three groups.
Twenty-six senior nursing students and two clinical faculty participated in this study,
assessing a total of 212 patients. Data collection also included in-depth interviews with
21 students and 2 faculty and field observation notes. The results suggest that handheld
technology, equipped with a tool such as GRIP, effectively develops clinical competency
and clinical decision-making skills in undergraduate nursing students. Students
identified the top three nursing care priorities at a level of expertise that compared
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favorably with faculty experts however the exact relationship between the use of the PDA
and the student ability to correctly identify these priorities remains unclear. About two
thirds of participants reported that the PDA was a barrier to the nurse-patient interaction.
Additional findings support the need to closely re-examine the GRIP tool, give serious
consideration to modifying the tool to improve design and functionality and to build a
web interface to support a virtual learning community of GRIP users.
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1. INTRODUCTION AND OVERVIEW
1.1 Introduction
Nursing students, while ever more computer and technically competent, continue
to have “problems identifying, defining, analyzing and articulating the nature of their
information needs” (Cheek & Doskatsch, 1998, p. 247) This may be due in part to lack of
hands-on experience accessing and utilizing relevant information in real-life, real-time
clinical experiences. Nursing educators must identify strategies to provide structured
learning activities that give students opportunities to practice accessing and utilizing
information in clinical settings. This, in turn, can support the development of clinical
competency and clinical decision-making skills. Personal Digital Assistants (PDAs),
having emerged as useful and often indispensable tools for healthcare providers, may be a
means to provide these structured learning experiences to nursing students in clinical
settings. Nurses as a group have been comparatively slow to adopt PDAs into their
practice. Primary reasons for the lag are lack of awareness of the potential uses of these
devices in healthcare and limited opportunities to "test-drive" these powerful tools in
one’s practice environment. (Hunt, 2002)
While the media has directed considerable attention at this exciting new
technology and its utility in clinical practice, there has been very little research
investigating the use of PDAs in health care and whether or not they contribute
significantly to the quality of nursing care, medication error reduction and clinical
decision-making. This may well be the case, since information required for clinical
decision-making is more readily available to the nurse with a PDA at the bedside, but
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there is no documented evidence supporting this belief. Clearly, a PDA is an effective
tool for streamlining documentation and accessing information (VanDenKerkhof,
Goldstein, Lane, Rimmer, & Van Dijik, 2003; Ruland, 2002; Ulfelder, 2002; Enger,
2001; Ruland, 1999) but there are no research studies that support the notion that it
improves nursing practice and decision-making. Specifically, no studies to date have
investigated the role of this technology in nursing education and development of clinical
decision-making skills in undergraduate nursing students.
1.2 Background
Accelerating technological advances in every arena over recent decades have had
an impact on all aspects of society, including the fields of education and healthcare.
Information overload has been one general result, and medical information in particular
has grown beyond a manageable level. Consider that, at the turn of the 21st Century,
medical literature added a new article every 20-25 seconds. Approximately 34,000
references from over 4,000 journals were added monthly to the National Library of
Medicine’s MEDLINE database, which included at the time only about 4% of all the
scientific journals published. (Young, 2000) In 2002, that increased to over 60,000 per
month almost doubling in a period of two years (National Library of Medicine, 2003).
Information is increasing exponentially, and access to and exchange of
information has become a major economic commodity. Employers are recognizing the
need to have employees who have “generic qualities that will enable them to adapt to
technical change and cope with a seemingly information overabundant environment”
(Cheek & Doskatsch, 1998, p. 243). This development presents a new challenge to
educators for “even the best and most comprehensive degree programmes cannot
3
anticipate and include all the changes that are likely to occur within an individual’s
lifetime”(Candy, 1994, p. 31). The specific challenge to nursing educators is the
development of student skills that promote clinical competency and complex thinking,
thus enabling these future nurses to access information efficiently from changing
technologies for the purpose of guiding their interventions in a variety of clinical practice
settings.
Traditionally, nurse educators have used structured learning activities in authentic
clinical settings to promote the development of clinical competency and complex
thinking among students. These real life experiences provide students with opportunities
to acquire knowledge in the settings in which it is to be applied (Neill et al, 1998). Such
situated learning remains highly applicable to nursing education today and can be further
enhanced through the introduction of point-of-care/point-of-need resources such as the
PDA.
Personal Digital Assistants have become one of the fastest selling consumer
devices in history. The Palm Pilot, the prototype for contemporary PDAs, was
introduced in 1995 and was a hit with consumers immediately, selling more than 1
million units the first year. (Freudenrich, 1997; Leong, 2001) Since then, sales have
skyrocketed. Sales for PDAs in the first quarter 2003 alone were almost 3 million.
(Inquirer, Tuesday, April 29, 2003) These devices have become well integrated in the
business world (Leong, 2001) and are making inroads in healthcare as well. “Total
revenues for healthcare mobile devices, applications and services were approximately
$50 million in 2002. This market is anticipated to grow significantly with a compound
annual growth rate of 120 percent to $1.2 billion in 2006.” (McGowen, November 1,
4
2003) In 2000, a survey of PDA use found that 20% of physicians and 1% of nurses used
the devices. (PDAcortex, 2003) A more recent survey, released in September of 2003,
indicated that these numbers have increased to 47% of physicians and 18% of nurses.
(Stolworthy, 2003)
Personal Digital Assistants have much to offer. These handy devices store,
organize, process and permit instant retrieval of important clinical and business
information. PDAs replace bulky reference note cards and outdated manuals. PDAs
move policies, references and standards of care from the shelf into the hands of nurses at
the bedside, in the office and in the home. (Hunt, 2002) According to VanDenKerkhof
et. al., patient assessments performed while using PDAs were more likely than paper
assessments to contain documentation regarding pain and side effects (e.g., nausea,
pruritus, and hypotension). The PDA may even enhance the efficiency of the patient
assessment process by providing more comprehensive digital data for research, clinical
and administrative needs. (VanDenKerkhof , Goldstein, Lane, Rimmer & Van Dijk,
2003)
These small computers have the capacity to store several clinical reference books,
which places the resources literally in the palm of your hand, easily accessible while
delivering care in a variety of settings. Other features, such as database input and
management and wireless technology, offer the healthcare provider additional resources
while saving time and may provide a means to deliver “just enough information, just in
time.”
Handheld computers are being used increasingly to “extend the human mind’s
capacity to recall and process large numbers of relevant variables and to support
5
information management, general administration and clinical practice” (Stolworthy &
Suszka-Hildebrandt, 2002). PDAs are utilized in the clinical setting primarily for
decision support and error reduction; checking drugs, dosages and compatibilities.
(Stolworthy & Suszka-Hildebrandt, 2002; McGowen, 2003)
The use of this technology has generated some criticism and the concern that it
will result in ‘de-skilling’ of the profession and decreased analytical, problem-solving
and clinical skills among healthcare providers. (De Ville, 2001; Martinsons & Chong,
1999) De Ville (2001) observes that these concerns are not unique to contemporary
educators, noting that Socrates’ worried 2,400 years ago that written documents would
lead to forgetfulness in the learner. He maintains that this technology merely provides
“information that is already available in a more convenient form…if clinicians give
electronic versions of standard research tools no more or less respect that they have given
their previously available hard copy versions, there is little reason for concern.” (p. 454)
Undoubtedly, information is valuable, often essential in helping healthcare
professionals do their jobs, but too much information can actually be a detriment to
practice. “An overabundance of information can actually keep an individual from
finding the information needed. While drowning in information, the individual may
starve for knowledge “(Young, 2000, p. 15). Information is only useful when it meets
the following criteria: It must be the right information, given to the right person, at the
right time, in the right place and in the right amount. It is only when these five criteria
are met that adequate decision support is available. (Young, 2000; Thede, 2003).
Information is critical to making sound decisions, and decision support
information is essential to nurses working with patients. The process of accessing
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relevant and timely information is an essential component of lifelong learning.
Understanding the context and manner in which nurses use an information retrieval
system is essential to that system's success. Such understanding provides insight into
how to make the right information available when the person needs it, with minimal
effort in an amount that answers the question without being overwhelming. In other
words, “just enough, just in time.” Understanding the user also gives nursing faculty and
leaders a grasp of the new skills nurses need in our cluttered information age and can lead
to educational innovations that facilitate development of those skills. By adopting this
technology, nurses can empower their practice by providing high quality care based on
current information and resources. When nurses have up-to-the-minute, patient specific
information, care is more likely to be appropriate, timely, effective, efficient and safe.
(Hunt, 2002)
1.3 Purpose
The purpose of this study is to investigate the effectiveness of handheld
technology in nursing education in the development of clinical competency and clinical
decision-making skills in undergraduate nursing students.
There is considerable discussion in the literature on handheld technology and its
use in healthcare. The emphasis is on practice resources, touting the value to the provider
as a means to improve efficiency, reduce errors, collect patient information for billing,
patient tracking and drug reference, not on research supporting its efficacy. Available
PDA resources for the healthcare provider are extensive and include:
1
Diagnostic Tools (identification and classification of disease)
2
Health and Fitness (lifestyle modification and alternative medicine)
7
3
Interventions (procedural and treatment protocols)
4
Investigations (lab tests and other diagnostic tools)
5
Record Tracking (databases for tracking healthcare)
6
References (grab-bag of medical knowledge base)
7
Research Tools (critical appraisal tools)
(PDAcortex, 2003)
Although not an exhaustive list, this clearly reflects the many resources available to
nursing faculty to integrate into curricula and enhance learning.
The use of handheld computers or personal digital assistants (PDAs) is relatively
new to the nursing profession, and PDA use in nursing education is in its early stages.
There is some evidence in the literature of PDA use in graduate nursing education.
(Suszka-Hildebrandt, 2001; Thomas, Coppola & Feldman, 2001; Kratt, 3-17-2003)
For
example, graduate nursing students at the University of Virginia School of Nursing began
using PDAs in early 2001 and are currently investigating the efficacy of handheld
technology in clinical nursing practice, although results are pending. (Huffstutler, Wyatt,
& Wright, 2002; Computers In Nursing, 2001) There is no record yet of use by students
in an undergraduate curriculum.
As PDA use in clinical settings has increased, nursing faculty have seen the value
of early introduction to students. References such as Lippincott’s Manual of Nursing
Practice: Procedures, Davis's Drug Guide for Nurses and others are essential resources
for the novice and can be stored easily in these pocket-sized devices. This has several
advantages: eliminating the need to carry several thick books to clinical settings and,
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more importantly, providing the student immediate access to information when a question
arises. This can provide a more enriching clinical experience for the student. It is that
"pedagogical moment," in addition to the resources that can be brought to the moment,
that provide opportunities for “exchanges of heightened meaning… within the
complexities of a given context” (Piantanida, Tananis & Grubbs, 2002, p. 2). The
structured methodology of grounded theory can form a framework for inquiry that will
provide nurse educators with an understanding of the conceptual relationships involved in
heuristics that will expand the student’s capacity to respond appropriately in practice
settings.
The adoption of any new technology into nursing practice is a challenging task.
The PDA is a tool, and just like the stethoscope or sphygmomanometer, the student must
learn to use it effectively. In an evaluative study among nursing students, Birx,
Castleberry and Perry, (1996) suggested that integration of computer technology into the
curriculum is an effective way to increase students’ computer skills while maintaining
positive attitudes towards computers. Skill is developed through consistent use in
clinical and classroom settings, across the curriculum, but additional skill-building
strategies must be identified for this technology.
Increasingly, the preparation of nurses involves development of skills need to
access information quickly and efficiently at the "point of care" or "point of need."
Accessing information is seen as a key curricular element. (Hunt, 2002) Cheek and
Doskatsch (1998) state: “Nursing graduates must be able to adapt to technical change and
cope with an environment where information is abundant. Attitudes, skills and
knowledge associated with information literacy must be cultivated in nursing education.”
9
(p. 247)
It is imperative that nurse educators incorporate into the curriculum opportunities
for students to develop critical approaches for utilizing technology as a tool for clinical
decision-making that will serve as a solid foundation for using technology later in their
careers. A key component of this is the development of the nurse as a lifelong learner.
(Cheek & Doskatsch, 1998) It is essential that nursing educators identify how this
technology can be effectively utilized to achieve this goal.
1.4 Research Questions
This research project has two goals:
1
To evaluate the effectiveness of handheld personal computers, equipped with an
assessment tool, in the development of clinical decision-making skills among
undergraduate nursing students.
2
To identify user issues associated with this technology in the clinical setting.
Mixed method research studies “need to have both qualitative and quantitative
research questions (or hypotheses) included in the studies to narrow and focus the
purpose statements.” (Creswell, p. 114) Therefore, this study investigates the following
questions:
1. What is the relationship between the use of handheld personal computers
(PDAs) and student’s ability to identify the three top patient care needs
(nursing diagnosis)?
2. What is the user experience associated with using this technology in the
clinical setting?
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1.5 Significance
Lindeman (2000) states that technology is having a significant impact upon
nursing education in that it mandates that nursing faculty work (and become comfortable)
in a “world of high technology in order to prepare nursing to work in a high technology
health care environment.” This presents nurse educators with the challenging task of
“structuring student learning experiences in an environment of rapidly changing
technology.” (p.6)
It is imperative for nursing educators to identify strategies to use this new
technology to support students in their development as life-long learners who are
proficient in utilizing technology as a tool for clinical decision-making. If effective
strategies are identified, new nursing graduates will be well prepared for a dynamic
healthcare environment in which innovation and transition is the norm. Such strategies
may also contribute to job satisfaction and retention. This is particularly important given
the current nursing shortage and growing enrollment of students who expect the
profession to provide career-long opportunities and job security. It is important to
identify educational strategies that will prepare students to be successful in their careers,
thereby reducing the attrition from the profession.
Effective utilization of information technology can make a difference to the
profession. “It can help people do a better job, but only if they are willing to use the
technology and if they become effective users” (Martinsons & Chong, 1999, p. 124).
Another concern is that often the technology and associated applications are, according to
Martinsons and Chong, misused, underutilized or abandoned. “Even a good technical
system may be sabotaged if it is perceived to interfere with an established social network.
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Thus a good understanding of the intended end-users, their tasks and the
interdependencies between the two is a likely prerequisite for IS (information systems)
success.” (p. 124) It is important that this be a major consideration for educators who
wish to experiment with this technology.
As stated earlier, it is impossible to provide students with all the knowledge and
skills they need to succeed in the future. The challenge for educators becomes
identification of innovative means, with the aid of new technology, that are effective in
building skills among students. The goal is to promote clinical competency and critical
thinking, among students, enabling them to access and retrieve information effectively
and efficiently, as the need arises or changes, for the purpose of guiding their nursing
interventions in a variety of clinical practice settings. If such strategies can be identified
and validated, they have the potential to revolutionize nursing education.
1.6 Definition of Terms
Personal Digital Assistants (PDAs) – any small mobile hand-held device that
provides computing, information storage and retrieval capabilities for personal or
business use. The term handheld computer is a synonym. (Gagne, Aug 09, 2000,
paragraph 1)
Clinical Competency – application of knowledge and skills appropriate to the
selected area of clinical practice. This involves demonstration of specific skills outlined
in the clinical evaluation form, which include clinical decision-making. (Appendix H)
Clinical Decision Making – Utilization of basic problem solving skills in
combination with current information/data to guide decision-making in the clinical area.
Nursing Care Plan – A document that reflects the nursing diagnosis and
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associated goals and interventions, which identify the type of care the patient needs. It is
developed using the Nursing Process
Nursing Diagnosis – A clinical judgment about patient needs related to actual or
potential health problems that serves as the basis for the selection of nursing
interventions.
Nursing Process – An organized, rational and systematic process of collecting
data from a variety of sources to evaluate the health status of a patient. The five-step
process includes: Assessment, Diagnosis, Planning, Implementing and Evaluation.
1.7 Limitations
Due to the purposive sampling procedure utilized in this study, the results may
not be generalizable to all undergraduate-nursing programs. Since some of the data were
collected through interviews, the accuracy is limited by the participants’ perceptions of
the experience as well as their willingness to share information. In addition, it would be
desirable to conduct a longitudinal study, which would permit observation of students’
skill development as they progress through the entire program benefiting from a
recursive, sequential component to learning and mastery.
1.8 Delimitations
Initially this study was confined to a purposeful sample of undergraduate nursing
students enrolled in the Accelerated Career Entry (ACE) Program at Drexel University’s
College of Nursing and Health Professions (CNHP). The investigation focused on one
course, NURS450 Contemporary Gerontological Nursing, during the winter or summer
2004 term.
Project participants included undergraduate nursing students enrolled in this
course as well as the nursing faculty associated with that course. Student nursing care
13
plan assignments completed during the term, using both the new PDA application and the
traditional pencil & paper method, were collected. These assignments were analyzed and
evaluated in comparison to benchmarks and performance standards established by course
faculty. In addition, the researcher conducted in-depth interviews as well as field
observations.
1.9 Summary
The advent of handheld technology has facilitated access to up-to-date clinical
information for healthcare providers where it is needed most – at the point of care.
Clearly, having the information available at the point-of-care or point-of-need, whether it
be at the bedside, in the clinic or in the classroom, can help students have a more
enriching learning experience and as a result, make better decisions. Developing skills
among student nurses that enable them to become proficient in accessing, retrieving and
using information to guide their nursing interventions is essential. The challenge to nurse
educators is to investigate and identify effective educational strategies or tools, such as
the PDA, to achieve this goal.
14
14
2. REVIEW OF RELATED LITERATURE
2.1 Introduction
While the use of handheld technology in nursing education is a relatively new
phenomenon, the devices have demonstrated considerable potential as a means for nurse
educators to achieve the goal of preparing nursing professionals for the challenges of the
21st Century.
To gain a better understanding of potential benefits and current
applications of this technology, a review of the literature will examine educational
models for business and academia, complex and critical thinking theories and current use
of handheld devices in education.
There has been considerable discussion about the usefulness of these devices at
the point of care. To gain a better understanding of the benefits of providing information
when and where it is needed, one must look to the world of business. The review of the
literature regarding Electronic Performance Support Systems (EPSS), which have been so
successful in the business world, will be conducted to demonstrate the potential this
technology offers the profession. (Gery, 2003; Gery, 2002) An overview of situated
learning and its relevance to nursing education to promote student skill development will
also be presented. The value of grounded theory methodology as a means to structure
this inquiry will be presented as well. An examination of the research on higher order
thinking and the challenges educators face when attempting to develop this in students
will provide additional support to the idea of utilizing this powerful new technology in
education.
15
While Personal Digital Assistants are not common in nursing education, they have
been widely used in other educational arenas, including K-12 and higher education. The
review will discuss results of these endeavors and lay a foundation that supports and,
indeed, encourages additional investigation to identify strategies to utilize this technology
to prepare nurses who are not only clinically competent but also able to adapt to changing
demands in the future.
2.2 EPSS as a Model for Nursing Education
Electronic Performance Support System (EPSS) may provide solutions for nurse
educators who are looking for innovative approaches to develop student decision-making
skills. EPSS is an electronic system that provides access to information, advice, tutorials
and tools that can assist the individual in performing a task with the minimum support of
others. (Bill, 1997, paragraph 6) The intent of an EPSS is to create an environment in
which the individual can become an autonomous and self-directed learner by providing
immediate access to information/support—when it is needed, at the place where it is
needed and in the amount and form in which it is needed. (Bill, 1997; Sleight, 1993) An
effective EPSS provides access to the discrete, specific information needed to perform a
task at the time the task is to be performed. (Sleight, 1993)
This concept is intriguing and full of possibilities, but Gery (2003) provides a
cautionary note. True, the idea of providing students with the "threads" of information,
guides or manuals at the point of need is desirable, but it is only the beginning. Gery
maintains that it is only when the various threads are integrated in a given work context
that the goal is achieved. Since the "weaving" has in most cases been left to each
individual, and individuals vary enormously in their capacity to create precisely the right
16
outcome in a given situation, it seems logical to look to new technology to do this, thus
supporting the individual and, more importantly, obtaining the desired optimal outcome
consistently. This observation is even more significant when one considers the
increasing complexity and contextual nature of nursing care. It is becoming more and
more difficult for the student to comprehend a given performance situation—including
the relevant data—and be able to integrate its unique components of process, content,
tools, collaboration (or the involvement of others). Gery states that has become an
“almost impossible task because of the following factors:
1
Too many variables, rules, and relationships
2
Too little time
3
Too little experience or expertise
4
Too much pressure
5
Too few experienced resources to help in the weaving
6
High anxiety due to the increasingly significant consequences of error” (Gery,
2003, paragraph 4)
Gery goes on to say that the more difficult or complex the situation, “the more
threads we spin and throw at people. If you watch people try to perform, you see them
grasping at threads…often without rhyme or reason—hoping to get the right resource,
tool, or person. People are strangling among the threads.”(Gery, 2003, paragraph 5) This
problem can be solved, Gery suggests, by using available technology to "weave the
threads of information" into integrated resources accessible at the point of care but such
initiatives must go even further to support the student in becoming a reflective and
17
anticipative practitioner whose actions arise from the “fluidity of rehearsals and
accomplishments that constitute practice across routine and contingent situations.”
(Beckett, 2001, p.75)
In addition, there is considerable discussion in the literature about the notion of
providing learning/training in the work environment. Instruction, where possible, must be
taken out of the passive classroom environment. Learning/training in the actual work
environment is widely used in industry and is considered not only cost effective and time
efficient but also a way to improve productivity and reduce errors (Gery, 2003;
Christensen & Greene, 1998; Beckett, 2001; Merrienboer, Clark & Croock, 2002).
