Infusing PDA Technology Into Nursing Education

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Ann White, MSN, RN, CCNS, CEN Because of the expanded use of Patricia Allen, EdD, RN personal digital assistants (PDAs) in Linda Goodwin, PhD, RN, BC today’s healthcare arena, the Duke Daya Breckinridge, MSN, RN, FNP University School of Nursing incorpo- Jeffery Dowell, AAS rated education and experience in the Ryan Garvy use of this technology as part of the second degree accelerated bachelor of science in nursing (ABSN) program in the fall of 2002. The project was funded for 1 year by a Center for In- Use of the personal digital assistant (PDA) has been infused into the structional Technology (CIT) Demon- accelerated baccalaureate program at Duke University to help prepare stration Project Grant through the nursing students for professional practice.The authors provide an Duke University Center for Informa- overview of the use of PDAs in the classroom, laboratory, and clinical tion Technology. The overall goal is to setting.Technical aspects of PDA infusion and steps to ensure regulatory infuse this current technology into the compliance are explored. Benefits of PDA use by both faculty and ABSN program by requiring PDA use students in the program and challenges met with the infusion of this in the classroom, learning laboratory, technology are also described. and clinical setting. The students use basic component functions such as the address book, calculator, calendar, and memo pad. They also have access to software providing current drug student to rapidly and efficiently ac- Generation-Xers, who have grown up and infectious disease information, cess pertinent data while in the clini- playing computer games, accessing calculation capabilities, growth charts, cal setting. The student is able to pro- the Internet, and having information at immunization guidelines, and medical vide immediate patient feedback to a their fingertips. This resource provides Spanish translation software. variety of questions ranging from, but the student a bridge to a tool they are Infusion of PDA technology into not limited to, the adverse effects of very comfortable with and that is the the ABSN curriculum supports the prescribed drugs to the date of the pa- computer. technology and leadership thread tient’s next tetanus immunization A recent technological advance in found throughout the program. PDA without leaving the patient. Current the healthcare environment, PDAs are use supports the development of software on bioterrorism and real-time used for clinical assessment, drug in- strong student organizational skills. In data on communicable diseases is at formation, language translation, calcu- addition, leadership skills such as em- hand on the PDA for students to an- lations, identification of normal labo- powerment are enhanced by provid- swer questions and concerns for pa- ratory values, pediatric developmental ing the student with evidence-based tients experiencing flu-like symptoms. milestones, medical sign language, information and data. The software Technology, such as the PDA at medical dictionary, anatomy, acuity of enhances learning by allowing the the student’s fingertips, allows for stu- illness scales, growth charts, and dent reinforcement of core knowledge immunization guidelines. The PDA for practice as well as strengthening can be uploaded with a wide variety Authors’ Affiliations: Assistant Clinical professional confidence by allowing of software and allows beaming of Professor (Ms White); Consulting Associate the student to provide immediate pa- programs between users. This techno- (Ms Breckinridge); Computer Technologist tient feedback. Also, this technology logical advance is a tool for use in (Mr Dowell); Computer Technician, Web fosters communication through lan- decreasing medical errors in today’s and Multimedia Developer (Mr Garvy); Pro- guage translation programs. Instructor- nursing practice arena. fessor (Dr Goodwin), Duke University student communication is enhanced School of Nursing and Community and Family Medicine, Durham, NC; Associate by wireless transmission or beaming Reported Use of PDAs in Professor (Dr Allen), Texas Tech Health Sci- information. Beaming information Nursing ences Center School of Nursing, Lubbock. encourages student accountability for Corresponding Author: Ms White, Duke learning, self-improvement, and gath- Nursing, a practice discipline, occurs University School of Nursing, DUMC Box ering and analyzing patient data. This in many environments: from home 3322, Durham, NC 27710 (white149@mc. unique pocket resource, the PDA, is care, to acute care, to the care of the duke.edu). particularly useful in teaching the community. Nurses in a variety of

