Lynn E. George, PhD, RN and Lynda J. Davidson, PhD, RN
George, L. & Davidson, L. (June, 2005). PDA use in nursing education: Prepared for today, poised for tomorrow. (OJNI). Vol. 9, No. 2 [Online]. Available at http://ojni.org/9_2/george.htm
This article provides an overview of information on the use of handheld computers or personal digital computers (PDAs) in nursing and nursing education. The incorporation of PDAs for all students in an undergraduate and graduate nursing education program is discussed as well as the decision making process that preceded the implementation. Examples of current utilization by students are also provided. Although some of the experiences may be unique to this particular new nursing program, this information contributes to a limited but growing body of knowledge regarding PDA use in nursing education.
Key words: handheld computers, personal digital assistants, nursing education, information technology, nursing.
The advent of handheld computer technology for general use is relatively new, with the first Palm device, Pilot 1000, debuting in 1996 (Johnson & Broida, 2003). For a technology little more than a decade old, the amount of material written about hand held computers or personal digital assistant ( PDA) use in health care would appear to be remarkable, reflecting the popularity of these types of devices. However, material written about PDAs and nursing, and, specifically, nursing education, is sparse.
We recognize that PDAs are not the sole solution to the nursing shortage. However, our excitement about this technology lies in its potential to support the student and, eventually, practicing nurse, in focusing more time on patient care and less time tracking down important information. The intent is to foster the mindset in our nursing students for using technology to support their practice and welcoming new advances that allow them to function more effectively and efficiently.
The results from the Canadian Medical Association Physician Resource Questionnaire (Martin, 2003) indicated that a third of Canadian physicians were using some type of hand held device in their practice. A 2004 Forrester’s Technology Survey (as cited in Stolworthy, 2004) indicated that 47% of U. S. physicians used PDAs in their practice. Physicians who use handheld devices indicate that the devices boost efficiency by helping to track patient data and capture reimbursement information (Miller, 2003). They also report using them for prescribing medications and reviewing dosaging. (Rothschild, J.M., Lee, T.H., Bae, T., & Bates, D.W., 2002). The variety of point-of-care uses is vast and growing daily. They included the patient tracking information mentioned above as well as applications for data collection and measurement (Ault, 1998). The applications are also not confined to any particular clinical specialty with examples of utilization from the Geriatrics to Pediatrics.
The Forrester’s Technology Survey (as cited in Stolworthy, 2004) also indicated that 18% of nurses use PDAs. Nursing use, though lagging behind physician use, is increasing. As PDAs have been reported to improve physician practice, nursing practice is equally enhanced by PDA use. Nurses report time savings in the reduction of paperwork, increased point of care use of references from PDAs and patient tracking utilization (Hunt, 2002) to name a few. With an estimate that every half hour of patient care is accompanied by an hour of documentation, (Womack, Newbold, Staugaitis, & Cunningham, 2004) significant cost savings and manpower hours could result from technologies that expedite the documentation process.
Measuring and managing patient outcomes data is an important function for today’s health care providers. Johnson and Nolan (2000) suggest that PDAs can be useful tools in the data collection and management of patient outcomes. For example, in the surgical intensive care of a Maryland hospital, nurses use PDAs to track compliance with best practices for central line insertion (Womack, et.al., 2004).
Utilization of PDAs is not confined to acute care settings. In both long term care and community based sites, nurses are utilizing the new technology to improve their practices. Community based nurses are using PDAs to provide patient teaching information and to track patient progress (Smith-Stoner, 2003). Nurses in one long-term care facility use PDAs to answer questions about each resident for shift reports (Edwards, 2001).
Another consideration for the use of PDAs is the 1996 Health Insurance Portability and Accountability Act (HIPAA, 1996). This act placed certain restrictions on the availability of patient information and HIPAA continues to require agencies to demonstrate actions used to safeguard health care information technology. Institution policy must be the guide and innovative strategies to protect patient information must be utilized. Palm, in a security brief available from their web site www.palm.com, identifies two sections of the HIPAA requirements that apply to handheld devices. The planning brief offers specific software product solutions. However, solutions for security of information on handhelds are still being developed and will likely require multiple strategies for success.
