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ED 248 748 

HE 017 606 







Computer Technology and Nursing Education. 
Southern Council on Collegiate Education for Nursing, 
Atlanta, GA.; Southern Regional Education Board, 
Atlanta, Ga. 

69p. ; Papers based on presentations at the Annual 
Meeting of the Southern Council on Collegiate 
Education for Nursing (Atlanta, GA, October 26-28, 

Southern Council on Collegiate Education for Nursing, 
1340 Spring Street, N.W. , Atlanta, GA 30309 

Collected Works - General (020) Reports - 
Descriptive (141) 

MF01/PC03 Plus Postage. 

Authoring Aids (Programing); * Computer Assisted 
Instruction; * Computer Oriented Programs; Delivery 
Systems; Higher Education; "Information Systems; 
Microcomputers; "Nursing; "Nursing Education; 
"Program Administration 
IDENTIFIERS Nursing Education Module Authoring System 


The influences of computer technology on college 
nursing education programs and health care delivery systems are 
discussed in eight papers. The use of computers is considered, with 
attention to clinical care, nursing education and continuing 
education, administration, and research. Attention is also directed 
to basic computer terminology, computer system design, sources of 
information on computers, and system costs. Functions of a medical 
information system are discussed, along with a specific application 
of computers; the Nursing Education Module Authoring System (NEMAS), 
which can be used to create instructional modules and to deliver the 
modules to learners and record their responses. Titles and authors of 
the paperjs, are as follows: "Computers in Nursing: Where Are the 
Leaders?" (Richard E. Pogue); "Basics of Computer Technology: 
Clearing the Crystal Ball" (Gary D. Hales); "Dean's Use of Computer 
Technology in Administering a Nursing Program" (Billye J. Brown); 
"Computer-Assisted Instruction in Nursing Education" (Donna E. 
Larson); "Computer Use in Nursing Service" (Carol A. Romano); 
"Nursing Education Module Authoring System" (Carole Hudgings); "Drug 
Therapy Course" (Lucille M. Pogue); and "Survey of Microcomputer Use 
in Southern Nursing Education" (Audrey F. Spector). (SW) 


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Southern Council on Collegiate Education for Nursing 
1340 Spring Street, N. W. 
Atlanta, Georgia 30309 

The Southern Council on Collegiate Education for Nursing (SCCEN), founded 
in 1962, is a membership organization made up of deans and directors of associate 
degree, baccalaureate;, graduate, and continuing education programs for nurses 
in more than 200 colleges and universities in 14 Southern states. 

The Council provides a forum for sharing information and promoting com- 
munication among all types of collegiate nursing education programs, conducts 
studies and publishes reports, plans and conducts regional activities to stimulate 
research in nursing in higher education, and engages in many other activities all 
designed to strengthen nursing and nursing education in the South. 

SCCEN is affiliated with the Southern Regional Education Board (SREB). 
The 14 member states are Alabama, Arkansas, Florida, Georgia, Kentucky, Loui- 
siana, Maryland, Mississippi, North Carolina, South Carolina, Tennessee, Texas, 
Virginia, and West Virginia. 





Richard E. Pogue 

Gary D. Hales 


Billye J. Brown 

Donna E. Larson 

Carol A. Romano 



1 "\ 

Carole Hudgings 

Lucille M. Pogue 

Audrey F. Spector 






Since its formation in 1962, the Southern Council on Collegiate Education for 
Nursing, in affiliation with the Southern Regional Education Board, has addressed a 
variety of issues and needs in nursing education. Some of the regional activities 
have stemmed from developments in higher education in general; for example, an 
increasingly diverse student population on college campuses prompted regional ac- 
tion to promote new and varied teaching strategies in the college-based nursing 
programs. Other activities have been in response to trends in the health care deliv- 
ery system and the need to prepare nurses with knowledge and skills to meet the 
changing demands of the work place. 

Now, new challenges are posed to the college-based nursing education pro- 
grams by the phenomenal growth in computer technology and the rapid changes 
surrounding its use both on college campuses and in the health care delivery system. 
It is predicted that there will be 20 times as many microcomputers in use on the 
nation's college campuses in 1985 as there were in 1980. As computer technology 
becomes more affordable, almost all college campuses are expanding its use for 
research and administration, and its use as an instructional tool is underway or is 
being planned. In this climate, college-based nurse educators are keenly interested 
in applying the newly available technology in nursing programs. At the same time, 
nursing schools are pressed to prepare graduates who can function in an increasingly 
automated health care delivery system. It is predicted, for example, that in the 
next three to five years utilization of computer technology in hospitals will increase 
by about 60 percent and that 70 to 80 percent of all hospital functions will be 

A 1983 survey of collegiate schools of nursing in the South documented the 
concerns, needs, and high level of interest among nurse educators regarding com- 
puter technology. Accordingly, the 1983 annual meeting of the Southern Council on 
Collegiate Education for Nursing, held in Atlanta, October 26-28, 1983, addressed 
the nurse administrators' needs— including the basics of computer use and application 
/in the health care system and for instructional purposes. This publication includes 
/ papers based on presentations at the meeting, descriptions of instructional programs 
that were demonstrated, and a report of the regional survey. 

Audrey F. Spector 
Executive Director 
Southern Council on Collegiate 
Education for Nursing 


Richard E. Pogue, Ph.D. 
Professor of Health Systems and Information Sciences 
Medical College of Georgia, Augusta 


Soon a college graduate with no facility in communicating with com- 
puters will be almost as handicapped in dealing with the challenges of 
society as a functional illiterate is now. 

This is not a statement by some far-out computer expert enamored with tech- 
nology. Rather, this statement was made by Vernon Crawford, chancellor of the 
University System of Georgia, in his 1983-84 budget request to the Georgia legis- 
lature for quality improvement funds to increase access to computer facilities by 
University System faculty and students. Moreover, he added: 

Many of our faculty members will soon be dealing with students who 
have had several years of experience in working at one level or another 

Let's approach our topic in another way— through scenarios which illustrate 
uses of computer technology within nursing. 

A. Clinical Care 

On a clinical unit, a nurse turns to the computer to get the care plan for a new 
patient just assigned to the unit. She reviews the care plan on the screen, notes that 




it has been changed slightly since yesterday, asks for expianations of components 
which she doesn't understand, and then prints a copy of the care pian. 


5 As she ieaves to go to the patient, another nurse uses the computer to carry 
out computations of drug dosages for severai patients, and prints the dosages to take 
aiong with her. She decides to return iater to take a lesson that reviews a category 
of drugs which she hasn't used for a whiie. 

B. Nursing Education 

A group of undergraduate nursing students enrolled in a self-study pharma- 
cology course enter the learning resources laboratory to take the next computer- 
based lesson in the sequence. They review certain disease entities, learn about the 
drugs commonly used in managing these diseases, practice computing dosages for 
these drugs, and then practice making clinical decisions in simulated situations 
where these drugs are used. 

At the end of the lesson, the computer shows each nurse how well he or she 
performed on the lesson. Two of the students are advised that they are weak on a 
couple of the topics covered, are directed to remedial study materials, and advised 
to go through the lesson again. The others remain at the computer to take the 
evaluation test which provides confirmation of their competency on this topic. 

C. Nursing Administration * 

A nursing supervisor is reviewing the staffing schedule prepared by the com- 
. puter for the units for which she is responsible during this shift. She concludes that 
two units need additional staff, and decides to pull them from another unit. She 
enters this information into -the computer and gets a. revised staffing schedule. 
However, this leaves her short one nurse, so she calls up a computer file of nurses 
available for extra duty. She points to the name of a nurse on the screen, and the 
computer automatically dials the telephone number of that nurse. The supervisor 
picks up the phone beside the computer, tells the nurse her problem, and the nurse 
agrees to come in immediately. 






D. Nursing Research 

A clinical nurse specialist decides to do research on a clinical problem in her 
specialty. Knowing that her hospital has all its\clinical patient records on the 
computer, she poses her research problem, identifies the patient data needed to 
answer her research question, and selects the appropriate statistical analysis. She 
enters her request for data into the hospital computer, which provides her with a 
data file that is coded to protect the privacy of the patients selected for her study. 
She realizes that the size of the data base is too large to be analyzed on the hospital 
computer, and forwards it for analysis on the large research computer in the state. 
Within a few hours of her request for data from the hospital computer, the results of 
the statistical analysis are printed out on her personal printer. 

E. Continuing Nursing Education \ 

In the staff development department, a group of new nursing employees have 
just finished taking the test on drugs required by the hospital. One has\passed all 
components of the test; the remainder have not met the requirements for several 
different categories of drugs. Those who have failed some parts of the test take 
lessons on the computer to review these categories. Several decide to take\ lessons 
on categories that they passed, but in which they feel unsure of their knowledge. 
All nurses in the group successfully pass the test by the end of orientation and are 

certified to administer drugs on their units. \ 


They also note that lessons are available on topics for which they may receive 
continuing education credit. All of them decide to return for lessons of particular 
relevance to their professional interests, thus helping them meet the continuing 
education requirements of the profession and increasing their value to the hospital 
as well. ^ 


These scenarios are real, and are being played out somewhere today. 


, Finally, let's consider a scenario for the future, posed in a book written by a 
physician, 3. S. Maxmen, and titled, The Post- Physician Era. The thesis of Maxmen's 

book is that computers will eventually make most of the technical diagnostic and 
treatment decisions currently made by the physician. Moreover, a new kind of 
health professional will fill the physician's current role in the delivery of front-line 
health care and will perform other technical tasks. These new health professionals 
would require less formal training than the physician of today, and would be selected 
for their humanistic characteristics rather than their scientific intellectual capabil- 
ities. Imagine, a restructuring of health care delivery in which the role of today's 
dominant player would be drastically modified! 

I ask you: Is not the nurse practitioner of today the logical candidate for this 
role of tomorrow? 

And now to the theme of my presentation. 

Where are the leaders within nursing with the vision— and courage—to pursue 
the technological challenges facing nursing today, and to prepare for this world of 

Where are the leaders in positions of responsibility who will accept Chancellor 
Crawford's mandate, and will lead their profession into a world that relies heavily on 
computers and communications technology? 

Where are the leaders within nursing with the technical expertise and under- 
standing to provide technical direction and support? 

That is the challenge which all health professions face today. And it is my 
contention that the challenge is perhaps more significant— and offers more oppor- 
tunity—to nursing than to any other health profession. 


To understand the reasons for Chancellor Crawford's statements and the chal- 
lenge of the new technologies to the health professions, it is helpful to look at what 
is happening in society as a whole. The technological developments occurring in 




society are a driving force to which the health professions are being forced to 
respond. Fortunately, they are a force which, with wisdom and leadership, can be 
used to better the health of our people and the well-being of the health professions. 

One can make a strong case for the argument that technology is a major 
factor in determining what a society is or may become. As a few examples, a 
primary difference between the "have"\and "have not" nations of the world is the 
difference in their technological development. The printing press provided the tech- 
nological basis that made education of the masses possible. The industrial revolu- 
tion provided the technological basis for changing societies from rural, agrarian 
forms of organization tc our modern urbanized, industrialized societies. And, al- 
though we in academia may not often stop to thmk about it, the invention of new 
technologies has been a major force behind the growing need to educate every citi- 
zen to function effectively within society. \ 



Those who study such things contend that the computer will have more impact 
on the history of mankind than did the industrial revolution) yThis case is particu- 
larly well made by Christopher Evans in his book, The Micro Mmenium. Evans de- 
scribes the characteristics of the industrial revolution as follows:\One, it amplified' 
man's muscle power, permitting us to carry out physical accomplishments never be- 
fore possible. Two, it brought about tremendous changes in society, including the 
way we organize and live. Three, it happened very rapidly, in a space of less than 
150 years. Fourth, once started, its growth was unstoppable, even remorseless in its 
impact. And fifth, and particularly interesting, no one really foresaw its total 
impact on society, so that society was surprised— and unprepared— when it happened. 

