Nurses, as well as other health care professionals, are increasingly being required to see computers in a new light, as broad information-based systems, rather than just statistically oriented tools. Increasing numbers of record keeping and accounting systems in hospitals are becoming computer-based. Diverse health care agencies in widely separate areas of the country now employ totally computerized systems to tend to patient record keeping, accounting and billing, clinical monitoring, personnel staffing, agency security and other administrative tasks. Advertisements proclaiming the desirability of such electronic conveniences in hospitals are appearing consistently in trade and business journals (GTE, 1979, p. 15).
The skills required for use of a computerized system will, in many cases, be totally unfamiliar to an individual nurse who may be expected to learn the technology as an additional on-the-job skill. The learning task is complicated by the fact that, aside from some newspaper and television coverage and perhaps a personal struggle with either billing or banking operations, few nurses have had much exposure to or experience with using computers in health care agencies.
A common pattern for a health agency's adopting a computer system consists of a gradual shift to the technology. Initially, an agency's computer often handles primarily billing and accounting functions. Gradually, more and more tasks are assigned to the computer, resulting eventually in a completely computer-based information system. This totally computerized system slowly expands, eventually including patient record keeping systems, utilization review processes and patient record auditing.
In some instances an agency chooses to adopt a totally computerized system in rapidly sequenced phases over a relatively short period of time. The time allotted for personnel orientation to and adaptation to computer systems is correspondingly brief. Regardless of which approach is selected by a clinical agency for adopting a computer system, the nurse is usually caught in the middle of the change. Traditionally responsible for communicating information about patients over an entire 24-hour period, the nurse is suddenly required to both adopt and adapt to an entirely new system for handling this same information.
An individual nurse, unfamiliar with computer technology, immediately needs basic information which must simultaneously serve several purposes. The knowledge should be useful for helping the nurse adopt the technology and adapt to the system, as well as develop a basic understanding of the effects of computer use on nursing practice.
However, if a nurse searches independently for practical and realistic information about clinically-based computer systems, she will find only a limited amount of usable and relevant information. Overall the articles lack very spécifie, relevant examples for assisting an individual nurse to learn how to use computerized systems. This scarcity of information also adds to the problems involved in training individuals to use computers effectively. The end result: it is difficult for an individual nurse to learn about and adapt to clinical computer systems independently. It is also difficult to design effective useful strategies to help nurses learn about computers except by trial and error methods.
Recent experience with helping nurses adapt to computers in a college course has shown that there are several basic strategies which, if sequenced properly, allow for a relatively easy transition and effective learning experience.
Reporting these experiences may reduce some of the trial-and-error approaches currently being attempted without any benefit of past experience. Although the specific strategies for assisting nurses to become oriented to computer systems were designed and incorporated in a course for graduate students at The University of Texas at Austin School of Nursing (Note 1), the approaches are also relevant for use with nurses of any educational level in clinical health care settings. The strategies are directed at helping nurses to: (1) lessen many unfounded fears about the technology (i.e., adjust their attitude); (2) increase their knowledge about computer systems (i.e., know the system); and (3) develop competency in using computers (i.e., use the system).
Discovery of fears about computers was noted quite accidentally. The course nickname, "Conquering Computer Cowardice," illustrates an initial attitude toward computers which nurses in both educational and clinical settings hold. This attitude was common among students and is frequently seen in nurses in clinical settings as well. The attitude must be addressed both early and consistently throughout the entire process of learning about computers.
Examining nurses' fears of computers led to the development of a relevant analogy: computer cowardice as a common social disease among nurses. Cowardice refers to avoidance of computers due to fright rather than avoidance due to a sense of power lessness. Although there are many possible reasons for the fright, it derives primarily from a lack of familiarity and understanding about the operation and practical uses of computers in health care settings. Consequently, the image of the complex and mysterious computer causes high degrees of uncertainty about what to expect with increased use of computer systems. For a practicing nurse, a tangible example of this uncertainty is the fear of losing control of essential patient information. Constant television and newspaper anecdotes about computer failures serve to reinforce these fears.