This
concept is based upon the principle that complex learning is increased when it occurs in
real work-life situations. It includes constructivism, organic learning/training and can be
applied to nursing education. Nursing faculty have long observed that students have
difficulty transferring knowledge and skills to the clinical setting. This would support the
notion that the gap needs to be bridged at the clinical area. Work remains to be done on
identifying educational supports that assist students in the process of transferring
theoretical knowledge to clinical practice. Identifying how students do this and how
educators can help them do it is essential. Clearly, the majority of this instruction should
take place on the clinical unit.
A key point made by Christensen and Greene (1998) is that instruction must be
designed systematically to meet both present and future needs. This involves creative
approaches to using new technology and indeed, pushing this technology in innovative
directions. Technology can assist the process of integrating information the student
needs. More importantly, this information is now more easily accessible at the point of
18
care (need) in the form of very powerful handheld devices. This supports the notion of
providing opportunity for learning to take place in the work (clinical) environment.
Clearly, such a model has a high degree of applicability to health education, since
development of an autonomous, self-directed learner is a key objective of nurse
educators.
2.3 Situated Learning
Situated learning is a general theory of knowledge acquisition and is a function of
the activity, context and culture in which knowledge is acquired or used. It is based on
the premise that in order for knowledge to be useful, it must be situated in a relevant or
real-life context. (Lave, 2004; Brown, Collins & Duguid, 1989) Advocates of situated
learning suggest that effective learning should take place in the context in which a
particular knowledge is to be applied. They argue that in order for knowledge to be useful
it must be situated in context and describe any knowledge that is taught out of context, as
in traditional classroom settings, as inert knowledge.
Supporters of situated learning maintain that educators should use strategies that
support social interaction and collaborative learning, incorporating authentic
tasks/activities to support the knowledge creation process. The role of the teacher is thus
to help students construct knowledge instead of giving them a particular set of knowledge
with a pre-defined structure. Hence, designers of situated learning should try to
incorporate authentic tasks: "real-life problem solving including ill-structured goal and
opportunity for the detection of relevant versus irrelevant information." (Young, 1997)
Education should embrace the enculturation process and allow students to learn
by engaging in authentic activity, i.e., through cognitive apprenticeship. (Brown &
19
Duguid, 1991; Brown & Duguid, 1992; George, et al., 1995; Robey, et al., 2000) It is in
real-life clinical experiences, where students have the opportunity to observe and interact
with experts, that skill and professional knowledge is acquired. “The individual learner is
not gaining a discrete body of abstract knowledge which (s)he will then transport and
reapply in later contexts. Instead, (s)he acquires the skill to perform by actually engaging
in the process, under the attenuated conditions of legitimate peripheral participation.”
(Hanks, 1991, p. 14)
This theory supports providing students with learning opportunities in the clinical
setting and therefore has a high degree of applicability to nursing education. This notion,
coupled with such available technologies as handheld access to additional references and
resources at the point-of-need, can provide very rich real-life learning experiences.
2.4 Grounded Theory
Grounded theory is the end result of a rigorous research methodology that moves
inductively from the specific to the general in an effort to understand observed,
contextually based phenomena. It is developed from data involving a method that uses a
systematic set of procedures to explain a phenomenon and thus understand the underlying
social/contextual forces influencing that phenomenon. Grounded theory methodology is
a very labor intensive process and requires that the researcher continually and
painstakingly study data gathered from in-depth interviews, open-ended questions, skilled
observations and other sources. (Davidson, 2002; Gillis & Jackson, 2002; McCarthy,
2001; LoBiondo-Wood & Haber, 1994). This process is not a linear attempt to fit into
existing theories. Rather, it involves simultaneous data collection and analysis to develop
rich, dense and complex analytical frameworks. (Fitzpatrick, 1998) The theory is
20
allowed to emerge: “…it is discovered, developed and provisionally verified through
systematic data collection and analysis of data pertaining to that phenomenon. Therefore,
data collection, analysis and theory stand in reciprocal relationship with each other.”
(Strauss & Corbin, 1990, p. 23)
According to Charmaz (2000) the “strengths of grounded theory methods lie in (a)
strategies that guide the researcher step by step through an analytic process, (b) the selfcorrecting nature of the data collection process, (c) the method’s inherent bent toward
theory and the simultaneous turning away from a contextual description, and (d) the
emphasis on comparative methods." (p. 599)
Piantanida et al. (2002) identify the need to utilize grounded theory within
practice “not to prove that our interpretations are right or true, and thereby, provide a
basis for prescriptive interventions” but to “understand and portray the range of meanings
that we and others might bring to our discursive exchanges, thereby expanding our
capacity to respond wisely within the ‘discursive moments’ of practice.” (p. 3) Given the
practice-based, context-bound nature of nursing, this point is particularly significant.
Grounded theory is particularly useful in this study, which strives to identify the
underlying relevant social/contextual forces associated with use of PDAs in nursing
education while avoiding any pre-conceived notions. As stated by Strauss and Corbin
(1990), “one does not begin with a theory, then prove it. Rather, one begins with an area
of study and what is relevant to that area is allowed to emerge." (p.23)
It is the intent of this study to learn what is relevant in the situation under
investigation and to use that to “…define conditional statements that seeks to interpret
how subjects construct their realities” in order to develop a “set of hypotheses and
21
concepts that other researchers can transport to similar research problems and to other
substantive fields” (Charmaz, 2000, p 594) This requires meticulous review and rereview of data collected through field observation and interviews. These procedures will
constitute a framework for inquiry that will offer nurse educators an understanding of the
conceptual relationships involved in utilization of PDAs in nursing education, thus
providing both explanation and understanding of the phenomena under investigation.
2.5 Complex Thinking
While an automated and integrated system such as EPSS may have applicability
to nursing education, such a system can only succeed when used by individuals who are
able to evaluate critically the information provided by the system. Indeed, it is
imperative that users of information “develop higher order thinking skills which facilitate
the process of acquisition, management and the use of health care information.” (Robins,
1998, p. 228) This process begins with the ability of the student to problem-sense, in
other words, to comprehend the problem or gap in information. Nursing educators have
observed that while student nurses are becoming more techno-savvy, they continue to
have problems “identifying, analyzing and articulating the nature of their information
needs.” In addition, students often have difficulty judging the appropriateness and value
of a variety of information sources.” (Cheek & Doskatsch, 1998, p 247) Clearly, this is a
problem for an information-dependent profession. Students must be able to perform
critical/creative/constructive thinking by analyzing the knowledge, information or
situation before identifying creative, next-step options or possibilities for
action/intervention. Finally, the student must construct meaning, assign value and make
a decision. (Thomas, 1998)
22
Critical thinking is described as the “intellectually disciplined process of actively
and skillfully conceptualizing, applying, analyzing, synthesizing and/or evaluating
information gathered.” (Thomas, 1998, p. 228) So, in order to become proficient in
accessing and utilizing information, students must develop critical thinking skills that will
enable them to use information appropriately. The body of literature also suggests that
there are four fundamental constituents of critical thinking. These are: 1) a prerequisite
knowledge base, 2) a series of intellectual skills, 3) a tendency or disposition to use both
knowledge and skills in scrutinizing and evaluating information and 4) a series of
intellectual standards to which such thinking should conform. (Ennis 1985; Siegal 1988;
American Philosophical Association, 1990; McPeck, 1990; Norris 1990; Gilovich 1991;
Paul 1991; Facione et al. 1994, Paul & Heaslip 1995)
Critical thinking and creative thinking culminate in complex thinking. Complex
thinking, or higher-order thinking, requires that students go beyond “conceptualizing,
applying, analyzing, synthesizing and/or evaluating information gathered” (Ribbons,
1998, p 228) and begin manipulating information to construct knowledge, solve problems
and gain a new understanding. It is a process that requires active involvement of the
learner and is most effective/meaningful when conducted in real situations. Such situated
learning provides more meaningful learning experiences that help develop the student’s
ability to sense problems, access information and solve problems. PDAs may provide the
means to engage students in such situated learning experiences and, as Ribbons observes,
this technology can be utilized as “cognitive tools (that) may provide an innovative
method of achieving these outcomes.” (Ribbons, 1998, p 228)
23
2.6 Clinical Decision-making
Clinical decision-making is a problem solving activity that focuses upon defining
patient problems and selecting appropriate interventions. (Higuchi, 1997) It is a process
that guides nursing practice. It involves a systematic approach to gathering and analyzing
information and is supported by complex thinking skills. This process of evaluating and
synthesizing information provides the opportunity to construct new knowledge and
understanding.
Both the systematic approach and complex thinking skills are
prerequisites for sound clinical decisions. (Conrick, 1997; Higuchi, 1997)
Conrick (1997) points out that even though all students have been engaged in
problem solving activities since early childhood, teaching clinical decision-making and
problem solving is a process that expands upon these existing talents and then encourages
the students to develop the specific techniques used by nurses for clinical decisionmaking. It is a complex process, because educators must also consider variables that
include the “range of learners' ages, the individuals' past learning and life experiences,
their individual approach to solving problems and the dynamic nature of the content to be
covered.” (¶45)
A review of the literature reveals several models to consider when examining
clinical decision-making in nursing. Higuchi discusses three models that she identifies as
the most commonly used to teach clinical decision-making: the Nursing Process, the
Nursing Diagnosis Process and the Diagnostic Reasoning Process. Of the three, Nursing
Process goes beyond the other two by including planning, implementation and evaluation
steps (see Table 1).
24
Table 1: Traditional Clinical Decision Making Models Used in Nursing Practice
Higuchi, 1997, p. 6
Higuchi points out that the three models are “limited to collecting patient
information and assigning a diagnostic category or label to the patient cues or cue
clusters” and do little to identify the cognitive processes required for effective decisionmaking. (1997, p. 6) She recommends that a conceptual framework for clinical decisionmaking include a contextual component that incorporates the situational aspects of the
decision-making process such as 1) setting, 2) clinician expertise (or, in this study,
student clinical competency) and 3) task (or problem) variables. Martin’s (2002) study
supports this recommendation and the notion that clinical decision-making is an outcome
of critical thinking that is influenced by similar contextual components.
In addition, effective clinical decision-making requires access to information.
Information, in order to be useful, must be relevant, timely and available at the point of
25
need. It can be obtained from a variety of sources such as the medical record, lab reports
and medical references, not to mention the patient. (See Figure 1.) This model
demonstrates how these components affect the entire complex and iterative clinical
decision-making process.
Figure 1: Complex Iterative Clinical Decision-Making Process
Effective clinical decision-making requires both complex thinking and access to
information. Ribbons (1998) states that complex thinking, a higher level thinking, is a
culmination of critical and creative thinking and both are essential precursors for clinical
decision-making. (See Figure 2.)
26
Figure 2: Complex Thinking and Clinical Decision Making Process
Martin proposes a critical thinking theory that is based on Benner’s (1984) Stages of
Clinical Competency and includes the concept that development of clinical competency is
a process that occurs over a period of time. Benner’s model describes a predictable,
sequential evolution from novice to expert and is accompanied by specific skill
developments/characteristics. (See Appendix A.) This concept supports the iterative
nature of the process of developing clinical decision-making skills and provides a model
to clarify this process. (See Figure 3.)
27
Figure 3: The Iterative Nature of Clinical Decision Making from Novice to Expert
The framework of this study of the development of clinical competency and
decision-making skills among undergraduate nursing students is based on a model of
clinical decision-making developed by this researcher, which incorporates the nursing
process, Benner’s Stages of Clinical Competency and complex thinking theory. While
Benner’s work focuses primarily on graduate nurses, it is the researcher’s belief that this
process is iterative and begins early in nursing education. Clinical experiences are
contextually or situationally based, the process in which the student acquires clinical
decision-making skills both predictive and recursive in nature. The foundation that
supports development of the skills set essential for a practicing nurse must be established
28
early in the academic career. Maynard states that while “new graduates are novices and
not finished products…. The educational process must provide the skills and knowledge
upon which the neophyte can develop an experiential base and service the opportunity
and time for development.” (January, 1996, p. 17)
2.7 PDAs in Education
2.7.1 Introduction
Clearly these small, powerful, portable devices can offer much to education.
PDAs can encourage active involvement of the learner by providing both individualized
and collaborative learning activities as well as eliminating the physical constraints of the
classroom setting. The use of non-traditional settings can result in more
effective/meaningful learning in real situations or contexts. Since the late 1990s, PDAs
have become increasingly visible in education. Initially, these devices were introduced in
grades K-12, but not long afterwards they emerged in higher education as well. Initial
successes have increased interest among educators, and a body of knowledge is emerging
from classroom experiments. Experts in higher education appear intrigued with the
possibilities this new technology may offer in supporting development of higher level
thinking among students.
2.7.2 PDAs in K-12 Education
Review of the literature on extensive K-12 use of handheld computers suggests
great potential in higher education, where use has not been as common. Several studies
(Crawford & Vahey, March 2002; Ray, McFadden, Patterson, Hocutt & Jenks, 2001,
Brooks-Young, 2002; Bauer & Ulrich, Nov 2001) report overwhelming positive response
to classroom use of handheld technology. In one extensive report (Crawford & Vahey,
29
March 2002) that examined the use of Palm PDAs in K-12 schools in urban, suburban
and rural settings, 95.6% of teachers indicated that handheld computers were an effective
instructional tool for classroom teachers, and 93% stated that the use of handheld
computers contributed positively to the quality of learning activities their students
completed. The major benefits cited were portability, ease of access and ability to
integrate computing into a wide variety of educational activities as well as promoting
autonomous learning and student organization, student motivation and student
collaboration and communication through use of infrared beaming and supporting
inquiry-based instructional activities.
Teachers also reported a very high acceptance of handheld computers in their
classrooms as well as a high level of enthusiasm for the many enhancements these
devices can bring to the learning process. Of participating teachers:
1
96.5% indicated that they believed handheld computers were an effective
instructional tool for teachers.
2
73.3% said handheld computers were more easily used in the "flow of
classroom activity" than desktop computers.
3
97.6% stated that they plan to continue using handhelds in instructional
activities with students. (SRI International, 2002, p. 6)
Another study demonstrated that PDAs can foster a socially supportive learning
environment that can build self-esteem and a sense of empowerment as well as the ability
to self-regulate. (Hunt, Alwell, Farron-Davis & Goetz, 1996)
30
2.7.3 PDAs in Higher Education
The success of these devices in K-12 education has not gone unnoticed by those
in higher education, and a number of universities have to experiment with handheld
devices. These endeavors range from broad institution-wide initiatives to smaller coursespecific activities.
The University of South Dakota was the first institution of higher learning in the
United States to mandate the use of handheld computers. This ambitious initiative began
in the 2001-2002 academic year for all first-year undergraduate students as well as firstyear law and medical school students. Other institutions are introducing PDAs on a
smaller scale, at program, course or project levels. University of Minnesota Duluth, for
example, requires all incoming freshman in computer science and engineering to have
handheld devices. Carnegie Mellon, George Fox, Wake Forest and Virginia
Commonwealth Universities have a number of smaller projects under way. (Deneen,
2001; Blurton et al, 1999)
Faculty that have effectively integrated handheld technology into meaningful
learning activities have had positive a reception by students. For example, at University
of Minnesota Duluth, students were able to download handheld applications as a basis for
class discussions as well as learning activities. In other instances, PDAs provided a
means for a professor to make the classroom paperless by beaming assignments, required
readings and grading rubrics. At East Carolina University, faculty are using this
technology to provide wireless, anyplace/anytime access to course content and
assignments. At yet another, the device is one of the learning tools used by music
31
students for pitch recognition. (Deneen, 2001; Ray & McFadden, 2001; Roach, January
17, 2002)
A review of the literature does, indeed, reveal considerable interest in higher
education regarding the potential of this new technology. (Ray, 2001, Deneen, 2001;
Varnum, 2000) It appears that PDAs are becoming major technology tools in higher
education and are likely to become an integral part of the educational landscape on
college campuses in the very near future. (Peterson, November 1, 2002) Educators are
becoming more acutely aware of the possibilities that this technology can enable
important changes in curriculum by fostering active learning through work on complex
projects, rethinking of assumptions and discussion. They are testing strategies that could
influence, and perhaps even significantly alter, the student’s total course of study and
have a significant cumulative effect upon higher education. (Ehrmann, 1995)
It is important to note, however, that there has been little investigation into the
effectiveness of this innovation upon terminal learning outcomes. Most of the literature
describes early investigation of strategies to integrate PDAs into college teaching and
learning. Preliminary work appears to be focused predominantly upon course
organization, content delivery, test preparation and course specific references such as a
periodic table for a chemistry course, which seem to serve as course enhancements rather
than techniques to develop higher-order thinking among students. (Peterson, 2002;
Varnum, 2000) The question that remains: Does the introduction of this teaching strategy
have a long-term impact upon the student? Ehrmann states that there must be a recursive,
sequential component to learning and that mastery must “accumulate over a series of
courses and extracurricular experience. Thus, to make visible improvements in learning
32
outcomes using technology, (educators must) use that technology to enable large-scale
changes in the methods and resources of learning. That usually requires hardware and
software that faculty and students use repeatedly, with increasing sophistication and
power.” (March/April 1995, ¶ 47) Clearly, more research is needed.
2.7.4 PDAs in Medical Education and Practice
Medicine has been the first discipline to integrate handheld computers. Many
medical schools are leading the way by using these devices to monitor student
performance, enhance student-educator communication, improve course management and
ensure that students have the latest information as they move between classrooms and
clinical settings. (Fallon, 2002; Saywell, 2003; Moffett, Menon, Meites, Kush, Lin,
Grappone & Lowe, 2003) PDAs are rapidly becoming as common as stethoscopes at
dozens of U.S. medical schools, with just under 25% of the country’s 125 medical
colleges requiring their third- and fourth-year medical students to use handheld
computers. Even at colleges that don’t require handhelds, large numbers of students own
and use these handy devices to (Fallon, 2002)
Physicians and medical students are quickly adopting this mobile technology as a
means to keep pace with their fast-paced work mode and the flood of new information
required to guide their daily practice. The devices provide medical students ready access
to clinical references in a variety of settings, which clearly facilitates student performance
and may improve learning. It is likely they will use the device more frequently and to
greater advantage simply due to convenience. Ready access to comprehensive references
during the clinical encounter may improve patient care as well. (De Ville, 2001; Fallon,
2002) Tschopp and Geissbuhler (2001) discuss the value of these devices in achieving
33
this outcome, reporting observations of “changes in physician’s information-fetching
patterns toward more frequent usage of medical resources” (p. 766) These observations
lead the researchers to the assumption of a positive impact upon quality of patient care,
but to date there have been no data supporting this conjecture.
Current use among practicing physicians is 33% among those under 45 years old
and 21% among older physicians. On closer examination, it is evident that the majority
of physicians use the PDA mainly for personal activities, although the number of those
using the devices as an integral part of their practice has risen from 18% in 2001.
(Healthcare Risk Management, 2001; PDA Cortex, 2003). Conservative estimates
project that by 2005, 50% of physicians will be using PDAs as a point-of-care medical
informatics tool (Bertling, Sipson, Hayes, Torre, Brown & Schubot, 2003).
Current use of PDAs in medical schools centers around a variety of medical and
drug references, clinical prediction applications and data/charge collection tools. These
applications are viewed by all as effective tools to save time, improve accuracy of data
collection, reduce medication errors, improve management and recording of patient
information and facilitate accurate documentation of care provided thus increasing charge
capture. (Young, January 26, 2003; Hochschuler, June 2001; Sausser, 2002; Blackman,
Gorman, Lohensohn, Kraemer, Svingen, 1999; McBride, Anderson & Bahnson, 1999).
Much of the literature discusses the use of PDAs to access drug information and how this
saves time and, more importantly, prevents costly medication errors. (Fischer, 2002,
Rothschild, Lee, Bae & Bates, 2002; McCreadie, Stevenson, Sweet & Kramer, 2002;
Grasso & Genest, 2001) Others have reported the utility of PDAs in facilitating
documentation and patient tracking, again saving time but also improving accuracy,
34
timeliness and quality of patient information. (Rao, 2002; Eastes, 2001; Pipas, Carney,
Eliassen, Menghol, Fall & Olson, Schifferdecker, Russell, Peltier & Nierenberg, 2002;
Siddiqui & Butcher, 2002; Wofford, Secan, Herman, Moran & Wofford, 1998) Another
study reports efficacy as a tool for faculty to monitor and evaluate medical student
clinical performance as well as tool for students themselves to self-monitor for
continuous improvement. (Bertling, Simpson, Hayes, Torre, Brown & Schubot, 2003)
While one may wish to surmise that the availability of these tools at the point of
care has a direct correlation to the ability of the medical student to achieve mastery, there
is minimal evidence in the literature that this is true. There is some discussion of the
value of evidence-based practice guidelines and clinical prediction tools for the PDA,
which can serve as decision assist programs to guide clinical practice. Wilcox and La
Tella (2001) discuss this potential superficially, inferring that this can improve medical
practice. De Ville (2001) points out that this technology must be approached cautiously,
as there is no evidence that it can support development of analytical, problem-solving and
clinical skills and may in fact be a detriment, as users may become so dependent upon the
tool that they may not be able to think on their own. De Ville states that since medical
students do not have “fully developed skills for clinical analysis and diagnosis” such
tools must be used with extreme caution so as not to lose the “foundational skills and
habits of the mind” (p. 460). Others are encouraged by the potential of this technology.
