Dr. Sandra Bassendowski,
Dr. Pammla Petrucka,
Jaime Mantesso Partyka,
This article was made possible by an educational grant from
Chamberlain College of Nursing
Bassendowski,S., Petrucka, P., Breitkreuz, L., Partyka, J., MacDougall,L., Hanson,B., Ayers, K. (June 2011). Integration of Technology to Support Nursing Practice: A Saskatchewan Initiative. Online Journal of Nursing Informatics (OJNI), 15, (2),
Available at http://ojni.org/issues/?p=635
This article addresses the theme of innovation in health care and describes a partnership with All Nations’ Healing Hospital, MITACS ACCELERATE, and the College of Nursing, University of Saskatchewan focused on integration of technology in a health care environment.
In 2009, the Director of Client Services at All Nations’ Healing Hospital, Saskatchewan, Canada, identified a need to introduce electronic nursing resources through the use of personal digital assistants (PDAs) to assist the nursing staff in accessing timely and up-to-date policies and procedures. The organization was interested in the use of best practice resources to support quality patient care and improve work life satisfaction for nurses. The move away from paper-based resources to online access to current information addresses Accreditation Canada’s recommendations related to patient safety. The research project assessed the impact of appropriation of technology by nurses in a rural practice setting.
This article discusses the partners and supporters, methodology, and the research results of the project that focused on the initiation, maintenance, and sustainability of a PDA-to-wireless network within a health care environment. This project demonstrates an innovative model for integration of technology that transects practice, professional development, administration, policy, and research.
All Nations’ Healing Hospital (ANHH) was a supporter and partner in this project. The hospital is owned and operated by the File Hills Qu’Appelle Tribal Council (FHQTC) and Touchwood Agency Tribal Council. It is funded through an operating agreement with the Regina Qu’Appelle Health Region and a transfer agreement with Health Canada. The FHQTC First Nations Health Services Program has an inter-agency service relationship with File Hills Community Health Services, Lakeview Lodge Personal Care Home, and the community health services of its member First Nations.
A full range of integrated services is provided to Fort Qu’Appelle and surrounding communities that includes acute care beds as well as a palliative bed, 24-hour diagnostic and emergency services, a women’s health centre, tele-health services, expanded maternal child health services, community-oriented services, and other medical and nursing services.
MITACS ACCELERATE is Canada’s Graduate Research Internship Program linking businesses across the industrial spectrum with university-based expertise in any faculty or department through short-term research projects. The graduate student is a highly skilled, up-and-coming researcher with fresh ideas and a new perspective who works closely with the community and the university and acts as the conduit between a business and the university. The cost for a four-month internship is shared equally between the company and MITACS, through the support of federal and provincial funding partners.
Since 1999, MITACS has played a leadership role in linking businesses, government, and not-for-profit organizations with over 50 of Canada’s universities to develop tools to support the growth of a knowledge-based economy. The programs focus on developing the next generation of Canadian researchers through skills training and entrepreneur workshops, technical training events, and graduate and post-doctoral internships.
The College of Nursing was the academic partner in this project and provided the supervision of the Master of Nursing students who participated in writing the initial application, conducting the literature review, and working with ANHH. The College is a leader in educating nurses in interprofessional health care, research, practice, innovation, capacity-building, and policy development. The College of Nursing strengthens nursing, health, and the health care system through the creation and integration of knowledge from research, education, and practice.
The College of Nursing’s strategic plan presents five initiatives for college-wide priority: create a quality environment within a sustainable, centralized home for the College of Nursing; develop a new interprofessional, university-governed, baccalaureate program for nursing at the University of Saskatchewan; maintain and sustain existing and new programs; invest in human capital (people and knowledge); and support excellence in scholarship. The key theme for attention at both administrative and programming levels is to “enhance the student experience.”
The International Council of Nurses (ICN, 2004) acknowledges that there is a shortage of nurses on a global level and, while not all countries are experiencing this shortage at the same levels, many countries are suffering from an imbalance in the supply and demand of their nurses. The Council stresses the urgency of the situation because the strain on nurses is leading to burnout and compromised patient care. The decreased number of quality health care workers is a huge obstacle when it comes to the attainment of health and well being for the global population.
The Canadian Nurses’ Association (CNA) identifies Canada as one of the countries currently in a nursing shortage crisis and they also note that none of the Canadian provinces have been left untouched by this shortage (2008). In light of the current nursing shortage, nurses are finding that they have increasing patient ratios, increasing workload, and less time to spend on actual patient care (Saskatchewan Registered Nurses’ Association, 2006).
