RESEARCH The Use of Personal Digital Assistants by Nurse Practitioner Students and Faculty Sally D. Stroud, EdD, APRN, BC. (ANP) Elizabeth A. Erkel, PhD, RN Carol A. Smith, DSN, RN, CRNP (FNP)
INTRODUCTION Purpose To describe the prevalence and patterns of use of personal digital assistants (PDAs) by nurse practitioner (NP) students and faculty, examine relationships between patterns of use of PDAs and demographic characteristics of NP students and faculty, and describe patterns of use of PDAs that support evidence-based practice (clinical scholarship). Data Sources Responses to a 20-item questionnaire administered via electronic or postal mail from 227 NP students and faculty. Conclusions A majority (67%) of the participants used PDAs. Use was higher among men (82%) than women (64%) (p < .05). On average, respondents who used a PDA (N = 153) had been using it just over a year (M = 13 months). Respondents reported using a PDA most days of the week (M = 5 days). The top three medical software programs identified by respondents as the most useful in clinical practice were ePocrates Rx (82%), Griffith’s 5-Minute Clinical Consult (26%), and MedCalc (22%). Most participants (96%) related that PDA use supported clinical decision making. Implications for Practice Personal digital assistants may facilitate the application of evidence-based knowledge to practice. However, until there is evidence that PDA software is valid and reliable, clinicians should continue to use a multitude of references to assure the quality and safety of care provided.
The knowledge needed to provide safe and effective health care is complex and dynamic in nature, making lifelong learning an integral part of practice. Knowledge essential for nursing practice is recognized as ranging from ‘‘intuitive knowing, acquired by experience and expertise, to the systematically verified knowledge of empirical researchers integrating clinical knowledge, conceptual knowledge and empirical evidence’’ (Schultz & Meleis, 1988, p. 217). The advanced practice registered nurse (APRN) engages in many basic nursing practice activities. However, the APRN is expected to demonstrate competence beyond the basic skill level in clinical judgment and decision making, patient management, organizational collaboration, independent practice, and communication in complex care (Hickey, Ouimette, & Venegoni, 2000). Nurses are challenged to operate from a base of knowledge that allows them to know and readily identify what they do not know. Ideally, decisions of all clinicians, including APRNs, are grounded in evidence-based practice, the application of current research to the individual care situation. The ultimate goal is to base care on best practices, which combine evidence-based practice with the clinician’s judgment and the patient’s preferences. Best practices in turn create new standards for care and can serve to improve the cost effectiveness and quality of care provided (Hickey et al., 2000). Clinician’s use of standards depends on ready access to accurate information sources. Current standards of care and best practices have become readily accessible via handheld computers, also known as personal digital assistants (PDAs). However, little is known about how nurse practitioners (NPs) incorporate this technology into their everyday practice. Nor are the implications of this new technology known for the acquisition of knowledge for evidencebased practice in APRN educational programs. Research skill is integral to APRN practice as the ‘‘collection and synthesis of existing information from various sources,’’ as well as the acquisition of new knowledge through empirical research (Stommel & Wills, 2004, p. 3). Ways to acquire and maintain the expert knowledge required for advanced practice need to be defined and tested for effectiveness. The use of knowledge in practice and the resulting ‘‘new intellectual understandings’’ are primary keys to clinical scholarship, defined by Boyer (1990) as the ‘‘Scholarship of Application’’ (p. 23). For this study, clinical scholarship is defined as the demonstrated application of current evidence, standards, and knowledge to clinical decision making. A better understanding of how PDAs do or do not improve the clinical scholarship of APRNs is needed for both advanced nursing practice and education.