(Helwig & Flynn, 1998, Ebell, 1998; Wilcox & La Tella, 2001)
2.7.5 PDAs in Nursing
PDAs are a relatively new technology for the nursing profession and data
supporting its efficacy are slowly emerging. A review of the literature reveals that
35
dissemination within the profession is following a pattern similar to that of medicine.
That is, for the most part, available data support the utility of this device in saving time,
reducing paperwork and improving accuracy of patient data. (Towers, 2000)
In some instances, putting the devices into the hands of nurses was a business
decision. In early 2001, for example, the Visiting Nurses’ Association (VNA) Home
Health Systems, in Santa Ana, California, was the first organization to initiate
progressive, institution-wide integration of PDA technology into nursing practice and did
so primarily as an employee retention tool. The VNA was also one of the first home
healthcare organizations in the nation to develop PDA software for nursing staff that
would improve accuracy, save time and streamline paperwork. Administrators found,
however, that PDAs also gave nurses access to essential patient information (lab results,
physician orders and other disciplines’ reports) at the point of care, which aided in
clinical decision-making and resulted in obvious benefits for patients. Employee
retention rates dropped to 4.5% from a high of 27%, a shift that administrators attribute to
the introduction of PDAs. (Ulfelder, 12/23/02)
In addition, there is growing evidence that PDAs can improve quality and
documentation of patient care. Studies have demonstrated that PDA assessments were
more likely than paper assessments to document pain and side effects (e.g., nausea,
pruritius, hypotension). The PDA may even enhance the efficiency of the assessment
process through the provision of more comprehensive digital data for research, clinical
and administrative needs. (VanDenKerkhof, Goldstein, Lane, Rimmer & Van Dijik,
2003) PDAs can provide computer-based support to record specific patient preferences
and priorities, which can shift nursing focus/interventions in response to these cues. This
36
not only provides a mechanism for patients to share in decision-making but has also
demonstrated effectiveness in improving nursing care, resulting in outcomes that are
more congruent with identified patient preferences. (Ruland, 2002, Ruland, 1999)
PDAs can also serve as data collection tools to gather clinical results in research
studies faster and more accurately and, in the end, help the healthcare community
incorporate new findings into clinical practice. This technology has proven to be the
fastest, most accurate and cost-efficient method for transferring field data into a computer
for analysis. (Hecht, 1997) The individual can enter data once in the clinical setting,
while it is still fresh in the individual’s mind. Electronic transfer to the computer
eliminates the risk of data entry error. This is a particularly significant benefit for the
present study, as these devices provide a means for collecting considerable data that may
demonstrate the usefulness of PDAs in nursing education.
2.7.6 PDAs in Nursing Education
The use of PDAs in nursing education is also a relatively new phenomenon. Just
as with medical students, emerging data support the premise that these devices encourage
learning by engaging students in information-seeking activities in real-life situations.
Much of the literature reflects initial ventures into this area of research, and much of the
data supports only that it increases organization, saves time, improves accuracy of
documentation and contributes to student satisfaction. (Suszka-Hildebrandt, 2001;
Thomas, Coppola & Feldman, 2001) What has yet to be demonstrated is the
effectiveness of this technology in the development of life-long learners who are
proficient in utilizing technology as a tool for clinical decision-making.
37
Most current use of PDAs is limited and course specific. For example, in spring
2001, the University of Virginia, School of Nursing (UVA-SON) introduced PDAs into
the graduate nurse practitioner program, becoming the first to require all students
enrolled in advanced pharmacology to purchase a PDA in place of standard reference
books. In this pilot project, students used two drug references: Epocrates and Tarascon
ePharmacopoeia. (Suszka-Hildebrandt, 2001) Preliminary results indicate that both
faculty and students believed the device was a valuable resource. “What would normally
have taken time to access via the ‘normal channels’ of asking a pharmacist or leaving the
room to check a reference book, was accessed with a few pen strokes in less than two
minutes.” (Suszka-Hildebrandt, 2001) This preliminary data spawned an ambitious study
at UVA-SON of the effect of PDAs on accessing evidence-based research and clinical
decision-making. (Results are not yet available.)
Columbia State University, School of Nursing has also recently initiated a PDA
project in its Medically Indigent Rural Area Psychiatric Nurse Practitioner Program.
This project provides students with access to the current medical resources, which are
typically available only at an urban medical center. The objective is for students to be
able to "immediately review medical issues relevant to the patient’s unique history and
make a diagnosis using up-to-date research and information.” (Kratt, 3-17-2003)
In another example, nursing faculty at Lienhard School of Nursing at Pace
University conducted a pilot study with students (N=8) enrolled in a community health
nursing course. Faculty and students used a commercial application, Nightingale
Tracker, to enhance student learning and performance. Both reported high levels of
satisfaction due to the ability to organize patient data and enter it during the home visit,
38
which was a significant timesaver. The next phase will involve integration of the PDAs
into student hospital experiences with embedded practice guidelines. The intent is to
investigate the effectiveness of PDAs upon patient outcomes.
Columbia University School of Nursing (CUSN) is also using handheld
computers for an initiative designed to promote evidence-based, error-free patient care in
nursing in the Advanced Practice Nursing program. (PDACortex, Feb. 20, 2002) Clearly
the initiative to integrate PDAs into nursing curriculum is gaining momentum.
2.8 Summary
While PDA use in higher education is increasing, there is presently little data
available on the effectiveness of PDAs in the development and support of higher-level
thinking at the point of care. In particular, there is little in the literature regarding the
effectiveness of handheld computer use in nursing and nursing education and its
effectiveness in development of clinical skills and decision-making. What literature is
available clearly indicates that this technology is capable of truly revolutionizing both
nursing care and nursing education; saving time, reducing errors, improving efficiency
and, more importantly, the quality of patient care through improved access to tools that
support clinical decision-making—at the point of care.
39
39
3. DESIGN AND METHODOLOGY
3.1 Overall Approach and Rationale
This study investigated the benefits of introducing handheld computer technology
into undergraduate nursing education as a means to enhance development of clinical
decision-making skills in undergraduate nursing students. It explored how handheld
technology can be used in nursing education to develop clinical decision-making skills
and evaluated the effectiveness of using a PDA-based assessment tool, developed inhouse, to accomplish this goal. As stated earlier, this research project had two goals:
1
To understand how handheld personal computers, equipped with an assessment
tool, can be utilized in the development of clinical decision-making skills among
undergraduate nursing students;
2
To describe user experiences with this technology in the clinical setting.
Specific research questions associated with this investigation are as follows:
1
What is the relationship between the use of handheld personal computers (PDAs)
and student ability to correctly identify the three priority patient care needs?
2
What is the user experience associated with this technology in the clinical setting?
This study was of a qualitative design. This study involved two phases. (Table 1)
The initial phase comprised field observations and on-the-spot brief interviews to
generate emerging themes, and a follow-up phase further explored the emerging themes
associated with the use of handheld technology by student nurses in a clinical setting.
Phase-one field observations and interviews were used to develop questions for in-depth
interviews of the participants.
40
Table 2: Study Sequence
Phase One
Clinical Field Observations
‘On-the-Spot’ interviews
Phase Two
In-depth Interviews of faculty and
students
Collection of patient care
priority data (identified by
students and researcher)
The use of PDAs in nursing education is relatively new, and little is known about
how handheld technology affects the development of clinical competency in
undergraduate students. Many variables are acting independently and in concert. These
must be considered in any attempt to understand how this technology can be incorporated
into nursing education. Initial investigations into this phenomenon were context-bound
with interpretation limited to the situation in which the data were collected. A qualitative
method was preferred for this investigation since this “approach to research is uniquely
suited to uncovering the unexpected and exploring new avenues.” (Marshall & Rossman,
1999, p. 38) Qualitative research occurs in natural settings and provides a better
understanding of the context in which a complex phenomenon is studied.
A phased approach was appropriate for this study since the major goal was to
explore the phenomena at the site and from the participants’ lived experience. This study
sought to incorporate data on both the perceptions and reactions of the target population
41
and assessments of their behavior. It was a naturalistic inquiry and involved collection of
qualitative data from field observations and in-depth interviews. (Appendices B and C)
In addition, this study analyzed and compared patient care priorities identified by
students with those identified by clinical faculty and the researcher to determine level of
agreement. Clinical faculty selected and assigned patients to the students.
The procedure was as follows:
1. Clinical faculty selected and assigned patients to students. Faculty identified the
top three patient care priorities associated with each assigned patient using
traditional nursing assessment, chart review and interview techniques. This
information was recorded and stored for later analysis.
2. Students were instructed to conduct patient assessments using the GRIP
assessment tool and to identify the three priority patient care needs using the tool
to guide in their decision-making. This information was collected from the
students by the researcher at the end of each clinical day.
3. The researcher also assessed a selection of the assigned patients, identified the
three priority patient care needs and used this data for comparison. The
researcher used traditional nursing assessment and interview techniques in
addition to chart review.
Key considerations included identification of the most suitable data collection
method as well as development of a strategy to combine and integrate the data into a
useful and meaningful format. This investigation was focused on collection of data that
would contribute to the careful description of the phenomenon from the perspective of
those experiencing it as well as observational data collected by the researcher.
42
This study required contextualization, which is the interpretation of results in the
context of the situation, or environment in which the data were collected. “The research
questions may change and be refined as the inquirer learns what to ask and to whom it
should be asked.” (Creswell, 2003, p. 181) As stated earlier, it was the intent of this study
to learn what is relevant in the situation under investigation and to use that to “…define
conditional statements that seeks to interpret how subjects construct their realities” in
order to develop a “set of hypotheses and concepts that other researchers can transport to
similar research problems and to other substantive fields” (Charmaz, 2000, p 594) This
required meticulous review and re-review of data collected through field observation and
interviews. In this study, the researcher was able to observe students using the PDA tool
in clinical settings, thus gaining new insights and observing phenomena that raised new
questions. This method clearly required flexibility of decision-making during the
research process, since “some decisions are best deferred until later stages of the
research, allowing for the process to evolve naturally and move the researcher perhaps
into directions that were not anticipated.” (Wiersma, 2000, p. 215) This investigation
evolved over time as emerging patterns guided the researcher. Therefore, the in-depth
individual interview questions were not determined until Phase Two of the study.
This inquiry had the potential to produce rich and perhaps surprising data that
could improve our understanding of this new technology and consequently our ability to
incorporate it into effective learning activities that will expand opportunities for
educators and students alike. Utilizing documentation from in-depth interviews, the
investigation described emerging patterns and attempted to construct meaning. This
43
endeavor was developmental, descriptive and inductive. It was a process, an ongoing
search for explanation and understanding.
The process required a well-organized, complete, comprehensive presentation of
results to establish external reliability. Attention to detail and well-documented research
enhanced external validity, which in turn enabled comparability or translatability of
findings. This was highly desirable since, as stated earlier, an increasing number of
nursing programs are beginning to examine the effectiveness of PDAs.
3.2 Site Selection
Drexel University College of Nursing and Health Professions (CNHP) boasts a
rich, 150 year plus history of educating nurses and health care professionals. The
University has a long tradition of innovation, cutting edge technology and responsiveness
to the needs of changing work environments. In keeping with that tradition, the
introduction of handheld devices into the undergraduate nursing program was viewed as
an essential step in developing clinical competencies and preparing students for the
workplace.
In fall 2001, CNHP opened an innovative, accelerated nursing program. The
Accelerated Career Entry program (ACE) is an intensive, full time program through
which a student can earn a Bachelor of Science in Nursing (BSN) in just 11 months in
lieu of the more traditional three or four years. This rigorous program demands that
students achieve specific objectives that demonstrate clinical competency (Appendices D
and E), and its compressed time span presented faculty with additional challenges. As
stated previously, nursing students have “problems identifying, defining, analyzing and
articulating the nature of their information needs,” which may be in part due to lack of
44
hands-on experience accessing and utilizing relevant information in real-life, real-time
clinical experiences. (Cheek & Doskatsch, 1998, p. 247) This becomes even more of a
problem when content is delivered (and must be mastered) in a shorter time period. As a
result, faculty began to explore curricular innovations that could help develop clinically
competent graduates in 11 months.
In 2002, a doctorally prepared faculty member received a grant from the Hartford
Foundation to integrate technology into a gerontology course within the ACE program.
PDAs were purchased and given to the first ACE class during their last term in the
program. During this term, students were enrolled in NURS404 Nursing Informatics and
NURS350 Contemporary Gerontological Nursing. Students were instructed in the use of
the PDA in the informatics course and were expected to use the PDA in their NURS450
clinical experience to conduct patient assessments and plan their nursing care. During
this term, it became apparent that this technology has considerable potential but must be
introduced earlier in the program to allow students to develop proficiency with the device
as well as to structure the learning experience in a manner that supports its integration
into the clinical experience.
As Lindeman (2000) pointed out, technology is having a significant impact upon
nursing education in that it mandates that nursing faculty work (and become comfortable)
in a “world of high technology in order to prepare nursing to work in a high technology
health care environment.” (p. 6) CNHP faculty realized the need for innovation to
achieve program objectives of clinically competent, technologically savvy graduates.
They identified strategies to provide students with new types of structured learning
activities that offer opportunities to practice accessing and utilizing relevant information
45
in clinical settings which can, in turn, support development of clinical competency and
decision-making skills.
Attaining competencies among students is a major goal in undergraduate nursing
programs, and having vital information for decision-making at the point of care is
essential to accomplish that goal. Early introduction to tools that assist in this process,
such as the PDA, is critical in skill acquisition and practice development. It is as
fundamental as the introduction to the sphygmomanometer or the stethoscope.
In fall
2002, NURS404 was moved to the first term, and course content was revised to provide
students with structured learning activities, including hands-on laboratory experiences, to
build PDA competency.
Faculty training was considered a high priority. A structured plan was devised to
provide faculty PDA training and ongoing support to help them integrate PDAs into
classroom instruction and clinical settings. Faculty workshops provided small group,
hands-on training in use of applications for clinical and classroom learning activities.
One-on-one instruction and support were provided as well. Faculty received monthly
updates on techniques to use PDAs more effectively in multiple settings. Additional
workshops were offered quarterly.
3.3 GRIP – A PDA-Based Patient Assessment Tool
In January 2003, CNHP faculty partnered with Drexel University College of
Information Science and Technology (IST) to begin development of a PDA-based patient
assessment tool that supports clinical decision-making. The Gerontological Reasoning
Informatics Program (GRIP) is the assessment tool students used for this study. (See
Appendix F) This tool was developed by a team of faculty experts in gerontology
46
collaborating with a programmer. It is designed to facilitate a comprehensive and
efficient assessment of an elderly patient. The tool consists of 11 essential patterns
(assessment modules) that provide a thorough patient assessment.
Table 3: Grip Assessment Modules
GRIP Assessment Modules
1. Cognitive/perceptual
2. Elimination
3. Sleep/Rest
4. Coping Stress
5. Values/Beliefs
6. Role-Relationship
7. Nutrition/Metabolic
8. Activity/Exercise
9. Sexuality
10. Self-Concept
11. Environmental
Each pattern was developed by a content expert (Appendix G) and then reviewed
by the entire team. Patient data entered into the tool is scored and ranked according to
risk level for complications associated with a particular pattern, such as elimination. The
tool automatically scores the data entered and identifies the patient’s risk level (very low,
low, moderate, high or very high) for complications associated with that particular
assessment module. For example, an individual who has problems with urinary
incontinence would receive a risk level score that would be high or very high, depending
upon other factors. A patient who does not have any problems with elimination (urine or
47
bowel) would receive a very low risk level score. This risk ranking helped the student
identify problems and prioritize nursing interventions.
3.4 Reliability and Validity of the Tool
It is important to establish the reliability and validity of the GRIP tool used in this
study. Reliability refers to the ability of the tool to produce consistent, repeatable and
dependable information. (Gately, 1999) Validity of a tool refers to the accuracy of the
tool in identifying and ranking patient risk level for complications associated with one or
more essential patterns (assessment modules). GRIP team members tested the tool
extensively using case scenarios. The results indicated that the tool appears to be
reliable in scoring risk level and valid.
In addition, the researcher and a faculty member, who is a certified gerontological
nurse practitioner, field-tested the tool at a local clinical site using the following
procedure:
1
Clinical Nurse Specialist (CNS) at the site, who has clinical expertise and
intimate knowledge of the patients, selected patients identified as being at
risk for complications associated with one or more of the 11 essential
patterns (assessment modules).
2
Researcher and faculty member conducted patient assessments/interviews
for each of the selected patients using the tool. Each patient had two
assessments conducted. Both assessments took place during the same day
(to minimize the variations that may take place day-to-day) and the results
were analyzed to determine if the tool is:
48
•
Accurate in identifying patient risk levels in comparison with those
identified by the CNS;
•
Consistent and reliable in scoring risk levels for a patient in
assessments conducted by different raters (researcher and faculty
member).
Results demonstrated that the tool is accurate in identifying patient risk levels and
consistent in scoring across raters. This pilot study (n=5) did identify several minor
problem areas with the user interface (question redundancy and the need to separate entry
points for observational data from interview data), and modifications of the tool are
currently underway. Of the five patients assessed, the priority patient care needs
identified by the CNS concurred with those identified by the GRIP tool. In addition, the
scores obtained by the researcher and faculty member corresponded closely. (Appendix
H)
3.5 Population Sample
Project participants included a purposeful sample will be comprised of students
enrolled in the CNHP ACE program taking NURS450 Contemporary Gerontological
Nursing during the summer 2004 term as well as faculty for the course. A purposeful
sampling procedure was preferable for several reasons. First, random assignment of
students to groups could be viewed as coercive and in violation of student rights. To
protect students against undue pressure from faculty, it was necessary to recruit student
volunteers. Second, since this was a pilot investigation that may lead to a broader scope
investigation, there were only a limited number of students relevant and appropriate for
the research study (Wiersma, 2000). The sample comprised of 26 student volunteers.
49
Student and faculty participation in the study and in-depth interviews was strictly
voluntary. Upon IRB approval, students were notified of the study via class
announcements, flyers and mass email (Appendices I & J). Volunteers were recruited
and offered an incentive for their participation in the study, a PDA reference (ebook) of
their choice at the conclusion of the study. Students were informed of the purpose of the
study and details regarding their involvement if they decided to participate. It was clearly
communicated that a decision not to participate would not adversely affect their grades
for the course.
It is likely that the sample was skewed and not entirely representative of the
student body due to the possibility that students volunteered for a variety of reasons
including convenience of clinical site location, friendships with other volunteers, carpooling and transportation issues. In addition, students volunteers may be technophiles
and consequently more technologically adept. Faculty participating in the study may also
have been biased in that they are invested in the project and wished it to be successful.
The researcher was mindful of these potential biases during data collection and analysis.
Two clinical sites for this study sites were selected by faculty as being
representative of the sites for the course. Other factors were the sites’ willingness to
allow the study to be conducted and the clinical faculty member’s interest in participating
in the study.
3.6 The Student Experience – Traditional vs. New Method
The traditional pencil and paper method involved the following scenario: The
student would print out a hard copy of the 6-page assessment tool (Appendix K) prior to
arriving at the clinical site. The student would take the tool into the assigned patient’s
50
room and conduct the assessment, flipping page to page while quickly noting patient
responses to the questions. The student may use incomplete sentences or cues to speed
the recording process, raising the risk of omitted or incomplete data. The student must
then transfer the written information into an electronic version of the assessment tool on
the computer. The student would then use this assessment data to identify patient
problems and patient care priorities. Since the student had to enter the data twice -- first
onto the worksheet at the patient’s bedside and second onto the computer -- and also rely
on his/her memory to ‘fill in the gaps’ of missing or incomplete information, the risk of
error is great. As a result, the student might not be able to accurately identify patient care
priorities and consequently provide proper care.
The new method involved the following scenario: The student would arrive at the
clinical site with PDA in hand. The student would enter the assigned patient’s room,
conduct the assessment interview and record patient responses and assessment data by a
simple tap on the PDA screen. Specific patient information can be entered easily using
radio buttons, drop-down menus and textboxes. Upon completing the patient assessment,
the student would synchronize the data on the PDA with his/her computer. The student
would not need to re-enter data, which minimizes the risk of error. Entering complete
data at the point of care enhanced the student’s ability to accurately identify the patient
care priorities.
3.7 Methods
Upon IRB approval, student volunteers were actively recruited as described
above. (Section 3.5). During the summer 2004 quarter, 60 ACE students were enrolled in
NURS450 Contemporary Gerontological Nursing.
Those who volunteered for the study
51
were assigned the clinical sites associated with the study and received the GRIP
assessment tool to use in the clinical setting to conduct patient assessments, data
collection, identify priority patient care needs and complete the nursing care plan
3.8 Reliability and Validity
It was important to establish the internal reliability and validity of the PDA-based
assessment tool. Internal reliability “refers to the extent that data collection, analysis and
interpretations are consistent given the same conditions. For example, if multiple data
collectors are used, a question of internal reliability is, ‘Do the data collectors
agree?’”(Wiersma, 2000, p. 8). A similarly question of internal reliability for the PDA
assessment tool would be, “Does the tool consistently score the patients’ risk levels?”
Internal validity refers to “the extent to which the results of a research study can be
interpreted accurately.” (Wiersma, 2000, p. 4) As stated earlier, the GRIP team
conducted reliability and validity testing using case scenarios, and a pilot field test of the
tool was conducted by the researcher.
