October 31, 2000
The original intent
of this research project was to explore the impact of technology
on nursing managers and their staff. Specifically, to evaluate the
effects of the latest technologies such as voice mail, email, computers
and Personal Digital Assistants (PDA’s) on nursing staff, leadership,
and the management of nurse’s work.
“nurses and technology” or “nursing leadership and technology” produced
few results. Substituting “Physician” for “nurse” produced significantly
more results. In light of this, the search terms “nurses and computers”
and “nurses attitudes and computers” were substituted successfully.
Future research may require a fine-tuning of search terms to produce
the desired results. But it does seem likely that there is a dearth
of both anecdotal information and research related to use of these
technologies by nurses, whereas literature about physician use is
readily available. The research studies ultimately chosen cover
several aspects of interest: attitudes and anxieties towards computers
and computer use, factors related to adoption of innovations, nurses
use of email, and use of handheld technology. These studies were
representative of the literature, had predictive value about nurses
and/or use of technology, with obvious implications for future study.
we have been
Nurses have been intimately
involved with technology in patient care for decades. From IV therapy
in the post war years, to the advent of the ICU in the early sixties,
to the current use of compact digital point-of-care devices, nurses
have become accustomed to and experienced in using technology adapted
from many arenas - space travel, warfare, and the medical arts –
for the provision of patient care. The collision of healthcare and
technology has created an industry that now drives both the cost
and the standard of healthcare. But while nurses were transducing
arterial lines and PA waveforms, and mastering microchip driven
IV pumps, other significant aspects of their work, specifically
documentation and communication have remained, as a rule, tied to
pen and paper, and face-to-face, or phone-to-phone encounters.
“The development of
computer technology has paralleled [the] evolution from performing
the dull and routine to challenging the entire range of human abilities”
(Delaney, 1989, p. 601). So, how do we measure the impact on the
nurse and her work as we shift from a low technology to a high technology
environment? Does movement towards technology detract from the humanistic
side of patient care? Harm morale and/or team unity? Diminish quality?
Does it minimize the value of the nurse when we replace tasks or
skills with technology? Is it all of the above ...or just the opposite?
Is technology, in reality, a boon to both patients and nurses, representing
an untapped gold mine?
Research - Computer Anxiety, and Computer Attitudes
In 1988, Lange reported
on a 15-item “computerxiety” scale designed to identify those who
might benefit from additional tutorials in computer operation and
use, and thus identified, could become part of a special focus group
to overcome anxiety or fear. The scale, developed by Feeg in 1985,
defines computer anxiety as a “general and subtle sense of psychological
discomfort that is experienced by a novice computer user in the
initial introduction to the computer and is accompanied by mild
to moderate physical and psychological behaviors of fear or negativism
towards computers”. This fear can lead to development of obstructionist
tactics, and technology resentment.
The study was small,
consisting of 32 subjects, divided between the treatment group and
the comparison group. The treatment group was enrolled in an introductory
course “Computer Applications in Nursing.” The control group was
enrolled in a summer practicum nurse practitioner program. Both
groups reported less than 10 hours of computer use in the prior
month. Feeg’s 15-item scale (Appendix 1) was administered over set
intervals. Findings indicated that differences between the groups,
when comparing anxiety, were not statistically significant, which
declined for both groups over time. Interestingly, in the treatment
group, anxiety may have been sustained or increased by the course
itself, a graded graduate level course given over a summer session.
Differences between the groups occurred in the following aspects:
1) Learning about computers: the treatment group scored higher at
every testing interval. 2) Beliefs in skill level: while initially
the same at the start of the study, it significantly increased for
the treatment group and remained high at the 6 months interval.
3) Measuring computer use: both groups reported increased use over
the course of the study, but at the 6 month mark, there was no significant
difference. Taking the computer course didn't have lasting effects
on the amount of time spent using computers, either. While the the
types of applications studied in the course were not specified,
it might be speculated that advances in technology in and of itself
may have more impact on long term results due to simplification
of software, if the study were repeated today. More nurses today
have access to computers both at home and at work, and skill retention
may last longer with a concurrent decrease in anxiety. The study
is different from others in that it looks at an interventional treatment
method, the introductory computer course, to change attitudes and
fear related to computer use.
In 1992, Coover and
Delcourt explored nurses’ attitudes towards computers, without a
treatment intervention. They wrote, “…creating, processing and using
technical information is a basic ingredient of [nurses] work.” (p.1).