Evans compares the computer revolution with the industrial revolution in its 
total impact on society but sees some important differences. The biggest, of 
course, is that the computer revolution is aimed at amplifying our intellectual and 
knowledge processes. Another, perhaps somewhat frightening, difference is that the 
computer revolution will take place in far less time, perhaps in as few as 50 years. 
(The history of the electronic digital computer as we know it goes back less than 40 
years.) Finally, and a most hopeful factor, is that our modern communications allow 





us to observe and predict what's likely to happen, therefore giving us time to pre- 
pare for the anticipated changes. 

Why is the computer having such an impact on society? The answer may take 
many forms, depending on your perspective, but my view is that the computer brings 
together into a single device four major threads of technological development 
through human history. 

One thread has been the development of computational machines to help cal- 
culate increasingly complex numerical problems. In fact, this was the major moti- 
vation for developing the first electronic digital computer. 

Second has been the creation of devices for storing, organizing, and retrieving 
the vast amounts of information being generated at an increasingly rapid rate by 
modern societies* 

Third has been the efforts to develop mechanisms for communicating with 
each other across distances. The drums of the jungle and the smoke signals of the 
prairies are indeed primitive when compared with the telephone, telegraph, radio, 
and television. 

Ihe final thread his been the development of intelligent machines to assist in 
making the increasingly difficult decisions that must be based on bpth a complex 
environment and large masses of information to be productive. 

In the computer, the genius of man has developed a single device which com- 
bines all of these capabilities into small, inexpensive, readily accessible, and easy- 
to-use devices available to us all. 

You might logically ask at this point: If computers really have^all of these 
capabilities, why haven't we made more progress in using them in the ways people 
envision? The answer lies in the perspective of time. The first electronic digital 
computer was invented less than 40 years ago, and began making its way into society 

only 30 years ago. Computers have been widely used in business for about 25 years, 
but were introduced to education and patient care only about 20 years ago. And, 
they remained under the control of the "high priests of computing" until the late 
1970s when the microcomputer "revolution within a revolution" began. 

From another perspective, the 1950s were a time of one machine/one user. In 
the 1960s, we learned how to allow many users to share one machine. 'The 1970s 
were the decade in which we learned how to make computers talk to one another 
and to provide access across broad geographical areas. In the 1980s, we are now 
back to the time of one computer/one user, except that each of us now has a 
computer with the ability to communicate with a wide variety of computers— and 
each other— over long distances. 

Never in the history of mankind has such a powerful technological device had 
such a tremendous impact on society within such a brief period of time. And therein 
lies the problem: we have simply not had enough time to learn how to use— and 
adapt to— the computer. This is certainly true for the complex and fragmented 
health care system that exists in this nation and elsewhere. 

An anecdote may help put the rapidity of progress in perspective. If the 
automobile industry had accomplished what the computer industry has over the last 
30 years, a Rolls Royce would cost $2.50, would get 2 million miles per gallon, would 
have power enough to drive the Queen Elizabeth II, and six Rolls Royces would fit on 
the head of a pin. At $2.50 each, I guess even those of us in academia could afford 
the luxury of a Rolls. 

To confirm that the technological challenge exists in your world of today, you 
need only read the popular press, watch television, or read the professional liter- 
ature and attend professional conferences to realize that the computer revolution is 
upon us now. o 

Supporting this nonscientific evidence is the fascinating book, Megatrends, by 
John Naisbitt. Naisbitt identifies 10 major trends impacting society today, trends 



which he expects to continue through the next few decades. Two of them are 
particularly important to our discussion. One confirms that we are indeed moving 
from an industrial society to an information society. The other, and perhaps more 
surprising, is a trend which he calls "high tech/high touch." As a compensation for 
the increasing use of high technology, mechanisms for providing greater human in- 
teraction will be necessary. In other words, the more high tech, the greater the 
need for high touch. This offers significant hope that we wiil be able to meet our 
needs for human interaction in the midst of a high technology world—certainly a 
matter of great concern to all involved in health care, both providers and users. 
Interestingly, he used several examples from nursing to illustrate his point. 

Within the health professions, work being done in the field called "artificial 
intelligence" is already demonstrating that the computer can be used to develop 
"expert systems" to support medical decision making. Perhaps of more significance 
in the short run may be recent work of Dr. Larry Weed in developing "problem- 
knowledge coupling" systems on microcomputers. Weed uses the computer to record 
information about a patient's problems , and couples it to existing knowledge about 
the causes of and treatments for the patient's complaints. The value of the com- 
puter in this role is that it can collate and relate far ''more information, far more 
rapidly, than the human mind can possibly handle reliably and consistently. 

One unexpected result of such work may be to put medical and nursing diag- 
nosis on a scientific foundation. Such a possibility must certainly be very threaten- 
ing to those who believe that the art of diagnosis represents the highest expression 
of their professional abilities. Should this happen, however, it will simply parallel 
other intellectual efforts which were, of necessity, practiced as an art form until an 
underlying rationale was developed and taught to its practitioners. 

Does this mean that the computer will "do it all," and that the health profes- 
sional will become a passive participant in key aspects of health care? Possibly, I 
suppose, but I have faith that mankind's ingenuity will be up to the task of defining a 
role for our technology that will be supportive of what will always remain essen- 
tially a human activity. In fact, as noted in the trend toward high touch, the 





humanistic role of the caring health professional will be even more important as we 
increase our use of technology in health care. 


First, let me say that there are nurses who are leaders in the use of computer 
^ technology within nursing. My perception, and therefore my concern, is that these 
leaders are too few in number, and that they have arrived at positions of leadership 
because of a personal interest in computing. While this is perhaps natural—and is 
definitely all to the good— we have yet to see many schools or departments of 
nursing that have decided to provide leadership in the use of computer technology as 
an organizational objective. It is my contention that this must happen if the nursing 
profession as a whole is to deal effectively with computer technology. 

Let's consider the problem of developing leaders in the use of computers in 
nursing. F ; rst, you should be aware that there is no commonly accepted definition 
of what it means to be computer literate— in the health professions or elsewhere. 
Two sessions at the 1983 second annual fall conference of the American Association 
for Medical Systems and Informatics (AAMSI) dealt specifically with this question. 
The ideas on the subject were diverse and in many instances contradictory. 

A major debate is whether health professionals should have to learn to program 
the computer in order to become computer literate. I think not, and both the serv- 
ice and academic programs at our institution are based on this premise. What is re- 
quired, however, is that all health professionals be expert in algorithmic thinking— the 
process of identifying and specifying the steps in instructing the computer on how 
to carry out a sequence of actions. Essentially, this requires nothing more than 
the ability to think logically and work systematically in solving a problem. You need 
only learn how to apply abilities you already have to an environment which uses 
computer technology. 

After all the discussion on computer literacy at the AAMSI conference, the 
clearest definition of computer literacy I heard was made after the session by my 
wife, who said, "To me, computer literacy is what I need to know in order to do what 
I want to do with computers as a practicing nurse." Succinct, and accurate. 




w At the same sessions, Dr. Harold Schoolman, currently acting director of the 
National Library of Medicine, differentiated between two aspects of computer lit- 
eracy: the acceptance and use of the computer as a computational tool, and its use 
as an intellectual tool for human decision making and other intellectual activities. 
(He also expressed his belief that the computer will eventually alter medical educa- 
tion as we know it today.) The first level of computer literacy will be more easily 
accomplished because it requires only the application of intellectual capabilities 
possessed by all health professionals. The level of learning how to use the computer 
as a tool of our intellects will be much more difficult because it requires a change 
of perceptions of the practice of medicine, and of the roles which health profes- 
sionals play in health care. Thus, a change in fundamental attitudes is essential. 

I believe that Dr. Schoolman's perception goes to the heart of the problem of 
computer literacy in all health professions, and also offers the basis for a solution. 
Let us begin by learning to use the computer in our everyday professional lives— for 
word processing, record -keeping, and other familiar activities. Only after develop- 
ing a basic understanding of the tool that comes with that process, can we begin to 
conceptualize about ways to use the computer in how we think about and practice 
our professions. 

A further approach which we have found useful in organizing the program for 
computer literacy training at my institution is to define three levels of computer 
literacy: attitudinal, application, and technical computer skills. 

At the attitudinal level, we offer courses, seminars, and general workshops in 
which the objective is to develop general awareness of the role of computers in the 
health professions, familiarity with general concepts and terminology, and comfort 
in using the computer for various purposes. 

At the application level, we offer courses and intensive workshops on a 
specific use of the computer, for example, word processing, computer-assisted in- 
struction, health information systems, etc., so that faculty learn specific skills at a 
further level of depth and detail. 


Our only offering at the technical skill level currently involves a computer 
programming course, which we advise nurses and other health professionals not to 
take. However, we have in. the approval process a master's degree proposal which 
will offer add-on decrees in computing for health professionals who wish to spe- 
cialize in the use of computer technology within their profession. The graduates of 
this program would be uniquely equipped to provide both technical and intellectual 
leadership on the use of the computer within their health profession. 

A major barrier to the impact of our program is that all courses are electives, 
and faculty attendance is an individual matter rather than a school or departmental 
matter. Thus, progress in computer literacy is slow and fragmented, and to date has 
had relatively limited impact on a school or departmental basis. If nursing is to 
meet the challenges outlined earlier, such training must be undertaken as a school or 
departmental objective, at the instigation, and with the support, of the dean or 

Resources must be committed, release time given to faculty, and a reward 
system established that recognizes new expertise through salary increments, promo- 
tions, and tenure decisions. Experience has amply demonstrated the difficulty in 
attempting to add a new area of expertise as an add-on to other responsibilities. 
Many faculty have attempted to do this, but are able to sustain the level of effort 
and time commitment for only a short period of time before they begin to suffer the 
classic symptoms of burn-out, and finally decide that their personal and professional 
survival requires that they give up their computing activities and return to more 
classical professional activities. That's a guaranteed road to failure, regardless of 
the profession. Computer literacy programs must be put on a programmatic, rather 
than a personal, basis if they are to succeed over the long haul. 

As far as educating our nursing students in computing is concerned, I believe 
that the best way is in the context of courses in nursing. This approach places com- 
puter technology in the role of a routine tool of the nursing profession, and provides 
students with role models of nurses making effective use of .the computer in nursing 
practice. It should also make it easier to incorporate computer training into the 



already crowded curricula. The current difficulty, of course, is that few nurses have 
the computer knowledge to serve in the required teaching roles. Thus, in the short 
term while nursing faculties are undergoing the necessary training, we will undoubt- 
edly have to rely on separate courses, taught more often than not by computet 

The long-term solution lies in training our nursing faculties in computer tech- 
nology. The proposal of the Southern Council on Collegiate Education for Nursing to 
provide decentralized workshops in computer technology for nurses throughout the 
Southern region is an excellent step in this direction, and I wish to compliment the 
Council for the vision and foresight which this prooosal represents. The program 
proposal seems to fit well into the model outlined earlier, in which the first stage 
would be to train faculty in general computer concepts and applications in nursing, 
with liberal amounts of hands-on computer experience so the attendees develop the 
facility to use the computer in particular applications after the workshop. From 
personal observation, I would expect that these faculty would in turn serve as cata- 
lysts in training their colleagues, facilitating cooperation and collegiality among 
faculty in dealing with the computer world. 