The presence of handheld computer devices at the point of care results in devices being present in areas where patient contact occurs. Just as other medical equipment may act as a reservoir for microorganisms and contribute to the transfer of pathogens so may PDAs. The issue of inanimate objects as reservoirs is not a new one. Solutions for PDAs may necessitate some of the same strategies that are also used for other portable patient care devices. Neely and Sittig (2002) discuss some strategies such as shielding, hand washing and gloving, and recommend consultation with infection control personnel at individual facilities. However, additional research will be needed to address the unique concerns related to infection control and handheld devices.
Finally, although the nursing shortage is not news to most, the use of PDAs to address the issue is an innovative strategy. Maryland’s Statewide Commission on the Crisis of Nursing has specifically looked at the use of PDAs to address their nursing shortage and found them to be effective tools to reduce nursing workload (Womack, et al, 2004). With a PDA, nurses can have a reference library in the palm of their hand. From drug formularies and laboratory and diagnostic manuals to textbook or journal information on the latest evidence based practices, nurses can retrieve information quickly and unobtrusively. Giving nurses and other health care workers ready access to information that is portable saves valuable time and provide the possibility of flexible utilization.
With all that has been written about the use of PDAs in health care, very little of the published literature on the use of PDAs has been research based. Most of the literature focuses on current utilization of the technology with anecdotal information about clinical or education situations. Examples of software applications for practice or education are described but little evidence is provided to explicate the perceived advantages of PDA use. The published research is also primarily physician focused with little reported research on nursing utilization. The following represent the majority of research based information.
Medication errors remain a major problem of concern for health care providers and their patients, and strategies that help reduce errors are needed. With the volume of medication information expanding rapidly, a reliable, comprehensive, easily portable source of information could be a valuable tool in reducing errors. As the PDA software is regularly and easily updated for users, current information is readily available. In the area of reference application one published research study (Barrons, 2004) looked at the accuracy and comprehensiveness of drug interaction software. In this descriptive study several PDA pharmacopoeias were compared to ascertain the accuracy and comprehensiveness of the software. Additional studies looking at the utilization of PDA pharmacological reference materials are needed.
Another research study (Carroll, & Christakis, 2004) looked at pediatrician’s use and attitudes related to PDAs. This descriptive study found that 35% of the respondents currently used PDAs at work, primarily for drug reference information. An international study from Germany (Stengel, Bauwens, Walter, Kopfer, & Ekkernkamp, 2004) compared the use of handheld computer-assisted documentation with traditional paper chart documentation. They found that documentation quality ratings improved significantly with the use of handhelds. Additional research may help to confirm these findings.
The results of a large national survey (McCannon & O’Neal, 2003) to determine the information technology skills that nurse administrators consider critical for nurses entering the work force indicated that knowing nursing specific software was a priority. The American Association of Colleges of Nursing (2002), National League for Nursing (2002) and the Institute of Medicine (2003) all recommend the incorporation of technology into the processes of nursing education. This recommendation has obvious implications for nursing education and the preparation of nurses for the demands of an evolving health care environment.
Several schools of nursing in the United States and internationally have incorporated the use of PDAs into their curriculum. The technology that was first used only by those involved in informatics at the graduate level is now being incorporated into other graduate and undergraduate level programs. However, few require the use of
handheld devices and there is limited published information on the use of PDAs by nursing faculty in programs of education.
There is variety to the types of applications reportedly used by programs of nursing education. Some schools of nursing are using the technology to track student progress (Lehman, 2003). For these applications, the utilization is more faculty focused with faculty owning and using the devices. More commonly, educators are helping students to use the PDAs as a reference device. Instead of heavy textbooks or notebooks students are taking PDAs to their clinical sites and using them to search for information. Hufstutler (2002) describes the incorporation of PDAs into a nursing pharmacology course, substituting the PDA format of a pharmacology reference for a textbook. Many PDA software programs are regularly and easily updated, providing students with readily available, current information that outdated textbooks do not contain. Students may also use their PDAs to perform calculations or to retrieve information about specific disease processes or lab and diagnostic procedures.
The articles discussed above are two of the few examples of published information about the use of PDAs in nursing education. While these articles provide a start, additional publications are needed to facilitate the sharing of information regarding the use of PDAs in nursing education.
