Application of the Nightingale Tracker: A Collaborative Research Project Between an Associate and Baccalaureate Degree Nursing Program

Judith A. Sutherland , Ph.D., RN

Donna Wofford, Ph.D., RN

Mary Jane Hamilton, Ph.D., RN

Barbara Schmidt, MS, RN

Abstract

Purpose: This study evaluating the application of the Nightingale Tracker (NT) and the Omaha Patient Care Record System (OPCRS) was a collaborative project between an Associate Degree (ADN) and Baccalaureate Degree Nursing (BSN) Program in the same community. The project was designed to analyze student demographics; obtain student reactions to the NTs over a one year period; identify potential educational barriers and benefits to using the NTs and determine the similarities and differences between the two student groups in response to the NTs and the OPCR.

Methods: The NTs were used by ADN/BSN students in five clinical areas: Pediatrics, Maternal/Child, Medical-Surgical, Psychiatric-Mental Health and Community Health rotations for a full academic year. Settings included inpatient hospitals, adult day care facilities and community health clinics. Student variables analyzed were in response to five quantitative Likert scale questionnaires and a demographic data sheet. Descriptive statistics were used to determine differences in the two student groups and inferential statistics (t-Tests) were used to analyze changes in groups Means between Post-teaching/Final-impact Questionnaires and Pre-impact/Final-impact Questionnaires.

Results: Findings indicated that significant changes in positive responses to the NTs occurred in the ADN group with the Post-teaching/Final Impact Questionnaire t=4.537 (p=.002) and the Pre-impact/Final-impact t=4.466 (p=.002). There were no significant changes in the BSN group scores over time.

Conclusions : Were that hardware related problems and system technological support significantly affected the ADN student responses and that faculty commitment to the clinical application of the NTs was crucial to student success. Both ADN and BSN students valued the OPCR system in the development of comprehensive and accurate patient care plans in all five clinical areas.

The Nightingale Tracker (NT) is a computerized Point of Care (POC) patient information processing unit using the Omaha Patient Care Record System (OPCRS) software incorporated into a personal digital assistant (PDA), the DataRover 840 (Merrill, Hiebert, Moran & Weatherby, 1998; Elfrink, 1996). The PDA is a hand-held unit with dial-up capability to a centralized patient data-base and is designed to access, document and communicate information to and from the POC to the central location. The development of the NT was initiated by the Fuld Institute for Technology in Nursing Education (FITNE) in 1994 and field tested in 1996 and 1997 (Elfrink, et al., 1999; 2000). The purpose of this system is to facilitate the supervision of students in community-based clinical education by establishing synchronous communications between faculty and students at distant sites and to augment the development of a patient care data-base for instructional purposes. The NT has been used in educational programs and home health care settings (Pearce, Castleman & Elfrink, 1999;Elfrink et al., 2000; Sloan & Delahoussaye, 2003; Thomas, Coppola & Feldman, 2001).

The OPCRS, integrated into the NTs as software, is a practice-based classification scheme recognized by the American Nurses Association and the North American Nursing Diagnosis Association (Merrill, Hiebert, Moran & Weatherby, 1998). It is comprised of three components – the Problem Classification Scheme, the Intervention Scheme, and the Problem Rating Scale for Outcomes; these elements were developed using taxonomic principles producing mutually exclusive domains, problems and intervention categories and targets (Martin & Scheet, 1992). The NT is uniquely designed to allow students to collect patient information at the POC and relay that information to clinical faculty for synchronous or asynchronus evaluations.

Findings from previous studies using the NT/OPCRS focused on the following areas: effective instructional strategies for students using the POC system, students' acceptance of POC usage and recommendations for clinical applications, negative and positive outcomes from using the NT/OPCRS in a home health care agency, application of the NT/OPCRS in a community health student home visiting program, and curriculum restructuring using the OPCRS. Elfrink et al. (2000) found that students needed more time to learn the technology along with practice and problem-solving the technology during clinical evaluation of the application. Pearce, Castleman & Elfrink (1999) reported that negative outcomes from the perspective of a home care nurse were related to reliable access to the internet during peak traffic times which was problematic in transmitting data, the limited storage capacity of the PDA and its processing speed when multiple assessments were being conducted. Positive results cited in this study were a comprehensive tool for developing a plan of care, the ability to integrate scheduling and communication functions and a standardized patient care documentation method.

