- Email: [email protected]
Nursing students' experience of using a personal digital assistant (PDA) in clinical practice — An intervention study
Nurse Education Today 33 (2013) 1246–1251
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Nursing students' experience of using a personal digital assistant (PDA) in clinical practice — An intervention study Pauline E. Johansson ⁎, Göran I. Petersson 1, Gunilla C. Nilsson 2 eHealth Institute and School of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden
a r t i c l e
i n f o
Article history: Accepted 30 August 2012 Keywords: Computers handheld Intervention study Nursing informatics Nursing practice Nursing students
s u m m a r y Background: A personal digital assistant (PDA) is a multifunctional information and communication tool allowing nursing students to keep up to date with expanding health related knowledge. Objectives: This study was aimed at exploring nursing students' experience of using a PDA in clinical practice. Method: In this intervention study, nursing students (n = 67) used PDAs during a period of 15 weeks, replied to questionnaires, and participated in focus group interviews. Results: The PDA was found to support nursing students in clinical practice and to have the potential to be a useful tool with benefits for both the patients and for the students. The PDA was regarded as useful, and was presumed to imply increased confidence and time savings, and contribute to improved patient safety and quality of care. Conclusions: With available mobile technology, nursing students would be able to access necessary information, independent of time and place. Therefore, it is important that stakeholders and educators facilitate the use of PDAs to support nursing students during their clinical practice, in order to prepare them for their future work, and to continuously improve the safety and quality of healthcare. © 2012 Elsevier Ltd. All rights reserved.
Introduction The continuous increase of health related knowledge implies that nursing students (NSs) handle large amounts of information in their clinical practice as well as in their future work. The latest information is usually available on the Internet, but a desktop computer or a laptop is rarely easily available at patient bedside. Consequently, there is a need for applicable mobile devices which can provide access to accurate information. Mobile computing with increasingly capable, flexible, and powerful personal digital assistants (PDA) provides people on-the-go with access to anything that can be done on a desktop computer (Johnson et al., 2011).
Background PDAs (i.e. mobile computing tools, handheld devices, handheld computers or smart phones) are small, portable, and convenient to
⁎ Corresponding author at: eHealth Institute and School of Health and Caring Sciences, Linnaeus University, SE-391 82 Kalmar, Sweden. Tel.: +46 480 446315; fax: +46 480 446955. E-mail addresses: [email protected] (P.E. Johansson), [email protected] (G.I. Petersson), [email protected] (G.C. Nilsson). 1 Tel.: +46 480 497124; fax: +46 480 446955. 2 Tel.: +46 480 446042; fax: +46 480 446955. 0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2012.08.019
use for fast data management, and enable users to accomplish tasks anywhere and anytime (Sarasohn-Kahn, 2010). Intervention studies have evaluated undergraduate NSs' use of PDAs during their clinical practice, and using a PDA is reported to increase self-confidence (Goldsworthy et al., 2006; Wu and Lai, 2009), to enhance their learning (Pattillo et al., 2007; Farrell and Rose, 2008; Koeniger-Donohue, 2008; Wu and Lai, 2009; George et al., 2010; Secco et al., 2010; Hudson and Buell, 2011), and to integrate more theories into practice (Wu and Lai, 2009). The PDA is time saving (Guillot and Pryor, 2007; Pattillo et al., 2007; Koeniger-Donohue, 2008; Wu and Lai, 2009; Secco et al., 2010), and making NSs more organized and/or efficient (Goldsworthy et al., 2006; Pattillo et al., 2007; George et al., 2010). The PDA might improve quality in nursing care and promote relatives' involvement in sharing information (Guillot and Pryor, 2007). In summary, PDAs have been found to be supportive for NSs, enhanced learning, increased effectiveness and saved time. Although, in Sweden PDAs are rarely used in nursing practice and not in nursing education. There are numerous information and medical software applications available but few are adjusted for technical, statutory, cultural, and language country-specific conditions, and not especially developed for nursing. Thus far, desktop computers or laptops are available at wards and healthcare units. To motivate the implementation and take advantage of the fast developing technology based on new PDAs, the end users' needs and attitudes must be taken into account. Therefore, this study aimed at exploring nursing students' experience of using a PDA in clinical practice.
P.E. Johansson et al. / Nurse Education Today 33 (2013) 1246–1251
Method Study Design In this intervention study, at a university in southern Sweden, NSs were supplied with PDAs during their clinical practice. This study was carried out during three final semesters of three consecutive undergraduate nursing degree programs. The NSs (n = 120) were provided information about the study and 67 NSs, who volunteered were randomly selected from the three final semesters, (n = 20, n = 22, n = 25) respectively, to correspond with the available number of PDAs. The NSs' clinical rotation, a total of 15 weeks, took place in non-institutional or institutional psychiatric care for children or adults, in rural district health services in sheltered accommodations or in patients' home, and in the university healthcare center run by NSs; and each rotation lasted five weeks at each location. All NSs participated in an introduction (3 h) and received the PDA together with technical training. Technical support was provided by the first author. The PDA (a Palm TX) contained pharmaceutical and medical resources freely downloaded from the Internet. These resources included FASS (an encyclopedia with information about the medicines that have marketing authorization in Sweden), Med Calc (a medical calculator, not adjusted for Swedish nursing), guidelines/techniques for treatment (e.g. pain relief, elderly care, test instructions and reference intervals), and acts and regulations for nursing. In addition, the PDA contained the usual functions, such as a word processing program, a calculator and calendar, and one could enter and download own's notes and documents into the PDA. Patient data that may reveal the patient's identity were not allowed to be stored in the device. Data Collection The NSs answered a questionnaire before and after their clinical practice, and they were interviewed in focus groups after the postquestionnaire. The questionnaires were developed for this study. The prequestionnaire included demographic characteristics and questions concerning the NSs' experience of having access to information and various tools in clinical practice prior to the study (Table 1). The post-questionnaire included four-point-scaled (Table 2), dichotomized (Table 3), and open-ended questions (Table 4), inspired from our previous research (accepted). The NSs (n = 39), from the first two semesters, were divided into seven focus groups (Kitzinger, 1995), and were interviewed at the university by two of the authors (PJ and GN). The interviews lasting 30–50 min, were recorded, and transcribed verbatim. The interviews began by asking ‘If you have a PDA when starting to work as a nurse, what information and functions should the PDA contain to be as useful as possible in your work?’, followed by probing questions, e.g. ‘In what situations?’, ‘What are the advantages and disadvantages?’ and ‘Can you explain further?’ Data Analysis Descriptive statistics were applied. The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 18.0 for Windows (SPSS Inc., Chicago, IL). The results from the four-point-scales (Totally disagree=1; Partly disagree= 2; Partly agree= 3; Totally agree=4) and the dichotomized questions are presented in the text as ‘disagree’ (grades 1–2/No) and ‘agree’ (grades 3–4/Yes); in tables, frequencies (n), median (possible variation= 1–4), and total score for each question (possible variation =58–232) are presented. The open-ended answers were sorted according to convenient categories emerging from the focus group interviews. Three NSs did not respond (all three from the second semester) and six post-questionnaires were excluded because of internal missing data, yielding a response rate of 87% (n=58).