PDA Incorporation, Questions for Consideration
The process of incorporation of PDAs into both an undergraduate and graduate program is described to provide information about both the process of decision making and beginning utilization. Table 1 summarizes the common questions for consideration when integrating PDAs into a nursing program.
How should PDA technology be incorporated into a nursing curriculum?
Before deciding on how to incorporate handheld technology, one should set the goals for the expected use of the technology throughout the program. Devices in the handheld category cover broad functions from simple scheduling to almost complete laptop capability. Do you envision your students using the device for clinical reference? Do you want them to enter clinical data for care plan assignments? Should they be able to develop databases to track their experiences? Do you want them to be able to play video clips for skills review? Do you want to beam class notes to them? These are questions to consider when planning how PDA technology can be best used in the curriculum.
What are desirable PDA capabilities for use by undergraduate and graduate nursing students?
In general, several key characteristics should be considered to determine the best PDA device for a program: These major decisions include: Type of operating system (Palm vs Pocket PC), cost, size, memory, and battery life.
Palm OS vs Pocket PC.
One of the first considerations is whether to purchase a Palm OS device or a Pocket PC. In general, the Palm OS devices are smaller, lighter and less expensive. Although software programs are written for both devices, Palm OS has more software available for healthcare. Palm OS has recently released a new PDA which has a built in flash memory and the ability to save programs even if the battery drains completely.
Pocket PC’s typically have more RAM (64-128 MB) than Palm OS devices but require more RAM to operate the same programs. They have larger screens than Palm OSS devices and usually come bundled with more standard peripheral options such as voice recording, MP3 players and video players. Also, Pocket PCs often have multi-tasking capabilities with Microsoft products.
Whether cost is incurred by the student or absorbed by the program, it is important to look at the inclusion of extra features, i.e. wireless capability, camera, telephone, MP3/video player, keyboard, extended warranties, and battery life. Device costs can vary from $100 to $1000. Of course, the more you spend the more features you get. Higher cost buys a clearer, crisper screen allowing for better graphics display. More money also may include a built-in keyboard and wireless capability. Decisions should be based on program goals with expectations for use clearly defined.
Size of the device is important to consider for ease of use. Do you want a device that easily slips in your pocket or do you want a device that is larger and heavier but has a build-in keyboard and a larger screen? Again, the purpose and cost may guide you to the best choice.
Memory is very important when selecting a device. Palm based PDAs have 16-105 MB of memory with Pocket PCs having 64-128 MB. Pocket PC devices have more internal memory than Palm OS but comparison reveals that Palm OS devices requires less internal memory to run the same programs. Also, most PDAs now come with the capability to add memory through an expansion card. These cards typically add anywhere from 64-512 MB of extra memory, greatly adding to the number of resident programs that can be loaded.
Finally, for clinical nursing students, battery life is important. If the device’s battery runs short, its usefulness is less appealing. Thus far, Palm OS devices are known to have a longer battery life than most Pocket PC devices.
What are the best software programs for the PDA to support student learning? Software can be classified as commercial, freeware or demo ware. Commercial software must be purchased and may be updated, usually after one year, for an additional fee. Freeware is free to download and use. Shareware is available usually at a nominal fee. Demo ware may be used for a limited time or may be limited in the number of times it can be accessed. Also, some demo ware has limited functionality and components of the program may be not be available, i.e. only certain drugs have full information accessible during the demo period.
The best software programs for nursing students again depend on the goals set for the use of PDA technology. If the student is expected to use the PDA for reference, then look for reference software that is reasonably priced and frequently updated. There are many good choices for pharmacology, laboratory and clinical reference software. Specialty software is available for many areas, i.e. ER, ICU, pediatrics, etc. Medical dictionaries, nursing procedures and many freeware diagnostic and calculation programs are available. Software exists for patient tracking/management, and electronic prescription generation. In addition, document readers provide a method to view Word, Excel or PowerPoint documents. A good overview of available software for nursing can be found on the PDA Cortex website, www.pdacortex.com
Can students replace required textbooks with PDA software?
