Development of a Personal Digital Assistant (PDA) as point-of-care technology in nursing education

Reprinted with permission of HINZ (Inc.)

By: Shona Wilson RGON, BHSc (Nsg) AIT, MA (Nsg)(Merit) VUW

Lecturer and Consultant, School of Health Science, Faculty of Health and Environmental Sciences, UNITEC, Auckland

Abstract

The emergence of informatics in nursing practice has presented a challenge to nurse educators to devise ways to integrate health informatics in contemporary undergraduate nursing curriculum. Integration in curriculum includes automation of existing processes as well as the development of strategies and tools that will meet the needs of future graduate practice. To this end the School of Health Science, UNITEC commissioned a market survey of existing automated processes in nursing practice along with emergent technologies, which resulted in the evaluation of a nursing education specific PDA from the United States of America (USA) to define its suitability for the New Zealand context. The studies informed the new development of a nursing education specific application for a PDA, which uses the categories of the New Zealand National Minimum Data Set to determine the client demographic details and the Omaha System as a standardised nursing language to determine the taxonomic categorization of care documentation.

The first study sought to explore student opinion about the utility of the Nightingale Tracker in the community clinical experiences of the undergraduate pre-registration nursing student and used mixed methods of data collection including questionnaires and focus group interviews. The results indicated that although the PDA was considered useful and recognized to be indicative of the technological future, limitations included training issues, ‘americanised’ language that was unsuitable to the New Zealand context and telecommunication difficulties with the dial-up system from within health provider services.

This initial study was followed by an evaluative study of the device, which sought to evaluate its utility and the standardised language that comprised the care documentation component. This second study reinforced the findings of the first study as well as the added finding that the Omaha System as a standardised language for documentation of care in the community appeared to be well suited to the demands of the New Zealand context.

The resultant development of software that meets the need of the New Zealand nursing education context, is available for use of undergraduate pre-registration students as a desktop application as well as on a PDA and contributes to an informatics integrated curriculum. It is currently within beta version testing with students and faculty at the School of Health Science, UNITEC.

This paper gives a summary of the research that informed the development and a description of the significance of the development as enabling informatics to be integrated within nursing pre-registration undergraduate curriculum.

Keywords:

PDA, informatics, integrated curriculum, nursing, point-of care technology.

Introduction

The concept of informatics has emerged over the past decade as integral to nursing practice. Of recent times the Nursing Council of New Zealand (2000), in a review of nursing education, has predicted that emergent technologies will reconstruct all that nurses do over the next decade, which has surfaced the issue of future oriented curriculum as an issue to be grappled with by educators.

Historically nursing curriculum in New Zealand has included little informatics (Watson, 1999). Where curriculum has included informatics, it has been offered as discrete courses, with little or no integration within generic curriculum. This in turn has provided the graduate of pre-registration undergraduate nursing programmes with little or no understanding of the role and function of informatics in practice.

In a review of their pre-registration undergraduate-nursing curriculum in 2001 the School of Health Science identified the issues and re-engineered their curriculum integrating the technologies of learning and practice throughout all courses. A thematic approach of the technologies of practice and learning was taken with major informatics concepts included within courses and at all levels, within content, activities, outcomes and assessments.

This approach is congruent with the conceptual framework that typifies nursing curriculum within New Zealand, based upon Habermas’ (1971) treatise, which identifies the three cumulative and progressive forms of knowledge as technical, practical and emancipatory. The technical form of knowledge has to do with skills acquisition, theories and frameworks and stems from the information technologies; the practical form of knowledge pertains to the technologies that bring about understanding by application;and the emancipatory form of knowledge uses the technologies that enable critical analysis (Wilson, 2000). The informatics concepts were situated within these three forms of knowledge according to their functionality and outcomes in a matrix, which guidesm lecturers in identifying what to teach where.