1247
Table 1 Nursing students' (n = 58) demographic data. Age, mean (SD) Range, year Gender, n (%) Male Female Estimated computer skills level, n (%)a Very good Fairly good Intermediate Fairly poor Very poor Used a PDA prior to this study, n (%) Yes No Worked in healthcare before the undergraduate nursing degree programs began, n (%)a Yes No Do you feel that there is sufficient information available to perform your duties in a satisfying way? n (%) Always Frequently Occasionally Never Do you feel that the handling of your personal notes is reliable? n (%) Yes No Do you feel secure in the manner you carry out calculations of medicines? n (%)a Yes No
27.3 (7.2) 21–50 13 (22) 45 (78) 6 (10) 29 (51) 21 (37) 1 (2) 0 (0) 1 (2) 57 (98)
41 (72) 16 (28)
1 (2) 46 (79) 11 (19) 0 (0) 28 (48) 30 (52)
42 (74) 15 (26)
Note: PDA = personal digital assistant. a Missing participant (n = 1).
The data from the focus group interviews were analyzed by content analysis method (Berg, 2007) by the first author. The data were read and reread to gain an overall understanding of the content. The next step was entailed identifying meaning units and grouping them into categories; finally, the meaning units were coded and organized into subcategories (Table 5). During the analysis process, the categories were refined by moving back and forth between the text Table 2 The nursing students' (n = 58) experience of using a PDA in clinical practice from the four-point-scales. Totally Partly Partly disagree disagree agree (n) (n) (n) 1. The PDA is useful in my clinical practice. 2. The PDA gives me a higher degree of confidence in my clinical practice. 3. The PDA might help to increase the quality of care. 4. The PDA might help to increase patient safety. 5. The PDA might help to save time. 6. The PDA makes it easier to manage my own notes. 7. The PDA makes it easier to carry out calculations of medicines.
Totally agree (n)
md Total scorea
2
10
39
7
3
167
2
11
33
12
3
171
0
11
38
9
3
172
0
14
34
10
3
170
4
18
27
9
3
157
5
15
29
9
3
158
3
16
27
12
3
164
Note: PDA = personal digital assistant. Totally disagree = 1; Partly disagree = 2; Partly agree = 3; Totally agree = 4. md = median (possible variation = 1–4). a Total score for each question = 58–232.
1248
P.E. Johansson et al. / Nurse Education Today 33 (2013) 1246–1251
Table 3 The nursing students' (n = 58) experience of using a PDA in clinical practice from the dichotomized questions. No Yes (n) (n) 8. Do you experience that the PDA is or could be a useful tool to give ac4 cess to the information you need to perform your duties in a satisfactory manner? 9. Have you used the PDA at the patient bedside or together with 32 patients? 9 10. Would you like to have a PDA in your future work as a nurse?a
54
26 48
Note: PDA = personal digital assistant. a Missing participant (n = 1).
and the emerging categories (Graneheim and Lundman, 2004). The analysis revealed four categories and eight subcategories (Table 6). The accuracy of the categories was verified against the original interview text to make sure that the meaning had not been changed during the analysis process, and that the categories were grounded in the data (Berg, 2007). Quotations are used to show the credibility of the categories that emerged (Graneheim and Lundman, 2004). For data reporting purposes, each focus group was given a number (Nos. 1–7). Results The results are presented below; firstly, the pre- and postquestionnaire, followed by the results from the focus group interviews, including the open ended questions from the post-questionnaire. The Pre-questionnaire Prior to the use of the PDA, the majority of the NSs regarded that they usually had sufficient accessible information to carry out their duties in their clinical practice in a satisfactory manner. Also, before PDAs, the NSs used scraps of papers, notebooks, or diaries to record memos about their patients; half of the participants considered the handling of their notes to be unreliable. However, the majority felt secure about the manner in which they carried out calculations of medicines with resources available before using a PDA. Further data from the pre-questionnaire is presented in Table 1. The Post-questionnaire During the intervention, 39 NSs used their PDAs one to five times a day, four NSs used it up to ten times a day, one NS used it 20 times a day, whereas 14 NSs used their PDAs only a few times during the entire intervention period due to a lot of schoolwork. The majority of the NSs agreed that the PDA is useful, gives a higher degree of confidence in their work, and that the PDA might help to increase the quality of care, and patient safety. More than half of the NSs agreed
Table 4 The open-ended questions in the post-questionnaire. • Give examples of one or more events where the personal digital assistant (PDA) could be of use in your clinical practice. • What functions of the Dr Companion — Nurse Edition software have you used? • What functions of the PDA have you used? • What information or functions are you missing in the PDA? • When is a PDA useful in your work today? • How do you think a PDA can improve your work? • How do you think a PDA would improve patient safety? • How do you think a PDA can help to increase the quality of care? • How do you think a PDA can contribute to time savings in your clinical practice? • Other comments.
Table 5 Examples of data analysis process: meaning units, codes and categories. Meaning units
Codes
Subcategory
Category
“The most important is that it is easy to get it, it's quick to get it and so, it is when you can have it in your pocket” “Then I can give this patient, who may be worried about something and have a question, an answer right away when I'm there” “There is no reason for anyone to take a chance because you always have the information with you and if you are unsure you can always check again” “In psychiatry the supervisor was an opponent [to the use of the PDA], — it did not look good in front of patients, it looked suspicious and … well, it looked like I had no knowledge when I was using it [he said]”
Quick access to information
Advantages in clinical practice
Usefulness
Patients need not wait for an answer
Nurse–patient interaction
At bedside
Information is always available
Updated information always at hand
Confidence for nursing students
Opposed to PDAs in psychiatry
Opinions among others about using PDAs
Other perspectives of the use of PDAs
that the PDAs facilitate the handling of their own notes, facilitate to carry out calculations of medicines and to save time in their clinical practice (Table 2). Nearly half of the NSs used their PDAs at the patient bedside and/or together with patients. Almost all NSs agreed that a PDA provides access to accurate information, which they need to carry out tasks in a satisfactory manner, and the majority would like to have a PDA in their coming work (Table 3).
