Conveying content related to computer applications for nursing presents unusual challenges to an instructor. Although students express a general desire to learn about computers, specific applications may not appear relevant unless students can immediately utilize them. Content related to nursing informatics is often technical and appears unrelated to clinical concepts. In addition, students frequently have little first-hand knowledge of the applications addressed in a course, so class participation in discussions is infrequent unless issues are discussed. Due to curricular compression, time allotted for "hands-on" experiences in lab is usually quite limited.
Experience gained from teaching nursing informatics content for five years has inspired several suggestions, learned by trial and error, which may facilitate the struggles of other nurse educators attempting to implement similar content in their curricula. Problems which are particularly challenging for informatics instructors include difficulties in three major areas: enhancing perceived relevance of didactic material; promoting class interaction and discussion; and designing useful, brief "hands-on" experiences which promote comprehension of the didactic principles discussed in lectures.
General goals for didactic instruction included comprehension of the advantages and limitations of a wide assortment of computer applications for nursing - an understanding which can transfer into an ability to select and use computer tools appropriately (McAlister & Corey, 1986). In general, students have very little knowledge of specific applications discussed in the course, so instructors must rely on lectures and assigned readings to convey a great deal of new knowledge. The lack of an experiential base with useful applications for nursing makes assimilation of the didactic material difficult. For instance, on the topic of accessing reference databases or networks via telecommunications, students have difficulty comprehending the significance of computer capabilities in this arena unless they actually access a computer via telecommunications to solve a clinical problem. Unless they have witnessed or experienced this type of computer usage in a clinical setting, lectures coupled with demonstrations do not make as strong an impression as actual "hands-on" interaction.
For this reason, if time and resources permit, lecture topics for every major informatics area can be coupled with brief "hands-on" experiences which will enhance comprehension of the concepts covered in lecture. For instance, informa-, tion retrieval via telecommunications can be illustrated by exposure to online databases (both bibliographic and fulltext), information services, and decision support systems.
Relevance can also be enhanced by providing a concrete secondary objective for lab experiences. If the primary objective is successful utilization of the computer, the secondary objective can involve applying the computer resource to solve a real problem the students have encountered, usually related to handling patient information or objectives for other courses. For instance, our students conducted simplified literature searches (on MEDLINE or PsycINFO) to research a paper required by another course. The usefulness of the computer product was therefore both immediate and concrete, so that students could grasp the value of this particular application. The theoretical benefits of computerized literature searching suddenly became relevant and personal to students as the lab experience saved them a substantial amount of library time on a required project.
Categories of applications which cannot be explored in a "hands-on" fashion, usually because of lack of time or computer resources, may be demonstrated to large classes with relatively inexpensive projectors which display computer monitors on large screens ( if the computer has a composite video output). Using these projectors, instructors can illustrate computerassisted instruction (CAI) programs or graphics generators, for instance, if they do not wish to indulge any lab time on these applications. Databases of clinical data may be explored in class to answer administrative or research-oriented questions. This type of demonstration can illustrate the computer's data manipulation capabilities and the concept that relevant information can only be extracted by communicating with the computer in precise, logical steps.
Advanced technology available through telecommunications, such as DXplain, a diagnostic decision-support system offered through the American Medical Association's computer network (AMA/NET), may also be displayed to discuss future effects of decision-support systems on nursing (Blois, 1987). Using the projector, computer applications which can facilitate clinical care may be easily demonstrated to large groups.
Enhancing clinical care is an objective all nursing students share, so applications with direct clinical impact should be of great interest to them.
Another method of increasing relevance for students relates to emphasizing the ability of the computer to theoretically support every aspect of the nursing process for nurses in a wide variety of roles. For a nurse researcher, for instance, assessment may be facilitated with computerized literature searches or by accessing databases or information systems for clinical data. Planning a research project may be enriched by the use of computer networks to facilitate the sharing of ideas. In implementing the project, the computer performs statistical calculations, and databases facilitate analysis by identifying patterns. For evaluation purposes, databases can readily provide interim reports as the research progresses, allowing researchers to refocus or alter the direction of their inquiry. Statistical reports provide for evaluation of the research from many perspectives.
In the same manner, other roles such as that of nurse administrator, educator, and clinician may be examined to identify useful computer applications which can facilitate every phase of the nursing process in a particular role. Students desire the practical benefits of computer applications, so emphasizing the computer's ability to streamline every nursing activity to some degree, ( except for psychosocial interaction and some physical tasks), expands their vision of computer usage. Exposure to concepts about the computer's versatility enables students to envision ways to use computers more effectively in their clinical settings.
Enhancing Classroom Interaction
Informatics content does not often generate much discussion because students lack the experiential base needed to relate to the material. Group projects are difficult to design since students usually cannot produce computer products without a great deal of assistance. Active student involvement in a classroom dedicated to conveying informatics content can therefore be challenging.
Lectures can capitalize on issue-related content, which tends to generate more discussion since informatics issues evoke student opinions and values. There is a surprising amount of issue-related content pertinent to computer applications regarding ethical, social, legal, and political concerns. Small group discussion sessions may effectively address a wide range of issues related to computerization (Renshaw & Ganley, 1987).
Major issue-related topics include confidentiality, potential overdependence, and liability concerns. Perspectives on the overdependence issue range from concerns related to suspending judgment in favor of a computer's recommendations to the inability to competently care for patients without monitoring systems. Students can easily relate to these concerns and brainstorm about methods for lessening negative effects of technology.
