Beers, G. W. & Berry, C.G. (2015). Traditional Versus Electronic Resources for Students in Clinical Nursing Courses: A Pilot Study. Online Journal of Nursing Informatics (OJNI), 19 (1).
The use of technology is a required competency of baccalaureate nursing graduates. The purpose of this pilot study was to compare perceptions of students who use traditional, paper-based resources with those who use electronic resources in the clinical setting. Students from clinical nursing courses from a southeastern university were invited to participate. The average age was 22.75, with a range of 20 to 45. Seventy five percent of the students were age 21 or 22. They were junior and senior nursing students enrolled in adult clinical courses on either a medical surgical or critical care unit in a baccalaureate nursing program.
Half of the participants used traditional written resources, and half accessed these resources electronically using an iPad as a personal digital assistant (PDA). Using an investigator-developed tool, data were collected and analyzed for statistical significance. The questionnaire contained both open ended and three-point Likert Scale questions. The responses to the qualitative questions were categorized for ease of interpretation. Responses to both types of questions indicated that students perceived electronic resources to be easily accessible, quick, and easy to use whereas traditional resources were perceived to be more time-consuming. Nurse educators can use this study's findings to improve students' use of evidence-based information at the point of care in the clinical setting.
Technology and informatics are essential components of contemporary undergraduate nursing education, as described by the Institute of Medicine (IOM, 2003); American Association of Colleges of Nursing (AACN, 2008); and Quality and Safety Education in Nursing (QSEN, 2005). Faculty need to incorporate the use of informatics and information technology into their courses that match the learning styles of today's students who are familiar with computers, smartphones, the Internet and touch-screen technology (White, 2005). To prepare nursing students to deliver evidence-based, safe, effective, high quality care to patients, faculty should incorporate teaching strategies that provide quick, up to date, evidence-based information at the point of care.
The purpose of this pilot study was to compare perceptions of students who used traditional resources with those who used mobile devices as personal digital assistants, (PDAs) in the clinical setting.
Rationale: Undergraduate nursing education differs significantly from most other majors because of the extensive amount of clinical practice (three clinical hours for every classroom hour) required in a wide variety of healthcare environments. Both students and full-time faculty spend between eight and 18 hours each week off campus in a clinical setting, which varies depending on specific course requirements. Each semester, students and faculty in these courses also spend a minimum of two days in on-campus Simulation Labs. The clinical setting is a fast-paced, stressful environment with each faculty member being responsible for up to eight students who are providing care to patients with complex health problems. Another unique aspect of nursing education are post-clinical conferences or debriefing sessions, a time for students and faculty to reconvene and discuss the day's experiences.
The acuity of patients has increased and the length of hospitalizations has decreased. The sophomore year foundations course and junior year adult health course have a preclinical component which allows a student time to meet their patient the day prior to the clinical experience and collect relevant information about the patient's reason for hospitalization, including diagnosis, procedures, and medications. This provides the student with time to review evidence-based resources specific to their patient assignment in preparation for clinical. In today's healthcare environment, it is common for patients to be discharged earlier than expected. In this case the student will be assigned to provide care to a different patient without the advantage of advanced preparation.
There are few resources available to the faculty and students after arrival on the clinical unit. Having access to an iPad or PDA enables students to develop a safe and effective plan of care on the spot. The senior level critical care course does not include a preclinical component. This does not preclude the need to access information during the clinical experience. Even a graduating senior will encounter situations that exceed their knowledge base. Safe patient care depends on available access to current information (Goldsworthy, Lawrence & Goodman, 2006; Greenfield, 2007; QSEN, 2005). This group of faculty and students often need up-to-the-minute information to develop an effective plan of care and discharge teaching plan for patients and families.
Currently, faculty and students bring cumbersome resources such as lab books, pathophysiology books, and course specific text books as well as calculators, drug cards, and concept maps which they use to plan patient care in the clinical setting. Access to electronic resources in the hospital setting is limited. Each nursing unit is equipped with several computers at the nurse's station, some patient care rooms have computers and some institutions have computers on wheels but they are primarily for the nursing staff to use to deliver care to patients. These same limitations are also experienced by faculty and students in our on-campus Simulation Lab. Only one computer is located in each simulation room and the use of cumbersome resources interferes with the student performance.
Review of the Literature
The healthcare environment is rapidly moving to electronic health record management. Physicians are being asked to utilize computerized order entry systems, nurses are inputting their documentation into computer systems, laboratory and diagnostic study results are instantly available, and all of the information is quickly and easily accessible wherever it is needed to meet the needs of the patient. Nursing education has recognized the necessity to include the use of informatics in undergraduate education. The standards outlined in the 2005 QSEN document include Informatics as one of the primary requirements for an undergraduate nursing curriculum. Competency in using technology to record and access patient information is crucial in the workplace. Equally important is the ability to access up to date, evidence-based information that should be used to guide patient care, including, but not limited to, evidence-based practice guidelines and current medication information.
