Making a Case for Personal Digital Assistant (PDA)
Use in Baccalaureate Nursing Education
Rhonda R. Martin MS, RN
Martin, R. (2007). Making a Case for Personal Digital Assistant (PDA) Use in Baccalaureate Nursing Education. Online Journal of Nursing Informatics (OJNI), 11, (2) [Online]. Available at http://ojni.org/11_2/martin.htm
This article gives an overview of the current use of handheld computers or personal digital assistants (PDA) in the healthcare realm. Specifically, PDA use in baccalaureate schools of nursing is targeted. The utilization of a PDA by nursing students at all levels of education is addressed and the benefits and limitations are identified. There is increasing information in the literature about PDA use with medical and nurse practitioner students, although information specifically related to baccalaureate nursing students remains limited. These schools lag behind other disciplines in utilization although no clear reason is evident. This author feels baccalaureate schools of nursing must begin to implement PDA use into the curriculum before graduates are left unprepared.
Five key words: informatics, nursing informatics, handheld computers, personal digital assistant, baccalaureate nursing education.
Nursing students experience high levels of stress and anxiety throughout their education. They are trying to learn and implement a large volume of information at a rapid pace. Students entering a new clinical setting frequently feel unsure of their skills, feel insecure about their knowledge level, and lack self confidence. In comparison to experienced nurses, they function in a disorganized manner. Rapid increases in knowledge and technology call for the use of such tools as a personal digital assistant (PDA) to increase the quality of education, performance, and patient care. Baccalaureate schools of nursing have been slow to implement this tool to enhance student learning and meet the requirements for nursing informatics in the curriculum. No policies prevent PDA use although these schools lag behind other disciplines in utilization. This author feels baccalaureate schools of nursing must begin to implement the PDA into the curriculum before our graduates are left unprepared.
High levels of stress and anxiety may be coupled with a decrease in performance and confidence. This scenario has led to medication errors made by the student, many of which are related to assessment knowledge or medication administration (Rosenbloom, 2003; Rosenthal, 2003). The PDA presents an approach that uses technology to access useful information; for example, it provides a quick reference to medications and laboratory tests in addition to being helpful with record keeping/patient tracking and organizational skills (Armour, 2004; Enger & Segal-Isaacson, 2001; Hunt, 2002; Lusky, 2000; Peterson, 2003; Rosenbloom, 2003; Rosenthal, 2003; Thompson, 2005), and decreasing students’ anxiety and stress. Another value of having information readily available through the PDA technology is that it “allows for student reinforcement of core knowledge for practice as well as strengthening professional confidence” (White, Allen, Goodwin, Breckinridge, Dowell, & Garvy, 2005, p. 150).
The history of health care began with a “hands on” philosophy. Through the centuries, the utilization of herbs and various treatments were added to basic “hands on” practice, often referred to as “folk medicine”. The 20th century saw the introduction of a variety of technological tools, many of which found their way into nursing. Computers represent one of these major technological tools that is changing the practice of nursing. Computers have gone through a long evolution, from the first automatic calculator (addition and subtraction) invented in 1642 by Blaise Pascal, a French mathematician, through the personal computers (PCs) introduced in 1975, to finally arrive at the bedside to facilitate healthcare delivery. Today microchip transistors enable storage and transfer of information in digital form (Evans, 2004). The term “personal digital assistant”, referring to the Apple Newton personal organizer was introduced in August 1993 (Newton Message Pad, n.d.). Technology and its influence on nursing and healthcare delivery will continue to evolve.
Through the late 1960s and 1970s there was little information about the application of computers in nursing. During the 1980s the literature began to describe computer use in nursing. Ronald and Skiba (1987) state “healthcare agencies were developing and/or acquiring automated information systems” (p. 6) during the 1980s. In 1985, the National League for Nursing created the National Forum on Computers in Nursing and Health Care, then published the monograph Guidelines for Basic Computer Education in Nursing in 1987 (Ronald & Skiba).
In 1989 the first descriptions of the field of nursing informatics was released. The American Nurses Association (ANA) later developed the Scope and Standards of Practice for Nursing Informatics (NI) in 1994, and revised it in 2001. ANA (2001) defines “nursing informatics” as
a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice…to support patients, nurses, and other providers in their decision-making…using information structures, information processes and information technology. (p. 46)
During the 1990s there was a rapid increase in technology and its implementation in clinical practice and various levels of education. The Generation-Xers, who grew up with computer games and Internet access, began to enter college and brought the use of this technology along. As early as 1997, Mace (2004) implemented PDA use with students in nursing clinicals. Since then, the literature shows increasing implementation in educational programs, mostly medical, and then the move into the hospital and other areas of healthcare.