The second phase might then be to train these faculty to become experts in 
specific uses of the computer of particular personal interest, whether it be record 
•management, research, or instructional uses of the computer. At least some of 
them should then opt for add-on degrees in computing, particularly if the means 
were made available for providing sabbatical time and financial support. Upon 
completion of such programs, the graduates would then be able to serve as the local 
computer experts within nursing schools and departments, and would be prepared to 
provide technological leadership within the nursing profession as a whole. 


Let me close by ^turning to the main theme of this presentation, but rephras- 
ing the title to ask: Who should be the leaders in computer technology in nursing? 

First, every nurse must be a leader in the integration of computers into the 
nursing profession, for only nurses can— and should— determine the role of computer 





technology in nursing. This does not .mean that every nurse must be an expert in 
computing. Rather, each nurse must understand and be able to use the computer 
effectively in her or his role within the nursing profession. 

You-the nursing deans and directors-are the leaders with the ability and 
• responsibility for conceptualizing the role of computers within nursing as a profes- 
sion, and for preparing nurses to function effectively in their use of computer tech- 
nology. You are the leaders who must foresee what is coming, so that you may 
direct nursing along a path that will benefit society and the profession of nursing. 
You are the leaders who must be convinced that computer literacy is a mandate for 
your faculty and for your students, a mandate which must be incorporated into your 
curricula. You are the leaders who will determine nursing's role in the computerized 
health care world that is upon us. 

My key note to you is for action— action which will make nurses, not someone 
else, the experts on the appropriate use of computers within the nursing profession. 

• Would you not rather direct your destiny, than allow others within or outside 
of the health professions to shape it for you? Nursing is at the heart of the health 
care system and it, more than any other profession, will feel the impact of the new 
technologies. To a great extent, it will be the nursing profession who will decide 
how humanistically computers will be used for the well-being of our people. Surely, 
nursing is the key humanizing and integrating force within the entire health care 


Crawford, C. V. (1982, October). As quoted in: Board seeks 33 percent increase in 
state funds. The System Summary (A publication of the University System of 
Georgia), 18 (10), 9-1Q. 

Maxmen. 3. S. (1976). The post physician era: Medicine in the twenty-first ce ntury. 
New York: John Wiley and Sons. 

Evans, C. (1980). The micro mille' ium . New York: The Viking Press. 

Naisbitt, X (1982). Megatrends: Ten new directions transforming our lives . New 
York: Warner Books. 




Gary D. Hales, Ph.D. 
Computer Consultant for Nursing, Health Care, 
Education, and Small Businesses, Houston, Texas 
Editor-in-Chief, Computers in Nursing 



CPU This is the central processing unit or "brain" of the computer which 
directs the computer's operations. There are various kinds of CPUs in use desig- 
nated by numbers, such as 8080, 8088, 6502, etc. The important thing to know is 
that the CPU (or microprocessor) in the computer dictates the type of software that 
can be used on that computer. You cannot, for example, run CP/M software on an 
Apple He which has a 6502 CPU unless you add a Z-80 CPU. 

Memory The computer system has storage areas for data and instructions. 
The greater the storage available, the longer, and often more complex, the program 
can be. In addition, large amounts of computer memory allow manipulation of large 
amounts of data. Computer memory is described by the number of Kilobytes, or 
thousands of characters, which can be stored. A 64K memory can store just /around 
64,000 characters— number, letters, symbols. A major dictum of computer use is 
that you cannot have too much memory. 

Peripherals This category contains all those devices that are literally periph- 
eral to the actual operation and use of the computer. That is, the computer can 
function without the peripheral, but you will not be able to use the product of the 
computer's labor. Peripherals include: 

Author's Note: This outline was developed from a verbal presentation made to 
the Southern Council on Collegiate Education for Nursing. 



ERIC :;. 20 

Monitors Video displays are used to view your input to the computer and 
to see the output from the data processing. Most displays use cathode ray 
tubes (CRTs), but the newest technology is the flat screen display seen on 
many portable computers. For educational use, color monitors are preferred 
since color can be used to convey concepts not possible with monochrome 

Storage mediums You must have some kind of unit used to store informa- 
tion when the computer is turned off. The most common storage devices are: 
Tapes With tape one can store large amounts of information, but 
the access is sequential. That is, the tape must be physically moved to 
the location of the information to permit reading; this is slower than disk 

Disks With a disk and the accompanying drive, there is relatively 
immediate access to any point on the disk. The disk, which looks some- 
thing like a record, spins, and the drive positions a read/write head over 
the section to be used to store data on the disk or xo read data which has 
been stored. Floppy disk drives are commonly used in microcomputers— the 
name deriving from the flexibility of the <Jisk used— and have storage ca- 
pacities of up to 1 megabyte. Hard disk drives use rigid dioks which spin 
at a much faster rate, resulting in much faster storage or retrieval, and 
have storage capacities of 5 megabtyes (5 million characters) and up. 
Tape drives of some kind are often used to ••back-up" (make a copy of) 
hard disks due to the large amounts of material stored. 
Printers Often one needs a printed or "hard 11 copy of the information that 
appears on the screen. The two most common types of printers are: 

Dot matrix The letters are made by the formation of a series of 
tiny dots on the paper. This quality of print is acceptable for internal use 
but "correspondence quality" print is desired for external communication. 
Some of the newer dot matrix printers nave this quality of print, which 
produces darker, more complete lettering b' overprinting the characters. 

Letter quality The printer uses an "element" similar to that used on 
IBM Selectric typewriters. The print is formed by the impaot of a letter 
shape on the paper, ju3t as it is formed when using a typewriter. The 




print quality is indistinguishable from that of a typewriter and is suitable 
for formal or official correspondence. 

Modems The modem (MOdulator/DEModulator) is a device which converts 
computer output to audio signals, can transmit these signals over phone lines, 
and can decipher such signals from other computers. The modem allows the 
computer user to make contact with other computers and use large databases 
or communication networks. 

Graphics tablets The tablet allows one to draw pictures on the monitor 
and save these pictures on disks for future use. CAUTION! If you cannot 
draw, the graphics tablet will not make you an instant artist— I speak from 
personal experience. 

Plotters The plotter will draw graphs, pictures, etc. on paper, and is very 
useful for showing output of statistical programs, spreadsheets, and any appli- 
cation where graphic presentation of data will assist interpretation. 

Buffered interfaces This device "stands between" the computer and some 
• other peripheral, usually a printer, and stores information until the printer can 
get to it. Simply put, the computer user constructs a document, sends 'it to 
the printer, and, after a short pause, depending on the length of the document, 
can use the computer to work on something else. The control over the print- 
ing, normally exercised by the computer, is done by the buffer, which feeds 
data to the printer when it is ready to receive it. This obviously increases 
processing and productivity since one does not have to wait until the printing 
is done to use the computer again. 

Clock cards The clock is standard on some computers and keeps track of 
date and itime. It is usually equipped with a battery to be used when the 
computer is turned off so that the date and time do not have to be reset each 
time the computer is turned on. The advantage of having the clock is that the 
computer user can, by writing a program or using commercially available soft- 
ware, have the computer run a program in the absence of the user. For 
example, the user could turn on the computer before leaving the office and 
have it access a database, using a modem, at 2:00 a.m. when the phone rates 
are low and there are fewer people trying to use the database. 




Special keyboard Due to the poor design of some keyboards, manufac- 
turers have developed additional keyboards that simulate a typical typewriter 
keyboard, have a number pad, etc. Perhaps in the future, new designs will 
consider the needs of the user, and not the desires of the designer, thus elimi- 
nating the need for add-on keyboards. 

Surge protectors Fluctuating current is a problem in many locales. In the 
worst case, power surges not only disrupt the operation of the computer, but 
also may physically damage the unit. The surge protector keeps dangerous 
power fluctuations from affecting the computer. 

Fans A small fan can keep the air circulating evenly in the computer and 
prevent overheating. Fans are built into some models and others, like the 
Apple II, have add-on fans available. Recent computer designs lessen heat 
problems by using fewer chips and chips that produce less heat. 

Joy sticks and game paddles These are used to move the cursor or game 
piece around the screen, and can also be used with some software to simulate 
• a pencil for drawing. The importance of using games to introduce novices to 
computer use is often not given adequate attention in computer implementa- 
tion. Gaming provides a very non-threatening introduction to computers and 
can spur the beginner to investigate more practical uses for the system. 

Network systems Networking will be one of the major trends in the 1980s. 
By connecting a number of computers together—using modems, cables, or 
both— more efficient use of mass storage (hard disks) and peripherals is possi- 
ble, since each user can access whatever peripheral is connected to the net- 
work. Software to permit electronic mail and electronic conferences can 
speed communication. Purchase of software that can be used on a network 
and can be legally duplicated (not all can) means that instead of purchasing 10 
identical programs to serve your student body, you can purchase one and have 
the students download it to their machine from the hard disk (i.e., transfer the 
program into their microcomputer's RAM). Future cable TV installation will 
allow connection of microcomputers as well as televisions and video recorders. 
The ubiquitous cable will become a natural extension of the computer network. 

Card readers and optical scanner In many cases, there is a need for large 
amounts of data to be entered into the computer. Input by keyboard is tedious 



and time-consuming. It is much more practical to collect the data on a 
medium which can be fed directly to a device connected to the computer, thus 
avoiding the possibility of data transcription errors and substantially decreas- 
ing the lag time between collection and availability for analysis. The data can 
be collected using M mark sense" cards, or sheets of paper with room for hun- 
dreds of items. The optical scanner or card reader interprets the marks and 
transmits this data directly to a file for later use. 

Interactive video interface and videodisk or vcr One of the most exciting 
advances in computer-assisted instruction is the introduction of Computer- 
Assisted Interactive Video Instruction (CAIVI). Quoting from Computers in 
Nursing, March-April 198^: 

CAIVI is a relatively new technique in CAI which joins the inter- 
activity possible on the computer with the realism possible on a 
video medium to produce unique and innovative training. The 
learner must no longer sit passively in front of a television screen or 
stare at screen after screen of computer generated text. Instead, 
the computer program controls the presentation of sections of video 
based on the responses the learner makes to questions. A correct 
response will show one scene, while incorrect responses will 
generate remedial video or scenes depicting the consequences of 
wrong decisions. The applicability of this technique to nursing edu- 
cation, where incorrect decisions may have deadly results, is 
obvious. The instructor, with the help of a video production staff 
and actors, can produce ^simulations which graphically depict the 
outcome of various decisions. The CAIVI (Computer-Assisted Inter- 
active Video Instruction) simulations which can be produced with 
this technique approximate the presence of the instructor and the 
student in the actual situation without the accompanying danger. It 
is not feasible to allow the student to make that last critical rriove 
which could harm a patient. With CAIVI, however, the student is 
allowed to make the mistake and view the results of his/her errors. 
It is much more effective to have the student see a patient shudder 
and die on the screen than to have the words "Patient expires." 
printed there. It is my firm belief, and that of many involved in 
CAI, that CAIVI will become the dominant methodology employed in 
computerized education. 


petermining the Needs 

The first step in computer system design is determining the need by answering 
the following questions: what, when, who, where, how much. 


What refers to the objectives that you wish to accomplish. It is very impor- 
tant that you are pragmatic and plan small-establish goals that can be met and your 
enterprise wilJ be successful, and will look successful to outside observers (including 
funding agencies). Unrealistic plans will inhibit future use. 