One of the concepts surfaced was that of automated documentation. Documentation processes in practice have become automated, yet students of nursing have no access to the automated system of the practice arena due to the security and privacy issues to do with levels of access for health professionals. Students have no status as employees of or as health professionals within the health provider services in which they undertake their clinical experiences and therefore do not have access to existing systems.

Research informs us that nursing documentation is progressively taking more of the work day for nurses, sometimes reaching 40% of work time which can be reduced by as much as 40% by automation of these processes. However when automation is introduced the proportion of time spent on documentation increases significantly until computer familiarity is achieved and then significant reductions occur (Elfrink, 1999). Educators therefore have a responsibility to their students to ensure a level of computer familiarity with regard to automated documentation is achieved prior to graduation so that graduates are prepared for the real world of practice prior to entering the workforce.

International trends indicate that nursing documentation is moving beyond inputting data into a stationery desktop to that of collecting data and inputting directly into a mobile system at the point of care delivery. That is, at the bedside for in-patients or at the client home or clinical agency of community delivered health care. Consequently customised PDAs appear to be emerging as the platform of choice for this function (PDA cortex, 2002).

The implementation of a customised PDA in nursing education appeared to provide some of the solutions to the issues facing educators in the development of integrating informatics within curriculum as well as providing solutions toward automated documentation issues in both learning and practice.

Informed by the cumulative findings of the research projects the School of Health Science has developed an application for locally sourced PDAs that enable student activities and learning strategies specific to nursing. The concepts involved are taught progressively throughout the three years of the pre-registration undergraduate programme as integrated within curriculum. Students use automation to document client and care details at New Zealand Qualification (NZQA) level 5 education as a skill progressing from a database entry onto a desktop to understanding the process by application to the practice world at NZQA level 6 learning and onto mobile collection of data onto a PDA, which later is transmitted to a database as a central server at NZQA level 7 learning, which requires some analytical skills. At this level of the programme all students take the PDA into their community clinical experiences and use the technology as a mobile learning device as well as a means of nursing care documentation. As such it is envisaged that students that emerge from the programme will be graduates who are ‘informatics ready’ for practice in the technologically driven health care environment of practice.

Research

The development of a nursing education specific application that has PDA capabilities has been informed by the recommendations of a single survey and two research projects over the last four years.

1. 1998 – A market survey of automated documentation processes in practice revealed that:

The results of this survey promoted an international search to explore the availability of an already developed computer solution to the gaps in existing documentation processes for use in pre-registration undergraduate education, so that graduates of programmes would be able to transfer the skills of automated care planning and documentation to the practice arena.

The Nightingale Tracker is a US developed customized nursing education specific application developed as proprietary for the Data Rover/Magic Cap hardware. It was a PDA for use in community clinical experiences. The School of Health Science imported and tested it for suitability to the New Zealand context within field trials. The PDA ran on a linux/unix platform with 4 megabytes of RAM storage. Importation to New Zealand for use entailed comprehensive tele-permit processes and adjustment to the NEW Zealand telecommunications networks, as the device at that time could not be purchased within New Zealand.

2. 2000 - Communication and Information Technologies in Nursing Education in New Zealand: A Pilot Study (Wilson & Eadie, 2000). This pilot study was undertaken as a way of examining the limitations of the Nightingale Tracker as well as exploring student attitude toward the utility of such technology. The sample included four students who used the NightingaleTracker within their usual clinical placements for a period of six weeks.

The research proposal was reviewed and approved by the UNITEC Research Ethics Committee.

Methods of data collection included questionnaires and focus group interviews, which were administered prior to the pilot but after some training, at the mid-point of the pilot and a week after its conclusion. Descriptive analysis of the data provided by the questionnaires revealed a positive attitude from the students toward the use of technology in nursing practice experiences.