The information age, they felt, included future challenges to harness
“the potential of the computer as a tool for effective management
of vast and diverse types of information.” (p.1). Their research
1) located a valid tool to assess nurses attitudes towards computers
and 2) examined those attitudes in relation to the nurse’s work
and access to computers, whether at home or at work. The tool, Adult-Attitudes
Towards Computers (A-ATC) originally developed by Delcourt in 1985,
was subsequently revised for use in different populations. This
study of 210 professional nurses, found that the tool could be successfully
and reliably applied. Additionally they found that environments,
technical vs. non-technical, had a slightly negative impact on interest
in using computers, but not on comfort levels with computers. Also,
accessibility to computers at work or at home, had a predictive
impact on interests in computers, while demographic factors such
as age, and years in nursing were not predictive factors of attitudes
It should be noted that
the majority of nurses in the study worked in a critical care setting
(Hi-tech) and less than 5% had any contact with large-scale information
systems in their daily work. Because these nurses have more technological
contact on a daily basis, this may have produced more positive attitudes
than might be encountered in the general staff nurse. The study
pointed out the need for further research in attitudes towards computers
with additional study in computer aptitudes, and/or perceived ability,
in other groups of nurses.
A larger study, by McBride
and Nagle (1996), on Attitudes Towards Computers, consisted of 394
RN’s and 299 Baccalaureate students. The RN’s worked in a hospital
before computerization was begun; the students were in a program
where all 4th year students used computers in a statistics course.
Using the Stronge and Brodt Nurses’ Attitudes Towards Computerization
questionnaire, (See Appendix 2) the investigators evaluated attitudes
about computers and nurse’s work, barriers, and issues about organization
and efficiency. Previously used in other studies, the questionnaire
had undergone only limited psychometric testing. Stronge and Brodt’s
original research led them to believe that level of education, years
of experience in nursing, and type of nursing unit were associated
with positive attitudes toward computers. McBride and Nagle note
that others did not support these findings, nor did they find that
the questionnaires supported Stronge and Brodt’s conceptualization
of six distinct attitudes. Additionally they postulated that changes
over time (years) may change item relevance. Psychometric testing
demonstrated a lack of support for construct validity in the instrument.
The authors recommend further investigation and development in the
substantive components of nurses’ attitudes towards computers.
“Technology is adopted
by society in stages. Initially, technology does work that was previously
done by people. That is, technology simply replaces a manual method
of doing some activity. As technology allows work to be accomplished
that previously was not possible, true innovation occurs. Finally,
adoption becomes so complete that all dimensions of society itself
are transformed by the technology” (Delaney, 1989 p.602)
In 1996, Kim & Kim,
report on “The Effects of Individual and Nursing-Unit Characteristics
on Willingness to Adopt an Innovation”. The authors considered two
variables, efficacy and cooperativeness as possible determinants
of willingness to adopt an innovation on both the individual and
unit based level. The authors posit that intention to adopt an innovation
is determined by favorable or unfavorable attitudes towards the
innovation and the whether the adopter is willing to practice the
intended behavior. Similarly, whether a nursing unit is willing
to adopt an innovation will be determined by the attitudes and intentions
of that unit towards the innovation. They then determined which
type of [individual or] nursing unit would adopt or reject a particular
innovation by looking at efficacy and cooperativeness, as individual
and unit-based characteristics.
The study data supported
the hypothesis that efficacy is associated with willingness to adopt
innovations at both an individual and unit-based level. Additionally,
they found that nurses from the same unit had similar degrees of
efficacy and willingness to adopt innovations. Cooperativeness was
also associated positively with innovation, but only at the individual
level. On a group level, cooperativeness is congruent with innovation
adoption only if the groups’ norm was innovation adoption. Groups
may be cooperative among themselves, and still contradict the organization’s
norm, such as willingness to adopt. Implications for this study
include the need to address both individuals and groups when adopting
innovations, such as a computer information system, or a email or
phone mail system for nurses.