Sloan & Delahoussaye (2003) found negative effects associated with use of the NTs related to the amount of faculty time required to support students with implementation of the application, the management and surveillance of patient information which required considerable vigilance on the part of students, faculty and the technological team to protect the data, and the economic investment in technological support was crucial to the success or failure of implementation. Positive results were related to the skills students developed in using technology in general and the transfer of these skills to other forms of electronic documentation. Thomas, Coppola and Feldman (2001) examined the use of the NT in a community based nursing curriculum and found that the limitations were related to the amount of faculty training provided prior to the use of the device and the absence of follow-up training sessions for students when technological problems arose. Positive outcomes were associated with the student's enthusiasm for the technology. Finally, Merrill, Hiebert, Moran and Weatherby (1998) reported that faculty education and experience in the OPCRS was important to its application in the clinical arena. These findings were considered in the implementation of this project.

This collaborative study was conducted by two schools of nursing residing in the same community: a community college – Associate Degree program (ADN) and a state university – Bachelor of Science Degree program (BSN), and involved two phases. Phase I was the pilot study instituted to provide a framework for the longitudinal study (Phase II) which would encompass expanded clinical application of the Nightingale Trackers (NTs) across three semesters and clinical rotations. In Phase I, training in the OPCRS was systematized between the two nursing programs along with training in the use and application of the NTs in two comparable program clinical rotations: maternal/child and psychiatric/mental health. This process allowed the researchers to regiment the research protocols for similarity and pilot the Nightingale Tracker measurement instruments.

Phase II expanded upon the pilot study by evaluating the use of the NTs by ADN/BSN students in five clinical areas: Pediatrics, Maternal/Child, Medical-Surgical, Psychiatric-Mental Health and Community Health rotations for a full academic year. Settings included inpatient hospitals, adult day care facilities and community health clinics. The two student cohorts were comprised of 9 students enrolled in the ADN program and 8 students in the BSN program. Student variables analyzed were in response to five quantitative Likert scale questionnaires and a demographic data sheet. Research questions were: a) What are the demographic characteristics of the student research subjects in the two programs?; b) What are student reactions to using the NTs as measured by the five quantitative questionnaires?; c) What are the educational barriers to using the NTs in five clinical areas?; d) What are the educational benefits to using the NTs in the various clinical settings? and e) What are the similarities/differences between the two student groups (ADN/BSN) in response to the use of the NTs and OPCRS.

Methodology

Five faculty from the two programs were trained in the OPCRS and the use of the NTs at FITNE in Athens , Ohio . The training program involved media, demonstration, practice and application of the OPCRS to a patient case study. The protocols and structure of this training program were replicated in both Phase I and Phase II of this study since a history of effective strategies had been established by FITNE (Elfink et al., 2000). The two student cohorts were constituted from a convenience sample of students who indicated an interest in learning and using a new computerized patient care documentation system in place of their traditional written nursing care plans. The training program encompassed a seven-hour time frame given in one day. A demographic questionnaire was developed and completed by students that included assessment of age, income, marital status, hours worked, mother's educational level, father's educational level, number of school loans funded, number living in the household, number of dependents and number of years and type of computer experience.

The five Likert scales used in this study were developed by the Nightingale Tracker Clinical Field Test Team (Elfrink et al., 2000) and modified from the Computer Acceptance Scale (CAS) (Casali, Williges & Dryden, 1990). The reliability of the revised CAS's bipolar scales using Chronbach alphas was 0.92 (Elfrink et al., 2000); there was no validity report in the article. Students in the two cohorts completed the Post-teaching and Pre-impact Questionnaires immediately following the instructional session; the Six-week Impact Questionnaire was completed at the six-week point in the study and the Final Impact along with the Final Interface Questionnaires were completed by the student groups at the termination of the last clinical rotation. In addition, students were asked to maintain an electronic journal of their experiences with the NTs.

Data Analysis

Data analysis involving the sample demographics and three impact questionnaires (Post-teaching, Pre-impact and Final-impact) are discussed here due to the significance of the findings. Data collected on the demographic instrument were analyzed using descriptive statistics and evaluated by the researchers for similarities and differences. The three Impact Questionnaires were analyzed using descriptive and inferential (t-Test) statistics and are described in the following paragraphs. Narratives from the students' electronic journals and faculty impressions from student care plans were compiled and are summarized.

