Kelly L. Fisher, PhD, RN and Ainat Koren, PhD, RN
Fisher, K. & Koren, A. (2007). Palm Perspectives: The Use of Personal Digital Assistants in Nursing Clinical Education. A Qualitative Study. Online Journal of Nursing Informatics (OJNI), 11, (2) [Online]. Available at http://ojni.org/11_2/fisher.htm
The purpose of this study was to explore the perceptions of students lived experience using a palm hand held technical device (personal digital assistant) (PDA) in clinical practice at the point of care in undergraduate nursing clinical education. The authors recruited nursing students in the third and fourth year of nursing from an undergraduate baccalaureate program. Qualitative analysis of the focus groups data followed a procedure, audio review of tapes from focus groups, coding the transcriptions, identification of conceptual themes, and assignment of thematic construct utilizing NVIVO computer software. The four focus groups involved 28 students and from the data collected within the focus groups, the following themes were identified: information resource; retaining information; clinical critical thinking; professional image; communication skills; and quality of care. The integration of PDA technology into a clinical practicum was successful and positively viewed by the junior and senior students. The breadth and depth of information in this study supports the implications of the use of PDA’s as a readily available resource at the point-of-care in many facilities.
The use of personal digital assistants (PDA) is growing, and these devices are becoming important in the health care environment with the advantage that PDAs can provide a compendium of drug, nursing procedures and treatments, and disease information. The hand held PALM PDA can be an important available resource for nursing students at the point of care during a clinical practicum. The PDA enables the nursing student to access a breadth of information that can be instrumental in applying safe therapeutic care to a variety of patients.
Mobile computing is the next technology frontier for healthcare providers. Data capture and retrieval using a PDA by physicians, nurses and allied healthcare professionals, enhance patient care and improve efficiency by reducing medical errors, improving quality of patient care and safety (Klainberg & Giordano, 2002). A few examples of this include: first, ePocrates, which provides a drug and infectious disease reference; and secondly, Taber’s dictionary and Davis’s Drug Guide as provided by Skyscape software (Scollin, Callahan, Mehta, & Garcia, 2006). The PDA can also be linked to information on the Internet and is capable of receiving programs important to the practice of nursing, which can be synchronized with a personal computer.
Nurse educators have a major responsibility in this arena and need to be aware of and responsive to new trends and changes in the health care milieu. The emergence of informatics in nursing practice presents a challenge to nurse educators to devise ways to integrate technology in contemporary undergraduate nursing curriculum (Simpson, 2001). The studies on PDA usage in undergraduate nursing curricula have been briefly reported in the literature.
The Institute of Medicine Committee on Quality of Health Care in America identified the critical role of information technology in designing safe and effective health care to ensure and promote patient safety (Bakken, Cook & Curtis at all, 2004). The use of PDA’s has been described as a useful new strategy to promote patient safety through an informatics-based approach to nursing education for the use of documentation during clinical encounters, to retrieve patient safety-related information at the point of care, and developing procedural skills (Bakken, Cook & Curtis at all, 2004; Kneebone, Nestel, Ratnasothy, Kidd, & Darzi, 2003; White, Allen, Goodwin, Dowell, & Garvy, 2005). All participants in these studies found the PDA a quick reference for assessment forms, easy to use, and included positive results in streamlining the process of data collection, entry and retrieval, thereby enhancing time management and lastly, provided the learner with immediate information.
One of the Healthy People 2010 objectives is related to health communication to increase the proportion of the persons who report that their health care providers have satisfactory communication skills (U.S. Department of Health and Human Services, 2000). Providing nursing students with a PDA could enhance their ability and confidence to clearly communicate accurate health information to their patients. Enhanced quality of the student-nurse communication can also make an effect on patient outcomes including adherence to recommendations and health status as stated in Healthy People 2010 (U.S. Department of Health and Human Services, 2000). Patients will gain knowledge and increased self-efficacy to participate in informed health care decision making and therefore have a better opportunity to manage their health (U.S. Department of Health and Human Services, 2000).
Healthy People 2010 defined another important goal concerning access to quality health services. Barriers to quality health care are not only impacted by the shortage of health care providers, lack of facilities, or health insurance but also by personal barriers such as language differences (U.S. Department of Health and Human Services, 2000). Having an available hand held resource of a language dictionary such as Spanish in hand will improve communication and access to quality health care.