Hughes and Pakheiser’s
study, (1999), “Factors that Impact Nurse’s Use of Electronic Mail
(E-mail)”, was aimed at identifying barriers and helping mechanisms
(facilitators) that influenced the use of e-mail in the workplace
by the nurse. 17 nurses participated in focus groups. The investigators
concluded that factors that positively affected use of this technology
were similar to those that predicted computer use in general, such
as training and recent education . In addition, they also reported
on other previously unidentified factors, such as lack of face-to-face
communication (a barrier and a facilitator), individual writing
skills (a barrier), mail volume (a barrier), technical support (lack
of – a barrier; 24 hours – a facilitator), recent educational experience
(a facilitator), and password integrity (a barrier). Recognizing
the limits of the study: small size, self-selection, and the study
format (focus groups), the authors are unable to generalize findings
to all groups, but they offer many suggestions for future research.
They conclude by stating that healthcare agencies are on the brink
of moving from paper to electronic transmissions and record keeping,
and identifying variables that may be barriers or facilitators will
assist in facilitating communication and innovation adoption across
all computer applications.
A second email study,
by Bunting, Russell, & Gregory, (1998), examined email as a primary
communication method between members of a research team. The authors
were working on multiple data sets and research texts. They found
that use of email provided a medium for quickly exchanging ideas
and insights, in a manner as if they were actually face-to-face.
Their electronic “meetings” also included telephone, fax and some
face-to-face meetings between the principal author and each coauthor
separately. Through electronic media, they were able to build consensus,
and felt that email made invaluable the process of writing and synthesizing
the work of three different researchers. In addition to the inherent
features of email described,another benefit was cost control, e.g.,
decreased use of phone calls and use of snail mail (postage). Barriers
identified included access to email by either reliability of Internet
connections, physical access to a computer, and affordability in
Internet service providers. They also found that use of email required
a minimum competency or proficiency. As a medium for sharing manuscripts
or editing documents, email requires that users have compatible
software applications that recognize and support features such as
highlighting, strikeout, and marking text for changes. Because of
the loss of personal nuance, and face-to-face communication, these
writers felt it essential to remain alert to feelings and implied
(or not) intonations, and recommended use of Internet etiquette
protocols, or Netiquette. The authors found that in their experience
of long distance research using email as the primary communication
medium, that email provided them with “an unexpected bonus” (p.
132); allowing for reflection, generation of new ideas, and broader
perspectives all around. Future use of the medium could be extended
to the international level.
Investigators at Mount
Sinai Hospital in Toronto, Canada will be publishing their results
of a study-using Palm computing technology. The goal of the study
was to implement this new technology in an ICU setting and study
its impact on efficiency and physician competence. Participants
included 24 medical staff, medical trainees, pharmacists, respiratory
therapists, researchers and nurse educators. Using regular group
focus meetings and feedback on advantages and disadvantages, their
overall findings were positive. The study investigators, Stephen
Lapinsky, MD and Tom Stewart, MD, concluded that handheld technology
could revolutionize patient data management as well as access to
medical reference materials. Unfortunately this study only included
nurse educators, not staff nurses, who “man” the ICU’s 24 hours
a day providing direct patient care. Future studies need to look
at the use of this technology within a nursing environment, by nurse
users. The implications for use by nursing are tremendous and as
yet, unrecognized. Cost of these tools range anywhere from $150
to $499. Cost may be a factor involved as why Palm use is seen less
with staff nurses, but other groups of nurses report increasing
use, such as administrators, and nurse practitioners (personal information).
Recently reported on
the RNpalm website is the WR Hambrecht & Co. report on eHealth released
October 19, 2000 which calls itself “ a comprehensive report of
the growing use of handheld computers in healthcare.”
RNpalm Webmaster Ken
McGowan says this about the study “ ... it is a physician-centric
report and fails to address the nursing component of healthcare.
For this reason the report is flawed in so far as it underrates
the potential market size and utilization of this burgeoning new
technology in healthcare.” See appendix 4 A (Cover of the eHealth
Report) and B, (pg. 5 of the eHealth report), and substitute “nurse”
every time you read “physician”, and “Nursing” every time you read
“medicine”. The possibilities are endless.
Coover and Delcourt
(1992) state that since 1982, the use of computers and information
systems in a nurse's daily work has become commonplace. Because
of this and because implementation of these systems is accomplished
so rapidly there is often little time spent on evaluating or researching
the impact on job performance. Is this why there is such a deficiency
in research on recent technology, such as email, and PDA’s? Are
nurses slower adapters to this type of technology? Are there barriers
that prevent nurses from using these technologies? The answers are
in future research. By developing nursing specific research to address
nurses’ unique needs, and by expanding current research from other
areas of healthcare we might begin to see more clearly the impact
of technology on the work of the nurse, and shed light on how and
why, nurses use (or don’t use) these technologies in their work.
