To be able to identify and use vital health care resources, nursing graduates must be sophisticated in the use of information technologies and must understand how these technologies interface with various health care systems. It is imperative that health care educators incorporate information technologies in their teaching because of the growing need for nurses to access the latest health information and have quick access to other health care professionals to meet patient needs. There are a variety of examples of innovative uses of information technologies to improve health care. Entrepreneurs are working with health care professionals and computer experts to develop viable, secure virtual medical records which can be available nationwide in real-time online (Lester, 1996). Using a computer network, health care professionals are providing home-based support services to family caregivers of people with chronic illnesses to promote decision making, connect them to others in similar situations, and provide encouragement to families 24 hours a day (Brennan & Moore, 1994). Improved clinical decisions and patient outcomes have been demonstrated as a result of a 9-year effort whereby nurses document patient data and nursing care on a bedside computer (Willson et al., 1994). A nurse-developed computerized patient education program and documentation tool are used in one medical center in response to the dramatic decrease in length of hospital stay (Weaver, 1995). In addition, advanced practice nurses are holding conferences on the World Wide Web (Graves, 1996). Nurses are accessing the latest nursing research, global databases, nurse researchers, and a vast array of information resources through the Sigma Theta Tau International Library (Killion, 1994). Telemedicine, telehealth, telenursing, telehome health care, teleradiology, telepsychiatry, and virtual medical centers are rapidly emerging to deliver health care and/or health information to patients and health care providers in remote areas and at major medical centers.
The online course described in this article was designed to enable nursing students to become sophisticated in the use of the information superhighway and to understand how new information technologies interface with various health care systems. A traditional computer course was expanded to include content on emerging information technologies related to health care, increased from 2 to 4 hours, and changed from a traditional classroom setting to Internet delivery. In developing the course, the major objectives were to:
* Develop e-mail delivery of course materials.
* Develop curricular materials which will prepare nursing students to understand and use new information technologies.
* Pilot and evaluate these materials.
The ability to use computers opens the gateway to the information superhighway. Burkes (1991) measured computer use attitudes and reported nurses' computer use was related to satisfaction, beliefs, and motivational attitudes. Findings suggested that computer knowledge may relate to nurses' motivation to use computerized nursing programs. Although nurses' attitudes toward computers has become increasingly positive, resistance to the use of and negative attitudes toward computers often has been attributed to lack of knowledge about computers, how they work, and how nurses might use computers today and in the future (Abbott, 1993). Early studies found that computer courses increased receptivity to computers and increased nurses' skills immediately and over time (Ball, Snelbecker, & Schechter, 1985; Lange, 1988). Ball and colleagues recommended that instead of focusing on computer technology, "emphasis should be on the responsibilities of nurses and ways in which computer technology can be functionally relevant for nurses and their work" (1985, p. 31).
Computer classes using the Internet as a teaching medium differ from traditional classes in that (Connors, Smith, DeCock, & Langer, 1996b):
* Active participation of each student is required.
* There is a greater level of personal interaction and sharing of information among students.
* The learner's independence is fostered.
* Scheduling is flexible, allowing students to work at their own pace.
These benefits of online course delivery are especially crucial for growing numbers of nursing students who simultaneously juggle responsibilities in the workplace and at home, as well as for those students who are at distance education sites.
A variety of computer courses are being developed across the country and around the world, In Kansas, Internet courses have been initiated for a master's Primary Care Nurse Practitioner Program (Connors et al., 1996b). Indiana established a Nursing Student Information Network to enhance opportunities for collaborative learning experiences and student-faculty communication (Halstead, Hayes, Reising, & Billings, 1995). In Japan, Kanai-Pak (1996) challenged traditional ways of nursing education that relied heavily on memorization by introducing a computer-assisted thinking program which allows nursing students to view patient situations and perform a nursing assessment. Although Japanese students expressed frustration that the program did not give the right answer or correct them, Kanai-Pak stressed the importance of encouraging students to actively think while they learned. The Visiting Nurses Association of Cleveland designed and implemented a continuing education course for visiting nurses focusing on gerontological home care through discovery learning and distance education via the computer (Hekelman, Niles, & Brennan, 1994).