When you want to accomplish the "what" is also important since this dictates 
plans for acquisition of personnel and equipment. The time to begin planning for 
implementation is today, and the time to implement is as soon as funds are available 
and planning is completed. I would suggest that you plan to start involving your 
students on a regular basis one semester after the equipment arrives. This will give 
you sufficient time to "work the bugs" out of the system, get faculty trained, and 
purchase additional equipment or software suggested in pilot use. Again, plan full 
implementation over a period of time, because your first efforts will give you valu- 
able experience in overcoming obstacles. 

Answering the Who question means you will have to decide what group(s) in 
your school to impact first. My suggestion is that you plan this as a dual approach. 
You must get the faculty involved to sustain the enterprise; they will start to work 
on the system and then h./olve their students. You should also plan to impact at 
least one class or level of students during the first year of the operation. This 
entails purchase of software for faculty use (word processing and statistics, for 
example) and student use (drill and practice in math calculation or dosages and solu- 
tions, clinical simulations) and scheduling use so that both gro 'ps have time to get 
used to the system. After you have made preliminary decisions in these categories 
your next task is to open this for potential users. However, you should have a plan 
in hand since this will add legitimacy to your task and also give nay-sayers less 
opportunity for attack; collect a "cadre" of enthusiasts and jointly develop a plan. 
Do not spend time making converts at this point, rather, work with the people who 
are already committed or are at least interested. The "non-believers" will soon 
recognize that for their own advancement and preservation they will have to come 

Where the computers will be placed is important since this may require 
modification of the physical plant which, in turn, may require a long lead time and 


expenditure of funds. The location should be secure and should also be inviting 
enough to motivate students and faculty to drop in and learn about and on the 
computers. This is the time to consider purchase of portable or transportable com- 
puters which can be taken home by the users and returned the next morning. Such a 
plan substantially increases the time computers are available for use; you get more 
out of your equipment if it is not sitting idle for 12 hours at night. 

How much money is available is always a bottom-line question. Make your 
plans over a three-year time period, projecting your funding needs during that time. 
This encourages you to plan your purchases systematically so that you do not buy 
whatever is available just to have something. This may mean starting with one or 
two expensive computer systems rather than a half dozen inexpensive computers, 
but you should buy capabilities and quality and not be "price blind." Planning over 
three years also gives you the opportunity to start the process of applying for funds 
for year number three now. Three years is recommended because the technology 
changes so fast that attempting to plan beyond this time will mean you are 
"working" with equipment which is obsolete-not only in design and structure but 
also in concept. Buy the best you can afford and build from this base. 

Sources of Information on Computers 

Trade publications The variety in depth and type of trade publications can be 
quite bewildering to the beginner. If you are setting up a computer lab or learning 
center, the following should be included as basic reference material: Byte, 
lnfoworld. Creative Computing, Popular Computing. Also, subscribe to one of the 
publications devoted to the type of computer(s) in your installation, e.g., PC World 
(IBM) or Softalk (Apple). Providing these materials will assure a good flow of infor- 
mation to all users. 

Journals Currently, there is only one journal devoted to computers in nursing, 
Computers in Nursing, published by 3. B. Lippincott. Other publications of interest 
are Computers in Healthcare and The Journal of Education Competing Research. 

Experts Consultants can be very helpful and cost-efficient if used correctly. 
Bringing someone in for a day or two and spending $1,000 to do so can save 10 times 





that much in mistakes. Remember, though, that the expert leaves and you must live 
with the consequences. Develop in-house experts and pursue computer experts in 
other departments of your school or institution. Avoid being provincial in your 
selection of computer consultants; as this presentation shows, many principles of 
computer use cross disciplinary borders— don't be afraid to consult a non-nurse. 

Trade shows One way to develop in-house experts is by sending your 
personnel to shows, exhibits, and training sessions. 

Selecting the System 

The size of the system will be dictated in part by the answers to what, when, 
who, where, and how much* Furthermore, software should be selected before pro- 
ceeding with hardware selection (see suggestions made by Dr. Donna Larson, page 37). 
In current applications, the most advantageous type of system is one that can be 
expanded to meet new needs and to incorporate new technology. This usually trans- 
lates into a decision to purchase a number of microcomputers rather than one large 
minicomputer. In addition, should you have access to a mainframe computer, the 
microcomputer offers a distinct advantage over purchase of terminals. When the 
large computer goes down, as they are wont to do, the microcomputer can be used 
as a M stand alone" unit for many purposes. When the mainframe is operating, the 
microcomputer, with the use of appropriate software and hardware, can be used as a 
terminal. Most educational software for nursing is being written for micro- 
computers; this should be considered when deciding the size and type of system to 

Whatever type of system is purchased, selection of type of peripherals will 
depend on the needs and priorities you have identified. The importance of adequate 
planning appears in every step of this process. The minimum computer configura- 
tion is a system with two disk drives, color monitor, and preferably a printer with a 
buffer. If your system has, or is planned to have, more than 10 computers, a network 
system, such as CORVUS Omninet, should be considered. 

The brand of computer and peripheral that you choose can haunt you for a long 
time. It used to be easy to choose a manufacturer since there were so few to choose 



from; now there are aver 250 manufacturers of microcomputers. Currently, the 
most important factor in selection of any hardware is to ensure that the software 
you have, or can buy, to do a particular job will run on that piece of hardware. If 
you choose your software first, you have the option of purchasing the most desirable 
computer, both in terms of cost arid features, that can use that software. Should 
you purchase the hardware first, you will be forced to choose from the software that 
will run on that machine and, perhaps, not accomplish the task you want accom- 
plished in the manner you desire. While it become: more and more difficult to 
predict who will and who will not be in business next year, consider that nursing 
publishers are focusing on Apple and IBM and that buying those machines, or com- 
patibles, is safe. A compatible machine should be able to use the program written 
for its "companion," and aiso to read files written by the companion and to write 
files that can be read by the companion. It is possible, for instance, to buy a 
computer that will outperform the IBM PC fo^r less money and still be able to run 
the software you want. Check with the software publisher to find out if his soft- 
ware will run on the compatible in which you ar^e i ^rested. At all costs avoid the 
"no-name M computers which, while cheap, are ial kin^ in reputation and support. It 
is perhaps in the selection of hardware that a consultant can be most helpful, since 
it is the consultant's job to stay well enough inforn\ed to predict potential problems 
and help guide you thrpugh the morass safely. 


The direct costs of buying the hardware and software are the most obvious 
and, in some ways, the easiest to work with. In manyy cases, equipment will be 
bought on state contract and the most imaginative part o\ the process is coming up 
with unique reasons why the computer equipment or software on contract will not 
meet your needs in order to justify purchase of more appropriate materials. Even 
when buying on state contract or using public moneys, however, the purchaser must 
be aware of the support, or lack thereof, that cpn be provided by the vendor. When 
writing bids, always require that the price quote be for the equipment delivered, 
installed, and demonstrated. This ensures that the vendor is\ providing you with 
something you can begin to work with immediately. Demand such treatment for 
your money and shop until you find a vendor who will provide it. \ Lastly, unless you 


ERIC 23 

have a great deal of experience with computers, you are safer buying all your equip- 
ment from one vendor. If any part of the system goes down you need to make only 
one phone call; also, the vendor will be familiar with your entire system and be able 
to suggest the best use. 

If you are experienced in working with computer systems or have access to 
someone who does, the advantages of mail order buying are obvious. In most cases, 
you can buy hardware or software for about 30 to 33 percent less than from a 
computer store. You should check out the company involved if you are sending it 
large amounts of money by calling credit references, its bank, and by checking with 
the better business bureau for the city in which it is located. You should know, how- 
ever, that if you buy mail order, the local vendor for that particular piece of equip- 
ment may relegate it, and you, to the the bottom of the list when time for service 
or troubleshooting comes, this is very unpleasant, but understandable, since local 
vendors must service first those clients who bought from them. In the case of 
buying software, however, mail order offers a price advantage and there is less risk. 
If you have never used a software package before and the package is quite compli- 
cated, you should buy it from a source where help is readily available. If there is in- 
house experience, or if the program is reputed to be easy to use, mail order is your 
best bet. 

Pick a vendor by asking others what their experiences have been and by visit- 
ing the shop and discovering for yourself how -helpful the company wants to be. If 
you have done some planning and reading beforehand, you can enter the shop armed 
with information and test the personnel on knowledge of the product. When picking 
software, I recommend visiting a store that sells only software. The selection will 
be much better than in a store which concentrates on computer sales, and the 
personnel will have experience with more programs. In a "hardware" store the 
personnel may push a product that they are familiar with or that the computer 
manufacturer packages with the system. 

The indirect costs of setting up a computer installation include the purchase of 
supplies, books, and publications; the funding of attendance at continuing education 


conferences and user group meetings; and maintenance. When you plan for your 
system, estimate that about 10 percent of your computer equipment cost should be 


set aside for supplies. 1 

i > 

Deciding what to do about maintenance is always a difficult question. You 
will have a warranty period on the equipment you buy; work the equipment as hard 
as possible during that period to discover what the weak links are. Printers and 
other mechanical devices are more prone to problems than the computers. When the 
end of the warranty period draws near, consider the problems you have seen, your 
budget, and the equipment which you cannot afford to be without for even a day in 
establishing the priorities for extended maintenance contracts. These contracts are 
never cheap and can total about 15 percent of the cost of your system. Unless you 
can afford downtime, however, you have little choice; support is important to a 
school or institution that cannot afford lengthy downtime. Demand a maintenance 
contract wherein the vendor indicates the turnaround time on repairs and the provi- 
sions for loaner equipment until repairs can be made. Some universities and colleges 
offer maintenance contracts on a narrow range of computers— this should be a 
factor in your purchase. Most persons who purchase a computer for home use do not 
buy extended maintenance contracts since their downtime is not critical. This is a 
decision that is based on the unique settings and applications for your computer 

The forgotten costs of computer installation are critical to operation, but 
often overlooked in planning. The most important of these neglected considerations 
Are personnel and updates and enhancements. 

The personnel needed to effect a complete and efficient computer operation 
are different from those using the system in the school (that is, faculty and 
students). Included in this group are persons who are computer experts, or at least 
computer experienced, and programmers. It is difficult to set up a computer instal- 
lation if all the users are naive. Even if some of your faculty or students have used 
or own computers, a computer installation needs someone who is knowledgeable 
about the system to oversee operations. This is not a task that can be assigned to 



whomever happens to be in the room at the time. When planning for your instal- 
lation, figure in the cost of a half-time (at least) position for someone to do these 
things. In an academic setting you may find such a person in the graduate or 
undergraduate program of the computer science department if no one is available 

One of the areas where your computer expert can help is the acquisition of 
updates and enhancements to hardware and software. Since most equipment will be 
obsolete in three years or less? you should purchase additions that will extend the 
life of your equipment; this is less costly than purchase of new equipment every 
year. Softvire companies, too, bring out new add-on packages for their programs 
and this should be considered in your budgeting. Plan for 10 percent of your budget 
each year to be used for purchase of new software or enhancements to hardware and 

One of the potentially mpre expensive forgotten costs is the amazing ability of 
neophyte and veteran computer users to discover new products they must have— other- 
wise, the computer lab might as well be closed or turned into a handball court. This 
highly infectious disease, "acquisitiveness,' 1 will begin to manifest itself from the day 
the first piece of computer equipment is carried in the door. I have suffered from 
this for years and do not expect, or desire, cure. If you have planned well for expan- 
sion you can treat the symptoms with small doses of money, but you will never cure 
the disease. 