The learning outcomes in a clinical practicum in nursing education expect the student to develop a solid nursing knowledge of areas disease processes and treatments, pharmacology, and nursing clinical skills to provide safe and competent nursing care. The use of PDAs in a clinical education setting can provide readily available information in areas as medications, disease processes, signs & symptoms, disease treatment, nursing procedures and skills, and health assessment. A clinical preparation project for students indicated three benefits of the PDA: size of the device allows students to record nursing skills or learning experiences immediately after clinical time, time management in perspective to clinical evaluations is that less time was expedited to complete evaluations with the documentation of performance and growth in a PDA file, and the PDA mobility was essential for work to be completed in conference rooms or other designated areas. Overall, these projects positively demonstrate that the integration of the PDA into clinical performance is effective.
The framework for this study is based on the premise that the functions of nursing, used in this study, constitute a systematic form of the ability to utilize both theoretical and practical knowledge, in provision of practical functions both including direct interactions with patients and those that are indirectly related to the patient. Overall, the content is based on perception that refers to both personal experiences and thoughts. A definition of perception, used in this study, refers to many forms of information stimuli from the environment, language, and social symbols as elements of thinking. In addition, the perceptions include students’ thinking about nursing practice functions and their own experiences in practice (Granum, 2004).
A descriptive and exploratory qualitative design was employed in which focus groups were used to elicit data from nursing students, with emphasis on how the PDA affects their nursing care in clinical practicum. A focus group methodology was chosen because it is an excellent means to gather opinions and beliefs in a cost-effective approach offering acceptable validity (Morse, Field, & Field, 1995). Focus groups have certain advantages because the students give feedback in a group and they can build upon each other’s answers therefore a lot of information can be gathered in a short time.
Students had assigned access for PDAs with licensed medical resources through the University library or were allowed to use a personal PDA loaded with medical software (Scollin, Callahan, Mehta, & Garcia, 2006). The students utilized these PDAs during their 7 week clinical practicums. Different focus groups were conducted for students from various practicum (pediatrics, maternity, medical/surgical, & psychiatric) both for those who had utilized PDA technology and those who did not. To avoid research bias the two researchers who are known to the participants did not conduct the focus groups. A professional facilitator experienced as a Registered Nurse and a nurse educator conducted the focus groups. A prepared set of open-ended qualitative questions was used to solicit responses during the one hour sessions, (e.g. What did you find most helpful about the PDA in your clinical experience? In what situations did the use of the PDA assist in researching client data?) based on a general semi-structured interview guide. Focus groups were audio-taped and transcribed verbatim. Students completed a demographic questionnaire and informed consent form allowing permission to tape record the sessions. Participants of the focus groups could complete a post-focus group comment sheet to share feelings not mentioned to the group and submit to the moderator prior to leaving the session. All measures were taken to protect students’ confidentiality by securing tapes and transcripts in a file cabinet of the research team. All subjects voluntarily responded within the groups to answer the questions.
Nursing students in both junior and senior year (aged 21-44 years) were recruited from a baccalaureate program at a university setting. A total of four focus groups were conducted with 25 females and 3 males. The groups consisted of participants who used PDAs and of those who did not use the PDAs in the clinical setting. The Institutional Review Board of University of Massachusetts Lowell approved this study.
Qualitative analysis of the focus group data was evaluated following a set procedure: (1) audio transcription of the tapes, (2) reading through transcriptions, (3) discussions among investigators regarding key elements of students’ perceptions of using the PDAs, (4) determination of conceptual themes, and (5) assignment of verbal responses to relevant thematic constructs. The researchers have experience in qualitative methods and with the target population from higher education teaching experience. Transcription was done within two weeks of each focus group, and study researchers analyzed all the transcripts and coded the data into emerging themes within 2 weeks of session completion. Data analysis was also conducted using the PC-based qualitative software package called NVIVO.
The four focus groups involved 28 nursing students from different clinical settings. Twelve participants had completed a junior rehabilitation medical-surgical clinical practicum, another 10 students came from a maternal-child/pediatric health rotation, and 6 senior nursing students just finished a psychiatric and acute care medical surgical practicum. The major themes that emerged from data were personal perceptions and experiences of using the PDA that evolved around two important goals of Healthy People 2010, Health communication and quality health services by supporting the role of the nurse achieving those goals. The major identified themes are presented in figure 1: Information retrieval, clinical critical thinking, professional image, communication skills and safety of care. The quotes presented were chosen based on their representative-ness.