3.9 Data Collection
A good design for mixed method evaluations should include specific plans for
collecting and analyzing the data. It is very useful to have such a plan when beginning an
investigation. (Miles & Huberman, 1994; Greene, Caracelli and Graham, 1989) The
following schedule was developed for this study:
52
Table 4: Project Timeline
Activity
After IRB
Approval
•
•
Recruit Student Volunteers
Orient Student Volunteers to PDA Application
Weeks 1-5
•
Weeks 6-7
•
Clinical Faculty identify and record top 3 patient care
priorities prior to assigning patients to students.
Student volunteers will use the PDA Application to conduct
patient assessments and complete assignment.
Researcher and outside observers conduct field observations
Researcher collects top 3 patient care priorities identified by
students and conducts comparison patient assessments.
Conduct individual in-depth interviews of students and faculty
Weeks 8-9
•
Begin analysis of data collected
•
•
•
Student volunteers and associated faculty received comprehensive training in the
use of the PDA Nursing Assessment Tool before beginning the study. Training included
demonstration and assistance with downloading and installing the application as well as
detailed instruction in entering patient data. Technological support was available to all
participants both during class and clinical experience. Online tutorials were available to
students. (Appendix L) Site visits were conducted by the researcher and associated tech
support to facilitate the introduction and use of tool.
The data were collected through field observations and interviews. Table 5 lists
the specific evaluation questions and data collected.
53
Table 5: Evaluation Matrix
Research
Question
Respondents
Methods
Question 1 –
Nursing
Faculty
Observation in
clinical setting
What is the relationship between the use
of handheld personal
computers (PDAs)
and student ability to
correctly identify the
three priority patient
care needs?
Weeks 6-7
Analysis and
comparison of
identified patient
care priorities.
Faculty
interviews
Question 2 –
What is the user
experience associated
with using this
technology in the
clinical setting?
Data
Collection
Schedule
Weeks 1-5
Weeks 6-7
Observation in
clinical setting
Weeks 1-5
Interviews of
participants
(nursing students
and faculty)
Weeks 6-7
Students
Nursing
Faculty
3.10 Field Observations
The researcher and outside observers conducted site visits to observe students
performing patient assessments while using the PDA tool during weeks 1-5 of the study.
A total of 26 students were observed over two clinical days per week for 4 weeks. The
researcher and outside observers also conduct brief interviews with students and faculty
in the clinical setting to obtain real-time anecdotal data relevant to the experience of
users. Observations were recorded using a simple checklist design with additional space
provided to include on-the-spot feedback as well as additional observations made by the
researcher. (Appendix B) Data from the field observation were organized and examined
54
to identify emerging themes or patterns. These were used to refine the field observation
tool as well as to develop questions for the in-depth interviews.
The researcher and the outside observers conducted observations unobtrusively to
avoid interfering with the student’s performance. Spontaneous comments made by the
student while using the PDA application were noted. After the task was completed, the
researcher asked the student for clarification of observations recorded.
Clinical faculty identified and recorded the top three patient care priorities of all
patients prior to giving student assignments and maintained this record during weeks 1-5.
(Table 6) The researcher obtained this data at the end of week 6. Clinical faculty provided
the following information to the researcher on a daily basis: 1) the names of all assigned
patients and 2) name of the student assigned to each patient.
Table 6: Assignment Sheet
Clinical Site:
Date
Student
Patient Name
Clinical Faculty:
Faculty identified Patient Care Priorities
1.
2.
3.
1.
2.
3.
The researcher conducted assessments on assigned patients to identify and record
patient care priorities using a similar format for later comparison with those identified by
students and faculty. At the end of each clinical day, the researcher collected from the
students the list of three priority patient care needs of all assigned patients for comparison
with those identified by the faculty and researcher.
55
3.11 Role of the Researcher
The researcher had access by virtue of employment as faculty in the program and
direct involvement in the CNHP’s initiative to integrate handheld technology across the
curriculum; serving as course coordinator for the informatics course, chair of the
technology initiative committee and lead faculty mentor. The researcher was not a
faculty member for NURS450 and therefore did not have any undue influence over
student performance and student participation in the project. All course grades were
determined by the course faculty without input from the researcher.
During this study the researcher functioned in the role of a participant observer
and served as a primary data collection instrument. The researcher maintained a log of
observations (both primary and secondary) as well as experiential data. On-the-spot
interviewing was conducted on an informal basis for the purposes of clarifying
researcher’s observations and comments made by study participants. For the most part,
questions were asked to verify perceptions of non-verbal behavior and prolonged silence
when using the tool or to ask a follow-up question on an interview technique utilized by
the student. These will be discussed in more detail in Chapter Four.
These field observations provided advantages in that they heightened the
“researcher’s awareness of the significant social processes” taking place and had the
added benefit of allowing the researcher to “experience the emotions of those who are
being researched.” (MacLaran, 1999, p. 9) The researcher recorded detailed observations
of the lived experience of the study participants, including the actions of students and
faculty. This will consist of the following 1) description of the setting, 2) description of
56
the activity, 2) description of the dialogue and 4) characterizing the participants. Specific
observations included:
1
What was the student experience?
2
Were students able to use the PDA tool easily to conduct the
patient assessment?
3
How long did it take to complete a patient assessment?
4
What were the problems observed?
5
Did the PDA Tool perform smoothly?
6
What were the student responses (verbal and non-verbal) to
using the application?
7
What were the patient responses (verbal and non-verbal) to
having an assessment conducted using the tool?
8
Any additional observational data
This method had disadvantages, including time intensiveness and data recording
difficulties, but they were outweighed by the potential of obtaining very rich data.
Another potential disadvantage was that this method can contribute to significant
observer bias. To counter this possibility an outside observer was also present to collect
observational data. This masters-prepared faculty member has over 20 years experience
in a variety of clinical settings, with considerable experience working with the elderly.
The data collected by the outside observer were analyzed and compared to those of the
researcher to validate observations regarding emerging themes and patterns and then
compared to determine congruence.
3.12 In-Depth Interviews
Open-ended questions for the in-depth individual interviews were generated from
themes that emerged from the analysis of the field observations. This approach placed
57
the “emphasis on the human capacity to know and understand others through empathic
introspection and reflection based on detailed description gathered through direct
observation, in-depth, open-ended interviewing and case studies.” (Patton, 1997, p. 271)
These interviews were conducted by the researcher and were recorded and
transcribed to facilitate analysis. Participants were given verbal prompts designed to
elicit unfettered discussion of the lived experience. Some of the verbal prompts were:
1. What stood out for you during this project?
2. What should be done differently in the future?
3. What were the unexpected outcomes or changes that occurred as a result of
the GRIP tool?
4. How did you feel using the GRIP tool?
5. Did the GRIP tool help or hinder your decision-making?
6. Give examples of how you used the GRIP tool.
The in-depth interviews were conducted with 21 students during weeks 6-7 of the
study at times and locations that were convenient for students.
3.13 Data Analysis
Meticulous review and re-review of all field observation data was conducted to
identify emerging patterns, themes or response clusters. This process involved looking
for categories and relationships in the data and attempting to make connections and
formulate propositions or assertions that imply a conceptual structure that fit the data.
This process can lead to actual theory building and creative conceptualization of
emerging phenomena.
Patient care priorities identified by students was compared with those identified
by the clinical faculty and the researcher. An analysis was conducted to identify any
58
differences. In addition, data was sorted by site and date collected to enable a
comparison between groups as well as to identify trends associated with increasing skill
development normally expected over the course.
3.14 Verification of Data Collected
In order to ensure that data collected has internal validity, the researcher utilized
the strategies identified by Creswell (2003):
1. Triangulation of data
2. Member checking
3. Long- term and repeated observations at the research site
4. Peer examination
5. Participatory mode of research
6. Clarification of researcher bias (p. 204)
As stated earlier, the use of more than one method to study a phenomenon
strengthens the validity of the results through triangulation. This study used two
qualitative methods, observation and interviews, which provided the researcher with the
opportunity to illuminate and corroborate the study findings. (Rossman & Wilson, 1994;
Frechtling & Sharp, 1997)
Member checking is the process of verifying the accuracy of the “qualitative
findings through taking the final report of specific descriptions or themes back to the
participants and determining whether these participants feel that they are accurate.”
(Creswell, 2003, p. 196) Member checking was achieved through on-the-spot interviews
conducted during field observations and will support an “ongoing dialogue regarding my
interpretations of the informant’s reality and meanings to ensure the truth value of the
59
data.” (p. 204) Member checking also occurred during the in-depth individual interviews
at which time the researcher presented the identified patterns and emerging themes to the
participants for verification.
This study involved long term and repeated observations in the field, over the
period of 1 month, enabling the researcher to develop a deep “understanding of the
phenomenon under study” and through this understanding be able to “convey detail about
the site and the people that lends credibility to the narrative account” (p. 196). These
regular and repeated observations took place on Wednesdays and Thursdays during the
clinical day, 7am-1:30 pm for 4 weeks.
Peer examination was achieved by having an outside observer participate in the
field observations. The outside observer was a nursing faculty member with clinical
expertise and not directly involved in the either the study or course. Her role was to
observe, review and ask questions. Her presence enhanced the accuracy of the data
collected.
Study participants were involved in most phases of this study. In particular,
participants were consulted during the field observations and in-depth individual
interviews to validate emerging themes, interpretations and conclusions drawn by the
researcher.
Clarification of the researcher bias was discussed in the section discussing the role
of the researcher. It is clear that the researcher by virtue of being a nurse and an
educator is deeply involved in the subject of this study. All efforts were made to report
findings in sufficient detail to permit readers to draw their own conclusions.
60
3.15 Protection of Human Subjects
Student participation in this project was entirely voluntary and was in no way
linked to course grades. Students who did not wish to participate were not be assigned to
the clinical sites where the study was conducted and therefore were not members of those
particular clinical groups. Since participation was voluntary and the researcher was not
in the position to affect student grades, there was no possibility of coercion.
Students participating in the study were not be harmed. The researcher relied on
both personal and professional integrity to ensure that program participants were
protected from harm.
An informed consent, which included consent to audio recording of the in-depth
individual interviews, was obtained from all study participants. The results of the study
were reported without revealing participant names.
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4. RESULTS
4.1
Overview of the Study
This study investigated the benefits of introducing handheld computer technology
into undergraduate nursing education to enhance development of clinical decisionmaking skills in undergraduate nursing students. It also evaluated the effectiveness of
using a PDA-based assessment tool, developed in-house, to accomplish this goal. The
goal of this research project was twofold. First, to understand how handheld personal
computers, equipped with an assessment tool, can be used to develop clinical decisionmaking skills and second, to describe user experiences. The specific research questions
are:
1. What is the relationship between the use of handheld personal computers
(PDAs) and student ability to correctly identify the three priority patient care
needs?
2. What is the user experience with this technology in the clinical setting?
This chapter will present the statistical analysis, using SPSS, of the data obtained from
the GRIP tool and a qualitative analysis of the observational data and responses obtained
from in-depth interviews.
4.2 Subject Demographics
Of the 26 students participating in this study, three were male and 23 were female.
The group consisted of 23 Caucasians and three African Americans. Ages ranged from
25 to 55 years. One of the two faculty participatants was female, and the other was male.
Both faculty members were Caucasian. Both were veteran clinicians with 27 and 28
years of nursing experience respectively. The faculty also had extensive geriatric nursing
62
experience.
4.3 Research Question One
A total of 212 patients were assessed by students, faculty and the researcher.
Upon completion of each patient assessment, the top three nursing care priorities were
identified and recorded. Two comparisons were made: Faculty priorities were compared
to researcher-identified priorities, and student priorities were compared to facultyidentified priorities. The data were analyzed using SPSS to identify similarities and
differences among the groups.
Since a comparison was being made among the top three nursing care priorities,
agreement in only one nursing care priority was scored as a 33% correlation. Agreement
in two priorities was scored as a 66% correlation, and agreement in all three was scored
as a 100% correlation between the raters.
4.3.1
Comparison of Faculty and Researcher Identified Patient Care
Priorities
Forty-seven patients were assessed by a faculty member and by the researcher.
The top three nursing care priorities for a given patient identified by the faculty member
and the researcher were compared to determine the level of agreement between the two
experienced clinicians and yielded a mean of 66.25% consistency with a standard
deviation of 24.2. The minimum score on Table 7 indicates that faculty and the
researcher consistently agreed on at least one of the nursing care priorities. The
maximum score indicates that there were instances where faculty and researcher were in
complete agreement. The analysis demonstrated that on average, there was agreement in
two out of three priorities. It is very likely that there would be an even higher degree of
consistency if variables associated with change in patient status over time and other
63
contextual influences were controlled.
These findings are consistent with those of Banerjee and Fielding (1997) in their
study describing the frequency and reliability of nursing diagnoses by nurses in long-term
care facilities. The researchers used the North American Nursing Diagnosis
Association’s (NANDA, 1992) nomenclature, which included 105 distinct nursing
diagnoses. In this study, the researchers found that complete agreement among nurses
occurred with only 56% of the diagnoses. The nurses were interviewed and asked to
identify the factors that might have affected agreement in a particular diagnosis. The
emerging themes were:
“(a) differences in time of day of assessments; (b)
differences in interpretation and use of NANDA language;
(c) occasional lack of sharp distinctions between NANDA
diagnoses; (d) varied background, experience, and
perspective of the individual RNs; (e) differences in how a
resident responded to each of the two RNs; and (f) previous
knowledge about the resident on the part of one RN.”
(Banerjee and Fielding, 1997, p. 470)
Specific factors that influenced this study will be discussed in more detail later in Chapter
5.
64
Table 7: Comparison of Faculty and Researcher Identified Patient Care Priorities
n=47
Minimum
33
Maximum
100
Mean
Standard Deviation
66.25
24.1989
4.3.2 Comparison of Student and Faculty Identified Patient Care Priorities
The 26 students conducted the patient assessments for a total of 212 patients.
Upon completion of the assessments, students identified the top three nursing care
priorities for each patient. These priorities were then compared with those identified by
the faculty member for the same patient. The mean consistency and associated statistics
are given in Table 8. On average, the range of agreement between an individual student
and the faculty was 39.6% - 83.0%. The minimum score on Table 9 indicates that the
minimum level of agreement between a given student and faculty member averaged
39.6%, which is only slightly better than an agreement in one out of three nursing care
priorities. The maximum score indicates that the highest average level of agreement
between a given student and faculty member was 83%.
Table 8: Comparison of Student and Faculty Identified Patient Care Priorities
n=26
Minimum
39.60
Maximum
Mean
83.0
63.47%
Standard Deviation
11.02
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4.3.3 Comparison of Student and Faculty Identified Patient Care Priorities
over Time
Student and faculty data were sorted according to date collected at week 3, the
midpoint of the study, to identify trends that may be associated with increasing skill
development normally expected over the course. The mean consistency of priorities
identified by students compared to expert priorities for time 1 was 62.60% with a
standard deviation of 14.1. The mean consistency for time 2 was 68.20% with a standard
deviation of 14.5.
Table 9: Comparison of Student and Faculty Identified Patient Care Priorities
over Time
n= 26
Time
n
Mean %
Std. Deviation
1
26
62.61%
14.051
2
26
68.21%
14.496
A paired samples t-test comparing the mean reliability at time 1 (62.61%) to the mean
reliability at time 2 (68.21%) revealed a mean difference of -5.60 with t = 1.40 and p =
0.16. The difference in reliabilities did not differ for time 1 versus time 2.
66
4.3.4
Comparison of Students and Faculty Identified Patient Care Priorities
by Clinical Site
Student and faculty data were compared to identify any differences in reliability
between groups using GRIP at the two sites. The mean reliability for Site A was 60.86%
with the standard deviation of 12.30. The mean for Site B was 66.07% with a standard
deviation of 9.32.
Table 10: Comparison of Students-Faculty Identified Patient Care Priorities
by Clinical Site
n=26
Site
n
Mean
Standard Deviation
A
13
60.86%
12.29
B
13
66.06%
9.32
In an independent samples t-test between the two groups presented a mean
difference of -5.21 with t = -1.22 and p < .24 with 24 degrees of freedom. This difference
was not statistically significant.
Analysis of the data demonstrated that there was a similar level of agreement
between student-faculty identified nursing care priorities and faculty-researcher identified
priorities. Similar to the faculty-researcher correlation, the students and faculty agreed in
about two out of the three priorities identified. Even when the faculty-student data was
examined in subgroups according to site or time, there was no significant difference
between the two groups. The slight differences in the means between the sites, 60.86 and
66.07, may be attributed to the variations of patient populations. In addition, although
not significant, it is interesting to note that there was a slight improvement over time in
67
the students’ ability to match the faculty identified nursing care priorities, increasing
from 62.61% to 68.21%.
4.4 Research Question 2
The investigation involved two phases (Table 11). The initial phase comprised
field observations and brief, on-the-spot interviews to generate emerging themes. The
follow-up phase involved in-depth interviews of student and faculty participants.
Table 11: Study Sequence
Phase One
Phase Two
Clinical Field Observations
‘On-the-Spot’ interviews
In-depth Interviews of faculty
and students
Collection of patient care
priority data (identified by students
and researcher)
This study used two qualitative methods, observation and interviews, which
provided the researcher with the opportunity to illuminate and corroborate findings.
(Rossman & Wilson, 1994; Frechtling & Sharp, 1997) An informal analysis of the
observational and interview data involved meticulous review and re-review of the data to
identify emerging themes.
Field observations were conducted during weeks 1-5, which
provided an opportunity to gather considerable data. The field observations provided a
means to verify observations through member checking.
The field observations allowed this researcher to gather data in real time and also
to establish rapport with the study participants that transitioned well into the in-depth
68
interviews. Participants were glad to be interviewed and provided insight. In fact, the
most illuminating data was obtained through the in-depth interviews conducted at the
conclusion of the study. Twenty-one of 26 students involved in the study participated in
the in-depth interviews, as did both faculty members. This provided an opportunity to
verify the data through triangulation in order to better understand the participants’
experience of using GRIP in the clinical setting. The predominant themes that emerged
from both the field observations and in-depth interviews were: 1) tool design and
functionality issues, 2) patient related issues and 3) student related issues. These findings
will be described in detail in this chapter.
4.4.1
Observational Data
The researcher and an outside observer conducted field observations of students
using the GRIP tool to perform patient assessments. On-the-spot interviews with
individual students and/or small groups followed in the unit conference room.
A total of 26 students were observed over a period of 5 weeks. A simple check
list was used to record field observations (Appendix B). Field notes were analyzed to
identify trends observed among the participants. It is important to note that during the
first week of observation; almost all the students observed had difficulty with the GRIP
tool. Major problems were related to lack of familiarity with the tool and design-flow
issues. All students admitted that they had not practiced using the tool since the initial
orientation session. The researcher conducted small group and individual review sessions
on-site. In addition, the tool had a programming error that reversed the scoring for the
Cognitive/Perception Pattern. This error was detected during the first week and corrected
by week two.
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During weeks 2-5, students were observed using the tool to enter patient
assessment data. A total of 24 complete patient assessments were observed; 8 by the
outside observer and 16 by the researcher. The major themes noted by both the
researcher and outside observer were predominantly in three categories: tool functionality
and design, patient-related issues and student issues.
4.4.1.1 Tool functionality and design issues
The major issue related to tool functionality and design involved the flow of the
tool itself. In the observed assessments, students asked each question in order, and
patients responded to these specific questions. Among these observed interviews,
patients for the most part limited their responses to the questions asked. On one
occasion, a patient expanded upon the question and moved off the topic. The student
redirected the patient back to the interview by asking the next question. Afterwards, the
student stated that this happened frequently, because the patients liked to have someone
to talk to and that usually he just let them talk, asking the questions when the opportunity
arose. In the on-the-spot interviews, many of the other students stated that they used a
similar technique. Several remarked that nurse-patient conversations are typically fluid,
and the tool was not flexible enough to allow them to go back and forth as the
conversation progressed. Several of the students admitted that they had memorized the
questions to allow a more natural communication process with patients and often entered
the assessment data later.
4.4.1.2 Patient-related issues
For the most part, patients were very receptive to being interviewed by students
using the GRIP tool. Some verbalized curiosity and interest in the tool itself, asking
70
questions about the research project and the information collected. No negative
comments from patients were observed. One of the patients seemed surprised by
question: ‘Are you currently questioning the meaning of life/death and suffering?’ and
asked the student for clarification. When questioned later, students reported that some
questions about roles and values, particularly those that are long, needed to be rephrased
for a patient. One student gave, as an example, the first question in the Self-Concept
Pattern. (Figure 4) This question, in particular, is very long. Other students also reported
that patients needed additional explanation before they were able to respond.
Figure 4: Screen Shot of Self-Concept Pattern Question
Three of the observed assessments, two by the researcher and one by the outside
observer, were not completed. In one instance the interview was terminated because the
patient could not hear the questions, and the ordeal became increasingly frustrating for
him. Another was terminated because it was clear to both the researcher and the student
71
that the patient was cognitively impaired and unable to understand and answer the
questions. The third was terminated after most of the assessment was completed because
the patient was scheduled for physical therapy.