In conclusion, purchase and efficient utilization of computers should be a top 
priority for any administrator who wishes first class status for her or his school. 
The use of computers will only grow, and the most important step to take is the first 
one of saying "Yes," and committing the time and money needed for implementa- 
tion. This paper has covered, in great brevity, the significant points in planning for 
computer use. The most important thing to remember is the word planning . With- 
out it, the computer system, regardless of funding, will never address your needs. 


Billye 3. Brown, R.N., Ed.D. 

Dean, School of Nursing 
University of Texas at Austin 

Personal computers could change the day-to-day activities of the nursing ad- 
ministrator to result in increased productivity, not^only of the administrator, but of 
the staff. At this point, I cannot prove to you through research that the administra- 
tor's productivity will be increased by use of computers; however, although bottom- 
line decisions are usually human decisions, the administrator can construct a 
computer-based system of data to give support to the decision-making process. 
Another area in which the functions of the administrative office can be facilitated 
is in communication. There are two other categories of use of the microcomputer 
system by the administrator: personal assistance and task management. 

I will describe some of the ways in which we have used computer technology to 
enhance the organization and administration of the University of Texas at Austin 
(UTA) School of Nursing. 

The first computer equipment for the Research Center was purchased in 1977. 
Presently there are 12 Apple Computers, 4 CRT's, and 6 Compucorps in use in the 
Nursing building. Following our first use of computers, we have moved very rapidly 
to expand the use of this technology in every program in the School. 

In 1980, a faculty committee in the UTA School of Nursing, chaired by Gary 
Hales, developed a five-year plan indicating a number of goals to be fulfilled in one- 
year segments. At the end of the third year, we find that we are ahead of schedule 
in some areas and on target in others; in no area are we behind schedule. Making a 


ERIC 32 

plan of this type has been a useful iool for budgeting purposes. In the next few 
months we will reassess our status in computer technology and usage, and develop an 
updated plan for the next few years. That plan will include our definition of compu- 
ter literacy for our graduating students. 

When we first discussed the use of technology in the School of Nursing, our 
goal was to acquire a mag-card and a memory typewriter for the School of Nursing. 
These two machines almost seem like the horse and buggy now. Although they are 
still used to some extent, much of the material which is presently on the mag-card 
either has been or will be transferred to hard disks on the computer. In 1980, the 
1980 to 1984 report on the predicted use of computers by the School of Nursing were 

1. Purchase k stand-alone word processing systems (Compucorp) and one cen- 
tral processing unit (CPU). 

2. Purchase 2 letter-quality printers to handle the output of the word pro- 
cessing systems. 

We have accomplished these goals. Two of the word processing stations, the 
Compucorp filing unit and one letter-quality printer, have been installed in the Word 
Processing Center. This Center is used for general correspondence, for course out- 
lines, for reports, tests, proposals generated by faculty, and most recently, for the 
self -study of the School of Nursing for the recent accreditation visit by the NLN. 
The third station and a letter-quality printer are located in -the business office for 
the School of Nursing. Another terminal is used in the Dean's office for word 
processing for reports, speeches, newsletters, correspondence, and the faculty hand- 
book. A fifth station is located in Continuing Education. This station is used for 
program designing and record-keeping, as well as for word processing. A master 
address list, which also contains demographic information and information on con- 
tinuing education units, will be added to expand the present system. 

The Continuing Education staff wonder how they ever managed before the 
Compucorp. Much of the last-minute preparation for workshops has been eliminated 
now that it is possible to prepare pre-registrant lists and registrat ons as received. 

Prior to the word processor, it was necessary to wait as late as possible, arrange 
everything alphabetically, and then type. Inevitably, a late registrant would have to 
be listed out of sequence. This same list is easily converted to a final list of 

The formatting capability of the word processor has greatly facilitated prepa- 
ration of frequently used forms, such as evaluation summaries, vouchers, and various 
standard reports. 

In. addition to the word processor, the use of a computer terminal to make 
immediate changes in the mailing list has reduced the cost of address correction 
charges and mailings that should have been deleted. 

Another application, although not administrative in the purest sense, is com- 
puter use in our Learning Center. During the last academic year, staff and the 
School of Nursing Learning Center computerized software holdings. System 2000, 
which operates on the Cyber (one of the main-frame computers located in the Uni- 
versity's Computer Center) was selected as a database management system because 
of its ability to handle large amounts of data and to complete rapid, efficient 
searches. With this system, we can update and correct listings as changes are 
needed. Using this system, three other files have been created— for film rental, for 
review data, and for work /study student data. During the time of inputting this 
data, we expended $164 per month for computer time-connection with the Cyber and 
$8.00 per month for supplies. We expect these costs to decrease in the future, since 
the data have now been entered. We will measure the cost-effectiveness of these 
files as we use them, beginning with fall 1983 semester. 

In November 1982, an academic development grant was funded for the School 
of Nursing out of the President's office. The project was designed to demonstrate 
the application of interactive computer-video technology to nursing and the Univer- 
sity computer. 

When the system is completed, five microcomputers in the network with a 
CORVUS hard disk drive will enable students to learn basic skills and theory at their 






own pace in a cost-effective setting. Videotape and printer links will be available as 

Staff members on the Computer-Assisted Instruction Project NEMAS — a proj- 
ect funded for the first two years by a speciai project grant from the Division of 
Nursing (NU260W02) and funded for this last year by Lippincott Publishers, who will 
be marketing the program after it is completed— are developing an authoring system 
which faculty members will use to create instructional modules on the steps of the 
nursing process. Microcomputers and an interdisciplinary team approach have been 
utilized to combine nursing content with instructional design. Faculty evaluations 
are the basis of the ongoing system refinement. 

Until this time, the only instructional computing available to our nursing stu- 
dents was through programming courses offered in other colleges and schools on 
campus. We plan to offer in spring 1984 a course in use of computers in nursing. In 
1983-84, four computers are available to nursing students in the. Learning Center. 
Based on our present student number and the hours which the Learning Center is 
open, we can only provide one-half hour of computer time per student per week. 
This will be barely adequate for courses leading to computer literacy. If we are to 
use computers as instructional tools for students, it is estimated that a minimum of 
two hours per week per graduate student and one hour per week per undergraduate 
student would be required. In order to meet this goal, we will need to have at least 
10 microcomputer terminals in our Learning Center. This would require some phys- 
ical changes in the Learning Center to allow ior privacy for the students learning at 
the computers. Our goal is to graduate students, both graduate and undergraduate, 
who are well-versed in the potential uses of computers. We will do this through 
utilization of computers as instructional tools in the curriculum, and to meet 
specific objectives in core courses. The graduate (doctoral) students will have skills 
in programming in several computer languages. We no longer have the luxury of de- 
ciding if computer technology will be an integral part of the curriculum. It must be! 

Another area c* increased use of computer technology, and the first area of 
computer use, is the Center for Research. The Research Center, established ap- 
proximately 10 years ago, has steadily increased services available to faculty and 


ERIC " °° 

graduate students. The primary mission of the Center is the planning, execution, 
and interpretation of statistical analyses. 

As part of their mission, the staff in the Center instruct faculty and students 
in the use of computer hardware and software, consult on research design, assist 
with programming in FORTRAN, BASIC, and PASCAL, and consult in the prepara- 
tion of proposals for theses, dissertations, and intra- or extra-murally funded proj- 
ects. Staff members in the Research Center offer assistance to UTASN faculty and 
students in the areas of: design of research projects; literature searches; grant 
writing; data processing and computer analysis; and interpretation and presentation 
of results. Several terminals, microcomputers, and printers are available to stu- 
dents and faculty in the Center, and portable terminals are available for home use. 
The Research Center's terminals are connected to the University's Computer Center 
equipment, making the vast resources of the Computer Center available to faculty 
and students. 

The Center for Research is funr.ed both from state funds and from soft mon- 
ies. During 1982-83, the Center «*uff participated in research development within 
the School by providing over 200 technical consultations to faculty and students. 
Many of them involved computer usage for research purposes. During this year we 
have observed a three-fold increase in the use of computers in research. 

One of our faculty members, who has a joint appointment' with a clinical 
agency, has used computer technology in conducting her research. She hypothesized 
that the length of the shift and the acuity of patients on units has a direct relation- 
ship to the "sick time" of staff nurses. She demonstrated by her study that these 
nurses in ICU/CCU with 12-hour shifts had more "off" time than their counterparts 
in less stressful situations. She was also able to demonstrate that those staff nurses 
with shorter shift time in ICU/CCU had less "off" time than their counterparts with 
12-hour shifts on this unit. 

Faculty collect their data, and they work with the Research Assistant, Re- 
search Associate, or Director of the Center to analyze the data using the computer. 



This assistance not only expedites the interpretation of data, but it results in less 

Great emphasis is placed on research and publishing results of the data by our 
faculty* Support provided them through use of the computers and by their support 
personnel has made this mandate less stressful for them* 

We have many master's and doctoral students using computers to assist them in 
their research to fulfill requirements for courses and for their theses and dissertations. 

Faculty will be encouraged to write grants that will include funding for compu- 
ters. When writing grants to include the purchase of personal computers, some large 
universities allow a great deal of latitude for entrepreneurs in research rompu- 
tation. This results in evolution towards a local system and away from a time- 
shared central facility. In this situation, a research program is based on a philos- 
ophy of 'bottom up entrepreneurship," with each faculty researcher or research 
group being responsible for obtaining funds from external sources to support their 
activities. Others believe that central systems give better utilization of capital 
resources. (Memo from Ross Shipman regarding visit to computer programs at Stan- 
ford and Berkeley, June 7, 1983.) To date we have not reached the point of needing 
to make a policy about this issue. 

Our goals for computer application in research for 1983-86 are: 

1. Provide support services to faculty research activity. 

2. Provide support services to graduate students in thesis/dissertation 

3. Provide support to UTASN courses requiring computerized statistical 
analysis and/or computer-based search facilities. 

Compucnrp equipment was selected for administrative application because of 
the available software that is adaptable for use. It is used administratively for 
record processing, word processing, and multiple mailings. Records on biographical 

, information and employment status are maintained on prospective, current, and ter- 
minated employees; this information may be processed and retrieved in different 
ways as needed* Word processing' is used for the more complex typing jobs, such as 
reports, speeches, newsletters, and procedure handbooks. Mailing lists are merged 


with letters or printed on labels to facilitate the dissemination of information to 
faculty, students, alumni, and supporters. Other general uses include maintaining a 
calendar of events for the School and sending and receiving electronic mail. (Elec- 
tronic mail is not used widely on our computers at this time.) 

We are writing a program for in-house use whereby three of our Compucorp 
work stations can be interactive. For example, when a prospective faculty member 
is interviewed, a note is made of that on the Compucorp in my office. The Assistant 
Dean can pick that up on her terminal and gain information about that particular 
person and the status of the interview process. Once the individual is interviewed, 
we will make a note of that and indicate recommendations regarding appointment, 
salary and rank, and the course the person is to teach. 

Documentation is to be kept to follow up on the interview. If the individual 
accepts the appointment, that information is entered on the terminal, the business 
office will pick this up, will process the necessary papers, and then, as appointment 
letters are written, that too is documented on the terminal. Again, the Assistant 
Dean can pull this up and know the status of the prospective faculty member. When 
the individual accepts the appointment, this is entered and everyone concerned 
knows the status simply by reviewing the documentation on the Compucorp. 