Calling computer avoidance a social disease among nurses also highlights a sex-role stereotyping related to the appropriateness of math -associated tasks for females. In the public mind, use of the word "computer" implies a complex technological system designed essentially for mathematical and statistical tasks generally associated with men. Though such stereotypes are changing, many of today's practicing nurses were socialized according to the belief that math competency is not an appropriate female task (Sherman, 1978). As a result, many nurses believe that women do not generally possess the same mathematical ability as men. This belief, if extended further, implies that women are incapable of dealing with the advanced math or statistical tasks associated with computer use. The general public's view of the computer as primarily a statistical tool compounds the problem by reinforcing nurses' avoidance of computer technology. As long as nurses believe that computers are primarily math tools, and as such are inappropriate for female use, they will avoid learning to use them.
Viewing computer systems as useful information tools for nursing practice can help diminish fears and the resulting avoidance of computers. Additionally, "handson" exercises can be designed so that computer "novices" can learn about various systems and use the machinery, and further decrease any fears and resulting avoidance of computers.
The sequencing of computer exercises is relevant for nurse computer novices in either educational or clinical settings. Since nurses in educational and clinical settings are similar in their degree of experience with computers, and report having had only minimal exposure to computer-based information systems, the learning exercises for both groups can be similarly structured.
Computer Systems: Clinical and Educational
Although the exercises used in the course were originally designed for a university-based computer system, each of the exercises can be easily adapted for use in either a hospital or clinical setting. It makes little difference whether the actual exercises are used within a clinical or an educational setting. Two examples will illustrate a few of the differences between the systems. And although the systems differ, broad commonality of knowledge is required for the use of either system. The exercises for learning are based on these broad commonalities. Therefore they can be used with either a clinically- or educationally-based system.
Several of the exercises are much easier to implement in health care settings. This is true because computer systems for hospitals or other health agencies are designed for simplicity of user operation. The same is not always true of computers in a university setting. As a result, there may be a marked difference in the level of skill required for interacting with computers, depending on whether the system is in a clinical or an educational setting. All that may be required in a hospital system is that an individual touch a special light pen to a cathode ray terminal screen (like a television screen), which has several readily available printed commands from which to choose.
EXAMPLE: Clinical Computer System. The following example will demonstrate the ease with which a nurse using a clinical computer system might order an ace bandage for a particular patient (Tobin, Note 2) The cathode ray tube, hereafter called CRT, displays the information found in Table 1.
Two steps are required for using this display of information. The user must touch a light pen to the screen in order to select a patient and specify the type of transaction desired. In this example the nurse touches the light pen to "dummy" and "order." Touching the pen to any one of the nursing stations (herein called the dummy unit) causes a listing of all the patients housed on that unit to appear on the screen. The "dummy" unit displayed here was included specifically in this hospital system for demonstration purposes. The "order" command identifies what process we wish to initiate for a patient.
ORIGINATING AN ORDER*
Touching the pen to "dummy" and "order" causes a new screen of information to appear which contains a listing of 18 fictitious or "dummy" patients. Dum-dum Ol through Dum-dum 18. For our purposes, the light pen is touched to dummy patient 01, thereby specifying that he is the patient for whom an order will be placed. The computer replies and verifies, at the bottom of the CRT screen, information that an order is being placed for the demonstration patient named Dum-dum 01. The eleven-digit number preceding the test patient's name is his hospital identification number (Table 2).
Another screen of information then appears. This next display asks the user for additional information. It asks for both the name of the department from which the user wishes to order, and the first letter of the desired item as seen in Table 3.
The user responds by touching the light pen to "A through C" in the CSR (Central Supply Room) listing. This requires that a user know that ace bandages are available from CSR.
A listing of the available CSR materials beginning with the alphabetic characters A through C immediately appears on the CRT screen (Table 4). With a touch of the light pen to "ace bandage 6 in.," the process of ordering is almost complete.
Elsewhere in the clinical agency several associated processes are occurring almost simultaneously. A label with the patient's name is being printed in central supply and the accounting and billing department is receiving notice to bill the patient for the ace bandage. Meanwhile, the nurse receives verification on the CRT screen that the ace bandage order for this patient is being processed (Table 5).