In informal interviews, students reported that they were not able to conduct GRIP
assessments on patients who were cognitively impaired and suggested that the tool be
revised to accommodate these types of patients. Students also reported that occasionally
they had to conduct interviews in several parts due to scheduled appointments/procedures
or patient fatigue. Several students also commented that it was not possible to add or
modify patient assessment and observational data that they obtained subsequently without
redoing the particular pattern. Most of students expressed frustration regarding this lack
of flexibility, because it required duplicate effort.
4.4.1.3 Student-related issues
Most of the students who were observed conducting patient assessments using the
GRIP tool appeared comfortable using the tool. All students were able to use the tool
easily to complete the patient assessment, although on four occasions, the tool froze and
required a soft reset by the student before continuing with the interview. In these
instances, students would make general comments about the tool ‘acting up’ and after a
short interval, resume the interview. Students reported that this had occurred previously.
Some noted that it occurred when they had other applications open concurrently.
One student began the interview by thanking the patient for letting her do the
interview and apologizing for any appearance that she was focusing more on the PDA
than the patient. She explained that she was still learning to use the tool, and the patient
response was very positive. After the interview, the student stated that she always did
72
that before starting the GRIP assessment, because she felt the tool interfered with the
nurse-patient relationship.
Many of the other students also made comments about the GRIP tool becoming a
barrier to nurse-patient relationship. Students remarked that they were spending much of
the interview focusing on the tool when the patient just wanted to have a conversation.
Many also reported that they integrated the questions into normal conversation and
entered data into the tool later.
4.4.2
In-depth interviews
The analysis of the observational data guided the refinement of the open-ended
questions for the in-depth interviews conducted at the conclusion of the investigation.
Twenty-one students and two faculty members were interviewed. An informal analysis
of these interviews was conducted to identify emerging themes and patterns.
4.4.2.1 Student Interviews
The interviews for the students consisted of six open-ended questions:
1. What stood out for you during this project?
2. What should be done differently in the future?
3. What were the unexpected outcomes or changes that occurred as a result of
the GRIP tool?
4. How did you feel using the GRIP tool?
5. Did the GRIP tool help or hinder your decision-making?
6. Give examples of how you used the GRIP tool.
The following is a description of the student data grouped according to interview
questions and emerging themes.
4.4.2.1.1 Question 1 - What stood out for you during this project?
For the most part responses to this question related to the tool itself, its
73
functionality and its design. Nine of the students had positive feedback regarding the tool
design, describing it as easy to use. Twenty-four percent of the students, N=5, reported
that they felt good about conducting patient assessments using the tool. The same
number also remarked that the tool was efficient and organized. A representative
comment from students follows:
"I think it stood out that is was well organized. I thought
that the flow of the program itself fit very well with the
interview, and it was overall pretty easy to use. There were,
of course, some glitches now and again, but I thought it
was pretty user friendly and flowed with normal interview
process of someone."
Some students (N=3) had negative comments that the tool was linear and did not
allow movement back and forth between questions. Students commented that because
the tool forced the user to follow a specific sequence when conducting the interview, they
were unable to enter data as information was provided by the patient during a normal
conversation. Twenty-four percent of the students (N=5) stated that they felt that the
questions within the tool did not have adequate response options nor allowed sufficient
opportunity to add additional observations. Representative comments expressing this
concern follow:
"There was something missing in the assessments that did
not give me the detail that I needed in order to put together
a care plan. True enough, the information in the
assessments was relevant and important but not detailed
enough, not detailed enough to put together a nursing plan."
"In essence the program was good, but every time I felt I
had to ask more questions of the PDA and the program
there was a stop, almost too objective in the questions that
were asked. So I felt myself asking more questions even
though they weren’t on there … every week I realized that I
74
was asking more questions."
Two students stated that the tool provided a mechanism to establish rapport and
supported interaction with patients, while about one third of the students reported that
they felt the device was a barrier. Two representative comments follow:
"I spent more time trying to look at the PDA, going through
the screens and ask the right questions, instead of paying
attention to the patient, and I think it took away from the
patient relationship."
"I thought it was very impersonal, like, sitting there with
the program in front of you and constantly looking at the
answers and choosing what to do and then waiting for it to
go back to, like, whatever screen you’re going next to. But,
I guess you can do that with any kind of interview paper or
what not."
Most students reported that using the tool became easier as the study progressed
and they became more comfortable and skilled using the tool.
"As far as using the tool, I found that obviously in the
beginning it was harder to use. Towards the end it was
easier to use, but with the tool itself it was almost, like, you
had to know it inside and out. You had to know the
questions inside and out. You had to already understand
where you were going to be going with these questions."
Two students reported that the built-in algorithm that scored the patient
assessment data was a characteristic that stood out for them and a feature that they liked.
Three students commented that the ability to conduct a better patient assessment was a
characteristic that stood out for them. The following table summarizes the student
responses to the first question.
75
Table 12: Question 1 - What stood out for you during this project?
n = 21
Theme
Frequency
Tool Design Issues – positive
Easy to Use
9
Efficient/Logical/organized
5
Tool Design Issues - negative
Flow –unable to move back and forth
3
Questions response options insufficient,
need more free text
5
Questions insufficient,
need to be able to add more data
4
Tool Technical Issues - Freezing
5
Device as a tool to build rapport/interaction
2
Device as Barrier
7
+ Notion of Using PDA for Pt Assessment
5
Liked scoring capability (algorithm)
2
Helped do better pt assessment
3
4.4.2.1.2 Question 2 - What should be done differently in the future?
Most of the responses (N=11) to this question centered upon need for the tool to
be revised, and many mirrored comments made in response to Question 1. Fifty-two
percent of the students stated that the tool did not capture all aspects of assessment and
felt questions needed to be revised and/or re-ordered and that there should be more
options for responses. These same students stated that the tool did not score the pattern
as high as they felt it should be scored. The same percentage of students stated that some
76
of the questions should be rephrased because they were not received well by patients or
were difficult to understand. In addition, three students observed that questions appeared
redundant between Self-Concept and Role-Relationship modules. Two students observed
that the tool was not able to record follow-up questions, modify questions to be more
interpersonal or record observational data. Sometimes observational data was needed,
because patients’ verbal responses did not seem to be reliable based on students’
observations of non-verbal behaviors. For example, one student commented:
"…we had certain clients who you could kind of tell they
weren’t being 100% honest. (It’s) not that they were trying
to be deceiving because they weren’t ready to open for
themselves (to acknowledge) that they had these kind of
issues. But you could feel that talking to them directly but I
wasn’t going answer the GRIP questions for them because
that’s what I saw. I had to kind of put in what they said."
In addition, one student observed that there was no way to differentiate between
the continuum of past and current levels of function, which is an important distinction in
patient assessments. This student reported that she recorded the patients’ responses to the
questions even though, in her view, the responses should have been different. The
student felt that, based upon her observation and assessment, the pattern should have
been scored higher, a factor that has clear impact upon the accuracy of a given
assessment. Her comment regarding this concern was as follows:
"I think a lot of them automatically thought that they were
going back to the way things were. They didn’t really
realize that there were some changes that need to be made.
They were just hoping that this is just a little short
(setback), something that’s holding them up, not
necessarily going to affect them when they go home."
77
Eight students stated that GRIP should allow the user to move back and forth within the
tool to update, modify and enter assessment data out of sequence. This coincided with
the comments made in Question 1. Representative comments of this observation follow:
"The main thing that stands out is that if we could go back
in the screens, and answer questions that we missed
previously. That was a big frustration. If we missed
something, you couldn’t go back to it without losing your
data. I almost felt like I was trying to make the patient tell
me the information in the order I wanted rather than the
way they were (giving the information)."
"I found that people wanted to go off on a different
direction, just wanted someone to talk to most of the time,
so we ended up going off and I tried to steer them back and
I could see them getting frustrated."
Three students commented that the tool should be modified or not used at all for
cognitively impaired patients. That same number also identified that more training was
needed prior to using the tool in the clinical setting. Two students commented that the
tool was too long and should be shortened. Only one student stated that nothing should
be done differently in the future. The following table summarizes the student responses to
the second question.
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Table 13: Question 2 - What should be done differently in the future?
n=21
Theme
Frequency
Modify Tool
Revise/add/re-order some Questions in Tool
11
Revise - Tool was too linear
8
Questions were redundant
3
Need to improve ability to enter/capture observational data
Therefore data did not reflect ‘real’ picture
2
Stream line tool – too long
2
Modify tool or don’t use for cognitively impaired
3
More orientation/training to use the tool
3
Nothing
1
4.4.2.1.3
Question 3 – What were the unexpected outcomes or
changes that occurred as a result of the GRIP tool?
The majority of responses to this question were positive. Forty-eight percent of
the respondents stated that the comprehensiveness of the assessment obtained using the
GRIP tool was an unexpected outcome. These students stated that the tool enabled them
to identify problems that they would likely have missed ordinarily. Representative
comments follow:
"One that stands out dramatically was I did it on a couple
who the sexuality came up because it was part of the GRIP.
I think that it made me ask the questions that I might not
have without the tool, so I got a lot of information that I
wouldn’t have normally, which, you know, helped me talk
79
to them about that issue. So that was something that I do
like about it, I guess like any assessment tool where you
have a box that you have to check it off, it makes you
address it. So I thought that the sexuality piece in that was
good, and other things that we might not think of, like
spirituality, and making us go through the screen even if we
just hit skip made us at least think about asking the
question to the patient."
"You may not have realized that a patient may have been
depressed. GRIP would point out you may want to use the
geriatric depression scale as another tool. Those were
unexpected outcomes, so it was helpful in pointing out
areas where you may not have considered."
One student did not agree with the others, stating that he believed that the tool
was not comprehensive enough.
One student stated that the tool was accurate. Two stated that the tool provided
organization of patient assessment data. Three stated that the tool was easy to use and
improved the quality of care they provided. Four stated that the positive response from
patients was surprising, and that the elderly patients seemed genuinely interested and
open to the technology. A representative comment follows:
"Another unexpected thing, some of the patients really
liked it. I think they thought it was neat, the technology,
and they would like to look what we were doing and they
were intrigued by that, so that was good. I didn’t have any
real negative responses; no one told me that "go away" or
anything like that when I was using it."
Only one student stated that she was surprised by the negative response from a
patient. Three students commented that they had not expected that the device would be a
barrier between nurse and patient. This observation correlates with several responses to
Question 1.
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Four students stated that they had not expected any technical difficulties. Two
commented that the tool focused on psychosocial problems and did not effectively screen
for physiological problems. Only one student stated that there were no unexpected
outcomes. The following table summarizes the student responses to the third question.
81
Table 14: Question 3 – What were the unexpected outcomes or changes that
occurred as a result of the GRIP tool?
n=21
Theme
Frequency
Positive
Comprehensiveness of assessment
10
Positive patient response
4
Tool provided organization
3
Surprised at ease of use
2
Personal satisfaction using the tool
2
Helped improve skill to provide good care
2
Identification of problems that may have been missed
2
Tool was very accurate
1
Negative
Technical difficulties
4
Barrier between patient and student
3
Did not pick up physiological problems and
focused on psychosocial
2
Tool not comprehensive
1
Negative Patient response
1
None
1
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4.4.2.1.4 Question 4 – How did you feel using the GRIP tool?
Almost all of the students stated that they felt comfortable and enjoyed using the
GRIP tool. Thirty-eight percent of these students admitted that they were uncomfortable
using the tool during the first few weeks of the investigation. Of the students who
reported that they were initially uncomfortable, all but one added that after a few weeks
they felt comfortable using the tool. Representative comments follow:
"I was not uncomfortable using it. By the third or fourth
week doing it, I was very comfortably using it. And it
doesn’t take long either. You think it would take longer, but
it takes about 20 minutes to half an hour."
"There was a little element of frustration in there, but all in
all I didn’t have a problem with it. I thought it was pretty
much user friendly. It was pretty easy to use, and I was able
to facilitate it fairly well towards the beginning and, of
course, at the end was much better at it. Bt yeah, I didn’t
mind it at all. It was kind of enjoyable, because sometimes
when you couldn’t think of where to go with the
conversation you could always look down at your GRIP
and, you know, there was another conversation you had. So
it was like you always had something to fall back on when
the ball dropped in the conversation, because you had your
next questions or your next conversation piece."
"It actually became part of me. Whenever I went to clinical,
it was pretty much part of me, I couldn’t forget my PDA, I
had to do an assessment… a day without an assessment
would be incomplete for me, it was already part of me."
"I felt relieved in the sense that I knew my assessment was
going to be thorough, simply upon the fact that I’m
following a template, that of the GRIP project. If I stuck to
that I was going to get information data in all of the key
functional pattern groups that needed to be addressed in
order to really care for my patient thoroughly and correctly.
So I felt relieved, but I pointed out to you I was troubled by
it. I was troubled by the mechanics of it the device in hand,
manipulating the device in hand and at the same time
wanting to effect a therapeutic communication dialogue
83
with my patient."
Six students stated that they felt good or proud about using the tool and being
involved in the investigation. Four students stated that they felt frustrated by technical
difficulties using the tool, particularly transferring data to the computer to complete a
nursing care plan. One student remarked that she was troubled by the effect the device
had in creating a barrier between the nurse and patient. The following quote summarizes
her response to question 4:
"I found it very frustrating overall, because it seemed to be
something that interfered with the face-to-face with the
patient, and that’s one of aspects of nursing that I enjoy the
most, I think, and especially given older people tend to not
be familiar with computers and I’m not super comfortable
with computer lingo. I’m comfortable with computers but
not necessarily in explaining it, so it was kind of hard to
explain what exactly was in my hand."
The following table summarizes the student responses to the fourth question.
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Table 15: Question 4 – How did you feel using the GRIP tool?
n=21
Theme
Frequency
Comfortable/enjoyed using tool
17
Uncomfortable initially (first few weeks)
8
Felt Good/proud
6
Frustrated with technical problems
4
Troubled by barrier effects of device
1
4.4.2.1.4
Question 5 – Did the GRIP tool help or hinder your decisionmaking?
A majority of students stated that the GRIP tool helped their decision-making. Of
the 15 students who reported that the tool helped their clinical decision-making, 13 said
that the tool helped them perform a more comprehensive and in-depth patient assessment.
Representative comments follow:
"I would have to say it helped because you have to look at
all aspects, especially as a nursing student, you are sitting
there nervous. 'What should I do? I don’t know what to do
in sequence,' when you see this it kind of puts all into
perspective."
"I thought it made you look at the priorities in a different
way. I thought it was very helpful."
"The GRIP program led to deeper conversation and, in my
mind, diagnosing differently than I would have had if I just
read a chart and spoke to the person briefly."
Two students stated that they felt the tool validated their assessment of the patient
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and expressed a sense of satisfaction that their assessment correlated with the priorities
identified by the tool. One student commented that the tool was so helpful that she
worried that users might become to dependent upon it.
Of the five students who reported that the tool neither helped nor hindered their
clinical decision-making, four said that they used the tool as an adjunct to regular patient
assessment and data collected using traditional means. They reported using the GRIP
tool assessment data in combination with other assessment data when planning
interventions. Table 16 summarizes the student responses to the fifth question.
Table 16: Question 5 – Did the GRIP tool help or hinder your decision-making?
n=21
Theme
Frequency
Helped
15
Hindered
1
Neither helped nor hindered
5
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4.4.2.1.6 Question 6 – Give examples of how you used the GRIP tool.
Most students reported that they used the GRIP tool for guidance and to help them
identify patient care priorities. Ten students stated that they used the tool to organize
patient data and complete the nursing care plan assignment. Representative comments
follow:
"It was a helpful tool in assessing the patient, and it helped
to bring some things to the forefront that maybe I might not
have seen. It’s like a second pair of eyes. You basically see
what you see, but then you got a second opinion on paper
here, and you kind of compare."
"I used it to formulate nursing diagnosis for the patient to
find out more about them. As I said before, I don’t really
know what I’m really going to do when I go into the room
sometimes; what I’m supposed to address initially. It
opened a lot of doors and enabled me to talk to people and
that’s what I felt was a great part about it was it enabled me
to have conversations and allow people to talk about things
they don’t normally probably get the opportunity or chance
to do as such detail or like, so I felt I was a help to these
people, because I was there and was available and I was
listening and I was introducing these questions that just
aren’t probably regularly asked to them. So I thought it was
a great tool in that way and it allowed me to start
relationships."
Three students stated that they used the tool as a means to establish rapport with the
patient and as a conversation piece. The following quote is representative:
"It helped me get into the patient. It created that rapport
between the patient and student nurse. It made them relax,
because I ask them those questions they were more open to,
like, tell me what’s going on expressing their feelings and
anything they were going through."
One student reported that she used it to improve her interviewing
skills. Table 17 summarizes student responses to the sixth question.
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Table 17: Question 6 – Give examples of how you used the GRIP tool.
N=21
Theme
Frequency
Guidance, Helped identify patient care priorities
12
Used it to organize patient data/do care plan
10
Used it as a means to establish rapport
3
Used it to improve interviewing skills
1
4.4.2.2 Faculty Interviews
Both of the faculty members involved in the study were interviewed. An informal
analysis of these interviews was conducted to identify emerging themes and patterns.
The interviews consisted of five open-ended questions:
1. What stood out for you during this project?
2. What should be done differently in the future?
3. What were the unexpected outcomes or changes that occurred as a result of
the GRIP tool?
4. Did the GRIP tool help or hinder students’ decision-making?
5. Give examples of how students used the GRIP tool.
The following is a description of the faculty interview data grouped according to
interview questions and emerging themes.
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4.4.2.2.1 Question 1- What stood out for you during this project?
Both faculty members stated that what stood out to them was how well the
students adapted to the technology and that students remained positive and open to using
the tool throughout the investigation. Both faculty members also noted that support was
timely and technical problems were resolved quickly. One faculty stated that she was
struck by students’ technical abilities in using the tool and troubleshooting problems as
well as the unit staff’s positive reaction to the tool.
4.4.2.2.2 Question 2 - What should be done differently in the future?
In response to the question regarding what should be done differently, both
faculty members agreed that more training should be conducted. Both also stated that
this would build student comfort with using tool and prevent some of the technical user
issues experienced. In addition, both stated that doing this would help students develop
skill in conducting patient assessments using the tool. One faculty member stated that
building student comfort and skill level may help minimize the perception of the tool as a
barrier to the nurse-patient relationship.
4.4.2.2.3 Question 3 – What were the unexpected outcomes or changes that
occurred as a result of the GRIP tool?
One faculty member commented that the tool did not always capture accurate
data. She attributed this to the interview design, the inability to enter information that
was observed by the nurse that may have contradicted the patient’s response and to have
this observational data included in the final scoring. This correlated with the comment
made by two students that the tool did not have the capability to record follow-up
questions or observational data if a patient’s response and non-verbal behavior appear
inconsistent. This could suggest that patients were not being honest or perhaps realistic in
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their responses.
The other faculty member stated that he could not really identify an unexpected
outcome. He did observe, however, that while the tool, for the most part, identified
problems appropriately it did not always rank these problems in the order that he would
have. For example, even though a problem identified was a legitimate problem, he might
have placed it as number four in priority while the tool ranked it as number one or two.
4.4.2.2.4 Question 4 – Did the GRIP tool help or hinder students’ decisionmaking?
In response to this question, the faculty differed. One faculty member stated that
while he believed that the tool neither helped significantly nor hindered the students’
ability to make clinical decisions; it did help the students learn. He stated that GRIP
served as a source of information that started discussion between him and students and
that the tool helped them develop their ability to consider all patient data and then
formulate patient care priorities. He noted that this analytical process strengthened as the
term progressed.
"The students used it to give them some direction but then
to do further assessment….look into what they’ve learned
in class, ask me better questions about what I thought was
going on than they were asking at the beginning of the term
and that was, in my mind, the ideal. That’s what I think
we’re aiming for in GRIP…to develop a thought process
more than just to utilize the tool to get data."
The other faculty member stated that the GRIP tool did have a positive impact on
the students’ clinical decision-making.
"It definitely did because it was right there in the PDA.
They could download it to their computer, and they had
easy access to everything. When they (the students) finally
got the hang of it, and things were going smoothly,
everything was right there for them, and they were
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definitely able to build from it."
4.4.2.2.5 Question 5 – Give examples of how students used the GRIP tool.
Both faculty members stated that students used the tool to complete the
comprehensive patient assessment, build their understanding of the geriatric patient and
provide care to their patients and that this contributed to their learning. One faculty
member made the following comment:
"…(students) would look and make the comparison and say
'Ah-hah. It is in the chart.' Or say, 'I was able to pull out
more information using the grip tool as opposed to what the
assessment was on the chart.' And then they did report
every day with the nursing staff and also with a social
worker and then would let them know their findings."
The other faculty member stated that the tool was useful and contributed to
students’ learning by making them think and make sense of what data were presented.
"In terms of never necessarily telling them that they have
the right and final answer but rather ‘Where’s this taking
us?’ or ‘What does it mean? What are the
implications?’…. It actually fit nicely with my teaching
style in that respect and I think it helped them get a
schematic down, but then to understand that they have to
flesh it out."
Chapter Five will include an interpretation of these findings and a discussion of
the significance of the emerging themes and the implications for future research in the
use of handheld technology in nursing education.
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SUMMARY AND IMPLICATIONS FOR FUTURE RESEARCH
5. 1
Overview of Study
An increasing number of nursing programs are beginning to examine the
effectiveness of PDAs in nursing education. Therefore this investigation has the potential
to contribute to the body of nursing and informatics knowledge as well as the ability to
incorporate this technology into effective learning activities for educators and students in
various settings. If strategies to effectively incorporate PDAs into nursing education can
be identified and validated, they have the potential to revolutionize nursing education.