Personal Perceptions of PDAs as a Resource
In general, most focus group participants found the PDAs to be useful in the clinical setting. The pace is fast in a practicum and often resources are not readily available were reasons the PDAs were especially helpful as a quick resource with access to information on medications, laboratory data, dictionary, RN assessment and RN diseases. For example, a few of the participants who used the university PDAs stated,
“I found myself using my PDA a lot because the textbooks were not available at my hospital. We did not have access to the internet either at the facility. I used the PDA even though my clinical setting had only one computer with access to the Internet. I think the PDA is a reference tool that is much easier to use than a book and is also quicker. It was a good tool. The best thing was the drug book. Also, if I needed to look up diseases with signs and symptoms it was accessible.”
Other participants indicated that the PDA was used in the clinical setting but they did refer back to their textbooks for supplemental information. Others spoke of the need for formalized training on the use of the PDA’s software programs prior to using them in the clinical setting. Many students had not used a PDA prior to this exposure and felt the unfamiliarity was a minor barrier in the beginning of the clinical. Statements as, “It’s so easy once you became familiar with the programs and how to link them to each other.” None of the participants noted that the PDA exerted negative influences, particularly regarding the information in the programs.
Perceptions of Retaining Information
Participants in all groups were asked to discuss how their PDAs affected their ability to learn medical, nursing or drug information. At the beginning of the clinical practicum many of the students felt uncomfortable using the PDA. The descriptions from the students’ narrative indicated a fear of reliance on this mobile device and the lack of retention following retrieval of information. For example, one student’s comment was, “I think it will be better for students to learn where to go to find the information, to check books or policies, then go to the PDA as a source. Another student stated, “Every medication I administered I needed to go over the information again and again to remember them better.” “We learn the same whether it is using a PDA or medication cards. I also think it depends on the person’s learning style”. Some students commented that they were “fearful” and worried about a “dependence” on the PDA. Another suggested, “I agree as a student I rely on it. But when I am in the clinical field I feel better relying on something that is factual than guessing on something and making a mistake.”
Perceptions on Use of the PDA to develop Critical Thinking
The practice of nursing requires the ability to critically think in a variety of situations. The focus group facilitator queried participants regarding their perception on the use of the PDA and development of critical thinking in the clinical setting. Participants stated that once the PDA technology became a tool rather than an obstacle to overcome, many students found creative uses of the PDA in clinical situations that enhanced their critical thinking and facilitated their own learning in the clinical setting. Several of the participants indicated they used the PDA in efforts of providing information to patients or communicating with/to patients and family members. One student told this story,
“The first time I needed my PDA was when one of my patient’s family members came running out of the room saying in an upset tone of voice, “My father’s confused, my father’s confused.” I thought to myself, Could this be a side effect of a medication that he received in the morning? I then quickly utilized my PDA to look up the medication side effects then calmly shared this information with the family member. It was then I realized how to critically think about the patient’s condition, applying the information from the PDA on the medication to allay the family members distress. The PDA was an easy tool to quickly look up information and respond to the urgency of a situation.”
Most participants indicated they utilized the PDA for drug information prior to the administration of the medications to their assigned patients. Another participant stated, “I utilized the PDA prior to hanging an antibiotic to check the compatibility of potassium and the antibiotic medication. I also called the pharmacist who confirmed the information found on the PDA regarding the medication compatibility identifying that potassium was not compatible with the drug.” Participants admitted that the PDA improves learning, especially when students have a new drug to give that they were not familiar with, they were able to look up the information within 5 minutes and not delay administering the drug to the patient. A few participants felt that the PDAs offer a great impact on access to clinical decision-making information at the point of care and reducing medication errors.
Professional Image Perceptions
The Professional self-image acquired by nursing students is an important component in the professional and academic development of the nursing profession. One theme that arose from the focus groups was the effect of using a PDA at the clinical rotation on their professional image perception. Interestingly enough there were two conflicting experiences about the use of point of care technology on their image. Several students noted a positive effect on their image. The fact that they had immediate available information to answer a patient question was revealed.
“…you are with a patient and you are not going to take this huge book and try to find out what they are asking… With the PDA you could just do it really quick. I think in the clinical setting that is really important because students are looked down upon sometimes not knowing every thing…”
Another comment supporting this feeling was,
“…it was great to have it in front of the client while you were answering their questions you could immediately look up the information and give immediate feedback.”
The positive image feedback was supported from the interaction with the nurses on the unit where the clinical rotation took place.