Although computer courses, and in particular those using the Internet as a teaching medium, are rapidly emerging in schools of nursing, Connors, Smith, and DeCock (1996a) caution that to assure their success, adequate infrastructure and technical support must be in place. While anecdotal reports are available regarding the success of these courses, few studies exist which examine the impact of using the Internet as a teaching strategy on student outcomes and student satisfaction. The purpose of this evaluation study was to determine the impact of a pilot Internet course for nursing students on a variety of student outcomes and describe student feedback related to their satisfaction with the course and their success in achieving course assignments. A nonequivalent, pretest-posttest, control group design was used in evaluating the impact of the pilot course. It was hypothesized that, when compared with students not taking this course, students in the pilot course would demonstrate greater knowledge of various information systems, greater perceived computer skill, greater use of the computer, and more positive attitudes toward computerization. It was also hypothesized that nursing students in the pilot Internet class would be able to use the information superhighway. Weekly qualitative data were gathered from students in the pilot group to assess their feedback about the strengths and weaknesses of the course, and assignments were evaluated to assess their use of the information superhighway.
The curricular materials were piloted with all 20 students who enrolled in an introductory course entitled, Information Systems Utilized in Health Care. The comparison group was initially comprised of 26 students enrolled in two community health courses. Both the pilot and comparison students were newly enrolled RN-toMSN students at a similar phase in their programs of study. During the semester, three of the comparison students dropped out of the course. The final number of students in this group with completed data was 23.
The two groups did not differ significantly on any background characteristics (Table 1). Most of the sample were females who had been in nursing, an average of 11 years, and most had used computers either at home or in their workplace.
The study protocol was approved by the University's institutional review board. Students were recruited into this evaluation study during a regularly scheduled class during the first week of the semester. The study was explained by each class instructor, and participating students signed informed consent forms at this time. In the case of the pilot class, the instructor was also the principal investigator. Pretests were administered at the beginning of this class. Posttests were administered to both groups by their instructors during their last class.
Each student had access to a computer through the University's student computer labs or through personal computers either at home or at work. Each computer had software provided by the University which permitted student access to e-mail, the Internet, and the University library system. Specifically, the course involved the following topics:
* Getting students online and connected with classmates and the instructor.
* Locating online nursing resources and connecting with a nursing network.
* Finding and evaluating health information, patient support groups, and the world of telemedicine.
* Using online library resources/informatics.
After the completion of each topical assignment, students in the pilot course completed an evaluation of the activities and e-mailed their assessments to the course instructor. Students were told that these were not graded but would be used to improve the course for subsequent students.
A demographic instrument developed by the authors was used to collect information on selected demographic variables, weekly computer use, and perceived computer skill. Students were asked about two aspects of weekly computer use. First, they were asked to indicate how many hours they used the computer in a typical week. Response choices ranged from (1) not at all to (5) more than 10 hours. Second, subjects were given a list of 13 possible uses for the computer and asked to indicate what they used the computer for in a typical week.
Background Characteristics of Students
Perceived computer skill was measured by asking the students to rate their present level of skill with these same 13 computer uses on a 5-point scale, where 1 = very low and 5 = very high. Coefficient alpha was .89 on the pretest and was .88 on the posttest.
To assess knowledge related to the information superhighway, a matching tool was developed by the authors using selected terms related to the information superhighway. Content validity was established during development of this instrument by submitting the terms and their descriptions, along with the course objectives, to two experts in the field of current information systems. Raters were asked to evaluate the relevancy, clarity of definitions, and representativeness of the items based on the course objectives. Minor revisions in definitions were made based on this process. The final knowledge instrument consisted of 13 terms to be matched with their description. Students were instructed to choose the response, "I do not know," if they did not know the correct answer. Correct responses were coded as (1) and incorrect or do not know as (0).