Technology is having a significant impact upon nursing education, mandating that
nursing faculty work and become comfortable with it in order to prepare students to work
in a high-tech health care environment. This presents nurse educators with the
challenging task of “structuring student learning experiences in an environment of rapidly
changing technology” (Lindeman, 2000, p.6). It is imperative for nursing educators to
identify strategies to utilize new technology to support students in their development as
life-long learners who are proficient in using technology as a tool for clinical decisionmaking. If effective strategies are identified, new nursing graduates will be well prepared
for a dynamic healthcare environment in which innovation and transition are the norms.
As discussed in Chapter Two, effective utilization of information technology can
make a difference to both the nursing profession and nursing education. “It can help
people do a better job, but only if they are willing to use the technology and if they
become effective users” (Martinsons & Chong, 1999, p. 124). In addition, to avoid
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misuse, underutilization or abandonment of new technology, it is important that there is a
“good understanding of the intended end-users, their tasks and the interdependencies
between the two” (p. 124). This is a major consideration for educators who wish to
experiment with this technology.
It was the purpose of this study is to investigate the effectiveness of handheld
technology in nursing education in the development of clinical competency and decisionmaking skills in undergraduate nursing students and to identify user issues associated
with this technology in the clinical setting. The specific questions explored were:
1
What is the relationship between the use of handheld personal computers
(PDAs) and student ability to correctly identify the three priority patient care
needs?
2
What is the user experience associated with this technology in the clinical
setting?
This investigation was conducted during July and August 2004. A total of 26
students and 2 faculty members participated in this investigation. Data was collected at
two clinical sites in Philadelphia, Pennsylvania. A total of 212 patients were assessed
using the GRIP tool. The intent of this study was to learn what is relevant in phenomena
under investigation and to use that to develop an understanding of conceptual
relationships involving use of PDAs in nursing education. This required a meticulous
review and re-review of data collected.
5.2 Conclusions
The first conclusion of this study is that GRIP is effective in helping students think
and construct meaning from information gathered supporting the process of decision-
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making. Students using the GRIP tool were able to collect and organize patient
information and use that information to construct meaning. GRIP created an
environment in which the student was able to become an autonomous and self-directed
learner by providing immediate access to information in an organized format—when and
where it was needed—encouraging the student to think at a higher level. Students
examined that information, assigned value and constructed new knowledge in the setting
in which it was to be applied. This resulted in learning that, as described by proponents
of situated learning, is more meaningful, valuable and useful for the student because it
occurred in a relevant or real-life context. (Lave, 2004; Brown, Collins & Duguid, 1989)
Faculty comments regarding the students’ performance during this study indicate
that the tool contributed to students’ learning by making them think and make sense of
the data that was presented. GRIP encouraged students to look critically at the data. As
stated by one faculty member, the GRIP tool supported this process by:
"…never necessarily telling them that they have the right
and final answer but rather ‘Where’s this taking us?’ or
‘What does it mean? What are the implications?’…. It
actually fit nicely with my teaching style in that respect and
I think it helped them get a schematic down, but then to
understand that they have to flesh it out."
This finding concurs with the literature centering on the benefits of Electronic
Performance Support Systems in the work (clinical) setting, (Bill, 1997; Sleight, 1993)
which supports the notion of using technology to help the user to more effectively
"weave the threads" of information to construct meaning and guide interventions.
Nursing is a very complex activity. Gery (2003) stated that the more difficult or complex
the situation, the more difficult the task becomes. She suggested that the use of
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technology to help "weave the threads of information" can support the student in
becoming a reflective and anticipative practitioner.
The second conclusion of this study is that handheld technology is effective in the
development of clinical competency and clinical decision-making skills of undergraduate
nursing students. Both faculty and students reported that they believe the GRIP tool had
a beneficial effect on clinical decision-making. Again, faculty comments regarding the
students’ performance during this study seems to validate that the tool helped the students
develop complex thinking, an essential precursor to clinical decision-making. One
faculty member articulated this point particularly well:
"The students used it to give them some direction but then
to do further assessment….look into what they’ve learned
in class, ask me better questions about what I thought was
going on than they were asking at the beginning of the term
and that was, in my mind, the ideal. That’s what I think
we’re aiming for in GRIP…to develop a thought process
more than just to utilize the tool to get data."
This finding is supported by Jirapaet (2001), who in her study of 16 neonatal
intensive care unit nurses demonstrated that the use of an "expert system" that organizes
data and provides decision support showed a significant increase in the nurses’
performance scores of diagnoses. She determined that a computer expert system is an
effective tool to support nurses’ clinical judgment by providing access to information at
the practice site and “providing real-time clinical decision support for nurses to advance
their practices from a novice to a proficient level.” (p. 194)
This supports the researcher’s model of clinical decision-making, which is an
iterative process and begins early in nursing education. Clinical experiences are
contextually or situationally based, and the process in which the student acquires clinical
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decision-making skills is both predictive and recursive in nature as illustrated in Figure 5
Figure 5: The Iterative Nature of Clinical Decision Making from Novice to Expert
It is this foundation that supports development of the skills set essential for a practicing
nurse and must be established early on in the academic career. Maynard stated that while
“new graduates are novices and not finished products…. The educational process must
provide the skills and knowledge upon which the neophyte can develop an experiential
base and service the opportunity and time for development.” (January, 1996, p. 17) This
is clearly what occurred in this study. Both students and faculty stated that the GRIP tool
supports student clinical decision-making by serving as a means to collect and organize
data, identify patient care priorities and obtain guidance/direction for patient care.
Faculty added to this that the tool provided a mechanism to generate discussion and
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thinking at a higher level, which contributes to clinical decision-making.
Incorporating the GRIP tool in real-life problem-solving tasks and clinical
activities created an environment that supported learning, allowing students to construct
meaning from data collected and then apply that new knowledge in that particular setting.
As stated by Hanks (1991), this provides the learner with much more than “a discrete
body of abstract knowledge which (s)he will then later transport and reapply in later
contexts. Instead, (s)he acquires the skill to perform by actually engaging in the process,
under the attenuated conditions of legitimate peripheral participation” (p. 14)
This is particularly significant for nursing education since as stated in Chapter 1,
the goal for nurse educators is to promote clinical competency and critical thinking
among students, enabling them to manage information effectively and efficiently for the
purpose of guiding their nursing interventions in a variety clinical practice settings. This
study has demonstrated that the use of an innovative tool such as GRIP, which provides
an automated mechanism to organize and present patient data, supports the development
of clinical decision-making among students.
The third conclusion is that students, when using GRIP, were able to identify the
top three nursing care priorities at a level of expertise that compared favorably with
faculty experts. Students and faculty were on average in agreement two out of three times
in their selection of the top three nursing care priorities. It remains unclear what the
relationship is between the use of the PDA and the student ability to correctly identify the
top three priority patient care needs since the analysis of the data collected did not
contribute to our understanding of this relationship. The similarity of results between the
novices and experts may be explained in part by the automated expert system provided by
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the GRIP tool. As in Jirapaet’s (2001) study, which found that such a mechanism helped
advance the practice of the novice to a proficient level, the GRIP tool may have had a
similar affect these nursing students.
It was surprising that there was not more consistency of agreement among faculty
in the nursing care priorities identified. As discussed earlier, these findings did concur
with those of Banerjee and Fielding (1997) and many of the same factors identified by
the researchers may have also influenced the results of this study. Specific factors that
influenced this study include:
1 Nursing as an art and science
2
Nature of the nursing diagnosis
3
Complex care needs of the elderly
4
Change in status of patient between interviews
5 Individual differences between study participants
6
Limitations of the GRIP tool
A major factor that must be considered is the nature of nursing itself. Nursing is
viewed by those in the profession as a both science and an art. The two elements are
critical components. While nursing practice involves the application of scientific
principles in caring for individuals, there are differences between practitioners and
patients, which are contextual and vary over time. Whelton (2000) stated that it is the
practitioner who integrates both the science and art of the discipline for the purpose of
guiding practice in any given situation. “It is important to realize that the practitioner as
scientist does not produce the individual singular existent. The science must be
completed by the art of practice, which uses scientific principles, and the decision of an
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individual practitioner that this is the proper action at this time in this particular set of
circumstances.”(2000, p.57)
The nature of the nursing diagnosis itself may have also contributed to the results.
Nursing interventions are always organized according to priorities. “High priority may
be assigned to life-threatening situations; intermediate priority to non-emergency, nonlife threatening needs of the patient; and low priority to those that may not be directly
related to a specific illness or prognosis, but arise from normal developmental needs, or
that require only minimal support.” (Hendry, 2004, p. 429) All nurses, even those with
less experience, will agree in situations where the diagnosis involves a critical
physiological function such as airway or bleeding and will give that diagnosis priority
ranking. There are other less acute nursing diagnoses that allow the nurse more
flexibility in the ranking of priority. It is this flexibility of individual nursing clinical
judgment that may have contributed to the findings of this study.
Another factor contributing to the findings is the decision to limit the data to the
top three nursing care priorities. Elderly patients are complex and often have multiple
nursing care needs. It is not unusual for an elderly patient to have more than three
nursing care needs. These needs may shift in priority from time to time, so a nursing care
priority that may have been among the top three priority needs may drop to number four.
This does not mean that this priority will be neglected, only that there are more pressing
needs at this point in time. In addition, identified nursing care priorities are often
addressed concurrently so limiting the data collection to the top three nursing care
priorities may have excluded some data. In the future, it may be beneficial to include all
relevant nursing diagnosis in the data collected.
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Individuals are dynamic beings and consequently one’s physical status does not
remain static. This is particularly relevant among the elderly, since they typically have
more health issues. In addition, the patients assessed were hospitalized so their condition
may have been less stable, fluctuating between assessments. These factors may have also
contributed to the lack of consistency noted between the nursing care priorities identified
by the study participants.
Yet another factor that must be considered is the individual differences of the
study participants. As in Banerjee and Fielding’s (1997) study, one must consider the
“varied background, experience and perspective of the individual” as these will
undoubtedly influence the interpretation of assessment findings.(p. 470) The influence of
individual participants’ bias is an important consideration that must not be overlooked.
The limitations of the GRIP tool itself may also have contributed to the lack of
agreement. As reported by study participants, the tool did not always capture all of the
assessment data and needed a mechanism to enter and score observational data. This was
a major theme emerging from the study and will be discussed in more detail later in
conclusion six.
The fourth conclusion is that students were able to do a more comprehensive
patient assessment/ interview when using GRIP. Forty-eight percent of the students
reported that the tool helped them conduct a more thorough and comprehensive
assessment and gave them direction to conduct additional assessments. The GRIP tool
provided students with structure as well as cues to ask questions that ordinarily might
have been omitted or missed, forcing them to “at least think about asking the question to
the patient.” One student reported that: “You may not have realized that a patient may
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have been depressed. GRIP pointed out you may want to use the geriatric depression
scale as another tool…it was helpful in pointing out areas you may not have considered.”
In other situations, the tool gave the students permission to ask the sexual history
question that may have been difficult to ask due to lack of experience, generational or
cultural issues. This finding is supported by Duldt (1999) who stated that “a few lectures
and minimal exposure to actual patient situations is not enough for students to develop
expertise in communicating about sexual activity.” GRIP, by providing a structured
interview format that included questions about sexuality, helped students overcome that
barrier. This finding is also in agreement with McKelvey et al's (1994) study, which
identified the need to “increase students’ ability to function more effectively as sexual
history takers” through structured experiential activities. (p. 260) This finding is also
supported by Jirapaet’s (2001) study, which concluded that the use of such technology
facilitates nurses’ learning processes, changes their nursing decisions, and assists them in
delivering better care.
The fifth conclusion is that the PDA can be a barrier to the nurse-patient
interaction. A frequent observation made by the students was that the GRIP tool
interfered with the nurse-patient interaction and was described by some as a barrier to
interpersonal communication. While two students stated that the tool actually helped
establish rapport with the patient, one third (N=7) of the study participants reported that
they believed that using the GRIP tool interfered with the nurse-patient relationship and
created a barrier to establishing rapport. One student summarized the experience this
way:
“I spent more time trying to look at the PDA, going through the
screens and ask the right questions, instead of paying attention to
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the patient, and I think it took away from the patient relationship.”
This certainly is an important issue to examine more closely because establishing
effective interpersonal relationships is essential in nursing practice. This finding may be
due to the combined effect of generational differences, student proficiency with the tool
and tool design issues.
First, generational factors may also have contributed to the perception that the
technology is a barrier to building rapport. Many elderly are not as familiar with new
technology and may find it stressful when it is introduced to them in the hospital setting.
Elderly patients as a rule have less experience with technology and therefore may be less
comfortable being interviewed using these devices. This finding concurred with those
reported by Czaja and Sharif (1998) in a study of 384 adults ages 20-75 years. They
reported that “older people reported less comfort and less competence with computers,
and felt they had less control over computers. They also perceived computers to be more
dehumanizing than did the other participants.” (p.337) Jay and Willis (1992) in a study
of 101 adults aged 57-87 reported that while as a whole the elderly were less comfortable
with computers, computer attitudes can be modified by direct experience. Clearly, the
influence of this factor as a barrier can be mitigated by a more purposeful, structured
introduction of the technology to this population.
In addition, the generational factor will likely be less significant as the baby
boomers age. It is important, however, to take note of these findings, to be cognizant of
aspects of the technology that contribute to the perceived barrier and to take measures to
minimize these effects. There are adaptive techniques that can be utilized to mitigate the
perceived barriers. For example, some students reported that they memorized the
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questions so that they could be more conversational with the patient while still gathering
all the necessary data.
Second, the student’s lack of comfort and familiarity with the tool did affect the
experience for both student and patient and negatively affected the nurse-patient
interaction. It is not unusual for a new user of any assessment tool—whether PDA based
or in paper format—to be focused more upon completing the task properly than upon the
person seated before them. This point was clearly articulated in the following comment:
"I thought it was very impersonal, like, sitting there with
the program in front of you and constantly looking at the
answers and choosing what to do and then waiting for it to
go back to, like, whatever screen you’re going next to. But,
I guess you can do that with any kind of interview paper or
what not."
More training was a recommendation made by many students and faculty and
should be a major component of any plans for future use of GRIP. Providing the
opportunity for more experience and training will increase participants’ feelings of
comfort and competence with the technology and support the development of a belief that
computers are useful. (Czaja & Sharif, 1998; Jay & Willis, 1992) Extensive training prior
to using the GRIP tool in the clinical setting will increase student proficiency with the
tool and lessen the impact of this factor on the nurse-patient interaction.
Tool design issues, particularly the inflexibility in navigation within the tool and
the linear characteristic of the tool, were reported to interfere with the nurse-patient
relationship. This factor reflects a need to reexamine the design and functionality of the
tool and will be discussed in more detail in the sixth conclusion.
The sixth conclusion is that the GRIP tool needs to be revised in design and
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functionality. Tool design and functionality was a major theme that emerged throughout
this study in both field observations and in-depth interviews. It played a significant role
in the user experience and influenced students’ ability to correctly identify the top three
nursing care priorities. Throughout the study, students provided considerable feedback
regarding the GRIP tool design and functionality, pointing out aspects of the tool that
worked well or needed improvement. For the most part, students found the tool easy to
use, logical in organization and comprehensive, but most also agreed that the tool needed
revision. Attention to these design and functionality issues is essential for the future
utilization of GRIP. Czaja and Sharif (1998) noted this important consideration in their
study, stating that “factors including level of frustration and level of performance during
initial interaction with a technology have an influence on attitude change. In this regard it
is important to ensure that users are provided with adequate support during their
interactions with technologies.” (p. 339) In addition, the researchers go on to say that
“extra attention should be given to training and design strategies that can minimize
mismatches between the cognitive demands of the computer task and the cognitive skills
of the user. Otherwise, there is a risk that users may feel that they are not capable of
handling the task and may adopt negative attitudes toward computers. This, in turn, may
influence their willingness to use computers in the future.” (p. 338)
Each GRIP pattern must be reexamined by the content experts, question-byquestion, in conjunction with the data collected to determine specific measures to
improve the tool. Given that about half of the students, N=11, stated that the tool did not
capture all aspects of assessment and that the questions need to be revised and re-ordered,
this should be a particular focus of the reexamination. It might be helpful to conduct a
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focus group comprised of elderly volunteers to review the questions and provide
recommendations to improve clarity and appropriateness of the questions. A mechanism
to include and score observational data should also be considered, because students
expressed concern that not being able to capture this data affected their ability to obtain
an accurate assessment. Another common recommendation was to modify the tool to
permit back-and-forth navigation, thus eliminating the forced linear flow of the tool. For
many students this was a concern because it interfered with the flexibility of entering data
and negatively impacted the patient interview process.
Clearly these findings support the conclusion that tool must be closely examined
and serious consideration must be given to revising and improving the tool prior to using
it again in the clinical learning environment. Czaja and Sharif, (1998) articulated this
point succinctly in their study, which concluded that “as levels of frustration increased,
overall attitudes toward computers became less positive-as did feelings of comfort,
control, and competence." (p. 338) Overall, these findings point to the importance of
providing users with adequate training so they have the skills needed to operate
computers successfully. The findings also underscore the importance of usability with
respect to interface design.
5.3 Limitations of the Study
There are several limitations associated with this study. First, the time frame was
limiting. It would have been preferable to conduct a longitudinal study of this
phenomenon. Also, the sample was not representative of nursing students in general.
Drexel University nursing students as a whole are more technically competent than
nursing students in general. In addition, Drexel students are required to have and use
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PDAs throughout the program. These students also take a nursing informatics course,
which introduces them to the use of the PDA and other healthcare technologies.
Another limitation for the study is that students who volunteered were likely more
technically skilled and interested in using technology than the typical student. As
discussed earlier, the GRIP software was new and relatively untested. Students were also
not experienced with using the software.
Another consideration is the researcher, herself. As stated earlier, the researcher
was deeply committed to the CNHP’s technology initiative, which strived to integrate
handheld technology across the curriculum. As a result, the researcher had sought out
opportunities, such as this, to identify new technologies/applications and develop
partnerships that may support achievement of this goal. While every effort was made to
maintain objectivity, it is impossible to eliminate bias entirely and is important to
acknowledge it as a limitation for this study.
5.4 Summary and Recommendations for Future Research
The findings of this study are significant to nursing education, demonstrating a
clear benefit when this technology is used in the clinical setting. As discussed in Chapter
2, an automated and integrated system does have applicability to nursing education when
utilized in situations that encourage the student to critically evaluate the information
provided by the system. Such structured learning opportunities provided in context, as in
this study, support the development of “higher order thinking skills which facilitate the
process of acquisition, management and the use of health care information.” (Robins,
1998, p. 228) This process begins with the student’s ability to accurately
identify/articulate the problem, need or gap in information, then gather the appropriate
106
information and finally make a judgment regarding the meaning of the information before
determining the appropriate nursing action/intervention.
The data organization capability of GRIP provided a mechanism to help the
students think at a higher level. When using GRIP, students were able to critically
analyze the patient information that they had collected and make this information
meaningful before identifying creative, next-step options for nursing intervention. This
was a process in which the student constructed meaning from the gathered information,
assigned value to that information and then used this to guide clinical decision-making.
This high level, complex thinking is precisely what nursing educators strive to develop in
students.
While the results of this investigation demonstrate that there is a positive
correlation between PDAs and student learning, more research is needed. Before any
additional research of the GRIP tool is conducted, a detailed examination of the data
collected by the tool in this study—question-by-question—may help identify specific
modifications that would improve the tool. Further testing to establish reliability and
validity of this tool is also indicated. As discussed earlier, it would be beneficial to have a
focus group examine the questions and make recommendations to improve the questions.
It may be beneficial to repeat this study after the recommended changes have been made.
This will likely provide deeper insight into this phenomenon as well as establish new
direction for inquiry.
Since situated learning involves a social, collaborative component, it would
beneficial to include in any future studies a web-based component. Providing a web
interface for GRIP users will allow them to share and discuss the data obtained. This web
107
interface will provide an opportunity for the development of a virtual community of
learning in which students can create and share knowledge that could further support
development of their clinical decision-making skills.
In addition, similar studies in other clinical settings may yield more insight and
provide additional validation that PDAs equipped with tools such as GRIP can contribute
to student learning and support the development of clinical decision-making. A more
extensive study that compares students who use the technology and those who do not will
also provide additional insights for educators. Another area for future research is the
effect of technology, such as the PDA and PDA based tools, upon the nurse-patient
relationship. This is particularly important, because so much of nursing practice centers
on establishing an effective interpersonal relationship.
As the effectiveness of this technology is established, there must be more research
to identify creative approaches to using it and pushing it in new, innovative directions.
This can result in more meaningful learning experiences that support the development of
the student’s ability to problem sense, access information and problem solve.
Technology can assist in the process of integrating information and, as Gery
(2003)suggested, can not only "weave the threads of information" into integrated
resources for the student to access at the point of care but also support the student in
becoming a competent, reflective and anticipative practitioner. That, of course, is the goal
of nursing education.
108
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APPENDIX A: BENNER’S STAGES OF CLINICAL COMPETENCE
Stage
Stage 1:
Novice
Stage 2:
Advanced
Beginner
Stage 3:
Competent
Stage 4:
Proficient
Characteristics
Beginners have had no experience of the situations in which
they are expected to perform. Novices are taught rules to help
them perform. The rules are context-free and independent of
specific cases; hence the rules tend to be applied universally.