A 2007 study by Greenfield compared students utilizing PDAs as a reference device to those using books specifically in regard to safe medication administration. Students were given a detailed case study which involved medication administration and then tested for accuracy and speed of dosage calculation and knowledge using t tests. The group using PDAs scored significantly higher on knowledge questions and dosage calculations (p = 0.037). The PDA group also took significantly less time to answer the questions (p = 0.002). The sample size for this study was small but the findings are consistent with other studies.
A recurring concern regarding PDA use is in relation to the Health Insurance Portability Accountability Act of 1996 (HIPAA). The potential problems with PDA use involve protecting patient information that may be stored on the device and maintaining that protection if the information was transmitted. For the purpose of the 2005 study by White and colleagues, PDA use was limited to obtaining information to plan and implement patient care and no patient data were recorded. The researchers acknowledged the HIPAA concerns in PDA use in an accelerated second degree baccalaureate of nursing program. Students were taught to de-identify patients and password-protect patient information stored in their device. During their most recent accreditation visit at this institution by the CCNE representatives of the AACN, the use of PDAs was thoroughly reviewed and no recommendations were made confirming that the use of PDAs in the clinical setting beyond a reference source can be done and meet HIPAA requirements. Feedback from the students and faculty involved in this program indicate that use of a PDA in the clinical setting was successful.
The use of a PDA for student learning in the clinical area is supported in the literature. A study by Kuiper (2010) involved students in a critical care area over an eight-week period. Although the students used a variety of sources available at the point of care, they stated that the PDAs were more readily available and made it easier to find information. Their confidence in using the device significantly improved from the second to the eighth week. They tended to strongly disagree that the PDA was frustrating or intimidating or that they were worried about losing data. Their comments indicated that they not only accessed data to plan care but they also used it to re-evaluate their care. Students' experience with using a PDA was also addressed by Johansson, Peterson, and Nilsson (2013). The students used a PDA in a variety of clinical areas for 13 weeks. The results were positive indicating students found the PDA useful, time saving, helpful in improving patient care and increasing student confidence in clinical practice. Specific responses to open ended questions included: "the ability to answer patient and family questions without leaving the patient," "no need to take chances with memory because you can always have information available," and "the information is reliable and accessible". A few concerns were also recorded. One student expressed concerns about co-workers' opinions of her ability if she used a PDA. A nursing supervisor in a psychiatric unit voiced strong concerns about the use of PDAs described by the student "it did not look good in front of patients, it looked suspicious… it looked like I had no knowledge when I was using it.".
Goldsworthy, Lawrence, and Goodman (2006) addressed the changes and differences in self-efficacy scores between students who used a PDA as a resource at the point of care and those that did not use a PDA. Students were tested at the beginning of their clinical experience and again at the end. The pretest for both groups indicated the groups to be homogenous with the means of the scores being 32.539 (PDA group) and 32.5 (non PDA group). There was a statistically significant difference (P = .002) in the post test scores with the PDA group scoring higher. The pretest and post-test scores of each group were also compared. The scores of the PDA group increased significantly (P<.001) but the non-PDA group scores did not increased significantly (P= 0.166). Student comments from the PDA group indicated PDAs were often used more than five times each day and that the drug book, laboratory book and the medical surgical tips were most helpful. The change in self-efficacy scores indicates that easy access to this resource improved students' confidence in what can be a stressful environment. Also noteworthy is that students reported staff RNs frequently asked them to look up information. The researchers also addressed the privacy concerns regarding technology use. Limits were placed on patient information contained in the PDAs. Wireless abilities were disconnected and all patients' identifying data was omitted.
George, Davidson, Barla, and Thotakura, (2013) included both graduate and undergraduate nursing students in a study to identify frequency and type of use, application use, perceived barriers or incentives to use, and their satisfaction with technical support. The results indicated that more than 79 percent of the students surveyed used their PDAs at least weekly and almost 50 percent using them daily. The majority (96 percent) of the students in this study used their PDAs most often in the clinical setting. Half of the students reported barriers to the PDA use. They included technical problems with the device, insufficient training sessions and lack of technical support. The drug guide was the most frequently used resource. Over half of the students indicated they felt the PDA use improved their efficiency. Every student involved in the study (100 percent) indicated that they found PDAs to be an effective educational tool.
