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October 31, 2000 Introduction 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. Unfortunately, querying “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. Where 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? The 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 towards computers. 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. Adoption of Innovations “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. Nurses and E-Mail 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. Personal Digital Assistants 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. Conclusion 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 final thought 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?” REFERENCES 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: ABI/Inform 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, unpublished manuscript. 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), 183-187. 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
Feeg’s “Computerxiety” scale Examples of Items in the Computerxiety scale –
All items were rated on a 4-point scale:
Stronge and Brodt Scale “Nurses Attitudes Towards Computerization” NATC Examples of Items in this questionnaire, which used a Likert Type Instrument included:
"Cyberpink: Are Software Companies Selling Our Girls Short?":
Lauren Kearns, RN, BSN, CRNI
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