The rule-governed behavior typical of the novice is extremely
limited and inflexible. As such, novices have no "life
experience" in the application of rules.
"Just tell me what I need to do and I'll do it."
Advanced beginners are those who can demonstrate marginally
acceptable performance, those who have coped with enough
real situations to note, or to have pointed out to them by a
mentor, the recurring meaningful situational components.
These components require prior experience in actual situations
for recognition. Principles to guide actions begin to be
formulated. The principles are based on experience.
Competence, typified by the nurse who has been on the job in
the same or similar situations two or three years, develops when
the nurse begins to see his or her actions in terms of long-range
goals or plans of which he or she is consciously aware. For the
competent nurse, a plan establishes a perspective, and the plan
is based on considerable conscious, abstract, analytic
contemplation of the problem. The conscious, deliberate
planning that is characteristic of this skill level helps achieve
efficiency and organization. The competent nurse lacks the
speed and flexibility of the proficient nurse but does have a
feeling of mastery and the ability to cope with and manage the
many contingencies of clinical nursing. The competent person
does not yet have enough experience to recognize a situation in
terms of an overall picture or in terms of which aspects are most
salient, most important.
The proficient performer perceives situations as wholes rather
than in terms of chopped up parts or aspects, and performance is
guided by maxims. Proficient nurses understand a situation as a
whole because they perceive its meaning in terms of long-term
goals. The proficient nurse learns from experience what typical
events to expect in a given situation and how plans need to be
119
modified in response to these events. The proficient nurse can
now recognize when the expected normal picture does not
materialize. This holistic understanding improves the proficient
nurse's decision making; it becomes less labored because the
nurse now has a perspective on which of the many existing
attributes and aspects in the present situation are the important
ones. The proficient nurse uses maxims as guides which reflect
what would appear to the competent or novice performer as
unintelligible nuances of the situation; they can mean one thing
at one time and quite another thing later. Once one has a deep
understanding of the situation overall, however, the maxim
provides direction as to what must be taken into account.
Maxims reflect nuances of the situation.
Stage 5:
The Expert
The expert performer no longer relies on an analytic principle
(rule, guideline, maxim) to connect her or his understanding of
the situation to an appropriate action. The expert nurse, with an
enormous background of experience, now has an intuitive
grasp of each situation and zeroes in on the accurate region of
the problem without wasteful consideration of a large range of
unfruitful, alternative diagnoses and solutions. The expert
operates from a deep understanding of the total situation. The
chess master, for instance, when asked why he or she made a
particularly masterful move, will just say: "Because it felt
right; it looked good." The performer is no longer aware of
features and rules;' his/her performance becomes fluid and
flexible and highly proficient. This is not to say that the expert
never uses analytic tools. Highly skilled analytic ability is
necessary for those situations with which the nurse has had no
previous experience. Analytic tools are also necessary for those
times when the expert gets a wrong grasp of the situation and
then finds that events and behaviors are not occurring as
expected When alternative perspectives are not available to the
clinician, the only way out of a wrong grasp of the problem is
by using analytic problem solving.
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing
practice. Menlo Park: Addison-Wesley, pp. 13-34.
120
APPENDIX B: FIELD OBSERVATIONS
The researcher and other outside observers will conduct field observations of
students conducting patient assessments while using the PDA tool in the clinical setting.
Key areas to observe include: detailed observations of the lived experience of the study
participants, including the actions of students and faculty. This will consist of the
following: 1) description of the setting, 2) description of the activity, 2) description of
the dialogue and 4) characterizing the participants. Specific observations may include:
•
•
•
•
•
•
•
•
•
•
What is the student experience?
Are students able to use the PDA tool to easily conduct the
patient assessment?
How long did it take to complete a patient assessment?
What were the problems observed?
Did the PDA Tool perform smoothly?
What were the student responses (verbal and non-verbal) to
using the application?
What were the patient responses (verbal and non-verbal) to
having an assessment conducted using the tool?
What were the faculty responses (verbal and non-verbal)?
What were the results of the data collected by the tool? Is the
data collected by the student comprehensive and accurate?
Any additional observational data
A simple check list will be utilized to record field observations (yes-no) which will be
comprised of likely observations both positive and negative with a comments area as well
to record spontaneous comments made by student as well as observations made that are
not on the checklist. (see example )
121
Sample check list
Yes
No
Are students able to use the PDA tool to easily conduct the
patient assessment?
Was the student able to complete an
assessment?
How long did it take to complete a patient
assessment?
Did the PDA Tool perform smoothly?
What were the student responses (verbal and
non-verbal) to using the application?
(Specify)
□ verbal +
□ verbal –
□ non-verbal +
□ non-verbal -
What were the patient responses (verbal and
non-verbal) to having an assessment
conducted using the tool?
(Specify)
□ verbal +
□ verbal –
□ non-verbal +
□ non-verbal -
What were the problems observed?
(Specify)
What is the student experience?
Any additional observational data
□ none observed
□ PDA freezing
□ PDA problems
□ GRIP difficult to
use
122
APPENDIX C: IN-DEPTH INTERVIEWS
Content and questions for the in-depth interviews will be will be derived from analysis of
the qualitative observational data collected during field observations and the on-the-spot
interviews of students and faculty in the clinical setting.
Some of the verbal prompts may be as follows:
1. What stood out for you during this project?
2. What should be done differently in the future?
3. What were the unexpected outcomes or changes that occurred as a result of the
GRIP tool?
4. How did you feel using the GRIP tool?
5. Did the GRIP tool help or hinder your decision-making?
6. Give examples of how you used the GRIP tool?
123
APPENDIX D: PROGRAM CURRICULUM
Drexel University
College of Nursing & Health Professions
ACCELERATED ONE YEAR BSN PROGRAM
FOR STUDENTS WITH A BACCALAUREATE OR MASTER’S DEGREE
Fall Quarter
NURS 100:
NURSING IN
SOCIETY (3)
NURS 102:
HEALTH
PROMOTION,
TEACHING AND
SELF CARE (4)
NURS 200:
PRINCIPLES OF
NURSING
PRACTICE (4)
NURS 201:
HEALTH
ASSESSMENT
ACROSS THE
LIFESPAN (4)
Winter Quarter
Spring Quarter
NURS 300:
COMPREHENSIVE
ADULT NURSING I
(6)
NURS 305:
COMPREHENSIVE
ADULT NURSING II
(6)
NURS 401:
COMPREHENSIV
E ADULT
NURSING III (6)
NURS 308:
MENTAL HEALTH
NURSING (6)
NUR 304: NURSING
OF CHILDREN (6)
NURS 403: PUBLIC
HEALTH NURSING (6)
NURS 450:
CONTEMPORAR
Y
GERONTOLOGIC
AL NURSING (6)
NURS 306:
PHARMACOLOGY
FOR NURSING II (3)
NURS 492:
SENIOR
SEMINAR IN
NURSING (3)
NURS 303:
WOMEN’S HEALTH
NURSING (6)
NUR 301:
PHARMACOLOGY
FOR NURSING I (3)
NURS 400:
LEADERSHIP,
MANAGEMENT,
&
ENTREPRENEUR
SHIP IN NURSING
(4)
NURS 337:
GENETICS IN
NURSING &
HEALTH (3)
NURS 330:
RESEARCH
BASIS OF
NURSING (4)
NURS 404:
NURSING
INFORMATICS (3)
21 CREDITS
Summer
Quarter
21 CREDITS
21 CREDITS
23 CREDITS
124
APPENDIX E: CLINICAL EVALUATION CRITERIA
Drexel University
College of Nursing & Health Profession
ACE Program – Clinical Evaluation Criteria
Objective
1. Utilizes the growing compendium of current knowledge and
information sources from nursing and other disciplines to learn, to
teach, to heal the sick and conserve health.
a. Is prepared for clinical practicum. Obtains patient assignment
and relevant data prior to clinical experience and by reviewing
pertinent data begins to initiate a preliminary plan of care.
b. Completes clinical preparation sheet and is able to discuss
current health care needs.
c. Completes Medication Sheet
d. Demonstrates ability to examine the concepts that form the
foundation of nursing care.
e. Verbalizes an understanding of current health issues and is
able to discuss a plan of care, drawing on previous acquired
knowledge and current treatment modalities.
f. Integrates information obtained from patient, family, medical
records, and other health care professionals into clinical
practice.
2. Contributes to the profession by sharing knowledge and skills with
patients, peers and other health professionals through effective verbal
and written communication.
a. Participates in Pre and Post conference sharing previously
acquired and current knowledge with the group.
b. Communicates effectively and in a professional manner with
other health care professionals within the clinical setting.
c. Obtains report from the Registered Nurse (RN) and reports all
pertinent data to the RN and clinical instructor in a timely
manner.
d. Utilizes therapeutic communication with individuals, families
and other health care professionals.
e. Accepts constructive feed back from instructor & peers and
incorporates into practice.
3. Utilizes multiple technologies, such as the computer and PDA to access
and manage information to guide professional practice
a. Accesses computer data bases and other relevant information
sources for patient/community care when necessary
b. Actively seeks new learning experiences and demonstrates
accountability as an active participant in the learning process.
125
4. Participates in culturally sensitive health promotion activities that
contribute to the health and wellness of the client and/or individual and
of the community.
a. Expresses sensitivity and cultural awareness when caring for
diverse populations incorporating cultural considerations into
the plan of care
b. Demonstrates recently acquired skills and incorporates them
into practice.
5. Participates in ongoing educational activities related to personal
growth, professional practice and community service
Identify areas of strengths and areas for potential growth
6. Applies knowledge and skills appropriate to the selected area of career
clinical practice
a. Utilizes the nursing process to identify the priority patient care
needs incorporating NADA Nursing diagnosis and Functional
Health Care Patterns.
b. Performs a health assessment of each patient incorporating and
applying skills learned in the health assessment class and
Nursing 200.
c. Demonstrates ongoing progression of health assessment
techniques and knowledge base.
d. Demonstrates the ability to care for 1-2 patients in the clinical
area.
e. Documents an accurate health assessment for each patient in a
head to toe systems narrative format.
f. Maintains safe nursing practice in all clinical areas
g. Administers medications identifying the Five (5) Rights of
Medication Administration. Demonstrates the ability to
identify the drug, pharmacological drug class and possible
rationales for its use.
7. Develops personal potential for leadership in a changing health care
environment
a. Maintains a professional demeanor with patients and health
professional members
8. Integrates ethical concepts, nurses code of ethics, principles and
professional standards into practice within professional and academic
settings
a. Practices within a legal and ethical framework.
b. Adheres to professional standards of practice.
c. Adheres to standards of conduct described in the student
handbook.
d. Arrives on time for clinical experience & conferences.
126
9. Utilizes critical thinking skills to improve the health outcomes of
patients, families and communities across the continuum of care.
a. Use of clinical skills to prioritize patient care needs
appropriately.
b. Implements basic problem solving skills to guide decision
making in the clinical area.
127
APPENDIX F: GRIP SCREENSHOTS
This is the start screen for the PDA
component of the GRIP program.
The student can select one of four
options:
1. Add an assessment for a new
patient,
2. Add an assessment to an
existing patient,
3. View the entire assessment
for a given patient, or
4. Edit data using the
delete/update feature
This is the screen the student would see
if he/she selects option #2 (Add an
assessment to an existing patient).
Please note that all completed
assessments will be shown with the
accompanying risk level score.
From this screen the student can select
another assessment module (one of the
11 essential patterns). The student may
choose to repeat an assessment module
that has already been completed to
determine if the risk level has changed
(improved or worsened) or select a
different assessment module to
complete.
128
If the student selects option #3 at the
GRIP Start Screen (View the entire
assessment for a given patient), they
will be able to see the specific details
of each assessment.
Each pattern completed will be listed
on the drop-down menu
If the selected pattern has been
assessed more than once, the students
will be able to select the appropriate
date from the drop-down menu.
To view patient demographic
information (diagnosis, vital signs,
etc) or view patient allergies, select
one of these options.
To view the specific details of the
pattern assessed (elimination), select
‘next’.
The program will generate a
calculated risk level score for
the pattern assessed.
The student will be able to
view the entire report for a
particular pattern.
Students would receive a cue
regarding the patient’s need
for a nursing intervention
which in this example is low.
129
This is the first screen of
the desktop interface of
this program.
Upon syncing the PDA
with the desktop
computer, the students
will be able to edit and
add additional information
to complete the patient
care plan.
Students can select three
options:
1. Add Medications
2. Add Plan of Care
3. View Reports
If the student selects option #2 – ‘Add Plan of Care’, the following screen would
appear.
Upon reviewing the assessment reports, students will be able to add an appropriate
nursing diagnosis, goals, interventions and evaluation criteria.
130
APPENDIX G: GRIP CONTENT EXPERTS
Gloria Donnelly, PhD, MSN, RN a developmental psychologist, will be
responsible for the Intellect Module. As identified by the findings of the
longitudinal Nun Study sponsored by the National Institute of Aging (Riley et al,
2000), the promotion of early and lifelong cognitive function appears critical if
mental and intellectual capacity is to be maintained as one ages. Students will
learn how to assess cognition and promote healthy intellectual functioning.
Lorraine Igo, MSN, RN, EdD will be responsible for the Nutrition Module.
According to the Nutritional Screening Initiative (1997) malnutrition among the
elderly is extensive and preventable. It has been estimated that malnutrition is
prevalent in 30-65% of the elderly in home care, nursing homes, or in the
hospital (Nourhashemi et al., 1999). Certainly nutrition is pivotal in the
treatment of chronic diseases and this module will seek to teach students
strategies to optimize nutrition.
Elizabeth Gonzalez, PhD, MSN a psychotherapist who has conducted research
on depression in the elderly and stress in caregivers of patients with Alzheimer’s
disease, will be responsible for the Self-Concept Module. Erikson’s
Psychosocial Stages of Development will serve as the platform for the healthy
promotion of ego integrity among the elderly and the findings of the Harvard
Study of Adult Development (Vaillant, in press) will be explored. Students will
learn strategies to assess mental health status, promote psychosocial health, and
make appropriate referrals.
131
Anne Ferrari, Ed.D., RN who has conducted research with the frail elderly,
will be responsible for the Physical Mobility Module. She will be assisted by Art
Therapist, Nancy Gerber MS, ATR-BC, who will focus on hand and arm
dexterity using art as a medium. Annually, approximately 33% of communitydwelling older adults and 50% of nursing home residents will suffer a fall and
the consequences can lead to debilitation and death (Alexander, 2001). This
module will instruct the student to promote healthy exercise and identify the
geriatric individual who is at risk for falls and implement preventive
interventions.
Barbara Blair, MSN, CS, a psychotherapist and professional coach who has
extensive group therapy experience, will be responsible for the Interpersonal
Behavior Module. Maximizing social functioning is critical to human
development. Problems of loneliness, social isolation, and inadequate social
support, can severely impact quality of life (Hicks, 2000). Students will learn
how to assess social function and learn interventions to promote healthy social
behaviors.
H. Michael Dreher, DNSc, RN is completing a postdoctoral fellowship in Sleep
and Respiratory Neurobiology, and will be responsible for the Restful Sleep
Module. It is a misnomer that elderly persons require less sleep (UCLA, 2000).
However, elderly persons have more nighttime arousals and awakenings.
Students will explore the phenomena of sleep in the elderly and learn to promote
sleep hygiene.
Judy Draper, MSN, CRNP, a certified gerontological nurse practitioner and
Program Director in the Division of Continuing Education at MCPHU, will be
responsible for the Elimination Module. Changes in bowel and bladder function
are usually of great concern among the elderly. It the mid-1990s it was estimated
that the economic burden of urinary incontinence alone costs $10 billion dollars
in the U.S. (Qualey, 1995). This module will instruct students to assess, monitor,
and implement interventions to optimize elimination.
132
APPENDIX H: PILOT STUDY RESULTS
Identified
Patient
Module Pattern
Care
Priorities
Nutrition
Cognitive/perceptual
Elimination
Coping/
Elimination
stress
Rater #1
Score
Rater #2
Score
4
VERY LOW: 0-4
3
10
11
Sleep/Rest
Coping Stress
Values/Beliefs
13
4
1
MODERATE: 616
LOW: 7-13
LOW: 3-13
VERY LOW: 0-2
Role-Relationship
8
MODERATE: 6-8
8
Nutrition/Metabolic
19
HIGH: 16 to 21
19
Activity/Exercise
(mobility)
Sexuality
4
VERY LOW: 0-5
4
0
VERY LOW: 0-5
0
Self-Concept
Cognitive/perceptual
3
0
LOW: 3-5
VERY LOW: 0-4
3
0
18
7
28
0
HIGH: 17-26
LOW: 7-13
HIGH: 17-26
VERY LOW: 0-2
20
8
24
0
Role-Relationship
Nutrition/Metabolic
Activity/Exercise
(mobility)
Sexuality
4
4
12
4
4
12
0
LOW: 3-5
LOW: 3-5
MODERATE: 1115
VERY LOW: 0-5
Self-Concept
0
LOW: 3-5
0
Mobility
Elimination
Coping/
Elimination
Stress
Sleep/Rest
Coping Stress
Values/Beliefs
10
3
1
0
VERY LOW:
0-4
MODERATE
: 6-16
LOW: 7-13
LOW: 3-13
VERY LOW:
0-2
MODERATE
: 6-8
HIGH: 16 to
21
VERY LOW:
0-5
VERY LOW:
0-5
LOW: 3-5
VERY LOW:
0-4
HIGH: 17-26
LOW: 7-13
HIGH: 17-26
VERY LOW:
0-2
LOW: 3-5
LOW: 3-5
MODERATE
: 11-15
VERY LOW:
0-5
LOW: 3-5
133
Nutrition
Cognitive/perceptual
Elimination
Coping/
Elimination
Stress
0
VERY LOW: 0-4
0
7
8
8
14
Sleep/Rest
Coping Stress
7
14
Values/Beliefs
0
MODERATE: 616
LOW: 7-13
MODERATE: 1424
VERY LOW: 0-2
Role-Relationship
3
LOW: 3-5
3
Nutrition/Metabolic
10
11
Activity/Exercise
(mobility)
Sexuality
0
MODERATE: 6
to 15
VERY LOW: 0-5
0
VERY LOW: 0-5
0
Self-Concept
Cognitive/perceptual
0
0
LOW: 3-5
VERY LOW: 0-4
0
0
15
15
Mobility
Nutrition
Elimination Elimination
0
0
Sleep/Rest
5
MODERATE: 616
VERY LOW: 0-6
Coping Stress
Values/Beliefs
4
0
LOW: 3-13
VERY LOW: 0-2
4
0
Role-Relationship
6
MODERATE: 6-8
6
Nutrition/Metabolic
9
9
Activity/Exercise
(mobility)
Sexuality
12
12
0
MODERATE: 6
to 15
MODERATE: 1115
VERY LOW: 0-5
Self-Concept
5
LOW: 3-5
5
5
0
VERY LOW:
0-4
MODERATE
: 6-16
LOW: 7-13
MODERATE
: 14-24
VERY LOW:
0-2
LOW: 3-5
MODERATE
: 6 to 15
VERY LOW:
0-5
VERY LOW:
0-5
LOW: 3-5
VERY LOW:
0-4
MODERATE
: 6-16
VERY LOW:
0-6
LOW: 3-13
VERY LOW:
0-2
MODERATE
: 6-8
MODERATE
: 6 to 15
MODERATE
: 11-15
VERY LOW:
0-5
LOW: 3-5
134
Mobility
Cognitive/perceptual
Elimination
Coping/
Elimination
Stress
Sleep/Rest
0
VERY LOW: 0-4
0
20
7
HIGH: 17-26
LOW: 7-13
20
8
Coping Stress
Values/Beliefs
18
0
HIGH: 17-26
VERY LOW: 0-2
18
0
Role-Relationship
Nutrition/Metabolic
Activity/Exercise
(mobility)
Sexuality
4
4
15
4
4
15
0
LOW: 3-5
LOW: 3-5
MODERATE: 1115
VERY LOW: 0-5
Self-Concept
0
LOW: 3-5
0
0
VERY LOW:
0-4
HIGH: 17-26
LOW: 7-13
HIGH: 17-26
VERY LOW:
0-2
LOW: 3-5
LOW: 3-5
MODERATE
: 11-15
VERY LOW:
0-5
LOW: 3-5
135
APPENDIX I: FLYER
136
APPENDIX J: EMAIL SENT TO STUDENTS
Gerontology Research Project – Volunteers Needed
Dear Student
As you know, I am looking for 18 student volunteers. This is entirely voluntary.
A decision not to participate will in no way affect your grades.
The intent of this project is to test an application that is designed to improve a student’s
ability to collect patient data, organize that data and then use that data to guide nursing
interventions. We believe that this tool will accomplish this but need your help to find out
for sure. We will have four clinical groups working on this project.
Clinical Sites: Nazareth – Wednesdays and Thursdays with Prof Manco
Fountains – Wednesdays and Thursdays with Prof Keller
Students volunteering will receive the Gerontological Reasoning Informatics
Program(GRIP) both PDA and Desktop application. It has been designed to be an easy
installation process however we will assist in this process and provide technical support
throughout.
