"Expert of the Day" using PDAs in class/clinical.

Abstract

A collaborative learning strategy entitled "Expert of the Day" using the technology of personal digital assistants (PDAs) improved students' perceptions of their ability to make decisions, increased their confidence and comfort with technology and resulted in decreased time needed by students to access data. The dream of retrieving relevant, timely information when needed at the point-of-care became a reality.

Introduction

Since personal digital assistants (PDAs) hit the general market in 1995 [1], health care professionals have become increasingly dependent on the technology to access information at the point-of-care. A handheld computer or PDA is a small pocket-sized device used for a variety of organizational tools including health care information data bases. Although physicians were among the early adopters of the use of PDAs [2], nurses are outpacing physicians in their embracing of this technology with 559,800 nurses versus 408,020 physicians using PDAs in their clinical practice in 2003. [3]

Because of the demands on nurses' time, they are becoming increasingly reliant on technology which is a recommended labor-saving strategy. [4] The present nursing shortage is expected to increase by 26% to more than half a million in the year 2010. Some of the reasons for this shortage include stresses related to increased acuity level of patients, fast-paced work environment, safety issues, long work hours and inadequate staffing. [2] In a study performed by ANA, 56% of registered nurses believed that time providing direct care had decreased in the previous two years. [5] Two of nurses' biggest dissatisfaction areas were too much paperwork and not enough time at the bedside resulting in one-third of all nurses under the age of 30 planning to leave nursing in the coming year. [6]

PDAs have been known to enhance a socially supportive environment in that they are used to interact with others including patients and health care professionals. [7] PDAs can be used by nurses as a performance support tool to increase productivity by providing immediate information at the patient's bedside. [8] In anticipation that practicing nurses will recognize the value of this technology, nursing education programs need to incorporate their use in the class room and clinical settings. Our students should be carrying their PDAs in their pockets the same as they currently hang their stethoscopes around their necks. The portability and availability 24/7 at point-of-care can help to streamline daily tasks to increase time at the bedside for delivery of care. Useful reference materials for students and practitioners can be found for all fields of nursing from pregnancy calculators to ABG evaluations to drug references. In addition, PDAs may eliminate the need for students to carry heavy cumbersome books to the clinical units. [9] On average, students currently spend between four to twelve hours looking up and transferring information onto paper while preparing for their clinical practice. [10] Consistent with the literature, junior baccalaureate students in the nursing department of a rural liberal arts college have complained bitterly about the amount of clinical preparation time needed prior to taking care of a patient.

Furthermore, the student would arrive at their clinical laboratory and discover that patient situations had changed invalidating portions of their previous preparation and requiring quick additional research before assuming accountability for the patient's care. In order to determine if the PDA would be an effective tool to assist nursing students at the point-of-care, we initiated a project to evaluate students' perceptions of comfort and confidence levels related to use of a PDA, investigate students' perceptions of the effect that a PDA had on their ability to make clinical decisions as patient needs changed and determine the amount of time spent finding information on a PDA versus a drug reference book.

Theoretical Background

Constructivist theory states that learners need to actively participate in the construction of their own knowledge. Students construct their own meaning from relevant experiences/events/situations rather than from being told/lectured content. [11] The instructor's responsibility is to provide an environment where students can construct meaning from the experience by asking open-ended questions, providing opportunities for students to discover the answer and encouraging students to question each other. Verbal discourse among students empowers them to present ideas, ask questions and reflect on ideas of others resulting in students revising their previous ideas and conceptions. [12]

The role of the instructor is to provide resources and support for learner performance. The PDA is a tool toward achieving constructivist thinking in the fast-paced working environment as students work to solve patient problems in a timely manner. Students learn best when they have a need to know something in order to solve a problem. [11] Computer technology tools will not inspire critical thinking without carefully designed instructional activities. [13, 14, 15] In addition, new computer technology needs instruction and ongoing support to decrease frustration which can lead to discontinued use. The shorter the learning curve, the sooner the student/practitioner is both confident and efficient with the technology. The use of PDAs in nursing education can promote students locating, evaluating and using information from a variety of sources; especially since printed material is frequently outdated by the time of publication. Through the use of PDAs, students are able to meet some of the National Education Technology Standards. When students meet these standards, they are proficient with the technology and choose technology to support life-long learning, collaboration and productivity. [16]

Research Design

The purpose of this study was to evaluate student's perceptions of their comfort and confidence levels related to use of a PDA, to investigate student's perceptions of the effect that a PDA had on their ability to make clinical decisions and to determine the effect on amount of time spent finding information on a PDA versus a drug reference book. A quasi-experimental method was used with a convenience sample of junior baccalaureate nursing students enrolled in a nursing pharmacology course at a small liberal arts program in rural upstate New York. Twenty students voluntarily participated in the classroom component of the project with one-half of these students having additional experiences with the PDA in the clinical environment as well as the classroom. A survey tool to determine comfort, frustration and confidence level was administered with a one group pre-test/post-test design to all students at the beginning and end of the course. Anticipated and actual perceived study time was solicited to evaluate the amount of time that students were preparing for clinical on a medical or surgical unit in a rural teaching hospital. Additional questions in the post survey asked students to report the effect of PDAs on clinical decision making and for a qualitative evaluation of the "Expert of the Day" learning strategy. In the last week of the course, students were asked to find the adult drug dosage of dantrolene in a nursing drug guide reference textbook and on the PDA. While finding their answers, they were assessed by the educational technologist on the length of time it took to successfully find the correct answer in each resource. One half of each clinical group was assessed for time needed to obtain the answer to the above question using the textbook first and then the PDA. The remaining half of each clinical group was assessed for time needed to obtain the answer to the above question using the PDA first and then the textbook. Anonymity and confidentiality were maintained during data collection.