The Post-teaching Questionnaire contains 22 questions asking for an opinion (positive or negative) about computers in general and about the use of the NT specifically. These questions are rated on a scale from 1 to 5 with highly disagree being 1 and highly agree being 5. Some examples of general computer use questions are: I avoid using computers at work whenever possible; It is neat to be the first to try out a new computerized system. Examples of NT specific questions are: NT makes my job more difficult; NT makes my job more interesting; NT is more work than it is worth; I easily learned the NT; My training in the NT will enable me to use it quickly and accurately . The Pre-impact Questionnaire contains 20 questions and closely replicates the Post-teaching scale but with the addition of future tense questions such as: NT will improve my ability to provide high quality patient care and NT will help me make better decisions about patient care . The Final-impact Questionnaire is comprised of 23 present-oriented questions such as: I feel at ease working with the NT system; I recommend permanent use of the NT system and I will need a lot more time to learn the NT system .

Findings

The ADN cohort was comprised of 2 males and 6 females; 3 were Hispanic and 6 were White (non-Hispanic origin); the Mean (M) age was 35 (SD=10.06); 6 were married and 3 single; M=3 dependents (SD=.948); hours employed outside of school was a M=25 (SD=17.8); Mean household income was $35,00-45,000 and number of years with computer experience was a M=4 (SD=3.57). The BSN group was composed of 8 females; 2 were Hispanics and 6 were White (non-Hispanic); Mean age was 22 (SD=1.9); 2 were married and 6 single; hours employed outside of school was a M=10 (SD=14.9); Mean household income was also $35,000 to $45,000 and number of years of computer experience was M=9 (SD=2.1). The ADN students were older, more likely to be married with more dependents and employed more hours outside of school than the BSN students. The BSN students had more years of computer experience indicating their earlier exposure to computers in the school and home.

Data analysis involved examining changes in the group means between the Post-teaching and Final-impact Questionnaires and between the Pre-impact and Final-impact Questionnaires to determine the stability of student responses over-time to the NTs. For the ADN group, significant changes occurred between the Post-teaching and Final-impact Questionnaires and the Pre-impact/Final-impact Questionnaires. The ADN group mean on the Post-teaching Questionnaire was M=65.66 and, when measured at the end of the study by the Final-impact Questionnaire, the mean had decreased to M=51.44. A t-Test for paired sample statistics was tabulated and resulted in a t=4.537 which was significant at p=.002. Similarly, the ADN Pre-impact and Final-impact Questionnaires showed a significant decrease over time. Group mean on the Pre-impact was M=65.55 and when measured at Final-impact the M=51.44. A t-Test (t=4.466) was significant at p=.002. This decrease in the group mean scores on the instruments indicates an overall decrease in positive reactions to using the NTs.

The BSN Post-teaching and Final-impact Questionnaire data did not show a significant group mean difference. In fact, the Post-teaching Mean was 66.62 and the Final-impact Mean was 66.375; a t-Test was not significant (t=.060). There was a slightly greater group mean difference between the Pre-impact and Final-impact (M=70 and M=66.37) respectively but this change was not significant (t=.90). The stability of the group means indicates stability in student reactions to the NTs over time. It is interesting to note that both groups had similar Mean scores on the Post-teaching Questionnaire (ADN M=65.66; BSN M=66.62). The Pre-impact group mean was slightly higher in the BSN group than in the ADN group (M=70 and M=65.55 respectively). This indicates both groups began the project with similar reactions to the use of the NTs but the ADN group demonstrated a significant decline in group means over the period of the study.

Discussion

Comments by students from the electronic journals indicate reasons for the decline in the ADN group scores and are displayed in the Table. ADN faculty reported continuing problems with the server and even resorted to grading the student care plans on the NT itself since students had so many problems sending the data thus defeating the purpose of the POC system. Overall, the ADN students did see the potential usefulness and efficiency of the NTs if the technical difficulties were eliminated. Students found the language of the OPCRS easy to use and the multifaceted assessment facilitated their evaluation of patient status. Students naturally focus on the physical aspects of assessment and often overlook psychosocial and community needs; the OPCRS prompted them to attend to the complex psychosocial and home care needs of the patients. College technology personnel were assigned the additional responsibility of providing technical support for the NT research project and one person attended the training at FITNE. This person trained other department members in the technological management of the NT program. However, these full-time technology staff members were not available to the students at all times. Additionally, faculty who worked with these students were not equally enthusiastic about using the NTs which greatly influenced the students' experiences and perceptions of the NT's usefulness.