Usefulness Advantages in Clinical Practice In the interviews, the NSs perceived that the PDA provides easy and immediate access to information integrated in one place. The information is always at hand and this immediate access to information implies that the NSs can check the information and document on the go. In order to replace loose scraps of papers, the NSs also found it useful to make their own notes in the PDA. The majority of the NSs believed that the PDA is very useful, especially in homecare where there is limited information and there are no computers available to use, whereas few were convinced that the PDA fills the same need in hospitals. In hospitals, there are a lot of stationary computers, laptops, paper based guidelines, and card index available. In the questionnaire, the NSs regarded that a PDA can improve their work by the immediate and accurate information always being available. By having a PDA, the NSs become their own “database” with the ability to quickly find information, with reminder and documentation functions anywhere and anytime, and colleagues can easily be consulted. The NSs stated that clinical practice becomes more efficient, safer, organized, and timesaving with the PDA. Table 6 The categories and subcategories that emerged from the data. Categories
Subcategories
Usefulness
Advantages in clinical practice Content and functions Nurse–patient interaction Benefits for patients Updated information always at hand Manage information wherever you are Opinions among others about using PDAs Implementation of PDAs in nursing
At bedside Confidence for nursing students Other perspectives of the use of PDAs
P.E. Johansson et al. / Nurse Education Today 33 (2013) 1246–1251
“The most important is that it is easy to get it, it's quick to get it, and so it is when you can have it in your pocket” (No. 4)
Content and Functions The NSs found the information and content useful but to be an optimal tool the NSs asked for more content and functions. Not only to be able to read information but also to document in order to avoid duplication, the NSs wanted access to the electronic health record (EHR) via the PDA. Some NSs regarded it important that resources in the PDA are verified and safe to use in nursing practice, in contrast to a lot of Internet resources which they found difficult to determine regarding credibility. “You can find many functions [at the Internet] but it is difficult to know which are reliable, if it [the content] is verified or if the content has been constructed by an amateur, thus everything will be wrong… //…[by means of a PDA] you would like to have controlled and reliable functions” (No. 1)
At Bedside Nurse–Patient Interaction In the interviews, most NSs used the PDA in the encounter with the patient; some NSs had even used the PDA to answer relatives' questions. This meant that the NSs could supply patients and their relatives with instant information, e.g. about medicines, and the NSs had also been able to take notes in the PDA during patient conversations. This availability of information via a PDA entails that the NSs can spend more time with patients, and patients do not have to wait for an answer, thus the NSs regarded it improved quality of care. The NSs described that the PDA can provide a basis for patient education. “Then I can give this patient, who may be worried about something and have a question, an answer right away when I'm there” (No. 4)
Benefits for Patients The NSs perceived that patients were positive and interested in their use of the PDA. One NS described that relatives regarded it as good that she used the PDA because it was perceived as troublesome when the staff ran out to retrieve information that was needed to answer the relatives' questions. In the interviews as well as in the open-ended answers, the NSs described the advantage of having instant access to a PDA implying that they did not have to leave the patient and thus regarded it improved patient safety. This was stated by the NSs in general as essential, e.g. if patients become very ill and could not be left alone. “Patient safety, do not have to leave the patient to retrieve information” (No. 7)
Confidence for Nursing Students Updated Information Always at Hand The NSs stated, in the interviews and in the open-ended questions that a PDA provided confidence for them in clinical practice and in their future work because it can provide access to everything they need. A PDA is a good support for NSs and newly graduated nurses when there is a lot happening. By having a PDA, recent information is constantly updated. A PDA can be a support when working alone and in the immediate encounter with the patient, because you do not always know in advance what information you will be needing. The NSs could get access to necessary information repeatedly and
1249
can check how to carry out procedures, anywhere, and anytime. Sometimes, the work could be very hectic and the NSs could not have all the necessary information in their minds. “There is no reason for anyone to take a chance because you always have the information with you and if you are unsure you can always check again” (No. 5)
Manage Information Wherever You Are The access to information and the medical calculation in the PDA were highly appreciated by the NSs and made them feel confident in clinical practice. A PDA is good for taking notes at patients' homes about things to remember when back at the office. In order to reduce the risk that any information will be lost, the NSs wanted to record directly into the patient EHR. The NSs regarded the PDA as secure in handling their own notes and appreciated that they individually could modify the content in the PDA. The NSs also wanted to have a camera to photograph patient wounds and to consult colleagues and/or a doctor while still being present in the patients' home. “A lot can happen between the patient's room and my office, lot of stuff can happen that you capture and that you forget … and we like to think that we remember very much but we do not and we also distort information” (No. 2) In general, the NSs stated that they wanted to have a PDA in their work, while some others felt that a PDA could be useful for some but, due to lack of technical interest and/or computer skills, not for themselves. Some NSs did not believe that a PDA in its present form could increase confidence at all. To be optimal and to increase confidence, a PDA needs more content and functions adjusted for Swedish nursing and technical condition. Other Perspectives of the Use of PDAs Opinions Among Others About Using PDAs During the interviews, several NSs reported about the positive feedback from their supervisors about their use of the PDA, primarily in rural district health services. In contrast, a few NSs said that their supervisors, not familiar with the use of PDAs, found the content “messy”. Several NSs said that their supervisors found that the PDA becomes useful only when the patients EHR could be accessed. However, in psychiatric inpatient care, there were some NSs that said that their supervisors were totally against the use of a PDA, especially in front of the patients who might become uncomfortable. “In psychiatry the supervisor was an opponent [to the use of the PDA], — it did not look good in front of patients, it looked suspicious and … well, it looked like I had no knowledge when I was using it [he said]” (No. 3) Implementation of PDAs in Nursing Based on their experience, the NSs supposed that it would be difficult to implement PDAs in healthcare. Sometimes, the NSs believed that the employer was interested, but not the registered nurses and this will make it difficult to gain acceptance for new technology. Therefore, some NSs were unsure how a PDA would be accepted among their nursing colleagues. Few NSs were afraid that their colleagues would think that they misuse the PDA for personal reasons like playing games and music. “I would like to have a PDA when I start working … but how will it be received, I'm so new? … I want to join in and be one of the team,… but if I have a PDA … what will other colleagues think and say? ..,.. yes, you never know how things are received either by one's manager or colleagues” (No. 3)
1250
P.E. Johansson et al. / Nurse Education Today 33 (2013) 1246–1251