The answer to this question depends on the purpose and expected use of PDAs by faculty and students. Some reference software could be used instead of textbooks if the faculty is supportive, willing and able to add the necessary course framework. For example, a pharmacology course taught by a senior faculty may use the PDA drug guide as the required text material, with the faculty supplying an underlying framework about general classes of drugs. Generally, the PDA software should be viewed more as reference material than a substitute for course textbook.
Should students be required to buy a particular type of PDA or would any PDA that was capable of loading required software be acceptable?
As previously stated, there are many types of handheld computers, Palm OS and Pocket PC and even tablet PCs. Once the goals for use of technology are determined, a decision about necessary software can be made. If students are required to purchase their own device, they could be given a list of the expected software and told to be sure the expected software can be loaded on the device they chose to purchase. However, it becomes more difficult to problem solve if students have difficulty running software programs, particularly for faculty who work clinically with the students and may not be familiar with several types of devices.
What is the best way to integrate PDA use among the faculty?
Faculty integration of PDA technology into existing nursing programs can be challenging. Ideally, faculty would have experience with PDAs prior to introduction to students. Support for faculty might include workshops, intense training immediately following hiring of new faculty or immediately after introduction of the PDAs, and frequent brownbag sessions. Both students and faculty would need to attend the brownbag workshops. The vision for integration must be supported by administration but embraced by faculty expected to use this technology on a regular basis.
Experience of a New Nursing Program to Integrate PDA Technology
The integration of PDA technology was built into the new nursing program at Robert Morris University (RMU) from the beginning of the program. The proposal to the state board and the department of education included providing PDAs to all students in all programs. The rationale for inclusion was derived from the mission of the university and school to “be a leader in providing high quality technological and professional education to qualified students”. In addition, guidelines for educating healthcare providers, released by the Institute of Medicine (2003), identified technology as one of the five important areas for integration into education. Our next step was to select the device and software.
Although the faculty member who developed the new nursing program had experience with a PDA as a scheduling and contact medium, she had not used it for clinical purposes. To determine which device to purchase, she read product reviews, published review articles, joined the nursing PDA listserv (www.pdacortex..com) and asked questions of the listserv members. She called schools known to be using PDAs for at least a part of their program, talking most frequently with faculty from nurse practitioner programs. After considering the goals of the program and projected PDA use, the Tungsten E (PalmOne) was chosen for the program. The Tungsten E provided enough memory for the selected software (32 MB) with a clear color screen, small size, and longer battery life than others considered. In addition, it could be purchased for a reasonable cost ($200).
It is extremely important to equip the PDA with the appropriate software. At RMU, students were given the PDA with the cost of software added as a fee, spread across each semester of attendance. Again, a search of software available, advice from faculty from other schools using PDAs and advice from the listserv participants was considered in selecting software. Given the numbers of PDAs purchased and the potential for many more in the future, hardware and software prices were successfully negotiated. Five software programs were selected for all students, including:
Ultimate Drug Guide by Davis
5 Minute Clinical Consult
Laboratory and Diagnostics
Each program was selected with a purpose for use in mind. The first three programs (Ultimate Drug Guide, 5 Minute Clinical Consult, and Laboratory and Diagnostics) are self-evident as reference programs. iSilo is a document reader required for many software programs and HanDBase is a database generation program.
The first step, after the decisions about hardware and software were completed, was to place the devices in the hands of the faculty so they could learn how to use them. The first students received their PDAs during one of several brownbag workshops held during and eventually, immediately prior to class. These sessions were very successful in helping students to learn the basic operating procedures. We distributed PDAs to students one semester prior to their first clinical experience in order for them to be somewhat familiar prior to use in the clinical setting. We also had technical support from an IT staff member who was given a PDA with all the loaded software. This support was invaluable as students could contact him anytime during normal business hours with problems which he usually could solve over the telephone.
What We Have Learned
Through this PDA selection and implementation process, we learned about “the good, the bad, and the ugly”. The good was mixture of delight and trepidation expressed by the graduate students, who were the first to use the devices clinically. Some of their hesitancy was related to lack of general technology preparedness; several students had minimal computer skills leading them to be afraid of yet another form of technology. Even these students became enthusiastic about the ability to enhance their practice through the use of their PDA. Student projects covered long term psychiatric facilities, adult acute care facilities, pediatric neonatal units, and outpatient pediatric settings. In all areas, students were able to use their PDAs to supplement their practice. For their last assignments, each student created a database to track some aspect of their own practice. Examples ranged from tracking their own clinical experiences and hours, to tracking the numbers of patients experiencing a particular type of pain. The plan to have faculty support students with the nursing application training and IT support the technical aspects was very successful.