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Key Words Personal digital assistant, handheld computer, clinical decision making, scholarship, advanced practice nursing. Authors Sally D. Stroud, EdD, APRN, BC, ANP, is the Coordinator, Adult & Family Nurse Practitioner Programs at the Medical University of South Carolina, College of Nursing, Charleston, South Carolina. Elizabeth A. Erkel, PhD, RN, is an Associate Professor at the Medical University of South Carolina, College of Nursing, Charleston, South Carolina. Carol A. Smith, DSN, RN, CRNP, FNP, is Professor-in-Charge of Graduate Programs and Outreach at Pennsylvania State University, School of Nursing, University Park, Pennsylvania. Contact Dr. Stroud by e-mail at
[email protected]
BACKGROUND For many years, physicians, medical students, NPs, and NP students have carried small handbooks, notebooks, and index cards in their pockets to access commonly used facts, practice guidelines, clinical pearls, and patient data. These peripheral brains had several limitations, such as a slow retrieval process, lack of organization, and the potential for illegibility. In the early 1990s, PDAs evolved from electronic calculators and organizers. These small, handheld computers included the standard features of an organizer—date book, address book, calculator, memos, and list of tasks—but also had the capability to download electronic software programs that contained drug information, medical calculators, and diagnostic tools. Other applications were soon developed, for example, data management, documentation of patient information, billing and coding of visits, medical text/references, and language translators. Clinicians found that these portable, slim, wireless devices helped organize their lives and clinical practices by replacing their cumbersome paper peripheral brains with convenient, rapid access to important medical references and patient information. The most popular PDAs are small enough to fit in a pocket, weigh less than a pound, and operate on either replaceable or rechargeable batteries. Information is stored on a credit card– sized integrated circuit card, similar to the disk drive of a desktop or laptop computer. The PDA turns on instantly without a boot-up process and can switch quickly from one application to another. The PDA easily interfaces with desktop computers that allow for downloading software programs and synchronizing data located on both devices (Cordell & Peak, 1992). With the PDA, clinicians can gather, enter, and store data at the point of care. The information is then easily organized and readily accessible. If desired, all data can be downloaded to a centralized database at a later time. Consequently, clinicians can use the PDA as a mobile tool to record patient data, log procedures, or clinical hours; translate English into a foreign 68
language; collect data for reports or studies; and access clinical management references and practice guidelines. Medication errors are a critical issue in health care. The Institute for Safe Medication Practices (2000) reported that 7,000 Americans die annually from prescription medication errors at a cost of nearly $77 billion. The Institute proposed that handwritten prescriptions be eliminated and replaced by electronically written prescriptions to help decrease these errors. PDAs have the potential to become part of today’s electronic prescription technology. In 2001, a Harris poll estimated that 26% of physicians were using PDAs and predicted that the number will double by 2005 (Harris Interactive Computing in Physician’s Practice, 2001). In the same year, Enger (2001) estimated that 1% of nurses were using PDAs. Anecdotally, acute and primary care NP students at the University of Virginia School of Nursing are being required to purchase PDAs in place of a pharmacology text for the advanced pharmacology course. Although the results have not been published, students’ response to using PDAs has been very positive despite the initial learning curve (Suszka-Hildebrandt, n.d.). Few studies have addressed the use of PDAs in health care; none have focused on nursing faculty and students. Weber and Roberts (2000) reported that a variety of handheld computers have been used by researchers conducting nutrition assessments, dental studies, nursing research studies, pharmacological studies, and behavioral assessments. Because data could be entered directly at the point of care, it was believed that fewer data entry errors occurred using handheld devices. Rothschild, Lee, Bae, and Bates (2002) conducted a 7-day online survey of randomly selected users of a drug reference, ePocrates Rx. Of 3,000 users contacted, 946 (32%) responded. A majority of respondents reported an improvement in drug knowledge (79%), improved drug-related decisions (80%), and avoiding one or more serious adverse drug events per week (50%) through the use of the PDA drug reference application. Alderson and Oswald (1999) studied 13 medical students who used an electronic spreadsheet on handheld computers to log clinical experiences for 15 months. The spreadsheets provided data for quantifying clinical experiences and identifying gaps in those experiences. According to the investigators, the device proved to be a practical and feasible way to record clinical information. Garvin, Otto, and McRae (2000) conducted a study of 22 family practice residents who were given handheld computers to log data on procedure experiences during clinical rotations. Most (88%) residents used the handheld computers to collect data, and 83% reported daily use of the device. The authors concluded that the handheld computers streamlined data collection and assisted in generating timely and useful procedural reports for the residency program. Use of a handheld, computer-based system on pediatric guidelines for office management of asthma exacerbations by nine physicians was studied by Shiffman, Freudigman, Brandt, Liaw, and Navedo (2000). They found that use of handheld computers was associated with increased adherence to guidelines. VOLUME 17, ISSUE 2, FEBRUARY 2005
However, visits were longer, fees were higher, and there was no improvement in intermediate-term outcomes. In summary, the few studies published to date in the healthcare literature have been conducted among physicians and limited to the study of prevalence of all-purpose PDA use, improvement in care through use of a specific PDA reference application, or data entry for research or generation of reports. Little is known about the use of PDAs by healthcare professionals in their routine provision of care.
STUDY PURPOSE The purpose of this study was to describe the current use of PDAs among NP students and faculty related to clinical scholarship. We asked 1. What are the (a) prevalence and (b) patterns of use of PDAs among NP students and faculty? 2. Are patterns of use of PDAs related to demographic characteristics of NP students and faculty? 3. What patterns of use of PDAs support or do not support clinical scholarship?