Thematic content analysis of the focus group interviews surfaced five major themes as:

1 Technical issues.

2. Clinical experiences.

In situations when students saw a client and then did not return to that same client they felt that the collection of data was of no use to their learning and considered the time spent collecting it was wasteful. This highlighted the need for subsequent client encounters for students to develop adequate documentation skills that represented the real world of practice.

3. Learning Strategies.

The learning involved being able to use the device as well as the standardised language and was new to lecturers and students alike. Training for use was based on the work of Elfrink & Martin (2000), who suggest teaching methods for preparing to use a standardised language for automated documentation. This was a challenge for the participants who saw the training as extra to an already busy study load. This highlighted the need for integration within curriculum.

4. Language.

Participants questioned the suitability of the American language that determined the demographic data categorisation for the New Zealand context especiallyin light of the development of a National Health Index and National Minimum Data Set specific to New Zealand data needs.

5. Utility.

The participants unanimously endorsed the usefulness of the Nightingale Tracker technology in their clinical placements despite the difficulties. They identified the need for portable computers in community nursing practice as point-of-care technology to ultimately reduce double handling of documentation and as a useful student-learning tool.

Recommendations from this study included:

Although the recommendations from the study pointed toward local development the study was limited by its small sample. Therefore it was decided to undertake a further study, which evaluated the Nightingale Tracker as well as the Omaha System as a standardised language for use in New Zealand.

3. 2001 - The Nightingale Tracker: An Evaluative Study (Wilson, Eadie & Ward, 2001).

Due to the limitations of the previous study of sample size an evaluation study of the Nightingale Tracker was developed and approved by the UNITEC Research Ethics Committee. Initial findings endorsed the findings of the first study with regard to the themes of language, technical issues and utility.

Based on these findings the School of Health Science set about to integrate the concept of automated documentation within curriculum and to develop a database application for a PDA that could be purchased within New Zealand, that and has the capabilities of transmitting to a central server from a PDA as well as being used as a desktop application.

The evaluative study of the Nightingale Tracker has been replicated with adjustment to evaluate the newly developed application running on contemporary PDA technology as well as on desktop as field-testing occurs.

Development of Point-of-Care Technology for nursing education in New Zealand.

Over the first six months of 2002 a database application has been developed that runs on a contemporary PDA, a Pocket PC. The Pocket PC has a windows based operating system, which is congruent with the UNITEC computer system providing a sense of familiarity for the students. It has 64 megabytes of RAM storage, capacity for a further gigabyte by flash card and the CE versions of the standard UNITEC computer applications. It connects for the transfer of data by a hot-synch mechanism as well as having the potential to use a dial-up system using cell phone by cable or infrared connection. The visuals of the database at the server resemble those of the practice arena.

The database application has two distinct parts that compile reports:

The application is to be used by students of nursing in their final community clinical placement at NZQA level 7 learning using the PDA. As point-of-care technology the data can be collected and later downloaded at a central designated desktop computer contributing to a database of pseudo client reports. The first beta version field test will be with 16 students, with another 16 students using a desktop version. A later cohort of 18 students will field test the upgraded version that results from the first beta version test.

A desktop version of the software will be used on standalone PCs within a designated computer suite, so that students at NZQA levels 5 and 6 can use the database that resembles the real world of automated documentation to formulate care plans that contribute to their usual assessment points within clinical courses. The development continues within a phased approach so that introductions of other features occur concurrently with results of evaluating implementation.

A variety of security strategies have been included in the initial development as:

As ongoing research and development occurs, so will further field testing occur. It is anticipated that as this automated documentation device develops according to international trends in automation in health care delivery other schools in New Zealand and within the Pacific Rim may be interested in trials.

Significance of the development in curriculum.

Concurrent with the phased approach of the PDA development a phased approach to informatics integration in curriculum is also occurring. Integration is congruent with the conceptual framework, which informs curriculum delivery.

Learning that surrounds the automation of student nursing documentation is integrated within curriculum according to the forms of knowledge of the conceptual framework. This includes:

1. Technical

2. Practical