“… They were so impressed to see us pull out the PDA’s and use them. They wish they had the technology when they were in school…”
The students expressed their satisfaction with being able to support the nurses’ knowledge when asked:
“…it was really good. I was able to pull out the PDA and resolve conflicts related to patient care that the patient should not have gotten a medication.”
On the other hand a there were students who felt that the PDA use had negative affect on their professional image especially in front of the patients. For example some of the students made sure they did not use the PDA in front of their patients.
“…I used it before I would see a patient, in case they may think I don’t know the information…” The students explain they felt the patient had less confidence in them when they pulled the PDA out to look up information.
Some participants noted they find it difficult to use in front of patients.
“I never used it in front of my patients. I do not think it would look professional. The patient might think I am writing something about them. I do not think it would be a good action without an explanation of what you are doing first. If it is a place where other nurses used it often, then that would be different”.
Perceptions of Communication
Students commented that the use of the PDA in clinical practice enhanced their communication skills and contributed to the quality of care they delivered. One of the Healthy People 2010 objectives related to health communication is to increase the proportion of the persons who report that their health care providers have satisfactory communication skills (Scollin, Callahan, Mehta, & Garcia, 2006). Nursing students commented that the PDA enhanced their ability and confidence to provide clear, accurate health information to their patients. When patients asked questions about their medications or diagnoses the students felt they could properly provide accurate information with the help of the databases on the PDA very quickly.
“… It was great to have it in front of the client. While you were answering their questions you could immediately look up the information and give them feedback immediately…”, “It enhanced my interaction with my client while I was talking to my patient…”
The use of the PDA contributed to clear communication by using the language database,
”…but the thing that was most helpful was that I used the Spanish-English interpreter/translator and if I didn’t have the PDA I would not have been able to communicate with the patient at all.”
Provision of Quality of Care Perceptions
Short patient hospital stays and the rapid discharge of patients in acute care settings mean students need to be able to adapt quickly to changes in patient assignments. PDAs gave students access to information needed to safely care for patients and provide quality of care during their clinical time. One example was with the new medication orders.
“…it is a quick reference.” I found in situations where drugs are ordered last minute it was helpful…”, “... it is a great safety net to provide quality of care...” “… A patient asked a specific question about a medication so I pulled out the PDA and looked it up immediately so I knew I was giving the right answer…”
Here again the data presented conflicting viewpoints. Some students viewed
PDA use as a distraction. They were reluctant to access the PDA in front of the patient
“… If I had one then my patient will get less attention…” Another student stated “…I don’t think it is wise to look it up information in front of the patient. The time with your patient is special and precious…”
One limitation of this study may be that it is not generalizable to other populations having utilized a purposive convenient sampling; however, themes that emerged as discussed by the participants may be transferable to certain other settings. The somewhat homogeneous nature of the sample (all from a large, public university) might be considered a limitation. The participants’ responses often revealed shared perceptions, and most agreed upon opinions, which allows the researchers to have more confidence in the data with shared perceptions of the participants as strength of this study.
This qualitative focus group study provides insight into students’ perceptions of the use of PDA technology at the point of care. From the discussion of the 4 focus groups, the following themes were identified: PDAs as a resource, retaining information, developing critical thinking, professional image, communication and quality of care. Short patient hospitals stays and the rapid discharge of patients in acute care settings mean students need to be able to adapt quickly to changes in patient assignments. The use of the PDAs gave students access to updated information needed to safely care for patients and maximize their clinical time. Once the learning curve was achieved, the use of a PDA assisted the students in safe clinical decision-making, supporting Healthy People 2010 goal of promoting access to quality health services (DHHS, 2000). Students commented on the use of the PDA in the clinical practice that enhanced their communication skills and contributed to the quality of care they delivered in various settings. This supporting evidence demonstrates that this technology can be a tool to meet the Healthy People 2010 objective related to health communication (DHHS, 2000).
Nursing clinical education should prepare baccalaureate nurses to work in a growing health care technology environment. Exposure to and skill practice of hand held technology supported the nursing students’ socialization process in their role and a positive professional image adaptation. Professional socialization is the process by which individuals acquire the specialized knowledge, skills, attitudes, values, and norms needed to perform in professional nursing.