BSN student negative responses were not as voluminous as the ADN due to the fact that server problems were resolved by increasing the modem speed to the maximum level and because there was a dedicated server for the NT. Additionally, the BSN program hired a graduate student in computer science to provide consultative support and problem-solving for the students when the situation demanded it. The graduate student attended the training at FITNE and was able to problem-solve such issues as individual NTs not connecting with the server and other communication problems the students experienced. The BSN students liked the prompting of the OPCRS software; the general consensus was that it assisted in the development of more comprehensive care plans for their patients. Negative experiences with the NTs paralleled the ADN group reactions and were: It takes so long to send and download information to the instructor; Sometimes the phone to the server would ring and ring with no connection; The screen on the NT is hard to read and particularly in poor lighting; The NT unit has to stay charged or you risk losing your data; It takes too long to type in with the stylus.

BSN faculty evaluations of student utilization of the NTs centered around the fact that student initial care plans were more comprehensive – the depth of assessment and problem identification were augmented by the OPCRS; the care plans could be quickly graded and returned to students with recommendations and the OPCRS revealed the students' lack of clinical experience when rating patient outcome status. Typically, patients had multiple and severe problems but students related the status as minimal or moderate when it should have been rated severe or extreme. This gave faculty the opportunity to teach the students about the significance of acuity ratings in assessing patient problems and planning interventions. Future utilization of the NTs would depend upon the resolution of these problems which are hardware related and those that affect the time commitments of faculty and technology staff.

Conclusions

Limitations of this study were the absence of data indicating the validity of the instruments to measure NT student reactions from previous studies and the limited number of faculty interested in supporting the implementation of the instrument. Future use of the NTs in these two programs is dependent upon the resolution of hardware and system technology problems that significantly affected student and faculty time commitments. The application of the NT/OPCRS was appropriate in the five clinical areas and augmented student learning as well as facilitating synchronous evaluation of student care planning. Areas for further research should focus in two areas: more in-depth evaluation of faculty responses to the use of the Nightingale Tracker in an educational setting with strategies for increasing positive responsiveness and analysis of student acuity ratings prior to and after use of the OPCRS and the NTs. This would entail a longitudinal study of student care planning over a period of time and perhaps across a variety of clinical settings. Data obtained from research in this domain would potentially identify methods for enhancing the student's ability to determine patient acuity.

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Table. Student Journal Responses

Author Bios

Dr. Judith Sutherland

Dr. Judith Sutherland is a professor in the School of Nursing and Health Sciences at Texas A&M University-Corpus Christi teaching in the undergraduate and graduate programs. She has a master's degree in psychiatric/community mental health nursing and is licensed as a chemical dependency counselor in Texas . Due to a life-long interest in alternative/complementary therapies, Dr. Sutherland received certifications in meridian therapy (acu-point stimulation) and Reiki.

Dr. Donna Wofford

Dr. Donna Wofford is Interim Director of the Department of RN Education at DelMar College in Corpus Christi , TX . Curriculum development and evaluation is an area of particular interest. Currently, she is assisting in the development and implementation of a generic online nursing curriculum through a Federal Grant awarded to Texas A&M University-Corpus Christi & Del Mar College.

Dr. Mary Jane Hamilton

Dr. Mary Jane Hamilton is Director and Professor of the Texas A&M University-Corpus Christi School of Nursing and Health Science. She utilized electronic information systems in teaching Research and Nursing of Children.

Barbara Schmidt

Ms. Schmidt earned her BSN from Texas Woman's University where was a charter member of the Beta Beta chapter of Sigma Theta Tau. She received her master's degree while serving in the Air Force Nursing Corp. Maternal/Newborn nursing has always been her passion. Ms. Schmidt has 25 years of labor/delivery and postpartum experience in various hospitals throughout the USA . She is active in her specialty organization as well as Sigma Theta Tau, NLN, and TNA. Her second passion is teaching the profession that she loves to new students. She has taught at Baptist Hospital School of Nursing in San Antonio , Texas , Tarlton State University in Stephenville , Texas , and currently is an associate professor at Del Mar College (DMC) in Corpus Christi , Texas . Ms. Schmidt's third passion and research interest area is curriculum development and student retention. For the last two years, she has had the privilege of working with a team of faculty from Del Mar College and Texas A&M University at Corpus Christi (TAMU-CC) in the development of a generic online nursing curriculum through a Federal FIPSE Grant jointly awarded to TAMU-CC/and Del Mar College.