The data processing division is responsible for maintaining University records. 
Programmers there have evolved "user-friendly" programs which allow staff to 
assess and update information about personnel and about students. A micom port 
(telex terminal and printer) connected with data processing is located in the business 
office, where it is used for accounting, payroll, budget, and personnel. 

Departmental accounting information is available. Terminal displays show 
current account information for appropriations and income, encumbrances, expendi- 
tures, transfers, and free balances. Signature authorization on the account, the 


date of the last accounting activity, and the identification codes of departments and 
colleges are also displayed. 

The Student Affairs Office is also connected with the data processing division 
with a telex terminal and printer. Many hours of travel to the Office of Admissions 
and the Registrar's Office are saved by use of this terminal. We use it for student 

Information about prospective students who have not yet been admitted, ad- 
mitted freshmen, transfer and graduate applicants, and enrolled students can be 
viewed. Another procedure allows up to five current semester class rosters, five 
student advising aids, or five unofficial transcripts to be printed at one time. 

Care must be used to prevent unauthorized release of anything other than 
directory information on a student. Grades, social security numbers, and even the 
classes students are enoJled in cannot be disclosed without the student's permission. 
Furthermore, if the student has requested it, even address information must be 

Student addresses may be updated by departments which have obtained ap- 
proval through the office of the registrar. 

An on-line procedure is now used for centralized "add/drops" during registra- 
tion. The Registrar's Office enters the student's requests for adding and dropping 
classes into the computer files. A copy of the student's revised class schedule is 
immediately printed for the student. A few departments were selected to use the 
system for processing all "add/drop" requests in a pilot test during the fall 1983 
semester; our school was one of these. The results of this test will determine 
whether the system will be available for use by all academic departments. 

Data processing started out as a service to users by specialists; traditional 
data processing services are still handled in that fashion. Now, however, capa- 
bilities are provided without the specialist as an intermediary. Word processing has 



followed the same path. It was initially a service provided by specialists, but it is 
now available to all. Most observers believe that the users of the future will be non- 
specialists who regard machines as tools capable of processing mail electronically 
and gaining access to information. We will pot concern ourselves with classifying 
functions as data processing, word processing, or other specialties. It is important 
to encourage personnel to be interested in developing these new skills, and broaden- 
ing them to include information technology rather than concentrating on special- 
ization. Another challenge will be the way information is managed. The approach 
to management of information in the future must concern itself with word pro- 
cessing, voice-mail systems, and microfilm or CRT-based graphic*displays. 

Although we found in our use of technology that we were able to reduce the 
number of secretaries, it is generally a misconception that computers will eliminate 
positions. Computers should be regarded as a supplement and a way to make the 
operation more efficient. 

The ways in which computer technology can be used in nursing programs is 
limited only by the knowledge and imagination of the user. While I have described 
systems in use in one public university, I believe that each program must make plans 
for computer usage to meet its needs after looking at the reasons for computer use 
and the human and material resources available to initiate the program. Our prog- 
ress in determining the various uses, costs of the programs, and the process of 
establishment of computer usage may be helpful as you plan to introduce this use to 
technology in your program. 


Administrator's Update . (1983, Summer). The administrator's use of microcomputer 
systems, p. k. 

Personal Computing . (1983, September). Buying computer furniture that really fits. 

Personal Computing . (1983, September). Making the most out of meetings. 

p hi Kappa Phi Journal . (1983, Summer). National forum: Information management 

OAG/Frequent Flyer . (1983, September). In search of the office of the future. 



Donna E. Larson, R.N., Ph.D. 
Associate Professor of Nursing 
Grand Vaiiey State Coiieges, Aiiendaie, Michigan 

Computer-assisted instruction (CAI) has been defined as one kind of iearning 
environment in which, through the use of computer technoiogy, a iearner receives, 
reacts to, and interacts with instructionai materiai prepared by an instructionai 
specialist (Burson, 1976). Contained in this definition are two key concepts. The 
first concept is that the iearner participates in active iearning activities. Only 
through active and continuai participation does the student progress through the 
instructionai materiai. The student must interact with the instructionai materiai. 
In weii-designed computer-assisted instruction, there is no way that the student can 
be a passive recipient of information. The second key concept is that weii-designed 
computer-assisted instruction individualizes the learning activities for each student. 
Within a specified framework, each student's own particular rate of learning and 
intellectual level can be accommodated. Through the use of branching and good 
instructional design, the same computer-assisted instruction program should appear 
very different to the "good" student than it does to the student who does not learn as 


Keeping in mind the key attributes in the above definition, the use of 
computer-assisted instruction has many advantages for nursing education. 

I) Provides effective, efficient methodoloEv . Research on computer - 
assisted instruction in health professional education has repeatedly demon- 
strated that, when compared to the more traditional teaching strategies (e.g., 
classroom lecture, discussion, lab), students learn equally as well with 




computer-assisted instruction, but in one-third to one-half the amount of time 
(Bitzer, Computers in Biology, 1973; Boettcher, 1981; Droste-Bielak, 1980; 
Huckabay, 1979; Kulik, 1980; Larson, 1982; Rubinson, 1977; Valish, \V5h In this 
age of exploding knowledge in nursing, the saving of student learning lime can 
be viewed as a tremendous advantage. \ 

2) Equalizes learning opportunities . Because of such variables las the 
changing nature of client populations, contracts with clinical agencies, and 
student clinical rotation scheduling problems, many clinical experiences are 
not consistently available to all students. Computer-assisted instruction, es- 
pecially the use of computer simulations, is one way in which variable clinical 
learning opportunities (such as in maternity and pediatric care settings) can be 
better equalized among students. Even if "real life" maternity nursing Expe- 
riences are in short supply, at least all students could be provided the oppor- 
tunity to practice planning nursing care for computer-simulated maternity 
clients. Computer -assisted instruction also can provide students with "rare" 
learning opportunities. For example, even though a particular geographic lo- 
cation may have a very small black population, students could still be provided 
with the opportunity, through the use of computer simulations, to plan and 
manage the nursing care of clients experiencing sickle cell crisis. 

3) Provides repeated practice opportunities . Computer-assisted instruction 
allows students to have repeated trials prior to implementation of care for 
actual clients. Students can learn on the computers and then apply what they 
have learned while caring for actual clients in the clinical settings. 

Offers safe practice environment . One of the primary advantages for 
the use of computer -assisted instruction in nursing education is that it allows 
students to make their errors in a safe environment. A computer is not going 
to become gravely ill because of an erroneous medication dosage calculation 
or a poor judgment in planning nursing care. Obviously, this is not the case 
with actual clients in the clinical settings! 

5) Promotes creative problem-solving and manipulation of variables. The 
computer can open up the world of the "what if's" to student learning. Be- 
cause no harm will come to actual clients, the student is free to explore many 
alternatives in solving patient care problems; the student is abl. to actively 



experiment with many different hypotheses. The student could also be allowed 
to purposely make errors in order to validate his/her own ability to problem- 
solve how to remedy a deteriorating client situation. Due to our concerns for 
client safety, the student is not usually allowed to engage in this kind of 
learning (active experimentation) in the clinical setting. Because of our own 
limit setting, the student's creative problem-solving may be thwarted. 
Through the use of computer simulations, we could actually encourage the 
student to think more creatively. 

6 ) Provides a private learning environment. Computers can provide a non- 
threatening environment for student learning. Computer-assisted instruction 
allows students to make their learning errors in private, without fear of ridi- 
cule from peers or of making a "bad impression" on faculty. The provision of 
this kind of private learning environment is especially important for the stu- 
dent who may be a slower learner. 

7) Permits freedom from repetition. Computer-assisted instruction can 
free the instructor from the repetitive aspects of teaching, so that more time 
can be devoted to higher level teaching activities, such as assisting students to 
apply theoretical knowledge to actual clinical stituations. 

8) Is cost-effective. There have been few attempts to determine the actual 
cost of computer-assisted instruction in nursing education. However, my own 
research on the effectiveness, efficiency, and cost of computer-assisted in- 
struction in psychomotor skill development demonstrated that the cost per 
computer learner was $ .94 compared to $2.17 per skills laboratory learner. 
The difference in cost was due mainly to the decreased amount of faculty time 
required when computer-assisted instruction was used (Larson, 1981). 



Computer-assisted instruction has been used in nursing education for the past 
10 years. The professional literature reports several very specific applications of 
this "new" teaching methodology in various aspects of nursing education. 

Undergraduate and graduate nursing education. In the area of theoretical 
instruction in undergraduate and graduate nursing education, several studies and 


erJc . 43 



reports have been noted in the literature. The seminal research into the effective- 
ness and efficiency of computer -assisted instruction in the teaching of nursing the- 
ory was conducted by Bitzer (Computer-based Instruction, 1973). She researched the 
use of the PLATO system in presenting maternity nursing content to diploma nursing 
students. Additional uses of the PLATO system to present computer-assisted medical- 
surgical nursing content to students at Ohio State University and the University 
of Illinois were reported by Collart (1973) and Kirchhoff and Holzemer (1979). Also 
at the University of Illinois, Rubinson and Robinson (1977) described their research 
on the use of the PLATO system to present an entire first aid course to students. 
Huckabay et al (1979) reported on research; on the use of computer-assisted instruc- 
tion to teach hypertension client management to graduate nurse practitioner stu- 
dents. Furthermore, Donabedian (1976) presented the results of research on the use 
of computer-assisted instruction in teaching epidemiology content to nursing 
students. ■ 

Computer-assisted instruction has also been used to teach various aspects of 
communication skills to nursing students. Kamp and Burnside (1974) described their 
use of computer-assisted instruction to teach therapeutic communication and inter- 
viewing skills to nursing students. Moreover, Droste-Bielak (1980) reported her re- 
search findings on the use of a micrcomputer-assisted instruction program to teach 
interviewing skills prior to a beginning level student's first community health home 

Another area in which computer-assisted instruction has been used in nursing 
education is in the realm of teaching clinical decision-making skills. Sumida (1972) 
reported on her use of computer-assisted instruction to evaluate terminal behaviors 
of both B.S.N, and A.D.N, graduates at the University of Hawaii. Further, Olivieri 
and Sweeney (1980) described their use of a series of four microcomputer simulations 
to teach clinical decision-making skills as a client experiences various phases of the 
health care delivery system (emergency room, cardiac care unit, medical-surgical 
unit, and cardiac rehabilitation program after discharge). 

One would not ordinarily think that computer-assisted instruction could be 
used for teaching psychomotor as weJl as cognitive skills. However, it has been 



demonstrated that selected nursing psychomotor skills can be effectively and effi- 
ciently taught by using computer-assisted instruction (Larson, 1981, 1982). 

Continuing education. Because of its accessibility and self -paced format, 
computer-assisted instruction is particularly well-suited to the adult learner. 
Computer-assisted instruction is potentially accessible 24 hours a day, 7 days a 
week. Additionally, students can learn in their own time frame, at their own pace. 

The literature describes the use of computer-assisted instruction in various 
staff development endeavors. For example* Hoffer et al (1975) reported on the use of 
computer-assisted instruction to provide instruction on cardiopulmonary resuscita- 
tion to "off-shift" nursing personnel. Hon (1982) also described his development of a 
tremendously exciting interactive videodisc/mannequin system for CPR instruction. 
Valish and Boyd (1975) reported on their use of computer-assisted instruction to 
provide in-service education programs on various aspects of client care management. 

Computer-assisted instruction has also been used to provide educational oppor- 
tunities for the registered nurse seeking baccalaureate nursing education. Reed et al 
(1972) at Ohio State University and Hannah and Conklin (1982) at the University of 
Calgary both describe the use of computer-assisted instruction to provide instruc- 
tion to nurses in geographic areas distant from the universities. 