150 NURSE EDUCATOR Vol. 30, No. 4 July/August 2005 settings have used PDAs, and the the technical team at the school of session included an overview of the results of PDA use have been briefly nursing, was informed early that the hardware, using the Palm operating reported in the literature. Goss and first cohort of ABSN students would system (OS), application skills, syn- Carrico1 have reported the use of be required to use a PDA. The grant chronizing with the student’s personal PDAs by the infusion therapy team of provided for the hardware, and the computer, and troubleshooting. Stu- the infection control department for CITDL’s responsibility was to assist in dents signed a form indicating which enhancing evidence-based decision the deployment, maintenance, and unit they received. Students were in- making. Data supported the positive support of the hardware. There were structed how to use the backup pro- impact on patient outcomes by this 3 distinct phases to the overall plan gram to install the applications that department with the use of PDAs. for this project: planning, implementa- had been preloaded onto the SD Several studies have reported a tion, and support. memory card. Once complete, each positive impact of PDAs on nursing student had a unit loaded with the practice.2-4 A common theme among Planning software collection chosen by the fac- investigators was the positive impact ulty. Students received the HotSync Selection of hardware was among the of PDAs on providing care consistent cradle and other documentation that first steps of this project. Technicians with the best evidence and reduction came with the units. Students were re- worked closely with the faculty to en- of errors. sponsible for connecting the cradle to sure that the hardware specifications Another report indicates the use their personal computer, and charging would handle the expected applica- of the PDA by nurses in the operating and synchronizing the unit. tions. The ABSN faculty selected the room, which improves care and saves applications that would be used in the them time by streamlining their work.5 curriculum. The CITDL staff assisted in Support Also, PDAs have been used by nurses any technical problems faced by the and the healthcare team for point-of- After the project was fully imple- faculty in testing these applications. care trauma documentation. Findings mented, the CITDL staff provided sup- Over time, a collection of software support the use for many reasons, but port to the units for faculty and stu- packages was selected. The CITDL fi- most notably the alleviation of repeti- dents. Several issues arose during the nalized their hardware recommenda- tive documentation by the nurse and support phase, such as synchroniza- tions on the basis of these applications. team members.6 tion problems or inoperable units. Palm 515™ units were selected Few articles appear in the literature Over time, the CITDL became more because of their support for color, on the use of PDAs by nurse educators efficient at resolving problems that amount of internal memory, and ca- for teaching and infusing technology frequently occurred. In addition, the pacity for upgradation through the se- into clinical practice. Clinical nursing CITDL staff provided technical guid- cure digital (SD) card expansion slot. instructors use PDAs for student record ance for the faculty on how to best Most of the applications that were se- keeping and evaluation.7 One article use the technology for activities. Sev- lected were free, so the remaining focused on the use of handheld tech- eral training sessions were held to in- grant funds were used to purchase a nology in nursing education and sug- crease technical knowledge. 16-MB SD card. gested infusion of the technology into The second cohort of ABSN stu- The CITDL received several units nursing curricula by first adopting the dents had to purchase their own PDA. and loaded and tested the specified ap- use of the PDA in a pharmacology The CITDL staff recommended they plications. After verifying the interoper- class.8 For this pharmacology class, the purchase Palm M130 to retain consis- ability of the applications and hard- students were required to purchase a tency in orienting students to the ware, attention then turned to devising PDA. In this course project, the faculty PDA use and simplify support issues. a software deployment strategy. The found incorporation of the PDA as a The majority of students purchased the CITDL had the task of installing 10 to teaching strategy challenge; however, model recommended. Although stu- 15 applications on 50 PDAs. Since the students reported positive re- dents were ultimately responsible for loading the software directly onto the sponses to the inclusion of this tech- their own hardware, the CITDL staff units too far in advance would drain nology. Currently literature is unavail- provided support to students if the batteries, software was loaded onto able on the evaluation of the use of the requested. Having the students pur- 16-MB SD expansion cards that were PDA by baccalaureate and/or acceler- chase their own PDAs worked well in purchased for each unit. After config- ated baccalaureate students. For docu- 2 ways. First, students had experi- uring one unit with all the necessary mentation of best practices in nursing mented and used the PDAs before software, a freeware backup program education, more investigation into this coming to the training session, which was used to load all 50 SD cards. The technology infusion in nursing curric- made the session more productive. Sec- nonvolatile SD card memory requires ula is needed. ond, after the program is complete stu- no power source to maintain the dents were able to begin directly using stored data. The PDAs were charged the PDA in their clinical practice. Technical Aspects of PDA the day before their implementation. Infusion Into the First Cohort of ABSN Students Implementation Regulatory Compliance The Center for Information Technol- Students were given their PDAs dur- The Health Insurance Portability and ogy and Distance Learning (CITDL), ing a scheduled training session. The Accountability Act of 1996 (HIPAA) is