Discussion We found that the NSs perceived that a PDA has the potential to be a useful tool in clinical practice, with benefits for both the patients and for the NSs. Even if most information required is available without a PDA, the majority of the NSs were of the opinion that the PDA is useful in their clinical practice and future work to easily and immediately get access to necessary, accurate, and updated information. The NSs appreciated that the information was integrated in one device, independent of time and place. The PDA was regarded as most useful in homecare, where there is limited access to information with no computers available to use. In addition, a PDA has the potential to enhance nursing care delivery at the patient bedside in hospitals, since stationary computers are not always available (Guillot and Pryor, 2007). Furthermore, a PDA might replace the use of paper based guidelines and card index, still used in some places. In a PDA, these documents will always be available and can be updated automatically. A nurse's job is information intensive and routines include extensive documentation. Using notes on scraps of paper, in notebooks, or in diaries was not regarded as reliable and the NSs stated that functions for documentation in the PDA could be useful. Although the majority felt secure in the manner they carried out calculations of medicines before using the PDA, more than half of the students regarded that the PDA could facilitate also for this purpose. Thus, to be as optimal as possible, more content and functions are needed, especially the EHR, and that available information is verified and safe to be used in nursing practice. Our NSs considered that a PDA could be helpful to ensure high levels of patient safety and quality of care, which is in accordance with the law (Ministry of Health and Social Affairs SFS, 1982:763; Ministry of Health and Social Affairs SFS, 2010:659). Some of the NSs used the PDA in the encounter with patients and/or relatives and received positive responses, in agreement with a previous report (Hudson and Buell, 2011). Even if the time saved by the use of a PDA has not been evaluated in our study, NSs believed that the PDA helped them to organize their clinical practice and made them more efficient, resulting in more time to be spent with the patients. In accordance with another study (Koeniger-Donohue, 2008), the NSs also believed that a PDA might be very helpful in situations when they had to answer questions from patients and/or family members. Furthermore, the PDA helped when conducting patient education and when checking how to carry out procedures; above all, in situations when the NSs were unable to leave the patient. The NSs in this study were at the end of their nursing education and close to graduation; a transition phase when the NSs need extra access to supportive information and functions. When working as novice nurses, they are more likely to experience stress (Wu et al., 2012), and their lack of experience would motivate their need for information (Saintsing et al., 2011). Stress because of time limitations, pressure from experienced nurses, the amount and complexity of information and lack of confidence are factors that affect the amount of errors made (Saintsing et al., 2011). A PDA can provide access to accurate information repeatedly, the users can check how to carry out procedures anywhere and anytime, and communicate with their colleagues. The NSs in our study found the PDA could provide them added confidence, in agreement with Goldsworthy et al. (2006). The NSs believed that a PDA could be supportive, especially when working alone, in homecare and in the immediate encounter with the patients. In addition, the NSs felt confident and secure to use the PDA in order to handle their own notes, replacing loose scraps of paper confirmed by another study (Kuiper, 2008). Furthermore, the possibility to record directly into the patient EHR might reduce documentation errors, by means of avoiding duplication of documentation or avoid the risk of loss of any information. The NSs met mostly positive feedback about the PDA from nurses, primarily in rural district health services. On the other hand, some
nurses, especially in psychiatric inpatient wards, were completely against the use of a PDA. This was in agreement with another study (Hudson and Buell, 2011), in which it was described that the NSs were considered not to be knowledgeable if they had to use a PDA; the information should be recalled from memory or patients might experience that the NSs were playing games on it. Based on our NSs' experience about other perspectives of the use of PDAs, they regarded that it would be difficult to implement PDAs in healthcare. Rather, the problem is mainly to gain acceptance for new mobile technology among colleagues. We regard the results in our study useful to illuminate NSs' experience of using a PDA in clinical practice. The sample selection was convenient and the size was moderate; thus, the results should be interpreted with some caution. However, the response rate was high, and each NS used their PDAs for 15 weeks, which should be sufficient to become familiar with its use. Although 14 NSs only used the PDA a few times during the whole intervention period, everyone did test it. Furthermore, a large part of our results was based on qualitative data, and a content analysis was seen as suitable to describe the participants' experiences (Graneheim and Lundman, 2004). The interviews were tape-recorded, transcribed verbatim, representative quotations confirmed the descriptions, and the categories were checked against the original data. Taken together with the triangulation of data, we have ensured the results are credible. Conclusions We found that the NSs perceived that a PDA has the potential to be a useful tool in clinical practice, with benefits for both the patients and for the NSs. Since technologies are changing rapidly, it is obvious that NSs should have the opportunity to access all the information they need, independent of time and place, during their clinical practice as well as in their future work. Therefore, it is important that stakeholders and educators facilitate the use of PDAs to support the nursing students during their clinical practice, in order to prepare them for their future work, and to continuously improve the safety and quality of healthcare. Ethical Approval All study participants provided informed consent. The participants received information about the study, about voluntary participation, and about confidentiality requirements. None of the authors were involved in the NSs education as faculty members. Ethical considerations were based on the guidelines of the Ethics Committee of Southeast Sweden, and received permission to be undertaken from the head of the School of Health and Caring Sciences at the Linnaeus University. Conflict of interest No conflict of interest existed. Acknowledgments We thank the NSs who participated in the study and Jean Stevenson-Ågren (MSc. Lecturer) at the School of Language and Literature, Linnaeus University, Sweden for revising the text. The study was funded by Linnaeus University, Kalmar, Sweden. References Berg, B.L., 2007. Qualitative Research Methods for the Social Sciences, 6th ed. Allyn and Bacon, Boston. Farrell, M.J., Rose, L., 2008. Use of mobile handheld computers in clinical nursing education. Journal of Nursing Education 47 (1), 13–19. http://dx.doi.org/10.3928/0148483420080101-03.
P.E. Johansson et al. / Nurse Education Today 33 (2013) 1246–1251 George, L.E., Davidson, L.J., Serapiglia, C.P., Barla, S., 2010. Technology in nursing education: a study of PDA use by students. Journal of Professional Nursing 26 (6), 371–376. http://dx.doi.org/10.1016/j.profnurs.2010.08.001. Goldsworthy, S., Lawrence, N., Goodman, W., 2006. The use of personal digital assistants at the point of care in an undergraduate nursing program. Computers, Informatics, Nursing 24 (3), 138–143. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24 (2), 105–112. http://dx.doi.org/10.1016/j.nedt.2003.10.001. Guillot, L., Pryor, S., 2007. PDA use by undergraduate nursing students on pediatric clinical rotations. Journal of Hospital Librarianship 7 (3), 13–20. http:// dx.doi.org/10.1300/J186v07n03_03. Hudson, K., Buell, V., 2011. Empowering a safer practice: PDAs are integral tools for nursing and health care. Journal of Nursing Management 19 (3), 400–406. http:// dx.doi.org/10.1111/j.1365-2834.2011.01251.x. Johnson, L., Smith, R., Willis, H., Levine, A., Haywood, K., 2011. The Horizon Report 2011. Austin, Texas. Retrieved September http://net.educause.edu/ir/library/pdf/ HR2011.pdf. Kitzinger, J., 1995. Qualitative research. BMJ 311 (7000), 299–302. http://dx.doi.org/ 10.1136/bmj.311.7000.299. Koeniger-Donohue, R., 2008. Handheld computers in nursing education: PDA pilot project. Journal of Nursing Education 47 (2), 74–77. http://dx.doi.org/10.3928/0148483420080201-01. Kuiper, R., 2008. Use of personal digital assistants to support clinical reasoning in undergraduate baccalaureate nursing students. Computers, Informatics, Nursing 26 (2), 90–98. http://dx.doi.org/10.1097/01.NCN.0000304776.40531.bc.
1251
Ministry of Health and Social Affairs, 2012a. Law of Healthcare [Hälso- och sjukvårdslag (SFS 1982:763)]. Retrieved April http://www.riksdagen.se/sv/Dokument-Lagar/ Lagar/Svenskforfattningssamling/Halso–och-sjukvardslag-1982_sfs-1982-763/. Ministry of Health and Social Affairs, 2012b. Law of Patient Safety [Patientsäkerhetslag (SFS 2010:659)]. Retrieved April http://www.riksdagen.se/sv/Dokument-Lagar/ Lagar/Svenskforfattningssamling/Patientsakerhetslag-2010659_sfs-2010-659/. Pattillo, R.E., Brewer, M., Smith, C.M., 2007. Tracking clinical use of personal digital assistant reference resources. Nurse Educator 32 (1), 39–42. Saintsing, D., Gibson, L.M., Pennington, A.W., 2011. The novice nurse and clinical decision-making: how to avoid errors. Journal of Nursing Management 19 (3), 354–359. http://dx.doi.org/10.1111/j.1365-2834.2011.01248.x. Sarasohn-Kahn, J., 2010. How Smartphones are Changing Health Care for Consumers and Providers. Oakland, California: California Healthcare Foundation. http://www.chcf. org/~/media/Files/PDF/H/PDF%20HowSmartphonesChangingHealthCare.pdf. Secco, M.L., Jamieson, B., Profit, S., Bailey, J., Brennick, D., Whitty-Rodgers, J., et al., 2010. A survey of nursing students' perspectives on use of nursing central information software in clinical learning. Canadian Journal of Nursing Informatics 5 (3), 2–20. Wu, C.-C., Lai, C.-Y., 2009. Wireless handhelds to support clinical nursing practicum. Journal of Educational Technology & Society 12 (2), 190–204. Wu, T.-Y., Fox, D.P., Stokes, C., C.A., 2012. Work-related stress and intention to quit in newly graduated nurses. Nurse Education Today 32 (6), 669–674. http://dx.doi.org/ 10.1016/j.nedt.2011.09.002.