The results of studies addressing student and faculty attitudes toward informatics education support the use of this educational tool. A study by Nkosi, Asah, and Pillay (2011) evaluated nursing students' access to and attitudes towards the use of technology in practice. Their data indicated that students had a positive attitude towards the use of technology and supported the inclusion of computer literacy in their nursing curriculum. A specific statement on the survey was "Computerization of nursing data offers nurses a remarkable opportunity to improve patient care" (Nkosi, et,al.). The positive response to that statement was 99.3 percent. The study also identified two primary factors that hindered the use of technology as limited access in the workplace and a lack of computer skills. The Johansson, et al (2013) study also identified the need for improved computer literacy as a hindrance in the study with undergraduate medical students. It also yielded positive outcomes for the use of evidence and for teaching and learning.
Hudson and Buell (2013) assessed the characteristics of PDA uptake and use in both clinical and classroom work for baccalaureate students. When asked what they liked about the PDAs, the students' responses supported findings of other studies. Students reported that they liked the accessibility, convenience and portability, the ease of access and navigation, the easy download, good information and that it was much lighter than books and fitted easily into pockets. However, the expense of the PDA devices with the related software can be a financial barrier for some students. Findings indicated that the students without this financial barrier and with good or excellent computer skills did very well with integrating PDA use into their learning tools.
Those who experienced problems in using the PDAs were more likely to lose interest and rate the value as low. Very few students in this study utilized the PDAs in front of patients. All of the comments from those who did were positive except one. The negative comment was similar to some recorded by other studies, that the need for the device indicated a lack of knowledge. Surprisingly more students reported a low level of satisfaction with use of the PDAs as a reference in the classroom. Despite the overwhelming positive comments, the students were evenly divided in their satisfaction/dissatisfaction with the PDA use in the clinical setting when asked that specific question.
The use of a PDA in a simulation setting was studied by Elliott, Decristofaro, and Carpenter (2012). Nurse practitioner students used PDAs in an advanced physical assessment scenario. The results of the study indicated that using the PDA allowed the students to utilize the device in a more meaningful way than solely as a drug reference. Role transition for a working RN to a nurse practitioner role is challenging and having necessary information for the new role at hand helped improve confidence during the transition. The authors emphasized the importance of faculty proficiency with the device. This FNP program required the purchase of an approved device by every student and also specified the required software. The PDA is used throughout the curriculum, thereby ensuring the students' competency with the device.
In summary, the studies reported are supportive of the use of PDAs as a clinical resource tool. Students consistently state they are time saving, improve patient safety and student confidence. Students demonstrated improved confidence and self-efficiency with PDA use in the clinical setting. Similarly, the same concerns are expressed in several studies. The two consistently reported concerns are a potential negative perception of the student by patients, families or co-workers and the need for proficiency in using the device. Another recurring theme in the literature is the need to address the users' computer skills prior to implementing PDA use and to have technology support available.
Undergraduate nursing students enrolled in adult clinical nursing courses were involved in this study. Faculty and students received orientation to the resources and their use prior to the beginning of the clinical component of all courses. One half of the clinical students in each of the courses used the PDA as a resource and the other half used traditional written resources. The groups using the PDA had Nursing Central©, an electronic app downloaded to a PDA. The other groups used hardcopies of the books included in Nursing Central©: Davis Drug Guide, Tabers Medical Dictionary, Diseases and Disorders and Davis Laboratory and Diagnostics. iPad technology was specifically chosen as previous studies have noted that the small screen size on more traditio0naol types of PDAs makes it difficult for faculty and students to access, read, and interpret information in a timely manner. The students utilized the resources as needed to locate information about new medications, disease specific information, applicable evidence-based practice guidelines, and any other information needed to provide safe, effective patient care. At the end of the semester, all students involved in the study, those using iPads and those using written resources were asked to complete a brief questionnaire, shown in Figure 1. The questions addressed their frequency of overall and individual resource use, perception of the resources in regard to benefits and limitations, accessibility, usefulness of information, and impact on performance and patient care. Students did not record any patient information on the iPad devices.
The total enrollment for the classes involved in the study was one hundred sixty and of those ninety eight chose to respond to the questionnaire. The average age was 22.75, with a range of 20 to 45. Seventy five percent of the students were age 21 or 22. They were junior and senior nursing students enrolled in adult clinical courses on either a medical surgical or critical care unit in a baccalaureate school of nursing. Consent was implied by response to the questionnaire.