NURSE EDUCATOR Volume 30, Number 4 July/August 2005 151 designed to protect the privacy and visit; no recommendations were re- secutive documentation of each stu- security of personal health informa- ceived. The school of nursing also dent’s experience over the course of tion.9 HIPAA regulations have a sig- complies with the policies of the the semester. nificant impact on the use of PDAs in Duke University Medical Center re- At the beginning of the semester clinical settings. Most healthcare ap- garding the use of PDAs in the clinical many of the students are uncomfort- plications for PDA use involve refer- setting. able using the PDA. Some have even ence materials (clinical guidelines, asked if they can e-mail the clinical in- formularies, etc) or clinical calcula- Use and Value of PDAs for formation later. E-mailing the informa- tors (eg, medication dosage, body tion later is appropriate if the stu- mass index, Glasgow Coma Scale); Students dent’s PDA is malfunctioning or it has HIPAA regulations do not apply to While useful in the classroom and been a particularly busy day, but it these types of PDA use. HIPAA regu- learning laboratory, PDAs are proba- should not become the norm. Using lations apply when patient-specific bly most useful in clinical settings, the PDA is what allows a student to data are added to or accessed by the where the pace is fast and resources become comfortable in using the PDA device. may not be readily available. Avail- technology. As students become com- There are 2 key issues related to able programs allow quick access to fortable, they figure out their own PDAs and HIPAA requirements: (1) information on drugs, laboratory val- uses for their PDAs such as entering protecting patient information stored ues, and diseases along with nursing information, while in the clinical set- on the device and (2) maintaining that considerations, procedures, and pro- ting, they will use later in written protection when transmitting patient tocols, to name a few. The informa- work, or to beam the information they information during a synchronization tion about specific diseases and nurs- have gathered to other students. For or wireless transaction.10 Since stu- ing considerations is particularly example, one student beamed her dents do not use a wireless PDA, syn- helpful, because in Duke’s ABSN pro- peers, answers to questions that might chronization generally takes place be- gram students receive their clinical as- be asked by accrediting visitors. Once tween their personal computers, signment at the beginning of each the technology becomes a tool rather never in the clinical setting. Students clinical experience rather than the day than an obstacle to overcome, stu- are told how to de-identify and pro- before. Since students come to the dents find creative uses to facilitate tect patient information stored on the unit without prior preparation, PDA their own learning. device. While stronger security would information is a valuable reference to de-identify and encrypt patient data, understand the patient situation and Use and Value of PDAs for present software options do not allow possible nursing considerations and encryption. We recommend that stu- interventions. In addition to practice Faculty dents’ password-protect access to information, the PDA can be used for The information the students beam to their PDA and de-identify all patient procedural information, such as the instructor each week can be used data maintained on the PDA. If the where the clinical postconference will for a variety of purposes. For the fac- PDA were lost or stolen and a hacker be held and phone numbers for ac- ulty, the PDA is useful for tracking got past a login password, the pa- cessing the various services in the each student’s experiences, including tient’s identity still could be protected. clinical facility. identification of patient problems The HIPAA lists 18 personal iden- Each week students are required and needs, and what the student tifiers of patient data that must be re- to enter the following data regarding learned during that clinical en- moved to de-identify.11 While students the assigned patient(s) into their counter. It also allows the instructor can access and use patient data when PDAs using the commercial word- to track student experiences and in a clinical setting, issues involve stu- processing program Palm OS “Memo knowledge acquisition over the dents taking their PDA (and patient Pad”: week of the semester; primary course of the semester. data) out of the organization for writ- medical problem(s) leading to this Following the weekly beaming ing their learning observations, care hospitalization; significant past med- of the students’ clinical documents, planning documents, and academic ical history; priority nursing diagnosis the instructor now has the informa- assignments. Students are instructed or problems and needs; skills and tion in his or her PDA. One way to to make up a code rather than use the procedures watched or performed; use this information is to plan future patient’s name or initials. When data and what the student learned that assignments. Managing a clinical are de-identified, the risk to patient week. At the end of the clinical week, group and seeing that each student is privacy is minimal. To date, there each student wirelessly sends the exposed to the needed learning op- have been no difficulties in maintain- document to the instructor’s PDA in portunities is a time-laden task for ing compliance with HIPAA regula- the clinical setting. The following the faculty. With the use of the PDA, tions on de-identification of data. week, the student enters the same in- clinical activity planning for students The use of PDAs to generate clin- formation regarding that week’s as- by the instructor is enhanced. Time ical records was thoroughly reviewed signed patient(s) to the same PDA on this task is reduced and a more by the Commission on Collegiate document from the week before. In comprehensive, easily accessible, Nursing Education representatives of this way, each week’s information is current record of student clinical ac- the American Association of Colleges added to the information from the tivities is readily available to the of Nursing during an accreditation week before. The end result is con- instructor.