Nurses, in a study by Davenport (2004), stated the benefits of using PDAs in clinical practice were “having quick access to a current drug database and nursing reference books…ability to manage patient and procedure information…bedside data entry… data collection for research and teaching… and improved team communication” (p. 5). These are all benefits that should facilitate a decrease in the medical mistakes identified in the To Err is Human report from the Institute of Medicine (2000), which asserts that an average of 270 deaths per day occur from medical mistakes.
Stanley 2003 found three psychosocial obstacles (fear, relevance and self-concept) that decrease motivation for acquiring computer skills. Many users have identified fear, privacy concerns, and not being a necessary tool in their lives as reasons for not using computers and related equipment. These are issues that need to be addressed to increase comfort supporting the use of all types of computers by the greatest portion of the population.
Various authors site PDA use with medical students (Rosenbloom, 2003), physician assistants (Brock, Scott, & Wick, 2003), and physicians. Use with this last group ranges from 15 to 25% (Armour, 2004). Multiple studies with physicians, medical students, and residents have documented safer administration of medication and, therefore, increased safety of patients (Grasso, Genest, Yung, & Arnold, 2002; Rosenbloom, 2003; Rothschild, Lee, Bae, & Bates, 2002). PDA use within educational programs for physicians and nurse practitioners is well supported in the literature, while limited information specifically related to baccalaureate nursing education can be found.
Would PDA utilization by undergraduate nursing students relieve anxiety, improve confidence, and improve performance? This question and resulting information addresses the concerns of nurse educators throughout the entire nation. As the delivery of healthcare has begun to incorporate computer use, the American Nurses Association (ANA) has defined the application of nursing informatics in nursing curriculum (2001). Faculty have begun to question where and how to implement this additional knowledge students need to practice safely.
PDA Use in Baccalaureate Schools of Nursing
The literature provides evidence that information is available and increasing related to PDA use with medical residents, nurse practitioner students, nurses and physicians while there appears to be a gap related to PDA use with undergraduate nursing students. Initial information in the literature appeared in the late 20th and early 21st centuries with slowly increasing numbers, although references related to undergraduate nursing programs remain sparse. Hunt (2002) stated only a 1% PDA use with nurses and the same or lower percentage of use with undergraduate schools of nursing. While other healthcare providers have used PDAs or similar technology, little has been reported about their use with undergraduate nursing students. Suszka-Hildebrandt (2001) discusses the success of the PDA pilot at the University of Virginia Nurse Practitioner Program, the first school of nursing to require use of PDAs. Miller et al. (2005) supports use of PDAs with undergraduate nursing students for the same reasons as discussed by other authors.
Most authors have described the process of implementing a personal digital assistant with students and some of the benefits that students have identified. Very few resources have been research based studies of PDA utilization. This concern is reported by George and Davidson (2005) as they discuss where PDA use stands today and how to continue preparation for the future. Recently, a group of Canadian faculty reported the implementation of PDA use with 17 undergraduate nursing students which resulted in a significant increase in their general self-efficacy scores after 8 weeks (Goldsworthy, Lawrence, & Goodman, 2006). Goldsworthy et al., utilized the General Perceived Self-Efficacy instrument to measure for “a broad and stable sense of personal competence to deal efficiently with a variety of stressful situations” (Schwarzer & Jerusalem, 2000, ¶ 2). They further described how the students utilizing a PDA reported they “felt more confident and effective than peers who lacked this resource” (Goldsworthy, Lawrence, & Goodman, p. 141). This literature is growing, although many more research based studies with undergraduate nursing students are needed to identify PDA use and support its appropriate uses.
Application to Baccalaureate Nursing Education
Significant problems for nursing seem evident in the current atmosphere of the healthcare setting; nurse shortages, increased patient acuity and increased numbers of errors are identified. The stress and anxiety the student experiences can lead to issues of not completing school, which then contributes to the nursing shortage, and low self-confidence contributing to increased errors and decreased longevity in the work force.