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Nursing students' experience of using a personal digital assistant (PDA) in clinical practice — An intervention study Pauline E. Johansson ⁎, Göran I. Petersson 1, Gunilla C. Nilsson 2 eHealth Institute and School of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden
a r t i c l e
i n f o
Article history: Accepted 30 August 2012 Keywords: Computers handheld Intervention study Nursing informatics Nursing practice Nursing students
s u m m a r y Background: A personal digital assistant (PDA) is a multifunctional information and communication tool allowing nursing students to keep up to date with expanding health related knowledge. Objectives: This study was aimed at exploring nursing students' experience of using a PDA in clinical practice. Method: In this intervention study, nursing students (n = 67) used PDAs during a period of 15 weeks, replied to questionnaires, and participated in focus group interviews. Results: The PDA was found to support nursing students in clinical practice and to have the potential to be a useful tool with benefits for both the patients and for the students. The PDA was regarded as useful, and was presumed to imply increased confidence and time savings, and contribute to improved patient safety and quality of care. Conclusions: With available mobile technology, nursing students would be able to access necessary information, independent of time and place. Therefore, it is important that stakeholders and educators facilitate the use of PDAs to support nursing students during their clinical practice, in order to prepare them for their future work, and to continuously improve the safety and quality of healthcare. © 2012 Elsevier Ltd. All rights reserved.
Introduction The continuous increase of health related knowledge implies that nursing students (NSs) handle large amounts of information in their clinical practice as well as in their future work. The latest information is usually available on the Internet, but a desktop computer or a laptop is rarely easily available at patient bedside. Consequently, there is a need for applicable mobile devices which can provide access to accurate information. Mobile computing with increasingly capable, flexible, and powerful personal digital assistants (PDA) provides people on-the-go with access to anything that can be done on a desktop computer (Johnson et al., 2011).
Background PDAs (i.e. mobile computing tools, handheld devices, handheld computers or smart phones) are small, portable, and convenient to
⁎ Corresponding author at: eHealth Institute and School of Health and Caring Sciences, Linnaeus University, SE-391 82 Kalmar, Sweden. Tel.: +46 480 446315; fax: +46 480 446955. E-mail addresses: [email protected] (P.E. Johansson), [email protected] (G.I. Petersson), [email protected] (G.C. Nilsson). 1 Tel.: +46 480 497124; fax: +46 480 446955. 2 Tel.: +46 480 446042; fax: +46 480 446955. 0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2012.08.019
use for fast data management, and enable users to accomplish tasks anywhere and anytime (Sarasohn-Kahn, 2010). Intervention studies have evaluated undergraduate NSs' use of PDAs during their clinical practice, and using a PDA is reported to increase self-confidence (Goldsworthy et al., 2006; Wu and Lai, 2009), to enhance their learning (Pattillo et al., 2007; Farrell and Rose, 2008; Koeniger-Donohue, 2008; Wu and Lai, 2009; George et al., 2010; Secco et al., 2010; Hudson and Buell, 2011), and to integrate more theories into practice (Wu and Lai, 2009). The PDA is time saving (Guillot and Pryor, 2007; Pattillo et al., 2007; Koeniger-Donohue, 2008; Wu and Lai, 2009; Secco et al., 2010), and making NSs more organized and/or efficient (Goldsworthy et al., 2006; Pattillo et al., 2007; George et al., 2010). The PDA might improve quality in nursing care and promote relatives' involvement in sharing information (Guillot and Pryor, 2007). In summary, PDAs have been found to be supportive for NSs, enhanced learning, increased effectiveness and saved time. Although, in Sweden PDAs are rarely used in nursing practice and not in nursing education. There are numerous information and medical software applications available but few are adjusted for technical, statutory, cultural, and language country-specific conditions, and not especially developed for nursing. Thus far, desktop computers or laptops are available at wards and healthcare units. To motivate the implementation and take advantage of the fast developing technology based on new PDAs, the end users' needs and attitudes must be taken into account. Therefore, this study aimed at exploring nursing students' experience of using a PDA in clinical practice.
P.E. Johansson et al. / Nurse Education Today 33 (2013) 1246–1251
Method Study Design In this intervention study, at a university in southern Sweden, NSs were supplied with PDAs during their clinical practice. This study was carried out during three final semesters of three consecutive undergraduate nursing degree programs. The NSs (n = 120) were provided information about the study and 67 NSs, who volunteered were randomly selected from the three final semesters, (n = 20, n = 22, n = 25) respectively, to correspond with the available number of PDAs. The NSs' clinical rotation, a total of 15 weeks, took place in non-institutional or institutional psychiatric care for children or adults, in rural district health services in sheltered accommodations or in patients' home, and in the university healthcare center run by NSs; and each rotation lasted five weeks at each location. All NSs participated in an introduction (3 h) and received the PDA together with technical training. Technical support was provided by the first author. The PDA (a Palm TX) contained pharmaceutical and medical resources freely downloaded from the Internet. These resources included FASS (an encyclopedia with information about the medicines that have marketing authorization in Sweden), Med Calc (a medical calculator, not adjusted for Swedish nursing), guidelines/techniques for treatment (e.g. pain relief, elderly care, test instructions and reference intervals), and acts and regulations for nursing. In addition, the PDA contained the usual functions, such as a word processing program, a calculator and calendar, and one could enter and download own's notes and documents into the PDA. Patient data that may reveal the patient's identity were not allowed to be stored in the device. Data Collection The NSs answered a questionnaire before and after their clinical practice, and they were interviewed in focus groups after the postquestionnaire. The questionnaires were developed for this study. The prequestionnaire included demographic characteristics and questions concerning the NSs' experience of having access to information and various tools in clinical practice prior to the study (Table 1). The post-questionnaire included four-point-scaled (Table 2), dichotomized (Table 3), and open-ended questions (Table 4), inspired from our previous research (accepted). The NSs (n = 39), from the first two semesters, were divided into seven focus groups (Kitzinger, 1995), and were interviewed at the university by two of the authors (PJ and GN). The interviews lasting 30–50 min, were recorded, and transcribed verbatim. The interviews began by asking ‘If you have a PDA when starting to work as a nurse, what information and functions should the PDA contain to be as useful as possible in your work?’, followed by probing questions, e.g. ‘In what situations?’, ‘What are the advantages and disadvantages?’ and ‘Can you explain further?’ Data Analysis Descriptive statistics were applied. The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 18.0 for Windows (SPSS Inc., Chicago, IL). The results from the four-point-scales (Totally disagree=1; Partly disagree= 2; Partly agree= 3; Totally agree=4) and the dichotomized questions are presented in the text as ‘disagree’ (grades 1–2/No) and ‘agree’ (grades 3–4/Yes); in tables, frequencies (n), median (possible variation= 1–4), and total score for each question (possible variation =58–232) are presented. The open-ended answers were sorted according to convenient categories emerging from the focus group interviews. Three NSs did not respond (all three from the second semester) and six post-questionnaires were excluded because of internal missing data, yielding a response rate of 87% (n=58).