The Plan:
Instead of completing the traditional paper/pencil patient assessment, student volunteers will
use the PDA to conduct patient interviews/assessments. The application will automatically
score the data and identify risk level (very low, low, moderate, high, very high) for
problems associated with that particular pattern. After you have completed the patient
assessment, you will sync with your computer. At that time you will be able edit/enter
additional info into the patient assessment and all of this information will be incorporated
automatically into the patient care plan. You will be able to view the ‘report’ (scored and
ranked patient assessment) and select the patient care priority. You will be able to select the
appropriate nursing diagnosis from a drop-down menu and individualize the care plan. The
entire completed patient care plan can be either printed or emailed to course faculty. In
addition, some students will be involved in reliability and validity testing of the application.
All students volunteering will participate in focus group discussions (at clinical post conf),
1:1 interviews and will be asked to complete a survey at the conclusion of the term. At the
conclusion of the study, student volunteers will receive a PDA reference of their choice,
valued at $50. I hope you will consider volunteering for this project. Without you, we
cannot move forward.
Thanks,
Professor Fran Cornelius
215-762-1868
137
APPENDIX K: CLINICAL PREP SHEET
Student Name: ________________________
Clinical Faculty: _________________
Clinical Site: _________________________
Date: __________________________
Patient Name (Initials only):
Allergies:
Age:
BP:
Temp:
Sex:
Current Disease/Disorders & Other
Chronic Conditions:
Chief Complaint/Diagnosis:
Safety Risk Assessment
Evidence of safety risk:
Falls
Hazard
Elopement
Aggression
Pulse:
Resp:
No
Yes
Fire
Suicide
The law requires me to ask if you have:
Advanced Directive:
Yes
No
Physician Notified:
________________________________
Organ Donation:
No
Yes
Comment:
________________________________
Do you have a living will? _______
Restraints? Wrist: ____ Vest: ______
Other_________
138
Attention Span: _________________
Nutrition/Metabolic
General appearance:
Weight: ______________________
Height: ________________________
Wt. Change: ____________________
Appetite Change : No
Yes
Over what period of time?
___________
Nausea
Vomiting
Dysphagia
Anorexia Bulimia
Heartburn/Indigestion
Difficulty
swallowing/chewing
Other
________________________________
Vision: ________________________
Dentures/Oral Prosthesis/Implants:
Hearing: _______________________
Current Diet: _________
Snacks: __________
Frequency:__________
Communication
Affect:
Relaxed
Anxious
Sad
Angry
Happy
Other: ___________
Oriented to: Time
Place
Able to follow commands:
No
Person
Yes
LOC: _________________________
Speech: _______________________
Primary Language: _______________
Fluid restriction: No
Yes
I&O:
No
Yes
Oral, Enteral, Parenteral, Supplements
______________________________
High/low risk for nutritional deficits:
No
Yes
139
Elimination
Last BM____ Character:____
Frequency: ____
Diarrhea
Constipation
Hemorrhoids
Rectal bleeding
Enterostomy
Distention
Use of
laxatives/enemas:_________________
Activity/Exercise - Activities of Daily
Living/Instrumental ADL's
I=independent
A=assistance
Urine:
Normal
Abnormal
Character of
Urine:__________________________
Toileting:____ Incontinence:
never_____ <1/wk_____ 1-2/wk
>3/wk____
Catheter
Dysuria
Frequency
Incontinence
Hesitancy
Nocturia How many times nightly?
Retention
Distention
Dialysis
D=dependent
Grooming:___ Bathing:__
Ambulation:__ Dressing:____
Telephone Use:____ Shopping:____
Food Preparation:_____
Laundry:_____
Housekeeping:____ House
Repairs:____
Taking Medications:_____
Transportation:___ Financial
Management:_____
Assistive devices for ambulation?_____
Type:__________________________
140
Sleep/Rest
1. Are you fully satisfied with your
current sleep patterns? Yes
____No____
(If no, go to #2; if yes, go to #3)
2. Describe problems with sleep:
3. Do you take any sleeping
medication?
Yes _______No_______
(If yes, what do you take?)
_______________________________
4. Do you snore? Yes
______No______
(if yes, assess for sleep apnea)
5. Approximate daily caffeine
intake:___________
6. Rate overall risk for sleep problems:
Very high ___ High ___ Mod ___
Low ___
Comments:
Sexual/Intimacy
Sexual activity Active
Inactive
Masturbation __Non-coital partnered
activities
Sexual dysfunction/concerns: No
Yes
Specify:
________________________________
________________________________
Sexual Abuse
No
Yes
Sexual interest? __ High __Med __Low
Body image and perceived sexual
attractiveness?
__Positive __Negative __Indifferent
Male:
Prostrate problem:
No
Yes
Describe
________________________________
________________________________
Female:
Menopause:
No
Yes
ERT Therapy?______________
Marital Status:
__Married __Single __Divorced
__Remarried __Widowed
__Gay couple relationship/partner
141
Self Perception/Self
Concept/Coping/Stress Tolerance
Verbalizes feelings of :
Hopelessness
Powerlessness
Hopefulness
Sadness
Anger
Anxiety
Fear
Restlessness
Other: _____________________
Values/Beliefs/Spirituality
Major life change:
No
Yes
Recent Mood Changes:
No
Yes
Describe: _______________________
________________________________
Religious/faith affiliation:
________________________________
Is religion important in your life:
No
Yes Describe: ______________
_______________________
Will this illness/hospitalization interfere
with any religious beliefs/practices?
No
Yes Describe:
________________________________
________________________________
Cultural/Spiritual Needs:
No
Yes Specify:
________________________________
________________________________
Have you thought about what kind of
care you would want at the end of your
life?
________________________________
________________________________
DNR order on chart:
No
Yes Comments:
________________________________
________________________________
Environmental Assessment
Housing: Single level _____
Multi-level ____
# of steps to enter house _____
Bathroom on first floor? ____ Powder
room/Full bath? (circle one)
Lives alone? _____
How close is nearest family? ________
Friend? _____________
Working stove? __ Oven? __
Refrigerator? ___
Support system: Family? _____
Who? ____ Neighbors? _____
Friends? __________
Cigarettes/Cigars/Pipes? ___
Alcohol? ___ Daily/Weekly/Monthly?
___ How much? ____
142
MEDICATION WORKSHEET
Medication
Dose &
Schedule
Classification
Mechanism
of Action
Nursing
Considerations
Relevant
Labs/Other
143
Patient Initials__________________________
NURSING 450 PLAN OF CARE WORKSHEET
Nursing Diagnosis
Short Term Goals/
Long Term Goals
Interventions
Evaluations
Instructions:
1.
2.
3.
4.
List at least one physiological and one psychosocial nursing diagnosis.
Place the nursing diagnoses in order of priority.
List rationales for all interventions.
List at least two nursing interventions for each nursing diagnosis.
144
APPENDIX L: GRIP TUTORIAL
GRIP Tutorial
Screen 1 - Menu
This is the first screen of the application. On this screen you will see 4 options.
1. Add Assessment for a New Patient
This option lets you add new patient details (Name, ID, BP, Temp, ICDs, and
Allergies etc.)
2. Add Assessment for an Existing Patient
This option lets you add assessment for the different Patterns (Elimination, Sleep
rest, Self Concept etc.)
3. View Assessment
This option lets you view the assessments added in the previous options.
4. Delete / Update Options
This option lets you delete assessments already added.
5. Exit
This option lets you exit the application.
145
1. ADD ASSESMENT FOR A NEW PATIENT
Customization Screen
This is the customization screen which is displayed only the first time the application is
used. This screen contains the following fields:
•
UID
Enter your University ID in this field.
•
First Name
Enter your first name in this field.
•
Last Name
Enter your last name in this field.
Once all the details are entered, click ‘Next’
Screen 1 - Enter Patient Details (1)
To access this screen click ‘Add Assessment for a New Patient ‘on screen 1.
This screen consists of several fields which let you add the following details:
•
Clinical Rotation
This field is a drop down box which contains a list of all the clinical rotations
i.e. Homestead, Liberty court etc. You can select the desired value by clicking
the required rotation in the list.
•
Date
This is the assessment date. This value is automatically displayed based on the
system date.
•
Clinical Faculty
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This field is a drop down box which contains a list of all the clinical faculty
members. You can select the desired value by clicking the required faculty in
the list.
•
Patient Name
This field consists of 3 fields i.e. First Name, Middle Initial and Last name.
You can type the First Name, MI and the Last Name using the keyboard or the
transcriber option on the PDA. If the Patient does not have a Middle Initial,
enter ‘X’ in the field.
•
Patient ID
This field consists of 4 fields i.e. FML, MM,DD and YYYY
In the ‘FML’ field enter the First Initial of the First Name, Middle Initial and
the First initial of the last name of the patient. For e.g., if the Patient’s Name is
John D. Smith, enter ‘JDS’ in this field.
In the ‘MM’ field enter the Birth Month of the patient. For e.g. if the Patient’s
date of birth is 02/03/1976 , enter ‘02’ in this field.
In the ‘DD’ field enter the Birth Day of the patient. For e.g. if the Patient’s
date of birth is 02/03/1976 , enter ‘03’ in this field.
In the ‘YYYY’ field enter the Birth Year of the patient. For e.g. if the
Patient’s date of birth is 02/03/1976 , enter ‘1976’ in this field.
•
Age
This field is a text box to enter the Patient’s age. The age will be automatically
entered here once you enter the date of birth in the above field. All you have
to do is click the text box once.
•
Sex
This field consists of 2 radio buttons with 2 options i.e. ‘M’, ‘F’. Select the
F)
desired option by clicking the radio button. ( M
•
Race
This field is a text box to enter the Patient’s race. Type in the race in this box.
Once all the fields are filled, you can proceed to the next screen (Enter Patient
Details(2))
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by clicking the ‘Next’ button on the bottom of the screen. You will also find a ‘Back’
button clicking which will take you back to the main menu (first) screen.
Screen 2 - Enter Patient Details (2)
This screen contains various fields to add the preliminary assessment details. Following
are the fields on this screen:
•
BP
This field consist of 2 fields i.e. systolic and diastolic separated by a ‘ / ‘
Enter the Systolic and diastolic values in these fields.
•
Temp
This field is a text box to enter the patient’s temperature. Type in the patient’s
temperature in this field.
•
Resp
This field is a text box to enter the patient’s respiration count. Type in the
patient’s respiration in this field.
•
Pulse
This field is a text box to enter the patient’s pulse. Type in the patient’s pulse
in this field.
•
Primary ICD
This field is a drop down box which contains a list of Primary ICDs i.e.
cardiovascular, respiratory etc. You can select the desired value by clicking
the required primary ICD in the list. Only one value can be selected.
•
Secondary ICD
This field is a drop down box which contains a list of secondary ICDs. You
can select the desired value by clicking the required ICD in the list and
clicking the ‘ADD >>’ button. Please note that multiple secondary diagnosis
can be added. Just select the required value and click the ‘ADD >>’ button.
The added values will appear in the text box.
Also note that you can add additional secondary ICDs by typing in the text
box directly. If typing, be sure to separate the values by a ‘,’ (comma).
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Once all the fields are filled, you can proceed to the next screen ( Enter Allergy Details)
by clicking the ‘Next’ button on the bottom of the screen. You will also find a ‘Back’
button clicking which will take you back to the previous screen. The ‘Back’ button can be
used to modify the values entered in the previous screen.
Screen 3 - Enter Allergy Details
This screen contains various fields to add the different allergy details. Following are the
fields on this screen:
•
Drug Allergies
This field is a drop down box which contains a list of drug allergies
(Tetracycline, sulfa etc). You can select the desired value by clicking the
required allergy in the list and clicking the ‘ADD >>’ button. Please note that
multiple allergies can be added. Just select the required value and click the
‘ADD >>’ button. The added values will appear in the text box on the right.
Also note that you can add additional allergies by typing in the text box
directly. If typing, be sure to separate the values by a ‘,’ (comma).
•
Food Allergies
This field is a drop down box which contains a list of food allergies (soy, milk
etc). You can select the desired value by clicking the required allergy in the
list and clicking the ‘ADD >>’ button. Please note that multiple allergies can
be added. Just select the required value and click the ‘ADD >>’ button. The
added values will appear in the text box on the right.
Also note that you can add additional allergies by typing in the text box
directly. If typing, be sure to separate the values by a ‘,’ (comma).
•
Environmental Allergies
This field is a drop down box which contains a list of environmental allergies
(Insect bites, cat, dog etc). You can select the desired value by clicking the
required allergy in the list and clicking the ‘ADD >>’ button. Please note that
multiple allergies can be added. Just select the required value and click the
‘ADD >>’ button. The added values will appear in the text box on the right.
Also note that you can add additional allergies by typing in the text box
directly. If typing, be sure to separate the values by a ‘,’ (comma).
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Once all the fields are filled, you can proceed to the next screen ( Select Pattern) by
clicking the ‘Next’ button on the bottom of the screen. You will also find a ‘Back’ button
clicking which will take you back to the previous screen. The ‘Back’ button can be used
to modify the values entered in the previous screen.
Screen 4 – Select Pattern to add assessment
This screen contains a list of all the patterns i.e. Elimination, sleep rest, Activity /
exercise etc. To select a particular pattern just click on the pattern name. This will take
you to the next screen which will contain a question for that pattern with 2 or more
answers.
Screen 5 – Add assessment
This screen will consist of one or more questions and two or more answers to that
question (multiple choice) depending on the pattern selected. You can select the answer
for the question by clicking the ‘checkbox’ at the beginning of the answer. Also, on
some screens you will see a text box to enter comments and details. These boxes can be
filled using the keyboard or the transcriber option.
After selecting the answer, click the ‘Next’ button to proceed to the next question.
Follow the same steps till all the questions are completed. You can use the ‘Back’ Button
at the bottom of the screen to change any of the answers.
Screen 6 – View assessment
This screen gives a summary of the assessment performed for the pattern in the previous
screens. A calculated score is also displayed based on the answers selected. Based on the
score the corresponding nursing intervention is also displayed.
Click the ‘Main Screen’ link at the bottom of the screen to get back to the main screen.
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2. ADD ASSESSMENT FOR AN EXISTING PATIENT
Once the patient details have been added, this option should be used to add
assessment for the different patterns.
Screen 1 – Select Patient to add assessment
This screen can be accessed by clicking the ‘Add assessment for existing patient’ link
on the main (first) screen.
This screen contains a list of all the patients added (ID, First Name and Last Name) in
a grid. You have to select the patient ID in order to proceed to the next screen.
Follow the steps below to select the patient:
•
•
•
Scroll to the extreme left of the grid, till you see the patient ID
(abc02131966).
Click the patient ID using the stylus.
Click the ‘Next Button’ to proceed.
Clicking the ‘Next’ button will take you to the next screen “Select Pattern” screen.
Screen 2 – Select Pattern
This screen displays a list of assessments already performed on the patient and also
gives a listing of all the Pattern Names. Select the pattern to add assessment by
clicking on the Pattern name.
The next screen displays the first question for that pattern along with the possible
answers. Now proceed with the assessment as explained in step 1. In this way you can
add the assessment details for all the patterns.
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3. VIEW ASSESSMENT
This screen lets you view assessment details entered using steps 1 and 2.
Screen 1 – Select Patient to view assessment
This screen can be accessed by clicking the ‘View assessment’ link on the main (first)
screen.
This screen contains a list of all the patients added (ID, First Name and Last Name) in
a grid. You have to select the patient ID in order to proceed to the next screen.
Follow the steps below to select the patient:
•
•
•
Scroll to the extreme left of the grid, till you see the patient ID
(abc02131966).
Click the patient ID using the stylus.
Click the ‘Next Button’ to proceed.
Clicking the ‘Next’ button will take you to the next screen “Select Pattern and Diagnosis
date” screen.
Screen 2 – Select Pattern and Diagnosis Date
This screen lets you select the pattern and the diagnosis date to view the assessment
details.
This screen consists of 2 drop down boxes, one contains a list of the Patterns
(Elimination sleep rest etc) and the second consists the different assessment dates
when the assessment was performed.
Follow the steps to select the pattern and date:
•
•
•
Enter the required Pattern name from the first drop down box.
Based on the pattern selected, the second drop down box contains a list of
dates when the selected assessment was performed. If the assessment was
performed once, then only one date is displayed in the box. Select the
required date.
Click ‘Next’
Clicking ‘Next’ displays the assessment summary for the selected values.
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4. Delete / Update Options
Screen 1 – Menu
This screen can be accessed by clicking the ‘Delete/ Update options’ link on the main
(first) screen.
You will see the following options:
•
•
•
•
Delete Patient
Delete Assessment
Refresh Database
Update Details
Screen 2 – Delete Patient
This screen can be accessed by clicking the ‘Delete Patient’ option in the above
screen. Once you click this screen, you will see a list of all the patients in your
database. You can select the patient you want to delete by clicking on the ‘Patient
ID’ on the screen. Follow the steps below to select the patient:
•
•
•
Scroll to the extreme left of the grid, till you see the patient ID
(abc02131966).
Click the patient ID using the stylus.
Click the ‘Next Button’ to proceed.
The patient will be deleted.
Screen 3 –Delete assessment
This screen can be accessed by clicking the ‘Delete assessment’ link on the above
screen.
This screen contains a list of all the patients added (ID, First Name and Last Name) in
a grid. You have to select the patient ID in order to proceed to the next screen.
Follow the steps below to select the patient:
•
•
•
Scroll to the extreme left of the grid, till you see the patient ID
(abc02131966).
Click the patient ID using the stylus.
Click the ‘Next Button’ to proceed.
Clicking the ‘Next’ button will take you to the next screen “Select Pattern and Diagnosis
date” screen.
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Screen 4 – Select Pattern and Diagnosis Date
This screen lets you select the pattern and the diagnosis date to delete the assessment
details.
This screen consists of 2 drop down boxes, one contains a list of the Patterns
(Elimination sleep rest etc) and the second consists the different assessment dates
when the assessment was performed.
Follow the steps to select the pattern and date:
•
•
•
Enter the required Pattern name from the first drop down box.
Based on the pattern selected, the second drop down box contains a list of
dates when the selected assessment was performed. If the assessment was
performed once, then only one date is displayed in the box. Select the
required date.
Click ‘Next’
Clicking ‘Next’ deletes the assessment for the selected values.
Screen 5 – Refresh Database
This option lets you delete all the patients, assessments at once. You should be careful
while using this option as, it will refresh the entire database. You should use this
option only if you need to start all over again.
Screen 6 – Update Details
This option lets you update some patient details such as BP, Resp, Temp, Secondary
ICD etc. Following are the steps:
•
Click Update details option
•
Select the patient using the following:
o Scroll to the extreme left of the grid, till you see the patient ID
(abc02131966).
o Click the patient ID using the stylus.
o Click the ‘Next Button’ to proceed.
•
•
•
You will see a form with the patient details.
Edit the details as required and click ‘Next’
The patient details will be updated.
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IMPORTANT GUIDELINES
a. Back Button
You will find a ‘Back’ button on every screen. You can use this button to
go back one screen and edit the details.
b. Skip
You will find the ‘Skip’ link on every screen. You can use this option to
proceed to the next screen without entering any details or checking any
options. Do not use the ‘Next’ button if you have not entered any details
or checked any options on the screen. Doing so will result in wrong
results. Use the ‘Skip’ option for such a case.
c. Errors
We have tried to keep this application as bug free as possible. In spite of
all our efforts, you may receive an error with the following message “
Invalid row count” at certain times while running the program. If you
receive this error then, go back to the main page, click on ‘exit’ and start
the application again.
If you get any error messages at any point during the operation do the
following:
1. Note down (remember) the screen where you got the error message.
2. Close the operation by clicking ‘ Exit’ on the main screen (You can
access the main screen by closing the individual screens using the (x)
on the top right of the screen.
3. Start the application again.
4. Select the ‘Add assessment for existing patient option’
5. Select the ‘Pattern / module’ which gave you the error.
6. Skip the screens till you reach the screen where you got the error.
7. Continue with the assessment from that screen as before by checking
the required option and clicking on ‘Next’
8. Post the error message, pattern name, screen question where you got
the error on blackboard. (if possible)
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VITA
Frances H. Cornelius RN, MSN is a graduate of Wayne State University in Detroit,
Michigan and has a master’s degree in Community Health Nursing. She has taught at the
College and University level since 1990 and has an extensive clinical background in
Medical Surgical, Psychiatric, Oncology and Community Health Nursing. She is
currently an Assistant Professor at Drexel University College of Nursing and Health
Profession(CNHP) and teaches Informatics. For the past six years, she has developed and
taught courses online in the CNHP’s distance learning program and has served as the
faculty mentor in the design, development and delivery of online course material. She
has extensive experience in the development and delivery of online course content. In
1998, Ms. Cornelius received a Cardiovascular Fellowship with the Health Care Forum
for the purpose of planning and implementing programs to improve the cardiovascular
health of residents in the 11th Street Corridor. In 2003, Ms. Cornelius received a
fellowship to the National Library of Medicine in Medical Informatics. Ms. Cornelius
has also received a grant from the Philadelphia Foundation for development of
Community Arts Theater Troupe (CATT), an innovative grass-roots approach to
addressing health and social issues through theatrical performances. In addition, Ms.
Cornelius has been the recipient of grants from the Philadelphia Higher Education
Network for Neighborhood Development and Pennsylvania Department of
Environmental Protection. Ms. Cornelius was also awarded two Drexel Synergy grants
for the HealthCare Arts Research Project (HARP) and Utilization of a PDA-Based
Decision-Making Tool in Undergraduate Nursing.
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