While the nursing shortage itself is very complex and will not be resolved overnight, there are ways that nurses can increase efficiency in their work lives and therefore create more time for patient care. One such strategy is the incorporation of technologies, such as personal digital assistants (PDAs), in the health care setting. Although PDAs have been used in health care for several years already, minimal research has been done on whether or not their use by nurses increases efficiency in the workplace.
The goal of this research project was to determine whether or not the incorporation and use of PDAs at the bedside by nurses in the acute care setting improved their quality of work life by increasing efficiency, improving time management, and allowing them more time for patient care.
For this literature review, several search engines such as MEDLINE Ovid, were used to search using the keywords of PDAs, handheld computers, nursing informatics, technology, and personal digital assistants. MEDLINE Ovid yielded 345 full text results. CINAHL was searched using the same keywords and 544 results with full text were found. Finally, a search was done of the Cochrane Library and only 14 results were obtained; a further search was done using the term of personal digital assistant and 30 results were achieved.
Ten articles were chosen in total based on their relevance to nursing and the use of PDAs. The majority of the articles found on PDA use were for physicians and medical students, in fact it was difficult to find ten relevant articles relating to nurses and PDA use in the clinical setting, so some of the articles chosen were about PDA use by nursing students, and a few involved PDA use by other health care professionals as well as nurses. The majority of the articles selected were research articles written on original studies and most of them were quantitative in nature.
Of the ten articles selected, a variety of research methods were used. A few of the studies used a cross-sectional design; several others (the majority) used descriptive studies relying on survey results or results from pilot studies with respect to PDA use. One described using a non-randomized, quasi-experimental design using a control group and an experimental group to determine if PDA use reduced medication errors. Two other articles were not original research studies but rather were synthesis analyses of existing literature and information on PDA use by health care professionals and/or students. The majority of the research studies took place in the clinical setting (both acute care and home care settings), one was in a teaching hospital, and a few others took place in educational settings (baccalaureate and master’s programs). Some of the settings were in Canada and some in the USA, with one study conducted in Taiwan.
A few different theoretical frameworks were incorporated into some of the research articles. Lindquist et al. (2008) used the Nielsen’s model of system acceptability in order to conduct their content analysis and identify themes, categories, and sub-categories from the qualitative data they obtained from the participants. DiPietro et al. (2008) used Rogers’ diffusion of innovation theory to predict successful adoption of PDAs by nurses and make recommendations to increase successful adoption of new innovations in the health care setting. Lee (2006) used Lewin’s change theory to demonstrate the natural progression through stages that people go through when faced with change. He tied this in with the nurses’ reactions to the introduction and incorporation of PDAs into their practice and further proposed a fourth “anticipatory stage” based on observations made that extended beyond the three stages in Lewin’s theory.
Data collection was also done through a variety of means from study to study. The most frequent means of data collection was through the use of surveys, questionnaires, and interviews. As there has been limited research in this area, most of the researchers develop their own tools or instruments to measure or capture data, often relying on peer review to validate them. One study used direct observation of a timed exercise as their data and another supplemented their surveys and interviews with some direct observation of the nurses in the clinical setting. Focus groups were used as an alternative to interviews in a few studies. Data from interviews and focus groups were often analyzed using content analysis and by developing themes or categories. Other data, such as that from surveys or questionnaires, were usually analyzed with the use of descriptive statistics.
Several major findings were identified in the multiple studies. The first one was that a majority of nurses or health care professionals were fearful of the introduction of PDAs and had limited skills relating to them. Secondly, there is evidence that the use of PDAs may reduce medical errors, improve patient safety, and contribute to health care personnel’s knowledge or learning. Third, nurses and other health care professionals often have valuable insight and suggestions to improve PDA usability within their practice settings, and several studies noted that modifications or improvements were made based on feedback during the studies.
Another major finding common in several studies was that in order for technologies, such as PDAs, to be adopted in health care settings, the health care workers must see them as beneficial to their work lives, as having the ability to improve efficiency or improve patient safety. The majority of the studies found that nurses most frequently used the drug guide references as well as patient assessment tools. More training and education on PDA usage was another common theme that arose in almost all of the studies. Pilot studies generally found that nurses and other health care workers liked the PDAs once they became familiar with them and felt that they improved the efficiency in their practice settings. Most studies also found that health care workers used their PDAs as a “second check” when making clinical decisions or decisions at the point of care.