A recent study by the
Women's Foundation of Colorado emphasized the continuing technology
gap between girls and boys. In 1996, women earned fewer than 28
percent of all computer and information science degrees. Included
in Appendix 3 are excerpts from the Executive Summary of "Cyberpink:
Are Software Companies Selling Our Girls Short?”
Bunting, S.M., Russell,
C.K., &Gregory, D.M. (January 1998). Use of electronic mail (Email)
for concept synthesis: An international collaborative [p.128-135].
Qualitative Health Research [On-Line], 8(1). Available Database:
Coover, D. & . Delcourt,
M.A.B. (Fall 1992). Construct and Criterion - related Validity of
the Adult-Attitudes Toward Computers Survey for a Sample of Professional
Nurses. Educational & Psychological Measurement [On-line], 52(3).
Available: Database:MasterFILE Premier Item # Item Number: 9210192543
Delaney, C. (1989).
Computer Technology. In McCloskey, J.O., & Grace, H.K. (Eds.), Current
Issues in Nursing (pp. 601-606). St. Louis: CV Mosby.
Feeg, V.D. (1985). Effects
of "hands-on" exercise on computer anxiety. George Mason University,
Fisher, J. & Wang, R.
(October 19, 2000). eHealth report: The Cure is in hand - Bringing
Information Technology to Patient Care. http://www.RNpalm.com/hambrecht.htm
Hughes, J. A. & Pakieser,
R. A. (November/December, 1999). Factors That Impact Nurses' USe
of Electronic Mail (E-mail). Computers in Nursing, 17(6), 251-258.
Kerven, A. (July 1999).
The Cyberpink Point. Coloradobiz [On-line], 26(7). Available Database:ABI/Inform
ProQuest:full text articles
Kim, I., & Kim, M. (May/June
1996). The Effects of Individual and Nursing-Unit Characteristics
on Willingness to Adopt an Innovation. Computers in Nursing, 14(3),
Lange, L.L. (1988).
Computer anxiety, computer skill, computer use, and interest in
learning about computers before and after a computer literacy course.
Proceeding of the Nursing Informatics Conference, "Where caring
and technology meet", 202-215.
McBride, S.H., & Nagle,
L.M. (May/June 1996). Attitudes Toward Computers - A Test of Construct
Validity. Computers in Nursing, 14(3), 164-170.
RNpalm Website http://www.RNpalm.com
scale Examples of Items in the Computerxiety scale –
Working with a
computer would probably make me feel uneasy or tense.
I enjoy using
computer or other types of technology.
I feel helpless
around a computer when I don’t know what to do.
I look forward
to computerizing much of my daily work.
All items were rated
on a 4-point scale:
Strongly Agree, Agree,
Disagree, Strongly Disagree.
Scores ranged from
15-40 with higher scores indicating more computer anxiety.
and Brodt Scale “Nurses Attitudes Towards Computerization” NATC
Examples of Items in
this questionnaire, which used a Likert Type Instrument included:
nurses jobs easier.
nurses’ had been greatly reduced by the use of computers.
a violation of patient privacy.
Part of the increase
in healthcare costs is because of computers.
only be used in the financial department.
a decrease in communication between hospital departments.
"Cyberpink: Are Software
Companies Selling Our Girls Short?":
Only 17 percent
of high-school students who took the advanced-placement computer
science exam in 1996 were girls, the lowest percentage of
girls' participation in advanced placement tests.
Boys are more
likely to learn the advanced computer applications needed
for high-paying careers, while the largest concentration of
girls remains in data entry courses.
In 1996, women
earned fewer than 28 percent of all computer and information
science degrees - down from 36 percent in 1985. ·
learn their proficiency through games; most video games target
boys. Those targeting girls are for the 12-and-younger set.
Boys prefer fast, action-driven games, while girls prefer
creative games or those with worthwhile goals, study findings
Many of the emerging
games for girls still stereotype them and fail to challenge
them. That situation is improving, though, with games from
such companies as The Learning Co. (acquired by Mattel), Disney
and Creative Wonders. Currently Mattel Media holds three quarters
of the girl game market, thanks to Barbie titles.
in schools and elsewhere may discourage older girls from pursuing
computer interests. · Women see technology as a way to solve
problems, while men enjoy the technology as well as its usefulness.
Kearns, RN, BSN, CRNI