152 NURSE EDUCATOR Volume 30, Number 4 July/August 2005 Clinical Evaluation Using a the lab coat pocket of the assigned and prior to their end-of-semester PDA faculty member. This is a stark con- conference with their clinical instruc- trast to the picture of faculty carrying tor, then e-mail or bring an electronic One of the many values of the PDA 10- to 20-page evaluation documents copy of this document with them to clinical template is its role in clinical for each of 8 to 10 assigned students the conference. The 2 perspectives evaluation. The PDA is a useful tool in as well as notebooks for anecdotal are merged into 1 document for final gathering data to be used for the eval- notes. printing and official filing at the end uation. The template contains the data The clinical evaluation tool for of the semester. needed for instructor evaluation of the ABSN program lists outcomes the student clinical performance. student must achieve to succeed in Use of a PDA by faculty and stu- the clinical component of the course. Benefits and Challenges dents for data collection and subse- This tool is supplemented with brief There are many benefits and some quent use in evaluation has not been anecdotal narratives that describe ob- challenges to the use of PDAs in nurs- described in the literature to date. servations of student behaviors, ing education. (Table 1). One benefit Most clinical evaluation tools are hard instructor-learner interactions, and relates to the mobility of the PDA. copy documents completed by faculty outcomes in the clinical setting. Com- Owing to this mobility, work can be with pen and pencil in hand. Instruc- pletion of the clinical evaluation doc- done in many different settings such tors struggle with the task of complet- ument is done by both the student as in a conference room waiting for ing these hard copy tools. The docu- and the faculty. meetings to start or on the shuttle bus ments are time-consuming to fill out Each week of the clinical experi- back to the parking deck after clinical. and later to analyze, with timely ence when the student beams the This mobility also allows the instruc- recording of significant events chal- completed PDA template, the clinical tor to complete the notes and review lenging in the clinical setting. Another instructor then adds his or her anec- the student’s entry promptly after the barrier to the use of lengthy pen and dotal notes. Some instructors add to actual events. paper evaluation tools is lack of con- the original student documentation The second benefit relates to sistency in record keeping. template described earlier with addi- work management. From a time man- Clinical days are busy, faculty tional categories: general perfor- agement perspective, this process time is scarce, clinical groups are mance, medication administration, saves the clinical instructor time in large, and students may be providing communication, and documentation. completion of the clinical evaluation care involving complex patient situa- As the weeks progress, the clinical in- document. The entries are made in tions in multiple units or areas. Liberto structor builds on the previous week’s real time by the students, with the in- et al describe how these factors may entries creating a comprehensive doc- structor supplementing the notations lead to inconsistency in documenta- ument depicting the student’s clinical with anecdotal notes. Overall, for 8 to tion as well as sampling of clinical experience. With frequent HotSync- 10 students per clinical group, the in- behaviors of each student being eval- ing and transferring of data into a structor spends approximately 15 min- uated.12 With this background, one word document by simply copying utes total for all students. At the can see how using the PDA would and pasting, the final clinical evalua- midterm and end of the clinical rota- lead to efficiency in completing a clin- tion tool is completed. tion, time is also saved. The maximum ical documentation tool. The PDA, The student also completes the time spent on each documented eval- with templates and word processing, same clinical evaluation document uation is approximately 15 minutes. stores all of the data for the entire using their PDA document. They are All of the data is there in one file. The clinical group, password-protected in required to complete this at midterm instructor can just copy the data and

Table 1. Benefits and Challenges to Using Personal Digital Assistants in Nursing Education Programs*

Benefits to Using PDAs Challenges to Using PDAs

Can be used anywhere/anytime Complying with HIPPA regulations Allows convenient access to large amounts of data Protecting patient confidentiality Increases student-faculty organization in the clinical setting Encouraging consistent use by faculty and students in the clinical setting Improves student-faculty time management in Troubleshooting synchronization problems documentation of clinical performance Encourages timely recording of significant events in Breakage or inoperable units the clinical setting Reduces paper usage through wireless transmission Acquiring software beyond the available freeware Prepares graduates for the future by embracing microtechnology use at the bedside *PDAs indicate personal digital assistants; HIPPA, Health Insurance Portability and Accountability Act.