Honeybourne et al. (2006) found that, in order for health care clinicians to use their PDAs in the practice setting, difficulties with download times needed to be eliminated and information needed to be found within seconds because they are so busy and rushed during the day. Greenfield (2007) found that between the control group of students who did not use PDAs and the experimental group who did use them, the experimental group showed greater accuracy and improved times when answering questions on medications and dosages during a case study exercise, showing a potential for PDAs to reduce medication errors.
Altmann and Brady (2005) found that a majority of nursing students in their study owned PDAs already, and the majority of those who did not own one cited lack of money as the number one reason. However, they also found that, although most students used PDAs, an overwhelming majority (84%) still felt that PDAs should not be considered mandatory for nursing school.
Wyatt et al. (2010) conducted a study focusing on nurse practitioner students. Their research provides evidence, as many other studies have (Honeybourne, Sutton, & Ward, 2006; Lindquist et al., 2008; Stroud, Smith, & Erkel, 2009), regarding the usefulness of PDAs as reference tools within clinical settings and in the classroom, particularly amongst novice clinicians. DiPietro et al. (2008) compared PDA use between home care nurses and nurses in the acute care setting and found that the home care nurses ran into some trouble with the wireless network, download speeds, and signal strengths in some clients’ homes, bringing into question the reliability of PDAs as a tool for the home care practice setting.
Most of these studies had extremely small sample sizes (with a range of n=5 to n=224). In fact, only three studies had a sample size greater than 100. The majority of the studies did not have findings that could be generalized to the greater population of health care workers and further studies need to be conducted with larger sample sizes. A few of the studies had samples that were not randomly selected, allowing for potential bias. In two of the studies the participants were health care workers who already used and accepted PDAs into their practice settings and this could also create or indicate possible bias.
It was very difficult to find enough relevant studies on PDA use with a specific focus on nurses, and in particular RNs. The majority of studies have been done with medical students and physicians or, if the studies are done with nurses, they usually focus on advanced practice nurses, such as Nurse Practitioners (NPs). More research needs to be done with a focus on RNs and whether or not the use of PDAs is beneficial in their work life.
There is also a need for studies that evaluate patient outcomes or quality of patient care when nurses use PDAs in the practice setting. The nurses in the study done by Stroud et al. (2009) reported that they thought patients would respond unfavorably to the use of PDAs by nurses caring for them, but the authors thought that this belief was unfounded. This shows a need for studies to be done evaluating what patient perceptions are about the use of PDAs by health care workers and nurses specifically. The majority of the studies acknowledged that there was a lack of an evidence base for the use of PDAs and other information and communications technology (ICT) in health care settings and, therefore, a lack of best practice guidelines surrounding their use.
Further studies of PDA use in a variety of settings is needed, as well as studies for specific groups of health care workers, and functionality of different software programs and their applicability to various practice settings. There is a need for more randomized controlled trials and intervention studies in order to start to build up an evidence base on PDA use in health care. Doran et al. (2007) identified that opportunities exist to improve documentation efficiency for nurses with the use of PDAs; however, no studies were found specifically relating to improvement of efficiency and time management in nurses’ work lives with the incorporation of PDAs at the bedside.
The need for ICT uptake and integration in the health care workplace by nurses is an emergent theme within the literature. In general, there was a lack of scientific, original research studies with quantitative designs relating to PDA use and outcomes in the clinical setting by nurses, and specifically RNs. Specific studies comparing the older methods of accessing information, such as resource books or asking colleagues, with newer methods, like accessing e-resources on PDAs at the point of care, are lacking in the nursing field. A huge opportunity exists for research to be done in this area using time-tracking tools and randomized, controlled studies to generate quantitative data and determine whether PDAs are beneficial to work efficiency and time management.
Appropriation of ICT in the health care work environment is a significant challenge, especially for nursing personnel who focus on direct care and patient service. ICT is frequently viewed as detracting from the nurse-patient therapeutic relationship – a type of barrier to human contact. Further, nursing work environments have not traditionally included ICT and, more significantly, the nurses themselves have not been significant users of ICT.
The potential of PDAs to enhance the quality of work life for nurses through uptake of the technology and to enhance access to information and evidence-informed practice of nurses was conducted in a select Saskatchewan health care environment, specifically, the All Nations’ Healing Hospital in Fort Qu’Appelle, Saskatchewan, Canada.