The student body for the pharmacology course was eighty-five percent traditional students and fifteen percent non-traditional students. Gender diversity was reflected by a ten percent male and ninety percent female distribution. Ethnic diversity was limited and represented by only five percent of students having a non-Caucasian background.

Instructional Method

Through a generous donation from a recent alumnus, the Department of Nursing purchased a PDA in the summer of 2003 for use in pharmacology class and on a surgical clinical unit. Specific hardware purchased with this donation included a Palm m515, 128 MB memory expansion card, and an aluminum hard-shell carrying case. The following software programs were installed on the PDA: FA Davis Drug Guide, e-Pocrates, RN Labs, and Medi-Calc. The PDA was synchronized with a Pentium 4 laptop computer (2 GHz processor, 256 MB, 30 GB drive) running Windows XP.

Budgetary considerations forced us to conduct this project with a single PDA, but allowed us the flexibility to establish a learning strategy which promoted collaboration as well as learning a new technology for use at point-of-care. All students were expected to seek out and collaborate with the PDA-holding "Expert of the Day" rather than looking to the instructor for answers. An educational technologist was available during class time to assist the PDA-holding student to navigate through the PDA software permitting the faculty member to stay focused on maintaining the learning environment on the expected course outcomes. In the classroom, the instructor used a Socratic questioning technique to engage the students in critical thinking. Traditionally, students were accessing information in their textbooks or in articles to help them to solve problems. This learning strategy required the "Expert of the Day" to help the class solve problems using frequently applied formulas in clinical practice (Medi-Calc) and the most up-to-date information about medications (FA Davis Drug Guide) and laboratory tests (RN Labs) through use of the PDA. Through this learning strategy, students were committed to building shared meaning in their search for solutions that went beyond one student's narrow vision of what is possible to solve a problem.

In the clinical laboratory, students on a surgical unit used the PDA while students on a medical unit were dependent on traditional resources. The single PDA was rotated among the surgical students providing each student with the experience of being the "Expert of the Day" on the clinical unit at least one day during a full semester. The surgical students collaborated on the content and needed to rely on each other: 1) to access the health care data bases using the PDA and 2) to critically analyze the clinical event to decide what information would be useful. The student assigned to carry the PDA on the surgical clinical unit was deemed to be the "Expert of the Day." This student was relieved from the responsibilities of administering medications allowing that student more time to collaborate with their peers on clinical issues. On the surgical clinical unit, the educational technologist was unavailable. With the additional time the "Expert of the Day" had opportunity to practice navigating the PDA and increase comfort level with the new technology. For example, using RN Labs a student assessed and correctly identified an abnormally elevated PT/INR in a patient on Coumadin. Rather than using the traditional method of approaching the clinical instructor for answers, the student sought out and collaborated with the "Expert of the Day." After determining the therapeutic laboratory test and value, the students continued to collaborate by using the FA Davis Drug Guide to decide on appropriate actions to take in this clinical situation.

Results

Using paired, two-tailed T-tests between pre and post usage, a comparison of students between the medical and surgical units documented significant increased comfort level with PDAs (alpha = .001 level) and significantly decreased frustration with the technology (alpha = .05 level) by students on the surgical unit. Every student on the surgical unit perceived that their clinical decisions were positively affected by the use of PDAs. Surgical unit students rated their confidence level in making clinical decisions using a textbook as 2.45 on a three point Likert scale with 1 equal to not at all confident and 3 equal to confident. The same students rated their confidence level in making clinical decisions using a PDA at 2.45 with the same Likert scale.

Using a paired, two-tailed T test, the comparison of access time with the PDA significantly differed at the alpha = .05 level between students on a unit with no clinical use of PDA versus student on a unit with PDA clinical use. One student from the medical unit refused to participate in this portion of the study. Students on the surgical unit with clinical PDA use were able to access information from the PDA more quickly by an average of 25 seconds than their peers on the medical unit having no clinical PDA use. Sixty-four percent of the surgical unit students perceived that the PDA provided a quicker answer than the textbook. Open-ended responses to the question about "How it feels to be Class Expert of the Day?" showed a predominantly positive experience. Students commented that they felt comfortable in the role, it felt good to give out quick, accurate answers, felt more confident and liked that classmates looked to them for answers. The negative responses by students were focused mostly on the experience being stressful.