The utilization of computer-assisted instruction in many aspects of nursing 
education is a beginning reality. Because of its many advantages, I believe that 
computer -assisted instruction has the potential to become a major methodological 
tool in nursing education. I invite you to join in my excitement over the potential 
benefits of this instructional medium. 


Bitzer, M., & Bitzer, D. (1973). Teaching nursing by computer: An evaluative study. 
Computers in Biology and Medicine , 3, 187-204. 

Bitzer, M., Boudreaus, M., & Avner, R. A. (1973). Computer-based instruction of 
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Education Research Laboratory. 

ti 45 

Boettcher, E., Alderson, S., 6c. Saccucci, M. (1981, August). A comparison of the 
effects of computer -assisted instruction versus printed instruction on student 
learning in the cognitive categories of knowledge and application. Journal of 
Computer-Based Instruction , 8, 13-17. 

Brennan, P. (1981). Establishment of a computer-assisted instructional program to 
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Brigham, C. R., & Kamp, M. (1974, March)* The current status of computer-assisted 
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Braun, L. (1980, July). Computers in learning environments: An imperative for the 
1980's. BYTE: The Small Systems Journal . 5, 6-10, 108-114. 

Buchholz, L. M. (1979, January). ' Computer-assisted instruction for the self- 
directed professional learner? Journal of Continuing Education in Nursin g. 10, 

12-14. : : _ 

Burson, J. (1981). A ten point-seven criteria CAI materials appraisal process. In J. 
Eisele (Ed.), Proceedings of the Annual Conference of the Association for the 
Development of Computer-based Instructional Systems , pp. 131-136. 

Burson, J. (1976). The author's guide to CAI .' Columbus: Ohio State University, 
Division of Computing Services for Medical Education and Research. 

Cassano, V., Sedlak, R., Wurzer, W., Lundy, D., Goodwin, D., & Hodder, R. (1982). 
Student-controlled scheduling of clinical rotations using a microcomputer. In 
B. Blum (Ed.) Proceedings of the Sixth Annual Symposium on Computer Appli- 
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Cavin, C. S., Cavin, E. D., & Lagowski, J. J. (1979, June). The use of computer- 
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Cpllart, M. E. (1973, August). Computer-assisted instruction and the teaching- 
learning process. Nursing Outlook , 21, 527-532. 

Cumber, D. (1981). Preparing the nurse for automation. In H. Heffernan (Ed.), Pro- 
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de Tornyay, R. (1970, April). Instructional technology and nursing education. Jour- 
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Donabedian, D. (1976, September). Computer -taught epidemiology. Nursing Outlook , 
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Droste-Bielak, E. (1980). The use ol computer simulation in teaching interviewing 
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Dwyer, J. M., & Schmitt, J. A. (1969). Using the computer to evaluate clinical per- 
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Edmunds, L. (1982, July). Computer-assisted nursing care. American Journal of 
Nursing , 1076-1079. > ■ 

Edmunds, L. (1982, Autumn). Teaching nurses to use computers. Nurse Educator, 
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Ellis, P. (1982, January). Matching students with clinical experiences by computer. 
Nursing Outlook , pp. 29-30. 

Erat, K., & McGrath, S. (1979). Developing a teaching/learning experience for 
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Farnsworth, J. (1974, November). Camp: Computer and me: Psychotherapeutically. 
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Grimm, F. M. (1978, September). Computer simulations as a teaching tool in com- 
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Grobe, S. (1982). NEMAS: Nursing education module authoring system— CAI soft- 
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Guttman, L., & Doyle, S. (1981). Evolution of a training program for a computerized 
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Hannah, K. (1976, September). The computer and nursing practice. Nursing Outlook, 
24, 555-558. 5 

Hannah, K., & Conklin, D. (1982). The CAI microcomputer project in the faculty of 
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of the Association for the Development of Computer-based Instructional Sys- 
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Hardin, R., & Skiba, D. (1982). A comparative analysis of computer literacy educa- 
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trial. JEN, I, 27-29. 


Hon, D. (1982, June). Interactive training in cardiopulmonary resuscitation. BYTE , 
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Huckabay, L., Anderson, N., Holm, D., & Lee, J. (1979, July-August). Cognitive, 
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Kadner, K. (1982). The use of nursing process in computer-based simulation design. 
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Carol A. Romano, R.N. 
Nursing Information System Specialist 
Clinical Center Nursing Department 
National Institutes of Health 
Bethesda, Maryland 

One of the goals of nursing is to manage the conditions under wnich patient 
care is practiced; one of the goals of nursing education is to prepare nurses to 
function in this role. The purpose of this paper is to present computer usage by 
nurses in the clinical practice area and to address the challenges this technology 
poses to nursing practice and to nursing education. 

As nursing care becomes more complex, the increased utilization of computers 
to coordinate and document that care becomes essential. At the Clinical Center, 
the research hospital of the National institutes of Health (NIH) in Bethesda, Mary- 
land, 'the Nursing Department is committed to the provision of care to patients and 
support to their families and to collaboration in biomedical research. The Clinical 
Center Medical Information System (MIS) is one of the tools used by nursing to 
manage patient care and to provide a data base for nursing research. This system 
provides a computerized method for handling patient care data. It replaces the 
traditional manual methods of communicating, recording, documenting, and archiv- 
ing records. Its usefulness and advantages lie in its ability to perform at high speed 
and with precise accuracy, according to specific written instructions (programs). 

For nursing to effectively use this tool and- exploit its potential for enhancing 
patient care, a critical analysis of nursing practice is required. A definition of infor- 
mation handled by nursing, nursing activities and functions, and a nursing content 

framework for documentation is needed. The Clinical Center Nursing Department 
addressed these requirements through intensive nursing participation in the design, 
development, and implementation of the Technicon Computerized Medical Infor- 
mation System. 

To understand what a computerized MIS can do to facilitate the management 
of patient care, one needs to assess the functions of an MIS from a nursing per- 
spective. Seven major functions can be identified (see Figure I). 


Seven Functions of a Medical Information System 

MIS Functions 


■ Records 

■ Reports 


48 f 


1) Establishing a patient file in computer memory enhances the availability 
and retrievability of patient information. This capability provides an obvious 
advantage in a research environment where data collection and retrievability 
of information are a significant part of the research process. 

2) The Clinical Center computerized systemprovides the ability to add in- 
formation to a patient's file in a direct (on-line), real-time (as events occur) 
basis, thus creating a dynamic, current patient record. In a manual system, 
this activity can be compared with making daily additions to the patient's 
record so that the chart reflects the current patient status at all times. The 
computer advantage, however, emphasizes the legibility and accessibility of 
patient information. 

3) Another function is that of sorting data. Sorting and classifying data 
have traditionally been the function of nursing personnel. For example, tran- 
scribing written medical orders involves the nurse's classifying and sorting a 
list of orders onto sections of a Kardex. This activity allows for information 
to be organized into a useful format to communicate nursing care require- 
ments to all nursing personnel. A computerized MIS is used by physicians for 
"writing" medical orders which are then automatically sorted into categories 
and printed into a computer-produced Kardex used by nurses. This computer 
printout, or medical care plan, sorts the orders into the categories of vital 
signs, medications, IVs, hygiene/activities, procedures, diet, other depart- 
ments, and is printed at the beginning of each shift. It reflects any revisions 
made to the medical pian so the nurse has the most current data base from 
which to practice. 

4) The MIS functions to disseminate information to other departments 
throughout the hospital in the correct format and at the appropriate time. In 
a manual system, initiating, completing, and dispensing requisitions involves a 
large percentage of nursing time-the , medical order transcription process. 
The Clinical Center MIS automatically notifies the pharmacy department of 
medication orders, the nutrition department of diet changes, and the radiology 
department of requests for X-rays. This automatic communication of informa- 
tion frees the nurse of the clerical responsibilities related to message and 
requisition handling of this kind. In addition it provides for the accuracy, 

« 53 

completeness, conciseness, and timeliness of communications that are essential 
to information handling in a hospital environment. 

5) The preparation of lists, records, and reports is also identified as an im- 
portant function of an MIS. A variety of lists are produced to facilitate 
nursing's management of patient care. For example, medication lists produced 
automatically each hour replace the traditional medication card system of 
dispensing medications; a list of unreported medications reinforces the time- 
liness and completeness required in documentation. The Nursing Record, a 
computer printout comparable to handwritten nursing or progress notes, is 
produced daily and encompasses all nurse charting, i.e., vital signs, medica- 
tions, and observations recorded within a 24-hour time frame. In addition, 
X-ray, laboratory, and other department reports are also automatically printed 
on the nursing units immediately after they are recorded by the appropriate 
departments. Consequently, this system eliminates the traditional "mailing 11 
or ■'hand carrying 11 methods of communicating patient information between 
hospital departments. 

6) In contrast to a manual recording system, a computerized MIS provides a 
mechanism for structuring the type and quality of information communicated 
about patients. For example, the format required for documenting an injec- 
tion dictates that the injection site be recorded by the nurse; the format for 
charting a medication as "not given 11 requires the nurse to record an explana- 
tion or reason for the patient's not receiving the medication. 

7) Finally, an MIS reviews the predefined formats for entering information 
and responds with a message to the user if the format is not adhered to. This 
checking mechanism can be viewed as a method for controlling the quality of 
information recorded by users. Because it is the user, not the computer, who 
determines the appropriate formats for data entry in system development, the 
function of the computer is to reinforce the user's decisions for quality control 
in communication and documentation.* 

As a computerized method of handling patient care information, the Medical 
Information System facilitates communications, patient care, and research at the 
Clinical Center. As a communications network, the system links physicians, nurses, 

50 5<j 

and all departments. Video matrix terminals (VMT) (input devices for sending and 
receiving messages) and printers are located throughout the hospital in all nursing 
units, all departments, and some offices. These devices, in turn, are linked to a 
larger IBM mainframe in the hospital. Patient-related information sent and re- 
ceived via MIS is readily accessible to appropriate departments. Confidentiality and 
availability are controlled through user class codes. Each code reflects the position 
descriptions of a class of users and allows for accessing the information needed to 
carry out designated responsibilities. 

Two major uses of MIS can be identified for nursing: I) the facilitation of 
interdepartmental communications and, 2) the facilitation of intradepartmental doc- 
umentation (see Figure 2). Traditionally, nursing has accepted the responsibility for 


Major Uses of a Medical Information System to Facilitate 
Interdepartmental Communication and Documentation 

Interdepartment Intradepartment 
Communication Documentation 



coordinating the communication of patient-related duta. In a large multidisciplinary 
organization this places increasing demands on nursing time as the nurse dissemi- 
nates information from the patient's chart to other departments which need that data 
but are physically removed from the area where patient information is housed. Via 
a computerized communication network, the pharmacy department need not phone 
the nursing unit to identify patient medication profiles or allergies; the nutrition 
department need not request patient location or diet change information from nurs- 
ing; and preoperative requests for laboratory data are no longer made to the nursing 
department but, rather, can be directly accessed via the computer system. 

Nursing documentation is also facilitated through the MIS. Legally and pro- 
fessionally, documented nursing care is interpreted and translated to reflect the 
nursing care that was given. The development of nursing content to reflect nursing 
practice necessitates critically analyzing how nursing is practiced and organizing 
the process of nursing into a finite framework. At the Clinical Center, the Nursing 
Department's philosophy about nursing practice directed this content development. 
Information was organized to reflect the nursing process and to define the inde- 
pendent and interdependent aspects of nursing practice. 