Undergraduate students began using their PDAs with their first clinical course. Initially, they were unsure about how these new devices would help their learning. With so much to learn, many expressed frustration with learning how to use something else that was new. As the students clinical requirements increased (giving medications and preparing care plans), they found how useful this new tool had become.
The “bad” experiences included some students whose preloaded software had disappeared by the time we distributed the student PDAs. The PDAs were delivered to RMU several weeks prior to distribution. Since we were unable to charge all 33 of them on a regular basis, some of the PDAs lost power completely. However, this situation proved to be a learning experience by providing a problem solving opportunity. To correct the problem, the PDAs were charged and we learned and taught the students how to reload the software programs.
The applications associated with the PDA use caused us to have second thoughts about our software selections. A case could certainly be made for including a medical dictionary for undergraduate students. The total cost would have increased, even if we had eliminated the document reading software, but, particularly for the undergraduate students, a dictionary may have been a better immediate choice.
The “ugly” is that, given all the software loaded onto the student PDAs, there is only 4 MB of empty space left. Therefore, each student may need to invest in an expansion card. Currently, cards with 256 MB cost around $30, and 512 MB about $60. Without the expansion card, it will be difficult to add many documents or other software programs.
Research specific to the use of PDA technology in nursing education is needed to develop a body of knowledge related to its use in programs of instruction. The questions and focus of the research will differ between nurse educators and practitioners. Utilization by faculty and by students needs to be explored. For example, does student use of PDAs facilitate the development of medication administration skills? Whether or not the utilization of this technology enhances student learning experiences must be examined and documented. What additional applications for PDA technology can be developed to further enhance its effectiveness as a teaching tool?
With employers expecting new graduates to have information technology skills, we need to ask questions about what skills are relevant and how best to help students to develop them. To discover “best practice” for incorporating PDA technology into nursing education, research must be undertaken to develop a body of knowledge that will guide practice.
Clearly additional research is needed in all areas related to the use of handheld computers or PDAs. Since applications exist that involve a vast array of health care workers, research in specific disciplines would contribute to the development of unique innovations and the overall utilization of handheld technology. While technology is playing a role in the advancement of health care and health care education, it is important to remember that “Technology is a facilitator; it is not a solution in and of itself. Technology is a vehicle within the context of a problem or opportunity that enables new capabilities and ways of performing work.”(Womack, et al, 2004, pg 4).
Questions to consider when integrating PDAs into a Nursing Program
1. How should PDA technology be incorporated into a nursing curriculum?
2. What are desirable PDA capabilities for use by undergraduate and graduate nursing students?
3. What are the best software programs for the PDA to support student learning?
4. Can students replace required textbooks with PDA software?
5. Should students be required to buy a particular type of PDA or would any PDA that was capable of loading required software be acceptable?
6. What is the best way to integrate PDA use among the faculty?
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Lynn E. George, PhD, RN
Dr. George is the Associate Dean of the School of Nursing at Robert Morris University. She holds a master’s degree from the University of Pittsburgh in nursing education and doctorate in nursing from Duquesne University. Dr. George has 15 years of experience in teaching and administration with funded research in women’s health and community based nursing. She also has international nursing experience. Her current areas of research include community oriented nursing and PDA use in nursing education.
Lynda J. Davidson, PhD, RN
Dr. Davidson has over 20 years in nursing education, with experience teaching nursing at the baccalaureate, masters, and doctoral level. In fall 2003, under her guidance, new baccalaureate and masters nursing programs were developed and approved by the Pennsylvania State Board of Nursing and the Pennsylvania Department of Education. She has served as board member and chairperson for the Commission on Collegiate Nursing Education, CCNE, who accredits nursing programs throughout the United States. She holds a master’s degree in nursing from the University of Washington and a PhD in nursing from Case Western Reserve University. Her current research interest is the use of PDAs in nursing education.