The Nurses' Attitudes Toward Computerization Questionnaire (Stronge & Brodt, 1985) was used to assess the variable of attitudes toward computerization. This is a 20-item self-report which asks respondents to indicate agreement or disagreement with each statement on a 5point scale. Items reflect issues related to the use of computers in nursing and include job security, legal ramifications, quality of patient care, capabilities of computers, employee willingness to use computers, and benefit to the institution. This scale has been used in a number of studies investigating nurses' attitudes toward computers and computerization and has adequate support for its validity and reliability (Stockton & Verhey, 1995). Coefficient alpha in the present study was .90 for the pretest and .86 for the posttest.
Amount of Computer Use in a Typical Week
Type of Computer Use In a Typical Week
Qualitative student feedback was elicited using an evaluation form posted on the instructor's home page. Students e-mailed an evaluation after the completion of each topical assignment. Topics that students evaluated were:
* Getting Online/Introductions/Online Manners.
* Finding Nursing Resources and Nursing Networks.
* Finding Health Information/Patient Support Groups.
* Online with Libraries/Informatics.
Students were asked about problems they encountered completing the activity, the kind and source of help they sought, the usefulness of the activity, their suggestions regarding other activities that would be useful to add, and the time it took to complete the assignment. Selected student comments are included in this report, providing an idea of the range of student reactions to the course topics.
Frequencies were computed to determine computer use in a typical week at the start of the semester (Tables 2 & 3). Nonparametric statistics were performed and indicated that the two groups were not significantly different with respect to the amount of time they used the computer nor the type of use. Most students used the computer for word processing and patient records. The next most frequent type of use was recreational. Pretest scores on perceived computer skills were significantly different (i = -.30; ? = .002), such that the comparison group reported greater skill (mean = 27) when compared to pilot students (mean = 19.5).
The two groups were then compared on their pretest knowledge of terms related to the information superhighway. Although mean scores were low for both groups, the comparison group had significantly better knowledge (t = -4.23; p < .00) of terms related to the information superhighway (mean = 6.6) when compared to the students in the pilot course (mean = 3.5).
ANCOVA Results of Group Differences on Knowledge, Attitudes, and Perceived Skill
Pretest scores on attitudes toward computerization were then compared, and although the comparison group had slightly more favorable attitudes toward computer use (mean = 78.5) when compared to the pilot students (mean = 73.4), differences were not statistically significant.
Frequencies of students' amount of weekly computer use at the end of the semester are displayed in Table 2. Using the Mann- Whitney U, a nonparametric test used to test the difference between two independent groups, the pilot group was found to use the computer for significantly more hours in a typical week when compared to the comparisons (p = .05).
Using chi-square analyses, the two groups were then compared on differences in posttest weekly computer use (Table 3). As expected, when compared to the comparison students, significantly more students taking the pilot course were using the computer for e-mail, searching the Internet, finding both nursing and health information on the Internet, and accessing chat groups. Use of the computer for patient records was significantly higher for the comparison group at the end of the semester.
Analyses of covariance were then conducted, which allowed us to compare group differences on posttest knowledge and attitudes scores and perceived computer skill, holding constant the respective pretest scores (covariates). Knowledge scores and perceived computer skill were significantly higher for students in the pilot class. While adjusted mean scores on attitudes were also in the predicted direction, these did not reach significance (Table 4).
Each of the topical assignments required a variety of online activities and are described below. Results of each student's search were shared via a listserv (an e-mail address restricted to the class where students could post messages) so that all students could interact with classmates and the instructor. Selected student comments from the evaluations of each unit's work are included in this article to communicate the essence of the students' experiences.
Getting Online I Introductions I Online Manners. Students were given the task to find a computer, get online, learn about online manners, use emotocons (Internet user shorthand that saves space and expresses feelings), and introduce themselves via e-mail to the class and instructor. This was the most difficult task for the students. Students found computers on campus, at work, and at home, and some students purchased computer systems.
Just when I thought I understood, :-( (frown, sadness), I didn't. Maybe this will be one of those experiences that I'll look back on and laugh at :-D! (big, delighted grin).
Tomorrow is another day and another chance to master (OK, maybe just understand) the computer.
I was very frustrated the other day but thanks to other frustrated students we succeeded.