The investigator developed tool contained both open ended questions and three-point Likert Scale questions specifically designed to obtain information on the students' perception of the benefits of using a PDA or iPad vs traditional, written resources for information acquisition during clinical experiences. The SPSS software package was used to analyze the data from the Likert Scale questions. The responses to the qualitative questions were categorized for ease of interpretation. It was predicted that the mobile device would be easier to use and meet the students' needs better than the traditional resources. Responses to both types of questions indicated that students perceived the iPads to be easily accessible, quick, and easy to use whereas the traditional resources were perceived to be more time consuming. Several students reported that the iPads provided more up to date information, however, the resources provided on the devices were identical to the information contained in the books provided. As shown in Table 6, the Likert scale question: "I often utilize the resources during the clinical day" is the only one with a statistically significant difference (p = ≤ 0.001) between the students using iPads and those using traditional resources with the iPad users reporting more frequent use. Tables 1 - 5 summarize data from all Likert scale questions on the data collection tool.
Additional findings showed that students (85%) used the Davis Drug Guide while Tabers Medical Dictionary was only used by 8.2%, Diseases and Disorders was used by 17.5 %, and Davis Laboratory and Diagnostics was used by 29.9 %. These data include both traditional and iPadd use and was true for all of the courses involved in the study: Foundations of Nursing, Adult Health Nursing and Critical Care Nursing.
The open ended questions asked about benefits and limitations of each type of resource. The benefits identified by the iPad users repeatedly included easy, time saving, and useful information. The limitations included the limited number of iPads available and the difficulty connecting to Wi-Fi at the hospital. The responses from the students utilizing traditional resources identified the benefits as including: quick access to drug information and no need to "deal" with technology. The main disadvantage was the amount of time it took to find the information needed. The consistent response to the question:" What other resources would you like to have available to you?" was an app on their personal phone. Further examples of student comments are found in Figure 2.
The application of the results of this study is limited by several factors. The sample was a convenience sampling thus results cannot be generalized to the general population. A factor that the researchers could not control was student access to information sources in the pre-clinical setting. Other limitations of this study include the limited number of iPads available (one per clinical group) and the need for an improved orientation to the study for the clinical faculty. In response to the opportunity to make comments about the study, feedback included: "clinical instructor didn't provide resources," "it wasn't carried out equally among clinical groups," "my instructor never mentioned anything about it."
Nurse educators can utilize findings of this study to improve students' use of information at the point of care in the clinical setting. Challenges to the use of hand-held technology will vary based on availability of Internet access at healthcare facilities. Although many facilities provide online resources for nurses, the challenge of having a desktop computer available when the information is needed supports the use of an individual handheld device. A consistent recommendation from students in this pilot study was the importance of having their own handheld device: a phone with an app, iPad, or a PDA. Several smaller devices have become available since the implementation of this pilot study which makes carrying the PDA in a uniform pocket more feasible. However, the expense of requiring students to purchase their own device can be a financial barrier to some. In addition to the initial device expense, software must be kept up to date to safely utilize the information which often incurs additional expense.
Regardless of the type of mobile device utilized, it is essential that the user be proficient with using the device and accessing information. QSEN includes informatics and technology use as a required competency of nursing graduates. Schools of nursing must ensure that computer literacy and the ability to access appropriate information is included in the curriculum and that students are exposed to its application in patient care areas. Faculty should not assume that all traditional college students have extensive computer experience and should always be aware of the likelihood that adult learners may face challenges in that area.
Educators must also recognize that there are limited role models in practice that routinely utilize hand held devices as a resource in the patient care setting. As more healthcare facilities move toward computerized healthcare management systems, this may change rapidly. New graduates should be educated to be change agents in moving perceptions from mobile devices as entertainment devices to use as a means to improving patient safety. Including an explanation of their use in patient teaching should be encouraged in addition to being a supportive team member as other healthcare professionals integrate technology into their practice.
Students found the iPads effective in meeting their needs, accessible and an important resource to improve the quality of the care they delivered. As students of all ages and backgrounds become more comfortable with acquiring information at the point of care using a mobile device, patient satisfaction and safety may be positively affected as students will have more time to effectively manage care. The continued study of different PDAs and other devices for bedside acquisition of information will allow schools of nursing to make decisions on which device is appropriate for use in their program.
Acknowledgement: This research was supported by a Samford University Innovative Technology Grant.
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Geri W. Beers, EdD, RN, CNE, is a Professor and the Undergraduate Chair at the Ida V. Moffett School of Nursing, Samford University. She is a MSN graduate of the University of Alabama at Birmingham and an EdD graduate of Samford University. Her clinical background is diverse and includes oncology, med-surg, and home health. Her interest is using technology to teach this generation of tech-savvy nursing students.
Cynthia Gurdak Berry, DNP, RN, CNE, is an Associate Professor at the Ida V. Moffett School of Nursing, Samford University. She is a MSN and DNP graduate of the University of Alabama at Birmingham. She worked in a variety of positions caring for critically ill trauma and burn patients for 23 years prior to beginning her teaching career. Her interest is incorporating technology into undergraduate nursing education.