If a wrong item was ordered by mistake, a similar procedure is used to cancel the order. The cycle again begins with the original display screen of commands (Table 6). The entire procedure can be repeated using "cancel" as an initial transaction command instead of "order."
If several more transactions need to be completed for this patient, the cycle can be continued as many times as necessary by using the word "continue" at the bottom of the CRT screen without respecifying the patient's name each time. The computer recognizes that the transactions apply to the same patient. When all the desired transactions for a patient are completed the nurse touches the light pen to "off1 at the bottom of the CRT screen (Table 6).
Thus, with only five touches of the light pen to a CRT screen, an individual nurse can easily order an item for a patient in fewer than 15 seconds. The basic requirements for communicating with the computer in this clinical setting example include skill in both reading and use of a light pen for making selections from a list of available commands on a TV-like screen.
EXAMPLE: Educational Computer System. On the other hand, an individual using an educationally-based system may need to learn several new symbols and command controls while using a typewriter-like keyboard at a cathode ray terminal (CRT). This new information of symbols and commands is necessary since educationallybased computers are generally extremely versatile and must serve a wider variety of users and purposes. Therefore, educationally-based computers are generally not designed for the same level of simplicity of operation as are clinically-based computers. The user in an educational setting may choose from a wide variety of available multipurpose programs or write new programs. Thus the user may need to learn either a specific computer language or some selected commands to use in programming the computer or adapting available computer programs. Most commonly a user does not need to write programs. It is usually necessary only to modify or adapt available programs.
VERIFICATION OF TRANSACTION
SELECTING A DEPARTMENT FROM WHICH TO ORDER
The following illustrates a few of the basics which a user might learn about to use available programs (University of Texas at Austin, Note 3). It will become clear from the examples that communicating with an educationally-based computer may require more new knowledge than is necessary for communicating with a clinically-based computer. With several simple commands users can proceed to run the program desired. When users are finished running the desired program on an educationally-based computer, it is usually necessary to log out or sign off the computer system, the equivalent to hanging up the phone at the end of a conversation. The computer user in the clinical setting example needed only to touch "off with the light pen.
SELECTING AN ITEM
VERIFICATION OF ORDER
Although the two examples demonstrate a marked difference in the level of skill necessary for interacting with a computer, (depending on whether it is clinically- or educationally-based), a broad commonality of necessary information does exist which can be used in helping nurses learn to use computers. This commonality exists because of similarities in both the attitudes and circumstances within which nurses must learn about computers and adapt to their use.
Course Exercises: Using Computer Systems
The specific exercises used in the computer course seemed to be an effective and efficient means for helping the nurses learn. The exercises which follow detail how nurses can be helped to increase their knowledge about computerized systems, develop a sense of competency with computer use, and ultimately reach the goal of relative comfort in using computers. The exercises, as presented, can be used in either an educational or clinical setting.
CONCLUDING A TRANSACTION
EXERCISE ONE: Information Storage and Retrieval Capabilities of Computerized Information Systems. At the beginning of the course each student is assigned both a user number and a password allowing access to the computer. This is similar to an accessing control system used with computers in health care settings. Using such a system in the course emphasizes the desirability of safeguards to provide for limited access to an overall information data base and confidentiality of patient records. In this first exercise, the process of storing information and retrieving selected information for use is demonstrated. The fact that the data called up cannot always be changed by the user is illustrated and discussed. For example, in health care settings the laboratory values reported on a computer-based system cannot be changed by users. Only lab personnel who put test result data into the system can change reported results. Likewise, in school settings, computer-assisted instructional programs can be used repeatedly but cannot be changed by learners.
Questions of confidentiality of computer-based patient records are discussed in conjunction with this exercise. Who should have access to which parts of a patient record? Which sections of the records can be altered by which users? Can professionals gain access to all personal and other records on all patients? Are there confidential portions of the records which need to be and are specified for limited access by specific persons? What information is stored as a part of a permanent information data base? For how long is particular information stored?