I bought a home computer and spent 48 hours trying to set up my printer, modem, and install the slip software to get to netscape. I'm not sure what I'm doing, but I'm hoping to figure it out soon :-) (smile, laugh, I'm joking)
Wasn't it wonderful to finally get online?
Finding Nursing and Nursing Networks. Once online, the learning activities were designed to help students explore nursing networks and nursing resources on the World Wide Web. Each student was allowed to select from areas of interest that would contribute to their professional growth and to find and contact a nursing network.
I've found a permanent listserv for pain and hope to do some communicating with patients experiencing chrome pain, as well as with other professionals in this field. This information is going to be valuable for me because I care for cancer patients and can apply this to my practice.
I now can report I'm on two nursing chat groups! That's the good side. The bad side is that I'm being bombarded with tons of mail from each one. I'm not sure how long 111 hold out. I'm already crazy.
I found a site loaded with information about nurse practitioners. There was information about salary scale, job openings, and that the market may already be saturated.
Finding Health Information I Patient Support Groups. Building on skills learned in the first units, students were then guided to health information and support groups on the Internet related to their own nursing practice.
I found a home line health forum discussing pregnancy myths. There was a lot of information being passed on that was not true. Chat groups can be very beneficial but also harmful.
I found Red Ribbon Net with the largest source of information and research on HIV and AIDS. I have some friends who are HIV positive and plan to share this information with them.
I searched the key word "ecmo" (extracorporeal membrane oxygenation) and ehared my reeults using the computer terminals in a patient's room where the family's baby was on ecmo. The family thought the information superhighway was really helpful and fun.
I found Prostate Cancer Info Link with statistics, treatment methods, signs and symptoms, how to talk to the doctor. Families would definitely benefit because of understandability.
Response: Thanks for your information on prostate cancer. My husband had prostate cancer 4 years ago with surgery- I will be interested to see any new information about prostate cancer.
Online With Libraries I Informatics. Learning activities were then expanded to have students get online with the University's library and explore the World Wide Web for libraries and informatics.
Boy, was this a field day! Now I can find any article or research information I want right here in the comfort of my own home, at my fingertips, any time of day. Plus, while doing this assignment, I found material for a project in another class.
I'm excited about my nursing informatics search! A family member was diagnosed recently with precancerous Barrett's esophagus and can hardly eat food. I found lota of information and I'm hopeful this information will help. I was doing my homework, helping my family, and also practicing parish nursing. Voila!
Nursing informatics brought another mind boggier- many nursing interactive !World Wide] Web sites, electronic Journals, electronic data Ln health care. I even found a whole section on the damage computers can do to your health.
I was able to access a wonderful source for online journals called Martindale's Virtual Medical Center. I read an article on chest trauma from the Journal of Nursing. Many more articles are listed there.
It is still hard for me to comprehend that I can get into libraries in Australia and the United Kingdom in a matter of minutes.
Cyberethics. The worldwide growth of the information superhighway increasingly raises issues such as privacy, confidentiality, censorship, freedom of speech, and an ever-increasing concern for control of personal information. Students were challenged to explore the Internet related to cyberethics and analyze the ethical dilemmas for nurses using the information superhighway.
The horizons of our world are expanding; so is our freedom to explore the world. To limit the content on the Internet might limit access to the information we need. I don't think the information can be controlled.
If information related to sex is censored, this might eliminate information that could be helpful to families I care for concerning contraception or breast cancer.
This is a tough issue to grapple with being a student with unlimited resources at her fingertips as well as a parent with children with the same access. It isn't black and white, I just don't know!
I found free software programs that maintain confidentiality with patients by encoding communications. Someday, I may use this type of program with my patients.
Telemedicine. The goal of telemedicine is to give all citizens immediate access to the appropriate level of nursing and medical care as new preventive technologies, disease, or trauma requires. Whether families are rural or urban, telemedicine tape the experts across the country so that local health care providers may have access to the latest research and experts in the field. Students were instructed to explore the Internet related to telemedicine and comment on how they might use the new technologies in their future nursing practice.