1247
Table 1 Nursing students' (n = 58) demographic data. Age, mean (SD) Range, year Gender, n (%) Male Female Estimated computer skills level, n (%)a Very good Fairly good Intermediate Fairly poor Very poor Used a PDA prior to this study, n (%) Yes No Worked in healthcare before the undergraduate nursing degree programs began, n (%)a Yes No Do you feel that there is sufficient information available to perform your duties in a satisfying way? n (%) Always Frequently Occasionally Never Do you feel that the handling of your personal notes is reliable? n (%) Yes No Do you feel secure in the manner you carry out calculations of medicines? n (%)a Yes No
27.3 (7.2) 21–50 13 (22) 45 (78) 6 (10) 29 (51) 21 (37) 1 (2) 0 (0) 1 (2) 57 (98)
41 (72) 16 (28)
1 (2) 46 (79) 11 (19) 0 (0) 28 (48) 30 (52)
42 (74) 15 (26)
Note: PDA = personal digital assistant. a Missing participant (n = 1).
The data from the focus group interviews were analyzed by content analysis method (Berg, 2007) by the first author. The data were read and reread to gain an overall understanding of the content. The next step was entailed identifying meaning units and grouping them into categories; finally, the meaning units were coded and organized into subcategories (Table 5). During the analysis process, the categories were refined by moving back and forth between the text Table 2 The nursing students' (n = 58) experience of using a PDA in clinical practice from the four-point-scales. Totally Partly Partly disagree disagree agree (n) (n) (n) 1. The PDA is useful in my clinical practice. 2. The PDA gives me a higher degree of confidence in my clinical practice. 3. The PDA might help to increase the quality of care. 4. The PDA might help to increase patient safety. 5. The PDA might help to save time. 6. The PDA makes it easier to manage my own notes. 7. The PDA makes it easier to carry out calculations of medicines.
Totally agree (n)
md Total scorea
2
10
39
7
3
167
2
11
33
12
3
171
0
11
38
9
3
172
0
14
34
10
3
170
4
18
27
9
3
157
5
15
29
9
3
158
3
16
27
12
3
164
Note: PDA = personal digital assistant. Totally disagree = 1; Partly disagree = 2; Partly agree = 3; Totally agree = 4. md = median (possible variation = 1–4). a Total score for each question = 58–232.
1248
P.E. Johansson et al. / Nurse Education Today 33 (2013) 1246–1251
Table 3 The nursing students' (n = 58) experience of using a PDA in clinical practice from the dichotomized questions. No Yes (n) (n) 8. Do you experience that the PDA is or could be a useful tool to give ac4 cess to the information you need to perform your duties in a satisfactory manner? 9. Have you used the PDA at the patient bedside or together with 32 patients? 9 10. Would you like to have a PDA in your future work as a nurse?a
54
26 48
Note: PDA = personal digital assistant. a Missing participant (n = 1).
and the emerging categories (Graneheim and Lundman, 2004). The analysis revealed four categories and eight subcategories (Table 6). The accuracy of the categories was verified against the original interview text to make sure that the meaning had not been changed during the analysis process, and that the categories were grounded in the data (Berg, 2007). Quotations are used to show the credibility of the categories that emerged (Graneheim and Lundman, 2004). For data reporting purposes, each focus group was given a number (Nos. 1–7). Results The results are presented below; firstly, the pre- and postquestionnaire, followed by the results from the focus group interviews, including the open ended questions from the post-questionnaire. The Pre-questionnaire Prior to the use of the PDA, the majority of the NSs regarded that they usually had sufficient accessible information to carry out their duties in their clinical practice in a satisfactory manner. Also, before PDAs, the NSs used scraps of papers, notebooks, or diaries to record memos about their patients; half of the participants considered the handling of their notes to be unreliable. However, the majority felt secure about the manner in which they carried out calculations of medicines with resources available before using a PDA. Further data from the pre-questionnaire is presented in Table 1. The Post-questionnaire During the intervention, 39 NSs used their PDAs one to five times a day, four NSs used it up to ten times a day, one NS used it 20 times a day, whereas 14 NSs used their PDAs only a few times during the entire intervention period due to a lot of schoolwork. The majority of the NSs agreed that the PDA is useful, gives a higher degree of confidence in their work, and that the PDA might help to increase the quality of care, and patient safety. More than half of the NSs agreed
Table 4 The open-ended questions in the post-questionnaire. • Give examples of one or more events where the personal digital assistant (PDA) could be of use in your clinical practice. • What functions of the Dr Companion — Nurse Edition software have you used? • What functions of the PDA have you used? • What information or functions are you missing in the PDA? • When is a PDA useful in your work today? • How do you think a PDA can improve your work? • How do you think a PDA would improve patient safety? • How do you think a PDA can help to increase the quality of care? • How do you think a PDA can contribute to time savings in your clinical practice? • Other comments.
Table 5 Examples of data analysis process: meaning units, codes and categories. Meaning units
Codes
Subcategory
Category
“The most important is that it is easy to get it, it's quick to get it and so, it is when you can have it in your pocket” “Then I can give this patient, who may be worried about something and have a question, an answer right away when I'm there” “There is no reason for anyone to take a chance because you always have the information with you and if you are unsure you can always check again” “In psychiatry the supervisor was an opponent [to the use of the PDA], — it did not look good in front of patients, it looked suspicious and … well, it looked like I had no knowledge when I was using it [he said]”
Quick access to information
Advantages in clinical practice
Usefulness
Patients need not wait for an answer
Nurse–patient interaction
At bedside
Information is always available
Updated information always at hand
Confidence for nursing students
Opposed to PDAs in psychiatry
Opinions among others about using PDAs
Other perspectives of the use of PDAs
that the PDAs facilitate the handling of their own notes, facilitate to carry out calculations of medicines and to save time in their clinical practice (Table 2). Nearly half of the NSs used their PDAs at the patient bedside and/or together with patients. Almost all NSs agreed that a PDA provides access to accurate information, which they need to carry out tasks in a satisfactory manner, and the majority would like to have a PDA in their coming work (Table 3).