METHOD A descriptive correlational survey design was used to describe the prevalence and usage patterns of PDAs among NP students and faculty. Participants were selected using a two-stage cluster sample from a list of organizations that offered NP educational programs in the United States in 2000. A 20-item questionnaire was administered via electronic mail. This study was reviewed by a university Institutional Review Board committee and approved for an exempt designation. Population and Sample The population for this survey was composed of NP students and faculty who were involved in clinical practice in the United States. An NP was defined as a registered nurse (RN) with specialized, advanced education who is qualified to provide acute or primary care for a proscribed population in collaboration with physicians and other health disciplines. NP students and faculty who enrolled or taught in one or more clinical courses involving direct patient care were eligible to participate. For the purpose of this study, nurse midwifery students and faculty were excluded from the population because of their separate professional organization and identity. A list of program directors from 238 organizations in the United States offering NP educational programs was compiled from the National Directory of Nurse Practitioner Programs of the National Organization of Nurse Practitioner Faculties (2001). Because no list of NP students and faculty existed, a two-stage cluster sample was conducted. First, a random sample of 150 organizations was selected. A letter to 371 directors of NP programs at the organizations selected into the sample JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
explained the purpose of the survey and sought participation. Organizations that declined to participate were replaced with a randomly selected alternate until 150 organizations were included in the sample. Second, the program directors or the directors’ designees identified NP students and faculty currently enrolled or teaching in clinical courses involving direct patient care who were willing to participate in the survey by either electronic or postal mail. A total of 855 questionnaires were distributed to individuals who had agreed to participate in the survey; 227 (27%) were returned. While a higher number of questionnaires were distributed and returned by electronic mail than postal mail, a higher response rate was achieved by distribution and collection of paper questionnaires by the program director (or designee) who returned them by mail (73/158 or 46%) than by electronic mail distribution directly to participants (154/697 or 22%). There was no difference in demographic characteristics between those who responded by electronic versus postal mail (p > .05). The Research Instrument The 20-item questionnaire was developed from a review of publications describing use of PDAs by health professionals. The questionnaire included 14 items related to PDA brand and use (duration, frequency, and types of software applications); 6 items were related to characteristics of respondents. Item construction and questionnaire distribution followed Dillman’s tailored survey design method (2000, pp. 50–78). Reading level of the instrument is at the 10th year of schooling according to the Gunning Fog Index, reprinted in Burns and Grove (2001, p. 402). Content-related validity was established by a four-member expert panel, who rated the content relevance of each item using a 4-point rating scale, where 1 = not relevant, 2 = unable to assess relevance without item revision, 3 = relevant but needs minor alteration, 4 = very relevant. All items but one achieved a mean rating of 3.75–4. One item had a mean rating of 3.5. The draft questionnaire was revised based upon input from the expert panel. Procedure Following compilation of addresses, the questionnaire was distributed by electronic or postal mail, as requested by the recipient. Up to five individualized contacts were made with the electronic questionnaire recipient: (a) a brief prenotice letter, (b) a questionnaire mailing that included a cover letter (2 days later), (c) an electronic thank you/reminder letter that included the questionnaire (1 week later), (d) a replacement questionnaire (2 weeks later), and (e) final contact (3 weeks later). Program directors who distributed the mailed questionnaires to their students were sent a thank you/reminder letter (2 weeks later). Upon receipt, questionnaires were prepared for data entry and entered into a Microsoft Excel database. After checking for completeness and correctness, the data were stripped of identification and imported to Statistical Program for the Social Sciences software for statistical analysis. Univariate and bivariate statistics were used to analyze quantitative responses. Differences in characteristics were examined using two-sided tests 69
(a # 0.05). Qualitative data from open-ended questions that elicited respondents’ experiences in using PDAs were subjected to a phenomenological method of analysis (van Manen, 1990).
respondents who were RNs currently enrolled or teaching in an NP course involving direct patient care. Demographic characteristics (except race/ethnicity) remained stable across the initial and restricted samples (Table 4).
RESULTS
Initial Motivation A majority of students reported that they had obtained a PDA for assistance in clinical decision making. Most faculty members had obtained a PDA for management of personal information. Only one respondent, a faculty member, reported that the initial motivation to obtain a PDA was a requirement by the NP program (Table 5).
A majority of the 227 respondents (63%) specialized in family practice, 13% in adult health, and 24% in 10 other specialties (Table 1). Most of the 227 respondents were women (83%) and students (72%). The sample was relatively mature in age (M = 42 years) and experienced as RNs (M = 16 years). Faculty, on average, were 12 years older than students and had practiced as an RN twice as long as had students (Table 2). Among all respondents, 96% (217) were RNs and 89% (202) were enrolled or teaching in a clinical course. One respondent was Hispanic (