Telemedicine is a positive step for nursing to develop and use our skills, especially advanced practice nursing. Nurses could use video diagnosis with home care patients. This would be excellent in a rural community. I do hospice home health. With this technology, I would be able to communicate with them.
I am excited about telemedicine. I work with a lot of cancer patients, and telemedicine would provide them with the ability to talk with other professionals and other patients with similar ailments. When I send a patient home from the hospital, it would be great to be able to rely on telemedicine for home care updates and daily check-ins with patients.
DISCUSSION AND IMPLICATIONS
The quantitative and qualitative results of this project demonstrate the impact of using the Internet as a teaching strategy on a variety of nursing student outcomes. Specifically, despite some of the pretest scores favoring the comparisons, by the end of the semester, students in the pilot course had significantly more computer knowledge, reported greater computer skill, and used the computer more. They also expressed more positive attitudes toward computerization than their peers, although the difference did not reach statistical significance. Further, these students from both rural and urban settings demonstrated success in achieving course assignments which enabled them to:
* Connect online with nursing networks,
* Use current health information found on the Internet in their nursing practices.
* Use skills learned in the pilot class to complete projects in other classes.
* Communicate with classmates via the Internet, forming a potentially valuable professional support system.
* Use the library and librarians early in their programs.
* Understand the relevancy of telemedicine and the Internet to the future survival of nursing in a changing health care arena.
The authors believe there were several reasons this project was successful. First, the course bridged the gap between academia and the "real" world, and it was relevant to nursing students' real work lives. Students began the course feeling somewhat frustrated, some having never turned on a computer, and ended feeling they had the "world at their fingertips." This supports earlier recommendations encouraging future researchers to not only teach about the use of computers but make activities functionally relevant for nurses and their work (Ball et al., 1985). Second, as noted by Connors and colleagues (1996b), the students in the pilot Internet course were active learners. They struggled to get online, supported each other throughout the semester, became increasingly independent, took pride in their new discoveries, and shared information with classmates. Fostering student initiative in learning and greater student-to-student interaction are important by-products of this method of instruction. As noted by others, it is also accompanied by a shift in emphasis on the part of the educator (i.e., from lecturing to guidance and facilitation (Connors et al., 1996a; Kanai-Pak, 1996).
Some limitations of the study must be noted to know the extent of confidence to place in the findings. The authors developed several of the measures used in this study because appropriate measures did not exist. Further, the sample size was small. This, in conjunction with the sampling strategy used, limits generalizability. However, it should be emphasized that even with the small sample size, significant differences were detected between groups.
Although the results of this study are promising, schools interested in using the Internet as a teaching strategy should be aware of the challenges and potential pitfalls of such an undertaking. An adequate computer infrastructure is needed to facilitate student success. At this institution, students have access to computer labs with onsite technicians as well as software, which allows students to access a variety of programs and electronic services from home. There is also a help desk available to students and faculty to troubleshoot computer and system problems. Even with such an infrastructure in place, technical problems are inevitable. Thus, faculty, librarians, and technology experts need to be continually available to help students as problems occur.
This course will continue to be offered to RN-to-MSN students at the College of Nursing, and similar teaching strategies are currently being piloted and evaluated in five additional courses. Knowledge of the relevancy and use of the information superhighway is crucial to the future survival of nursing in a rapidly changing health care arena. If nurses do not adapt and keep pace with the revolutionary changes occurring in the health care environment, they will be in danger of becoming the "dinosaurs" of the health care industry. This final course evaluation comment illustrates the importance of this knowledge from the student perspective:
I was forced to learn all the valuable information on the Internet by taking this course. I realize now how important it will be for me to utilize this information in future classes. I have been talking about the Internet at work, hoping to get my employer to begin to see what an asset.. .computers would be. All this information is just waiting to be accessed. You can help patients help themselves by getting into chat groups on cyberspace for current information on disease processes and support groups.... For the first time since I [have] live[d] here in the boonies, I feel connected to the world!
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Background Characteristics of Students
Amount of Computer Use in a Typical Week
Type of Computer Use In a Typical Week
ANCOVA Results of Group Differences on Knowledge, Attitudes, and Perceived Skill