This research project contributed to an identified research gap related to the application and implications of ICT within the Saskatchewan health care workplace and addressed the trend towards incorporating ICT to support the work of health care professionals. This project was relevant to the scholarship of teaching and learning as it built upon the characteristics of expansive learning environments for employees (Fuller & Unwin, 2004); recognized and fostered opportunities for quality work life (Paloniemi, 2006); and demonstrated the value of employee competence, skills, and learning (Fuller & Unwin, 2004).
The objectives of the project were to determine technical and educative requirements needed to initiate, maintain, and integrate a PDA-to-wireless network within a health care environment in Saskatchewan; to use this network to enhance evidence-informed practices by nurses related to client/patient/community conditions; and to assess perceptions of the end users (i.e., nurses) regarding the network in terms of its appropriation and its contributions to quality of work life. The research assessed the impact of appropriation of technology by nurses in a Saskatchewan setting. The specific research questions were as follows:
The methodology for this study was a mixed methods, collaborative-action research approach. Through a hands-on training session and with ongoing support in the format of workshops and a project website, the research team worked with the staff to appropriate and incorporate the technology. The research focused on comparative pre- and post-technology introduction quality of work life. A train-the-trainer guide was developed for use by staff following the completion of this project to educate other staff members and to help with the sustainability of the project objectives.
The outcomes of the program were as follows:
- The first project output was a PDA guide inclusive of utilization of PDA-to-wireless network technology in the health care environment. This guide is being used in the education of other staff and as a review for staff members.
- The second project output was the development and description of a model for the integration of technology and tools that transected areas of care, quality, health human resource planning, and research capacity. The project highlighted opportunities to integrate PDAs into a number of areas of practice, administration, and research.
- The third project output was related to presentations and publications that outlined the model used and the experiences of the project in order to facilitate the introduction and uptake of ICT technology in other health care environments in Saskatchewan.
As part of the research project, the Master of Nursing intern spent 50% of the four-month time frame on site with the staff at All Nations’ Healing Hospital. The hospital has a 14-bed acute medical unit and an emergency department, and the intern worked with 30 staff members from the unit and the women’s health centre. The staff members were registered nurses, licensed practical nurses, nurse practitioners, and a midwife. The student was supervised throughout the internship by the co-researchers. In conjunction with the Director and staff at the All Nations’ Healing Hospital, the student was involved in the following activities:
- Orienting staff to general use of PDAs;
- Administering pre/post surveys regarding staff learning needs related to the integration of technology into their practice;
- Developing specific in-service sessions on use of PDA software and use of the national nursing portal (NurseONE) to meet the identified learning needs;
- Conducting “just in time” sessions for staff related to concerns and issues with the PDAs;
- Analyzing results from pre/post surveys;
- Developing the PDA guide to assist with orientation of new staff;
- Creating documents for dissemination of research results (abstracts, posters, papers); and
- Completing final reports as requested by partner organizations.
In addition, the intern worked with the College of Nursing faculty and assisted with the development of the ethics application for the University of Saskatchewan, updated a previous literature search completed by another Master of Nursing student on the use of PDAs to support the theoretical and practical applications of the project, and worked on other tasks as needed for this project.
This research focused on integration of technology in a health care environment. The following results are indicative of the changes that occurred over several months of the project.
Throughout the project, a number of steps and strategies were undertaken to successfully initiate, maintain, and sustain the PDA-to-wireless network from both the technological and human resources perspectives.
First, the establishment of a robust wireless environment was not only foundational but provided the underpinnings of the staff’s confidence and uptake with the technology. In the early stages, there was evidence that the staff members were reticent to rely on the technology until the wireless system was extended to all practice areas and supported by onsite technical personnel. As a recommendation, the nurses emphasized that a robust and stable PDA-to-wireless network should be established and tested prior to the implementation of the rollout of the technology to the practitioners. Further, they suggested that the on-site personnel have a sound working knowledge of the technology and the network in order to support and facilitate the nursing staff in successful uptake and optimal utilization of the system.
Second, the research team learned that individualized and consistent orientation and reinforcement with the use of the PDAs was critical to both the uptake and sustainability of the tools within the practice context. Due to shift work, variable levels of experience with technology, and personal anxiety level, group and/or self-directed learning opportunities were found to be insufficient and/or unsatisfactory.