Usefulness Advantages in Clinical Practice In the interviews, the NSs perceived that the PDA provides easy and immediate access to information integrated in one place. The information is always at hand and this immediate access to information implies that the NSs can check the information and document on the go. In order to replace loose scraps of papers, the NSs also found it useful to make their own notes in the PDA. The majority of the NSs believed that the PDA is very useful, especially in homecare where there is limited information and there are no computers available to use, whereas few were convinced that the PDA fills the same need in hospitals. In hospitals, there are a lot of stationary computers, laptops, paper based guidelines, and card index available. In the questionnaire, the NSs regarded that a PDA can improve their work by the immediate and accurate information always being available. By having a PDA, the NSs become their own “database” with the ability to quickly find information, with reminder and documentation functions anywhere and anytime, and colleagues can easily be consulted. The NSs stated that clinical practice becomes more efficient, safer, organized, and timesaving with the PDA. Table 6 The categories and subcategories that emerged from the data. Categories
Subcategories
Usefulness
Advantages in clinical practice Content and functions Nurse–patient interaction Benefits for patients Updated information always at hand Manage information wherever you are Opinions among others about using PDAs Implementation of PDAs in nursing
At bedside Confidence for nursing students Other perspectives of the use of PDAs
P.E. Johansson et al. / Nurse Education Today 33 (2013) 1246–1251
“The most important is that it is easy to get it, it's quick to get it, and so it is when you can have it in your pocket” (No. 4)
Content and Functions The NSs found the information and content useful but to be an optimal tool the NSs asked for more content and functions. Not only to be able to read information but also to document in order to avoid duplication, the NSs wanted access to the electronic health record (EHR) via the PDA. Some NSs regarded it important that resources in the PDA are verified and safe to use in nursing practice, in contrast to a lot of Internet resources which they found difficult to determine regarding credibility. “You can find many functions [at the Internet] but it is difficult to know which are reliable, if it [the content] is verified or if the content has been constructed by an amateur, thus everything will be wrong… //…[by means of a PDA] you would like to have controlled and reliable functions” (No. 1)
At Bedside Nurse–Patient Interaction In the interviews, most NSs used the PDA in the encounter with the patient; some NSs had even used the PDA to answer relatives' questions. This meant that the NSs could supply patients and their relatives with instant information, e.g. about medicines, and the NSs had also been able to take notes in the PDA during patient conversations. This availability of information via a PDA entails that the NSs can spend more time with patients, and patients do not have to wait for an answer, thus the NSs regarded it improved quality of care. The NSs described that the PDA can provide a basis for patient education. “Then I can give this patient, who may be worried about something and have a question, an answer right away when I'm there” (No. 4)
Benefits for Patients The NSs perceived that patients were positive and interested in their use of the PDA. One NS described that relatives regarded it as good that she used the PDA because it was perceived as troublesome when the staff ran out to retrieve information that was needed to answer the relatives' questions. In the interviews as well as in the open-ended answers, the NSs described the advantage of having instant access to a PDA implying that they did not have to leave the patient and thus regarded it improved patient safety. This was stated by the NSs in general as essential, e.g. if patients become very ill and could not be left alone. “Patient safety, do not have to leave the patient to retrieve information” (No. 7)
Confidence for Nursing Students Updated Information Always at Hand The NSs stated, in the interviews and in the open-ended questions that a PDA provided confidence for them in clinical practice and in their future work because it can provide access to everything they need. A PDA is a good support for NSs and newly graduated nurses when there is a lot happening. By having a PDA, recent information is constantly updated. A PDA can be a support when working alone and in the immediate encounter with the patient, because you do not always know in advance what information you will be needing. The NSs could get access to necessary information repeatedly and
1249
can check how to carry out procedures, anywhere, and anytime. Sometimes, the work could be very hectic and the NSs could not have all the necessary information in their minds. “There is no reason for anyone to take a chance because you always have the information with you and if you are unsure you can always check again” (No. 5)
Manage Information Wherever You Are The access to information and the medical calculation in the PDA were highly appreciated by the NSs and made them feel confident in clinical practice. A PDA is good for taking notes at patients' homes about things to remember when back at the office. In order to reduce the risk that any information will be lost, the NSs wanted to record directly into the patient EHR. The NSs regarded the PDA as secure in handling their own notes and appreciated that they individually could modify the content in the PDA. The NSs also wanted to have a camera to photograph patient wounds and to consult colleagues and/or a doctor while still being present in the patients' home. “A lot can happen between the patient's room and my office, lot of stuff can happen that you capture and that you forget … and we like to think that we remember very much but we do not and we also distort information” (No. 2) In general, the NSs stated that they wanted to have a PDA in their work, while some others felt that a PDA could be useful for some but, due to lack of technical interest and/or computer skills, not for themselves. Some NSs did not believe that a PDA in its present form could increase confidence at all. To be optimal and to increase confidence, a PDA needs more content and functions adjusted for Swedish nursing and technical condition. Other Perspectives of the Use of PDAs Opinions Among Others About Using PDAs During the interviews, several NSs reported about the positive feedback from their supervisors about their use of the PDA, primarily in rural district health services. In contrast, a few NSs said that their supervisors, not familiar with the use of PDAs, found the content “messy”. Several NSs said that their supervisors found that the PDA becomes useful only when the patients EHR could be accessed. However, in psychiatric inpatient care, there were some NSs that said that their supervisors were totally against the use of a PDA, especially in front of the patients who might become uncomfortable. “In psychiatry the supervisor was an opponent [to the use of the PDA], — it did not look good in front of patients, it looked suspicious and … well, it looked like I had no knowledge when I was using it [he said]” (No. 3) Implementation of PDAs in Nursing Based on their experience, the NSs supposed that it would be difficult to implement PDAs in healthcare. Sometimes, the NSs believed that the employer was interested, but not the registered nurses and this will make it difficult to gain acceptance for new technology. Therefore, some NSs were unsure how a PDA would be accepted among their nursing colleagues. Few NSs were afraid that their colleagues would think that they misuse the PDA for personal reasons like playing games and music. “I would like to have a PDA when I start working … but how will it be received, I'm so new? … I want to join in and be one of the team,… but if I have a PDA … what will other colleagues think and say? ..,.. yes, you never know how things are received either by one's manager or colleagues” (No. 3)
1250
P.E. Johansson et al. / Nurse Education Today 33 (2013) 1246–1251