Futuristic discussions of the potential effects of computer utilization on the role of the nurse also spark discussion. Automated monitoring systems, telecommunications capabilities, and expert systems may all be addressed in this regard. Potential advantages and negative side effects of emerging technological capabilities may all be thoroughly explored. Examples of group projects which do not involve actual computer manipulation include recording methods of utilizing force field theory to effectively implement new information systems (Huckabay, 1986); identifying methods of applying computers to provide documentation needed to offset budgetary constraints (resulting from DRGs); and describing the use of computers to address a wide range of liability concerns.
Maximizing Exposure to Selected Computer Applications
Whether taught as a separate course or in integrated fashion, this instructor has found breadth of exposure to various applications a useful objective since wide exposure enables students to select appropriate applications in their clinical settings (Skiba, 1985). The instructor did not intend for students to acquire expertise in any particular computer application since the software or information system students encountered in practice would probably differ from the software utilized in the course.
While breadth of exposure may be the major objective of interactive experiences, computer courses should offer some degree of depth of exposure on one or two computer applications. Focusing on one or two areas enables students to develop a sense of mastery over the machine and overcome the dread phenomenon of "computer fear." Computer anxiety or "computerphobia" may encompass many emotions, including fear of failure, performance anxiety, fear of being out-of-control, fear of being depersonalized, or fear of being replaced (Koch, 1984). All of these emotions may inhibit students from becoming involved with computers. If the course does not accomplish affective objectives related to relinquishing computerphobia, students will remain reluctant to utilize computers in practice.
The selection of the focus area for the interactive experiences should be as germane as possible to the targeted group of students. Databases and spreadsheets are currently the two generic applications with the most transferable usefulness, in this instructor's opinion. If students are required to construct and utilize a database, such as a file of client information (for nurse practitioner students), or a file of staff information (for nursing administration students), they gain an appreciation for the computer's ability to manipulate a large amount of data and quickly compile relevant reports (Sinclair, 1987).
From this exercise students learn the steps necessary to formulate reports from a database as they experience the process of selecting desired data categories for the report and specifying search criteria to select certain records. Students gain an appreciation for the ease with which the computer sifts through all the records and presents useful information in a report format of their design. Exposure to a small database also enhances the students' understanding of information systems, such as the concept that data retrieval depends upon the design of the data categories in the information system. Information systems must be structured so that data related to nursing process and nursing interventions can be retrieved if nursing is to capitalize on the availability of hospital information systems. After utilizing a small database file, students can appreciate the importance of structuring databases with thorough consideration of output needs in mind.
The "hands-on" experiences tend to transfer concepts related to the computer's ability to make information retrieval and management more efficient. Allowing students to conduct their own MEDLINE search, for instance, illustrates the tremendous storage capacity and ease of data retrieval associated with a large database. Students also learn that careful selection of key words or descriptors greatly facilitates the retrieval of pertinent data.
For similar purposes, Grobes graduate students (1984) performed literature searches on bibliographic databases such as ERIC. Increasingly, nurses will be accessing databases via modems to solicit information about professional literature, clinical research, and clinical advice for particular problems (Safran & Porter, 1986). Armstrong (1985) discusses the growing use of telecommunications and computers by nurses to access personal resourcesharing networks and reference databases. The MEDLINE search offered many of these students their first experience with accessing professional online information via telecommunications systems.
Spreadsheets are a particularly useful application for nursing administration students since their capability to store numbers and formulas enables them to produce a wide variety of statistical reports for administrators (Lange & Mark, 1987). In addition to producing budgets, spreadsheets may be utilized to prepare staffing schedules, quality assurance statistics, patient acuity reports, and cost allocation reports (Schank & Doney, 1987; Johantgen & Parrinello, 1987). Both databases and spreadsheets are useful for nursing research purposes; databases for qualitative research and spreadsheets for researchers with relatively small data sets (Nicoli, 1987). The depth of exposure and facility acquired with a particular application has correlated with the degree of enthusiasm for that application, in this instructor's experience. The more adept students become at database or spreadsheet manipulation, the more positive they appear to be about their capabilities.
Objectives for the interactive experiences include exposure to a wide variety of computer applications; in-depth experience with at least one application; overcoming computer fear; appreciating the rigid, logical flow of computerized problem-solving; and appreciating the benefits and limitations of computer applications for a variety of purposes. Ultimately, a major purpose of transferring informatics content is related to stimulating students' imagination with respect to the computer's ability to aid their professional endeavors.
Robinson (1984) describes the imagination factor: "I think the total potential of computers is only limited by our imagination. It's like giving an artist a palette that has an infinite number of colors, some of them invisible to the naked eye ... It is a tool for the realization of ideas." Students who have been exposed to the benefits of major categories of computer applications can appreciate computer capabilities with respect to exploring scientific and nursing phenomena, and building databases to store and access information (Newbern, 1985). These students should have enough theoretical and experiential knowledge of computers to become actively involved in making creative, informed decisions about how computers will be applied to nursing in their professional setting.
Hardin and Skiba (1982) noted a gap between the powerful information processing capabilities of the computer and its relatively limited use by nursing - a gap which still exists today. Students who have participated in an idea generation course on computer applications can help to bridge this gap, helping nursing to take full advantage of the computer-saturated environments of the future.
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