"Should the information be stored?" and "Who has access to the information?" are but a few of the questions discussed in conjunction with this first exercise.
Small group discussion with this first exercise helps clarify and illustrate the major issues surrounding the use of computerized patient information data bases. Misconceptions regarding unauthorized and surreptitious release of accumulated confidential and private information are also discussed. This first exercise introduces learners to the entire information system and the underlying rationale used in planning, constructing and implementing a computer-based information system.
EXERCISE TWO: Hands-On Computer Experience. The second exercise consists of the use of a short personalized computer program to provide a learner with an actual hands-on experience with the computer. The program is written in a language and format which allows simple responses from the user. The user sits at a typewriter-like console attached to a CRT. This first actual "hands-on" experience focuses on "logging-in" to the computer and developing a beginning sense of comfort using the equipment in a simple no-fail situation. Running a simple educational program involves only a minimum of knowledge about computer operations while providing immediate personalized feedback. Success with this simple task can begin to decrease fears about computer technology, Since the program selected can be personalized, a bit of the impersonality of the "monstrous machine myth" is reduced.
EXERCISE THREE: Searching a Data Base. This exercise illustrates the tremendous information storage capacity of the computer. Increased learner involvement is often necessary for conducting a computerized search of a current literature information base. Performing a search involves "logging-in" and following a simple, yet very specific, set of instructions for purposes of data retrieval. Almost any data base can be used. Through careful selection of key words, or "descriptors," a search of current literature for articles on a selected topic can be accomplished. Any one of a large number of available data bases can be used for course demonstration purposes. The Educational Research Information Center (ERIC) (Note 4) data base is appropriate for educationally- based learners wanting to search a topic related to nursing education. ERIC is readily accessible on many college and university campuses. Other similar computer-based searches are available in general libraries and in some hospital and professional association libraries throughout the country. Other commonly available search systems include AVLine, Toxline, and Cancerline (National Library of Medicine, Note 5), Examples of the output from computer searches of data bases are available through the Nursing Component of the National Health Planning Information Center (Note 6).
After an initial demonstration, students can conduct their own search using a topic of their own choosing. Examination of the printed output containing current journal articles and manuscripts related to the selected topic are discussed in order to further highlight the storage and retrieval capabilities of the computer as an information system.
If a literature-based search is not readily available in a health care setting, a variety of patient care record audits can be used to demonstrate the storage and retrieval capabilities of the computer. Total number of patients with a particular diagnostic classification or other information used for auditing patient records can be easily compiled from most computerized hospital data bases. The purpose of this exercise is to demonstrate both the information storage capacity and the relative ease of data retrieval using computer-based systems.
EXERCISEFOUR: Collecting and Analyzing Data. This exercise involving collection of data for input and computer analysis is divided artificially into several steps. Although each of the steps is not equally applicable and varies slightly between educational and health care settings, the overall purpose of the exercise is examination of methods for collecting and entering data into a computer system.
In the educational setting any nursing research or nursing education research tool can be used. The WICHE compendium, Instruments for Use in Nursing Education Research (1979), provides a wide variety of nursing education research tools to choose from. Once a tool (i.e., a questionnaire) has been selected by the group, participants enter their responses to the tool. In the educational setting, each course participant keypunches a computer card reflecting his or her responses. This computer card is then duplicated as many times as there are students in the class so that each participant has a complete set of everyone's responses to the tool. Specific directions for the use of selected statistical packages are provided and the course participants execute several statistical routines (Nie, Hull, Jenkins, Steinbrenner, & Bent, 1975; Veldman, 1978).
The associated exercise for use in a clinical setting does not extend to the use of statistics. The equivalent exercise for use with a health agency computer, however, can be structured similarly. Since the purpose of the exercise is to provide an introduction to the particular rules of computer language and the types of input required of the user, this exercise can demonstrate the process through which any patient information is entered and becomes a part of a patient's data base, i.e., clinical record or chart. Required language translations and specific rules about necessary kinds of data input for patient's medical and nursing records can be introduced during this exercise. The exercise can be repeated using a variety of realistic situations until the learner demonstrates a degree of competence and comfort with both the use of the equipment and the skills required for ease in computer use.