Discussion We found that the NSs perceived that a PDA has the potential to be a useful tool in clinical practice, with benefits for both the patients and for the NSs. Even if most information required is available without a PDA, the majority of the NSs were of the opinion that the PDA is useful in their clinical practice and future work to easily and immediately get access to necessary, accurate, and updated information. The NSs appreciated that the information was integrated in one device, independent of time and place. The PDA was regarded as most useful in homecare, where there is limited access to information with no computers available to use. In addition, a PDA has the potential to enhance nursing care delivery at the patient bedside in hospitals, since stationary computers are not always available (Guillot and Pryor, 2007). Furthermore, a PDA might replace the use of paper based guidelines and card index, still used in some places. In a PDA, these documents will always be available and can be updated automatically. A nurse's job is information intensive and routines include extensive documentation. Using notes on scraps of paper, in notebooks, or in diaries was not regarded as reliable and the NSs stated that functions for documentation in the PDA could be useful. Although the majority felt secure in the manner they carried out calculations of medicines before using the PDA, more than half of the students regarded that the PDA could facilitate also for this purpose. Thus, to be as optimal as possible, more content and functions are needed, especially the EHR, and that available information is verified and safe to be used in nursing practice. Our NSs considered that a PDA could be helpful to ensure high levels of patient safety and quality of care, which is in accordance with the law (Ministry of Health and Social Affairs SFS, 1982:763; Ministry of Health and Social Affairs SFS, 2010:659). Some of the NSs used the PDA in the encounter with patients and/or relatives and received positive responses, in agreement with a previous report (Hudson and Buell, 2011). Even if the time saved by the use of a PDA has not been evaluated in our study, NSs believed that the PDA helped them to organize their clinical practice and made them more efficient, resulting in more time to be spent with the patients. In accordance with another study (Koeniger-Donohue, 2008), the NSs also believed that a PDA might be very helpful in situations when they had to answer questions from patients and/or family members. Furthermore, the PDA helped when conducting patient education and when checking how to carry out procedures; above all, in situations when the NSs were unable to leave the patient. The NSs in this study were at the end of their nursing education and close to graduation; a transition phase when the NSs need extra access to supportive information and functions. When working as novice nurses, they are more likely to experience stress (Wu et al., 2012), and their lack of experience would motivate their need for information (Saintsing et al., 2011). Stress because of time limitations, pressure from experienced nurses, the amount and complexity of information and lack of confidence are factors that affect the amount of errors made (Saintsing et al., 2011). A PDA can provide access to accurate information repeatedly, the users can check how to carry out procedures anywhere and anytime, and communicate with their colleagues. The NSs in our study found the PDA could provide them added confidence, in agreement with Goldsworthy et al. (2006). The NSs believed that a PDA could be supportive, especially when working alone, in homecare and in the immediate encounter with the patients. In addition, the NSs felt confident and secure to use the PDA in order to handle their own notes, replacing loose scraps of paper confirmed by another study (Kuiper, 2008). Furthermore, the possibility to record directly into the patient EHR might reduce documentation errors, by means of avoiding duplication of documentation or avoid the risk of loss of any information. The NSs met mostly positive feedback about the PDA from nurses, primarily in rural district health services. On the other hand, some
nurses, especially in psychiatric inpatient wards, were completely against the use of a PDA. This was in agreement with another study (Hudson and Buell, 2011), in which it was described that the NSs were considered not to be knowledgeable if they had to use a PDA; the information should be recalled from memory or patients might experience that the NSs were playing games on it. Based on our NSs' experience about other perspectives of the use of PDAs, they regarded that it would be difficult to implement PDAs in healthcare. Rather, the problem is mainly to gain acceptance for new mobile technology among colleagues. We regard the results in our study useful to illuminate NSs' experience of using a PDA in clinical practice. The sample selection was convenient and the size was moderate; thus, the results should be interpreted with some caution. However, the response rate was high, and each NS used their PDAs for 15 weeks, which should be sufficient to become familiar with its use. Although 14 NSs only used the PDA a few times during the whole intervention period, everyone did test it. Furthermore, a large part of our results was based on qualitative data, and a content analysis was seen as suitable to describe the participants' experiences (Graneheim and Lundman, 2004). The interviews were tape-recorded, transcribed verbatim, representative quotations confirmed the descriptions, and the categories were checked against the original data. Taken together with the triangulation of data, we have ensured the results are credible. Conclusions We found that the NSs perceived that a PDA has the potential to be a useful tool in clinical practice, with benefits for both the patients and for the NSs. Since technologies are changing rapidly, it is obvious that NSs should have the opportunity to access all the information they need, independent of time and place, during their clinical practice as well as in their future work. Therefore, it is important that stakeholders and educators facilitate the use of PDAs to support the nursing students during their clinical practice, in order to prepare them for their future work, and to continuously improve the safety and quality of healthcare. Ethical Approval All study participants provided informed consent. The participants received information about the study, about voluntary participation, and about confidentiality requirements. None of the authors were involved in the NSs education as faculty members. Ethical considerations were based on the guidelines of the Ethics Committee of Southeast Sweden, and received permission to be undertaken from the head of the School of Health and Caring Sciences at the Linnaeus University. Conflict of interest No conflict of interest existed. Acknowledgments We thank the NSs who participated in the study and Jean Stevenson-Ågren (MSc. Lecturer) at the School of Language and Literature, Linnaeus University, Sweden for revising the text. The study was funded by Linnaeus University, Kalmar, Sweden. References Berg, B.L., 2007. Qualitative Research Methods for the Social Sciences, 6th ed. Allyn and Bacon, Boston. Farrell, M.J., Rose, L., 2008. Use of mobile handheld computers in clinical nursing education. Journal of Nursing Education 47 (1), 13–19. http://dx.doi.org/10.3928/0148483420080101-03.
P.E. Johansson et al. / Nurse Education Today 33 (2013) 1246–1251 George, L.E., Davidson, L.J., Serapiglia, C.P., Barla, S., 2010. Technology in nursing education: a study of PDA use by students. Journal of Professional Nursing 26 (6), 371–376. http://dx.doi.org/10.1016/j.profnurs.2010.08.001. Goldsworthy, S., Lawrence, N., Goodman, W., 2006. The use of personal digital assistants at the point of care in an undergraduate nursing program. Computers, Informatics, Nursing 24 (3), 138–143. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24 (2), 105–112. http://dx.doi.org/10.1016/j.nedt.2003.10.001. Guillot, L., Pryor, S., 2007. PDA use by undergraduate nursing students on pediatric clinical rotations. Journal of Hospital Librarianship 7 (3), 13–20. http:// dx.doi.org/10.1300/J186v07n03_03. Hudson, K., Buell, V., 2011. Empowering a safer practice: PDAs are integral tools for nursing and health care. Journal of Nursing Management 19 (3), 400–406. http:// dx.doi.org/10.1111/j.1365-2834.2011.01251.x. Johnson, L., Smith, R., Willis, H., Levine, A., Haywood, K., 2011. The Horizon Report 2011. Austin, Texas. Retrieved September http://net.educause.edu/ir/library/pdf/ HR2011.pdf. Kitzinger, J., 1995. Qualitative research. BMJ 311 (7000), 299–302. http://dx.doi.org/ 10.1136/bmj.311.7000.299. Koeniger-Donohue, R., 2008. Handheld computers in nursing education: PDA pilot project. Journal of Nursing Education 47 (2), 74–77. http://dx.doi.org/10.3928/0148483420080201-01. Kuiper, R., 2008. Use of personal digital assistants to support clinical reasoning in undergraduate baccalaureate nursing students. Computers, Informatics, Nursing 26 (2), 90–98. http://dx.doi.org/10.1097/01.NCN.0000304776.40531.bc.
1251
Ministry of Health and Social Affairs, 2012a. Law of Healthcare [Hälso- och sjukvårdslag (SFS 1982:763)]. Retrieved April http://www.riksdagen.se/sv/Dokument-Lagar/ Lagar/Svenskforfattningssamling/Halso–och-sjukvardslag-1982_sfs-1982-763/. Ministry of Health and Social Affairs, 2012b. Law of Patient Safety [Patientsäkerhetslag (SFS 2010:659)]. Retrieved April http://www.riksdagen.se/sv/Dokument-Lagar/ Lagar/Svenskforfattningssamling/Patientsakerhetslag-2010659_sfs-2010-659/. Pattillo, R.E., Brewer, M., Smith, C.M., 2007. Tracking clinical use of personal digital assistant reference resources. Nurse Educator 32 (1), 39–42. Saintsing, D., Gibson, L.M., Pennington, A.W., 2011. The novice nurse and clinical decision-making: how to avoid errors. Journal of Nursing Management 19 (3), 354–359. http://dx.doi.org/10.1111/j.1365-2834.2011.01248.x. Sarasohn-Kahn, J., 2010. How Smartphones are Changing Health Care for Consumers and Providers. Oakland, California: California Healthcare Foundation. http://www.chcf. org/~/media/Files/PDF/H/PDF%20HowSmartphonesChangingHealthCare.pdf. Secco, M.L., Jamieson, B., Profit, S., Bailey, J., Brennick, D., Whitty-Rodgers, J., et al., 2010. A survey of nursing students' perspectives on use of nursing central information software in clinical learning. Canadian Journal of Nursing Informatics 5 (3), 2–20. Wu, C.-C., Lai, C.-Y., 2009. Wireless handhelds to support clinical nursing practicum. Journal of Educational Technology & Society 12 (2), 190–204. Wu, T.-Y., Fox, D.P., Stokes, C., C.A., 2012. Work-related stress and intention to quit in newly graduated nurses. Nurse Education Today 32 (6), 669–674. http://dx.doi.org/ 10.1016/j.nedt.2011.09.002.