NURSE EDUCATOR Volume 30, Number 4 July/August 2005 153 add this information to the clinical ing students to purchase a commer- 3. Moore L, Richardson BR, Williams RW. The evaluation document template by the cial software package featuring gen- USU medical PDA initiative: the PDA as an appropriate outcome and summarize eral nursing references (PEPID).13 educational tool. In: Kohane IS, ed. Bio the student’s clinical performance and The cost of approximately $140, *Medical Informatics: One Discipline/The areas for growth. comparable to one textbook, would Annual Symposium of the American Medical Informatics Association, Proceed- The third benefit of the use of be justified for use in the 16 months ings, November 9–13, 2002. Philadelphia, PDAs relates to the size of this device. of the program. Pa: Hanley & Belfus; 2002:528-532. Students are required to complete the Overall, the infusion of PDA tech- 4. Scordo KA, Yeager S, Young L. Use of PDA template categories such as nology into an accelerated baccalaure- personal digital assistants with acute care “skills done” and “my learning” imme- ate program has been very successful. nurse practitioner students. AACN Clin diately after the events of the clinical The technical challenges and lessons Issues. 2003;14(3):350-362. time. This instant reflection creates an learned from this project have kindled 5. McCord L. Using a personal digital assis- account of their experiences and al- an interest in PDA technology in the tant to streamline the OR workload. lows the clinical instructor to plan fu- school. To better understand the PDA’s AORN J. 2003;78(6):996-1001. ture assignments to move the student specific impact and as part of the initial 6. Eastes L. Use of the personal digital assistant for point-of-care trauma docu- toward attainment of the clinical ob- grant process, data are being collected mentation. J Emerg Nurs. 2001;27(5): jectives. Students are encouraged to from 1st-semester students concerning 516-518. refer to the clinical evaluation tool fre- their baseline knowledge and prior use 7. Lehman K. Clinical nursing instructor’s quently and use their PDA template of PDAs and from students right before use of handheld computers for student document to begin their self-evaluation. graduation concerning their overall im- recordkeeping and evaluation. J Nurs Use of the data from the PDA template pression of the PDA application in Educ. 2003;42(1):41-42. is frequently evident. The students their nursing program. 8. Huffstuler S, Wyatt T, Wright C. The use comment on the benefit of having In the future, the hope is to see of handheld technology in nursing edu- such a comprehensive record of their nurses routinely synchronizing their cation. Nurse Educ. 2002;27(6):271-275. progress. Use of the PDA allows faculty handheld computers with strategi- 9. Department of Health and Human Ser- vices, Office for Civil Rights. Summary of and students to have all information cally centralized database ports the HIPAA Privacy Rule. 2003. Available at: related to clinical experience evaluation throughout a healthcare agency. Re- http://www.hhs.gov/ocr/privacysummary. in one tiny device. markably smaller with each new pdf. Accessed May 25, 2005. One of the main challenges to build, these microcomputers are 10. Johnson L, Rivers S. Implications of using PDAs with nursing students is helping pioneer very important ad- HIPAA on handheld clinical applications ensuring that all faculty use the PDA vancements in healthcare. It is im- [pdaMD Healthlink page]. Available at: consistently, require its use with all portant that nursing graduates know http://www.pdamd.com/vertical/ students, and promote its application how to embrace the tools that mi- features/HIPAA2.xml. Accessed June 9, in the clinical setting. Achieving con- crotechnology is bringing into daily 2004. sistency is especially difficult with ses- patient care operations, and using 11. Centers for Disease Control and Preven- tion. HIPAA Privacy Rule and public sional faculty who may not be as fa- PDAs in baccalaureate nursing edu- health: guidance from CDC and the U.S. miliar with evaluation processes, cation is an effective way to accom- Department of Health and Human Ser- technology, and informatics standards plish this. vices. MMWR Morb Mortal Wkly Rep. 2003; for nursing education. 52(suppl):1-20. 12. Liberto T, Roncher M, Shellenbarger T. References Anecdotal notes: effective clinical evalua- Conclusion 1. Goss L, Carrico R. Get a grip on patient tion and record keeping. Nurse Educ. safety: outcomes in the palm of your 1999;24(6):15-18. The faculty recognized early that ad- hand. J Infusion Nurs. 2002;25(4):274-279. 13. PEPID RN. Student Clinical Companion ditional clinical resources beyond 2. Craig AE. Personal digital assistant use: Suite. Available at: http://www.pepid.com/ the available free software are practical advice for the advanced practice products/rnscc/default.asp?product needed. The faculty are now requir- nurse. Top Adv Pract Nurs. 2002;2(4):6. SCC. Accessed May 31, 2005.

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