EXERCISE FIVE: Analyzing the Data Collection Instrument System. In this last exercise, attention is directed to the design of the research tool or patient record form used for collecting, recording and coding data. The tools used for data collection in both educational and clinical settings can be examined in order to identify the specific characteristics which contribute to their utility, accuracy and efficiency in storage and retrieval of data. The computerized medical and nursing records can easily be examined using these same characteristics.
This final exercise is an important step for orienting individuals to the use of computerized record systems. The analytic approach to either the research instrument or the computer-based patient record helps individuals become more skilled in use of the system quite rapidly. The process also helps individuals learn enough about the system's operation to be able to begin to assess both the advantages and disadvantages of particular types of research tools or patient record systems.
The last portion of this exercise involves analysis of the collected data. The type of analysis varies according to the setting. Within the educational setting the analysis selected is derived from the nature of the tool, and the purposes for which it is used. The data collected for the medical and nursing care records should also be examined by the learners. To be most meaningful the clinical information could be analyzed in a manner which replicates audit and utilization review procedures.
Specific concerns related to accuracy, validity and reliability of the information entered into the system should be discussed in both settings. Examples of computer system difficulties and aberrations due to data inaccuracy can easily be illustrated and discussed. Reasons for the inaccuracies and some of the means to both avoid and correct the discrepancies can be demonstrated at this time.
It has been my experience that once these course exercises have been completed, a nurse has progressed from a novice to a more competent, and less frightened, individual with decreased fear of the computer. The misinformation regarding computer use has been corrected, and a basic understanding of the capabilities and limitations of computer-based information systems is achieved. Knowledge gradually displaces an individual nurse's fear and avoidance of the system.
The overall sequenced strategies, relatively simple "nofail" encounters and repeatedly successful exercises change the individual nurse's image of the computer from that of a monstrous, mysterious machine to a manageable ally. The desired outcome, a nurse knowledgeable about and well-oriented to computerized systems, is accomplished. Fear is replaced by knowledge and feelings of competence. Finally, "computer cowardice" is conquered.
- GTE advertisement. How we're helping create the electronic hospital. Wall Street Journal, September 19, 1979, p. 15.
- Nie, N.H., Hull, C.H., Jenkins, J.G., Steinbrenner, K.S., & Bent, D.H. (1975). SPSS: Statistical Package for the Social Sciences. New York: MeGraw-Hill Book Co.
- Shermsn, J.A. (1978). Sex-Related Cognitive Differences: An Essay on Theory and Evidence. Springfield, IL: Charles C. Thomas Publisher.
- Veldman, D.J. (1978). The Prime System: Computer Programs for Statistical Analysis. Austin, TX: The Research and Development Center for Teacher Education, The University of Texas at Austin.
- Ward, M. J, & Fetler, M.E. (1979). Instruments for Use in Nursing Education Research. Boulder, CO: Western Interstate Commission for Higher Education.
- Reference Notes
- 1. The University of Texas at Austin School of Nursing. Nursing 397L.2 Research Methodology: Evaluation and application of computer techniques to nursing, 1979.
- 2. Tobin, R. Director of Data Processing, Brackenridge Hospital, City of Austin, Austin, Texas, 1979. (With permission).
- 3. The University of Texas at Austin Computation Center. Austin, Texas: The University of Texas, 1979. (With permission.)
- 4. Educational Resources Information Center (ERIC). U.S. Department of Health, Education and Welfare, National Institute of Education, Washington, D.C. 20208.
- 5. National Library of Medicine. Literature Search Program, Reference Section, 8600 Rockville Pike, Bethesda, Maryland 20014.
- 6. Nursing Component. National Health Information Planning Center, PQ Box 1600, Prince Georgefe Plaza Branch, Hyattsvule, Maryland 20788.
ORIGINATING AN ORDER*
VERIFICATION OF TRANSACTION
SELECTING A DEPARTMENT FROM WHICH TO ORDER
VERIFICATION OF ORDER
CONCLUDING A TRANSACTION