Third, ongoing educational tools (i.e., training manual) and self-assessment tools assisted participants to revisit the protocols, restrictions/limitations, and operations of the PDA-to-wireless network as necessary.
Through interviews and pre/post questionnaires, the team identified a number of key areas of impact on quality of nursing work life and on client care.
(Scale: 1 to 5 with 1 being strongly disagree and 5 being strongly agree)
The nurses indicated the PDA-to-wireless network contributed to their perceived quality of work life in a number of significant ways.
During the course of this study, the nurses indicated that they experienced improved communication, enhanced interprofessional contributions, and greater visibility at the senior management level.
Improvements included availability of needed equipment, workplace safety, and an evidence-based supportive environment.
The nurses indicated a positive change in terms of sufficient time to document care, competence and confidence, desire to go to work, and a respectful workplace.
Participants indicated increased participation in selection of technologies, in the policy process, and in evaluating change.
Overall, the nurses articulated positive growth personally, professionally, and organizationally in relation to the project. Through enhanced leadership, workplace participation, and collaborative practice environments, the nurses’ quality of work life was seen to be positively impacted in terms of safety, inclusiveness, recognition, and communications. By catalyzing the interest of other health care team members and demonstrating momentum to enhance quality of care to the community, the nurses at All Nations’ Healing Hospital felt increasingly recognized, engaged, and visible.
The nurses indicated the PDA-to-wireless network contributed to patient care provision. Key areas of difference within the timeframe of the project included a perceived increased time for patient care and teaching, improved patient safety environment, and enhanced care relationships.
There was, however, a decrease in the nurses’ confidence in patient confidentiality.
In moving forward with a PDA-to-wireless project, especially in an environment that was not previously e-enabled, a number of considerations and opportunities can be expected. At the All Nations’ Healing Hospital, these were categorized as challenges, facilitators, and unanticipated opportunities.
Challenges were basically project-related or technology-related. The project-related elements were resource aspects, such as time availability (i.e., shiftwork, dedicated time for project implementation/maintenance), and support availability (i.e., IT staff competencies in PDA-to-wireless). The technology-related challenges included software appropriateness (i.e., Canadian content) and maintenance of the equipment.
Facilitators were related to supportive strategies and addressing accessibility. In this study, the supportive strategies related to management support, individualized teaching, and inclusiveness of nurses in selecting desired software. Accessibility related to the gradual introduction of the technology, flexibility in the timing and process to encourage buy-in, and including all members of the nursing team in the project.
During the course of the project, a number of unexpected opportunities arose which further catalyzed the project’s course. There was significant learning and mentoring between the nurses which led to the sharing of resources and improved utilization of the devices.
Secondly, the project was able to provide additional software near the end of the project, which was customized to the specific areas of practice and determined based on the input of the nursing staff during the course of the project.
Finally, there was support for the nurses’ use of the devices by the physicians throughout the project, and eventually there was parallel uptake of the PDAs by the physicians at All Nations’ Healing Hospital, which furthered collaborative and inter-professional practice at the agency.
The uptake and utilization of technologies in the current health care system are imperative. Through partnerships between community and academic entities, there is potential to move this agenda forward. Through technology, such as the PDAs used in the project at All Nations’ Healing Hospital, there is potential to impact organizational, professional, and individual growth and development.
In this study, the preliminary findings clearly showed perceived improvements in quality of work life, patient care, and utilization of evidence in practice. Indeed, this project has provided a road map forward in the continuous use of technologies to promote safe, competent, and knowledge informed nursing practice at point of care.
Altmann, T., & Brady, D. (2005). PDAs bring information competence to the point-of-care. International Journal of Nursing Education Scholarship, 2(1). doi:10.2202/1548-923X.1127
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Greenfield, S. (2007). Medication error reduction and the use of PDA technology. Journal of Nursing Education, 46(3), 127-131.
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College of Nursing
University of Saskatchewan
4500 Wascana Parkway
Regina, SK S4P 3A3
College of Nursing
University of Saskatchewan
Director of Client Services
All Nations’ Healing Hospital & FHQ Health Services
450 8th Street, P.O. Box 300
Fort Qu’Appelle, Saskatchewan S0G 1S0
Masters of Nursing student
College of Nursing
University of Saskatchewan
Masters of Nursing student
College of Nursing
University of Saskatchewan
Staff Registered Nurse
All Nations’ Healing Hospital & FHQ Health Services
Staff Registered Nurse
All Nations’ Healing Hospital & FHQ Health Services