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)
Lecturer and Consultant, School of Health Science,
Faculty of Health and Environmental Sciences, UNITEC, Auckland
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
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
PDA, informatics, integrated curriculum, nursing, point-of care
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.
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
1. 1998 A market survey of automated documentation processes
in practice revealed that:
Care planning occurred without standardisation
There appeared to be a lack of automation in practice to
support the care-planning process
There was a rising need to be able to measure nursing interventions
and outcomes and so substantiate nursing actions especially with
regard to funding issues..
A gap existed between the rhetoric of documenting the planning
of care and the reality in practice with time constraints posited
as the major influencing factor
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
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
Thematic content analysis of the focus group interviews
surfaced five major themes as:
1 Technical issues.
As an imported operating system, previously
untried in New Zealand students found that the dial-up facility
was incompatible with some of the health providers internal
phone systems, such as PABX switchboards. Therefore transmission
to a central server was an intermittent activity, with most resorting
to dial-up from home. This constraint detracted from the concept
of point-of-care technology as although student could collect
information at the point of care, they were at times prevented
from getting reports from the server as well as sending current
The device had 4 megabytes of RAM storage. This amount was
insufficient to meet the current needs of downloading course or
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.
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.
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:
Develop an automated version of the Omaha
System as a standardised nursing language for documentation of
care delivery by nursing students.
That demographic categorisation of any developed software
uses an already developed New Zealand specific language, such
as the National Health Index
(NHI) and National Minimum Data Set (NMDS).
That the operating system that is used for the development
is sourced locally, rather than being imported, has a sense of
familiarity for students, has reasonable sized RAM storage availability
and enables connection to a local area network (LAN).
That the nursing education specific applications that are
developed can be developed further for cross platform use rather
than as a proprietary development.
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:
1. The Client Details Record, which collects the
demographic details of the client, based upon the National Minimum
Data Set to provide a Client Detail Report
2. The Care Record, which uses the Omaha System Problem Classification
Scheme, Intervention Scheme and Problem Rating Scale for Outcomes
to provide a longitudinal report of plans of care over time as
a Care Report.
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:
No data is collected and stored as actual
client data. All data is allocated a unique identifying number
that is issued to the student by their lecturer along with pseudonyms
to protect clients. At no time is any data traceable to actual
clients. Reports can only be accessed by the search facility for
the unique identifying number.
Input is controlled so that the unique identifying number
cannot resemble an actual NHI number.
A variety of categories from the NHI and NMDS have been
capped so that although they appear as reinforcing actual categories
of the NHI and NMDS, data cannot be entered into them.
Four distinct levels of access ensure that students can
only access reports that they have entered onto the database.
The four levels of access are secured by login and password
Upon transmission students have one opportunity to alter
their documentation. Once the report is verified it cannot be
changed. This is to emulate the real world of documentation.
Student access precludes a full set of database reports
being on the hand-held at any time.
A stand-alone designated computer houses the server. Students
hot-synch to the computer, which is not associated
with any network system.
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:
Standardised nursing language
Care plan formulation
Health Information Service role and function
Emergence of the electronic health record
Automated documentation skills
The legalities and ethics that surround automated documentation
in health care delivery
The role of standards in data collection and their relationship
to health promotion and care delivery
The role of the Health Information Service in determining
health needs of New Zealanders
Relationship between theory and practice at the point-of-care
Access to course notes, activities and progress as mobile
learning, at a time that suits the students in accordance with
adult learning principles
The capacity to meet academic assessment criteria using
contemporary information and communication technologies
Analysis of responsibilities associated with documentation
Analysis of clinical experiences
Role of data collection in health promotion, disease management
Data collection, collation and dissemination
Future Research and Development
This project is phased toward future research and development.
It is anticipated that the evaluation research that surrounds the
field - testing will continue and will provide guidelines for future
Current plans are to move toward wireless or satellite connection
to a server when strategies have been devised to ensure that security
is sustained. Expected developments include a mechanism to use the
Pocket PC for mobile learning so that students can experience geographically
dispersed community experiences whilst being able to access course
content and information from the point-of care delivery using wireless
or satellite connection without returning to the educational organisation.
Plans include the integration of a nurses drug guide on the system
and the development of communication technologies that will enable
virtual communication with lecturers.
This paper has given an overview of the research and development
of a PDA application as point-of-care technology for use in nursing
education in New Zealand. Following international trends the School
of Health Science, UNITEC identified the need for the integration
of informatics within existing curriculum and undertook several
research projects to evaluate an existing imported system and the
requirements to develop a database that would function on a PDA
for use in student community clinical experiences.
The resultant PDA uses New Zealand based categorisation processes
for automated student documentation and is currently within its
first beta version trial with students in the field.
Research is ongoing and it is anticipated that development will
be ongoing as the project is implemented within New Zealand educational
The reality of informatics as integral to extant nursing practice
has encouraged educators to find ways of integrating within curriculum
enabling future graduates to better represent practice based requirements.
The author would like to acknowledge the support of the Faculty
of Health and Environmental Sciences, UNITEC, management team that
has enabled this project to take place. Without the resource allocation
to support this research and development, automated documentation
processes in nursing education would not have been possible.
That support has also enabled the development of anapproved informatics
integrated curriculum for pre-registration undergraduate students,
which can only have positive outcomes for the profession of nursing
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Author Details for Correspondence
Shona Wilson RGON, BHSc (Nsg) AIT, MA (Nsg)(Merit) VUW