PDA technology is not yet widely used in hospitals and other health care facilities; it has the potential to become an important unit support. Nurses may consult the student’s PDA to check a medication, procedure, and laboratory value or disease profile. Use of the PDA can potentially enhance student-staff exchange that hopefully may result in higher quality patient care. This type of exchange can have a positive effect on student’s socialization and demonstrate an academic contribution to the clinical field. Technology in nursing education has been proven to be useful for clinical evaluations, assessment documentation, and a resource at the point of care. The features of the computerized evaluation tool, assessment system for tracking students’ performance, and immediate information in order to make informed clinical decisions using a wide variety of resources at the point of care has been proven effective (Korte, 2005).
Information technology has integrated in the health care delivery systems to include PDAs and Tablet Personal Computers. Data from these devices collected on patients by students and student evaluations can be transmitted to faculty PDA devices. The application of these devices is numerous ranging from use as an information resource to managing clinical data on assigned patients. Students in this study initially had to achieve a learning curve of the use of the hand-held device and to navigate the software. Once this was no longer an obstacle, the advancement of the application of the PDA was revealed to assist student’s clinical decision-making while providing patient care, which supports the current literature. A study in the literature using PDAs in nursing education revealed findings that there was both delight and hesitancy to use the technology due to a lack of general familiarity with the device, initially the undergraduate students were unsure of how the device could assist in their learning but quickly adapted to incorporate the resource into their clinical experiences, and the results recommended a continued need to explore the application of the PDA into nursing education to determine the correct software for specialized areas (George, & Davidson, 2005). Further studies discuss the implications that the students identified regarding the potential of PDAs to reduce medication errors which supports the use of new technology advances related to drug administration (George, L. & Davidson, 2005; Galt, Rich, & Young, 2002).
Overall, the integration of PDA technology has been successful and was positively viewed by the students in the junior and senior levels of a baccalaureate program. The breadth and depth of the information gleaned from this discussion has implications for those whose goal in the future is to incorporate the use of PDA in a nursing program. Further collection of data on the impact of the use of the PDA at the time of graduation following 2-3 years exposure to using the hand-held technology in multiple clinical settings over time would assist to measure their overall impression of application of PDA’s in the classroom or clinical setting. In general, the outcomes of this study support the capability of Personal Digital Assistants as hand held PALM devices as a quick and reliable resource available to nurses.
The PDA can maintain many reference resources that are readily available such as, drug guides, medical dictionaries, maintaining numbers of physicians, and information about patients. It can also be linked with the Internet to support sending and receiving email, exploring medical web sites, as well as, provide patient related programs at some hospitals necessary to practice as a health care provider. Future studies should examine learning outcomes with the use of PDA’s in a nursing curriculum, examine what it brings into daily patient care related to time management, and how this tool is effective at the point of care to provide safety to patients in the clinical area.
Figure 1: Themes of Students’ Perspectives on PDA’s in Nursing Education
Funding for this project was provided by Eta Omega Chapter, Sigma Theta Tau International Honor Society. The authors would like to acknowledge the support of Dr. Patrick Scollin and John Callahan at UMass Lowell.
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Kelly L. Fisher, PhD, RN
Dr. K.L. Fisher received a PhD in Nursing from the University of Rhode Island, S. Kingston, RI. Her clinical expertise is in the specialty area of medical-surgical and critical care nursing with over fifteen years of teaching experience in B.S. Nursing programs. Dr. Fisher currently involves technology in her teaching methods with a focus on incorporating remote personal response systems in classroom, integration of PDA’s, tablets, and internet technology to assist students learning in laboratory and clinical settings.
Ainat Koren, PhD, RN
Dr. Ainat Koren received a PhD in Nursing with a health promotion focus from the University of Massachusetts Lowell. Her experience includes working as a nurse in pediatric intensive care and pediatric surgical units where technology is a major vehicle for patient care and monitoring. Her teaching experience includes seven years at the Nursing program of the Hebrew University in Israel and three years as Quality Assurance Coordinator of Preventative Services in the central district of Israel, where she was involved in developing methods and technologies for safe and high quality delivery and administration of immunizations for children. Currently in her third year of teaching in the Nursing Department at the University of Massachusetts Lowell, she is involved in teaching junior and senior nursing students both in theory, clinical practice, and research. Dr Koren continually involves technology in her teaching which includes incorporating the use of PDAs in clinical practice, remote personal response systems in class lectures and streaming essential video to enhance students learning.
Correspondence to Kelly L. Fisher, PhD, RN, Associate Professor, Department of Nursing, Endicott College, 376 Hale Street, Beverly, MA. 01915