Conclusions

The "Expert of the Day" learning strategy provided an opportunity for students to successfully solve problems with up-to-date information. Even if funding permitted us to purchase one PDA per student, continuation of this learning strategy would be desirous related to its perceived effect on collaboration, learning of technology and promotion of critical thinking. In the role of the "Expert of the Day" or more familiarly in the practice arena as a resource nurse, students were able to discuss ideas, ask questions of their peers and other health care workers and reflect on this information to come to their own conclusions about clinical decisions. Anticipated modifications include incorporating this learning strategy throughout the upper level courses within the nursing curriculum to promote higher level critical thinking and a collaborative nature necessary in performing the roles of a resource nurse in the professional setting

As Sprague and Dede [11] have emphasized, use of computer technology needs to be integrated within the learning environment to be meaningful and to promote independent problem solving behaviors. Valentine's research on information seeking behaviors by undergraduate students being characterized by quick and easy methods to conduct research [17] supports the successful use of the PDA by students who enjoyed the quick easy access to information. The relatively short learning curve makes the PDA an ideal technological tool to adopt in nursing education and practice. Students perceived that the PDA was as reliable with current, up-to-date information as the textbook and the nature of quick access to the information matches students' desire to retrieve material rapidly. Limitations of the research design included a small sample size and a positively biased question on the survey regarding effect of PDA on clinical decision making. Replication of this study on a larger sample size with rephrasing the question on effect of PDA use on clinical decision making would be desirable to increase validity of the research. Further investigation needs to occur related to the learning strategy entitled "Expert of the Day" to determine changes in students abilities to collaborate and think critically about problems.

In summary, students responded very favorably to the learning strategy of an "Expert of the Day" and to using PDA technology in their efforts to learn critical thinking and collaboration skills. The nursing program intends to expand the use of this learning strategy and promote technological use of PDAs in class and clinical.

References

[1.] Barnett S. Jeff Hawkins the man who almost single-handedly revived the handheld computer industry. Pen Computing 2000; 7 (33): 17-24.

[2.] HRSA. National Sample Survey of Registered Nurses. Available: http://www.bhpr.hrsa.gov/healthworkforce/rnsurvey/. Accessed January 30, 2004.

[3.] Stolworthy, Y. (2003). RNs are mobilizing. Available: http://www.pdacortex.com/ RNs_are_Mobilizing.htm Accessed February 18, 2005.

[4.] The Nursing Shortage. Office of the Professions: New York State Education Department. Report presented at the New York Sate Board of Regents. Available: www.op.nysed.gov/nurseshortage.htm. Accessed February 13, 2004.

[5.]American Nurses Association. Analysis of American Nurses Association Staffing Survey. http://www.nursingworld.org/staffing/ana_pdf.pdf Accessed March 29, 2004.

[6.] Nurses using PDAs to save time. PDAStreet.com. www.palmblvd.com/articles/2001/ 5/2001-5-19-Nurses-Using-PDAs.html. Accessed February 2, 2004.

[7.] Hunt, P., Alwell, M., Fanon-Davis, F., & Goetz, L. Creating socially supportive environments for fully included students who experience multiple disabilities. JASH. 1996; 21 (2): 53-57.

[8.]Derry, S.J. & Lajoie, S.P. Computers as cognitive tools. Hillsdale, NJ: Lawrence Erlbaum. 1993.

[9.] Moore, J. Faculty use of personal digital assistants in clinical settings: Lessons learned. The Oklahoma Nurse. 2003; 48: 10.

[10.] Curry, M., Martin, M. & Stanforth, D. Skills through the use of Palm Pilots during the nursing student's clinical experience, www.iue.edu/it/nursingaward.shtml. Accessed February 13, 2004.

[11.] Sprague, D. & Dede, C. If I teach this way, am I doing my job? Constructivism in the Classroom. 1999; 27 (1): 6-9.

[12.] Jonassen, D.H. Computers as cognitive tools. Journal of Computing in Higher Education. 1995; 6 (2): 40-73.

[13.] Scarce, R. Using electronic mail discussions groups to enhance students' critical thinking skills. Available: http://ts.mivu-org/default-asp?show=article&id=526. Accessed August 29, 2004.

[14.] Reimann, P. & Boxnjak, M. Supporting hypertext-based argumentation skills. Available: http://www.psyconsult.de/bosnjak/publications/edmedia98/default.htm Accessed August 29. 2004.

[15.] Santos, L.M. & DeOliveira, M. Internet as a freeway to foster critical thinking in lab-activities, http://www.educ.sfu.ca/narstsite/conference/santosdeoliveira/ santosdeoliveira.htm. Accessed August 29, 2004

[16.] Christmann, E.P. Projecting your PDA. Science Scope. 2003; May: 63-75.

[17.] Valentine, B. Undergraduate research behavior: using focus groups to generate theory. Journal of Academic Librarianship. 1993; 18 (8): 300-304.

Peggy Jenkins, Hartwick College 

Bonnie Nobiling, Hartwick College

Jenkins, M.S., CCRN is Professor of Nursing and Nobiling, B.S. is Manager of the Center for Learning and Teaching with Technology.