PDAs are emerging as a useful tool in the delivery of healthcare in many avenues. Several studies with nurses, nurse practitioners, and nurse practitioner students have documented the increased safety of patients through safer administration of medication (Altmann & Brady, 2005; McGill, 2004; Rempher, Lasome, & Lasome, 2003; Rosenthal, 2003; Stolworthy, 2003; White, Allen, Goodwin, Breckinridge, Dowell, & Garvy, 2005). Other identified benefits of PDA use in clinical are (a) increased knowledge and availability of references at their fingertips, (b) assisted delivery of more comprehensive care, (c) increased timeliness of assessments and documentation, (d) greater continuity of care utilizing tracking software, and (e) decreased stress on the practitioner when given more quality time with the patient.
The literature supports implementing the use of PDAs in clinical practice to reduce student stress, anxiety, and medication errors while enhancing confidence and productivity (Armour, 2004; Grasso, et al., 2002; Hunt, 2002; Rosenbloom, 2003, White, et al, 2005). The use of a PDA may (a) decrease stress by providing access to the information students need, (b) decrease fear of making a medication error with information readily available, and (c) assist with organizing information and time management skills. Currently students attempt to carry bulky textbooks to the clinical site and have to leave them in a conference room. Facilities do not provide consistent availability of reference books close to the patient area for student use. A personal digital assistant is lightweight, compact and can be easily carried in a pocket. The PDA is a tool to utilize in the nursing world of today (White et al, 2005). Students need this tool to access and assimilate information quickly.
According to White et al., further utilization by nursing students could lead to more thorough “clinical assessments…language translation, calculations” (2005, p. 150). Students can submit assessments and other “paperwork” entered into the PDA before leaving the clinical area by “beeming” the data to the faculty member. The instructor can then use a PDA to track student progress through the semester and complete the evaluation at the end. The use of various PDA monitoring software would be very beneficial for patients with hypertension, diabetes, preeclampsia or preterm labor.
Some of the actual benefits to the students using a PDA include reducing duplicate documentation; increased communication with patients and faculty; and easier tracking of patient assessment, problems and needs. The mobility of the PDA, the convenience of having needed information readily available at all times, and positive effects on work management, along many yet-to-be identified benefits are all reasons to implement use with baccalaureate nursing students.
Before implementing the PDA, it is important to consider potential limitations. The most obvious one relates to the PDA itself. Multiple studies discuss cost of the PDA and acquiring software as the initial challenge. Then troubleshooting problems with hotsyncing (to get the reference books or forms to the PDA), and inoperable or broken units must be considered. White et al. (2005) state a “main challenge…is ensuring that all faculty use the PDA consistently, require its use with all students, and promote its application in the clinical setting” (p. 154). Before this happens you may have to overcome both the student and faculty’s anxiety or unfamiliarity with the unit.
The issue of maintaining patient confidentiality and following Health Insurance Portability and Accountability Act (HIPAA) regulations is another limitation to address. Any patient information the student enters in the PDA should use an identification code instead of the patient’s name or initials (White et al., 2005) and care should be taken if this information is transferred by beeming or synchronization. If the information is to be retained, it is recommended that “students’ password-protect access to their PDA and de-identify all patient data” (White et al., 2005, p. 152). The breach of a HIPAA privacy risk is small if the de-identifying step is followed.
While these limitations should be addressed, most applications of the PDA in healthcare do not involve specific patient information. The use of reference materials (drug books, guidelines, formularies, etc) or clinical calculators (e.g., medication dosage, body mass index, Estimated Due Date formulas) have been the most common uses.
Nursing has come so far to still have so far to go. While the utilization of a PDA has greatly increased in the nursing practice arena during the 21st century, nursing has not made the strides needed to implement its use most effectively, especially in introducing it to undergraduate students. The limited information available regarding its usage does discuss ways to use it and introduces possible benefits and limitations. An immediate focus area of need is the implementation of PDAs within baccalaureate schools of nursing. There is a need to examine the best method of implementation; familiarize faculty and students with equipment use; facilitate the depth and speed of integration in clinical areas; and to address ways to lower anxieties, increase self-efficacy, and reduce reluctance to change. Realizing change can be difficult and challenging Baccalaureate schools and nursing students must rise to the occasion, embracing the technology of the 21st century. If not, nursing education and patient care will be left behind.
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Rhonda R. Martin MS, RN
Ms. Martin, Clinical Assistant Professor at The University of Tulsa School of Nursing, has over 17 years experience as a nurse educator. Her areas of expertise are high-risk and maternal-child nursing with a growing focus in nursing informatics. Rhonda is currently pursuing a doctorate in nursing at Texas Woman’s University.