Interdependent nursing encompasses the nursing interventions that require a 
medical order for validity. Documentation of these activities taken on the patient's 
behalf involve the nurses' recording of 1) business activities, such as admission, 
transfer, and discharge; 2) patient activities and procedures, prescribed to and for 
the patient in the medical plan, which the patient is legally, physically, emotionally, 
or conveniently unable to execute without nursing intervention; and 3) medications, 
intravenous therapy, or blood component therapy that involve communication and 
coordination with other hospital departments. The nurses' responsibility for document- 
ing these activities involves recording the medically ordered activities as "done/ 
not done" or "given/not given" so as to validate implementation of the medical plan. 

Independent nursing is defined cs the area of practice involving health prob- 
lems that nurses can independently identify, influence, or resolve and interventions 
that complement the medical plan. The focus of nursing care in this area is patient 



needs; thus, the framework of 13 patient-need categories defined by the Clinical 
Center Nursing Department is used for documenting this aspect of nursing. This 
framework allows for the systematic organization of data and was used to develop 
assessment, care planning, and reassessment content for nurse documentation. 

As described in the model by Romano et al (1982), nursing information is clustered 
into the three major categories of assessment, care planning, and reassessment. The 
nurse records assessment data by addressing a patient's specified pattern in each 
need area, any impairment related to meeting the need in that area, and any aids 
used to facilitate the need. Recording aids currently used and identified by the 
patient as part of the admission process provide the opportunity to assess the pa- 
tient's level of self care and to begin addressing continuity from home to health care 
setting. Nursing assessments are printed on a daily computerized nursing record that 
reflects all nurse charting for that day. 

Care planning data is recorded by identifying the appropriate nursing diag- 
noses, expected patient behavioral outcomes, and nursing actions that address meet- 
ing the patient's needs. With a primary nursing system of care delivery, it is the 
primary nurse who identifies how frequently each outcome will be evaluated and 
when the projected deadline for accomplishment is. The nurse then defines and 
records the expectations for documentation for which he/she is held accountable. 

Care planning data is retrieved on the Nursing Care Plan, a computerized 
printout that reflects nursing diagnoses, patient outcomes, and nursing actions. This 
document is printed as requested and always at the point of discharge. It reflects 
all nursing planning done from admission to discharge and is included as part of the 
patient's permanent record. Each patient at the Clinical Center has two care plans: 
1) a medical care plan to organize medical orders related to the medical diagnosis 
and research protocol, and 2) a nursing care plan to organize nursing orders related 
to the nursing diagnosis and research protocol. 

Implementation and evaluation of the nursing process are recorded in the data 
cluster called reassessment. This cluster is appropriately named because imple- 
mentation of care involves the delivery of care as well as the reassessment of a 

patient's response; evaluation of care involves the analysis of the patient's re- 
assessed response in relation to the anticipated response defined in the plan. Delin- 
eation of a course of action is then pursued by the nurse. Documentation of imple- 
mentation and evaluation on the MIS is accomplished by recording procedures and 
observation in the appropriate patient need categories. 

As in the dynamic process which it reflects, the documentation of inter- 
dependent nursing actions and independent nursing actions merge in the recording of 
patient responses. Professionally and legally, the unquestioned independent area of 
professional nursing is the responsibility for making observations and recordings 
about patient responses, that is, patient responses to the medical plan as well as to 
the nursing plan (Lesnik & Anderson). Computers are used in clinical practice to 
support and foster the documentation of those patient responses— the documentation 
that reflects the cognitive and evaluative aspects of care entrusted to nursing. 

An examination of computer use in clinical practice stimulates new challenges 
to nursing education. Computers can force the closing of the gap between nursing 
education and nursing practice by fostering the application and documentation of 
nursing frameworks and nursing theories. They can force the emergence of full 
professional roles by executing the information-handling, non-nursing functions tra- 
ditionally assigned to nursing in the health care environment. However, to prepare 
nurses to practice in the increasingly technological environment of the future, and 
to direct and control the impact of technology on nursing, is no small challenge. 
But, as with any challenge, one must take that awesome first step. An awareness 
and involvement with the state of the art of computers and technology in health 
care can be that first step. A goal of nursing education can be to maximize the 
potential of the new tools of our society so that the computer, like many other 
once-new tools, can enhance the practice of professional nursing. 


Henderson, V. (1972). The nature of nursing . London: The Macmillian Co. 

Lesnik, M. 3., & Anderson, B. 3. (1975). Nursing practice and the law . (2nd ed.). 
Philadelphia: 3. B. Lippincott Co. 



Lewis, T., & Macks, G. (1980, July /August). A physician's perspective-computer 
applications in medicai care and clinicai research. Computers in Hospitals . 

Romano, C. (1981). Documentation of nursing practice using a computerized medicai 
information system. In H. Hef ferman (Ed.), Proceedings of the Fifth Annual Sym- 
posium in Medicai Care . Los Angeies: Institute of Electrical and Electronic 

Romano, C, McCormick, R., & McNeeiy, L. (1982, January). Nursing documen- 
tation: A model for a computerized data base. Advances in Nursing 
Science , » (2). 

Romano, C. (1984, January/February). A computerized approach to facilitating dis- 
charge care planning. Nursing Outlook . 

55 53 


Carole Hudgings, R.N., M.S.N. 
Doctoral Candidate and Graduate Research Assistant, CAI Project 

University of Texas at Austin 

The Nursing Education Module Authoring System (NEMAS) has two major sec- 
tions: an authoring component and a learner delivery component. The authoring 
component allows faculty to create instructional modules. The learner delivery 
component delivers the instructional module to learners and records their responses. 

The authoring component of NEMAS allows nursing faculty to create computer- 
assisted instruction (CAI) modules on any of the five steps of nursing process, i.e., 
nursing assessment, diagnosis, planning, intervention, or evaluation. The authoring 
system, consisting of computer programs, prompts authors for both content and in- 
structional decisions in creating learner modules. Authors first use a NEMAS utility 
to create a patient. The patient data is then used as the content base for an in- 
structional module on one of the nursing process steps. Next, authors enter prereq- 
uisite assessment items, instructional module information (including feedback mes- 
sages for learners), and outcome assessment items. By using NEMAS utilities, authors 
transfer all the information to learner module disks. Authors are thus able to create 
a learner CAI module without having done any computer coding or programming. 

The learner delivery component of NEMAS consists of programs\hich present 
the learner module (containing the faculty's authored content) to users\ Learners 
are directed through the three parts of a module: prerequisite assessment section; 
instructional section; and outcome assessment section. The prerequisite assessment 
section consists of mult -choice items used to determine learners' entry knowl- 
edge. Authors can provide essential information for learners who do not answer 
prerequisite items correctly through the use of corrective paragraphs for each pre- 
requisite item. The instructional section of the learner module requires learners to 





make decisions based on the patient data created for the nursing process step. In 
the outcome assessment portion of the module, learners respond to multiple choice 
questions created by faculty authors. Learners' scores on assessment items and 
several selected responses from the instructional section of the module are recorded 
on a learner record disk. The information on each learner's record disk can be 
reviewed by the faculty author using a NEMAS utility. 

NEMAS is designed for authors and learners who have not had computer expe- 
rience. Menu selections allow easy use of both the authoring and learner delivery 
components. The system has been implemented for use on a personal micro- 
computer using floppy disks. The system currently operates on an Apple II Plus, 
DOS 3.3, with a language card (64K) and double disk drives. 

NEMAS documentation consists of an authoring manual with a variety of use- 
ful appendices, and wall charts for both authors and learners. The first chapters of 
the manual are tutorial in nature, guiding authors in a step-by-step manner to learn 
use of NEMAS. Later chapters, i.e., reference chapters, offer further explanation 
about how to use the system to its maximum. Examples of patient data and a 
sample learner module are presented to orient faculty to the use of NEMAS. One 
chapter explaining NEMAS can be copied for distribution to learners. 

In summary, NEMAS is a template authoring and learner delivery system on 
nursing process. It incorporates principles from instructional design, learning 
theory, and nursing process theory. The learner modules created using NEMAS can 
be tailored for difficulty level by faculty. New modules reflecting updated knowl- 
edge can be created easily. Since nursing process is used in all nursing practice 
areas and taught in most types of nursing education programs, NEMAS' use is not 
constrained by practice specialty area, type of nursing education program, or any 
particular curricular conceptual framework. 

NEMAS: Nursing Education Module Authoring System. Supported by DHHS, 
Division of Nursing (D10 NU26CM), 1981-1983; and 3. B. Lippincott Co., 1983-84. 
Susan J. Grove K.N., Ph.D., Project Director. © The University of Texas at 
Austin, School of Nursing, Austin, Texas 78701, 1983. 

58 6i 


Lucille M. Pogue, R.N., M.S.N. 
Nurse Educator and Coordinator of Microcomputer Activities 
Department of Nursing, Talmadge Memorial Hospital 
Medical College of Georgia, Augusta 

The computer-assisted drug therapy lessons were developed by three nurse 
educators in the Department of Nursing at Talmadge Memorial Hospital, which is 
the clinical teaching facility at the Medical College of Georgia. 

The lesson material was developed to be used by licensed nursing staff both 
during their initial orientation and as an ongoing review and update. All nursing 
employees who have responsibility for administering drugs at Talmadge Memorial 
Hospital, Medical College of Georgia are required to successfully complete a medi- 
cation test during orientation and at five-year intervals. The computer lessons 
serve as remedial reviews for nurses who do not meet the established standard for 
the drug categories tested. The lesson material is also used by nurses who have a 
"felt" learning need in any drug category. 

The course consists of 15 lessons: Antibiotics, Gastrointestinal Drugs, Anti- 
diabetic Drugs, Respiratory Drugs, Antiallergic Drugs, Sedatives/Hypnotics, Anal- 
gesics and Antagonists, Anticonvulsants, Glucocorticoids, Antihypertensives, Digi- 
talis, Antianginals, Antiarrhythmics, Diuretics, and Anticoagulants. Plans are being 
made for the development of additional lessons. 

Each lesson is a series of multiple-choice and short answer questions. Reme- 
diation is offered for all wrong answers and rationales are presented with the cor- 
rect responses. When appropriate, a short review, either required or optional, is 

59 62 

offered on disease entities for which the group of drugs is used. Drug action, 
expected therapeutic effects, possible adverse effects, patient education aspects, 
and pertinent nursing responsibilities associated with the group of drugs are covered. 
Optional scored self-assessments are available at the end of each lesson. Study 
guides which are sequenced with the computer lesson are also available. 

The lessons vary in length from approximately 45 minutes (Antianginals) to 
three hours (Antibiotics). The total length of time required to go through all the 
lessons ranges from 17 to 24 hours. Some new nurses, particularly the graduate 
practical nurses, may require up to 30 hours. 

Each lesson has been reviewed by clinical specialists, other nurse educators, 
experienced practicing nurses, and faculty members at both baccalaureate and asso- 
ciate degree programs. Use of the initial lesson material was begun in June 1981. 
Ongoing evaluations by nursej using the lessons have been used for lesson revisions. 
Data have been collected relating to attitudes concerning the use of computer- 
assisted instruction in the staff development setting. The results of these surveys 
will be published at a later date. Preliminary indications are that the use of the com- 
puter for instructional purposes has been received very positively at our institution. 

The project was begun in 1980 on two Apple microcomputers and was funded by 
a grant from the Apple Education Foundation. Lesson material has been authored 
using the CAI System that was developed by Dr. Richard Pogue, Medical College of 
Georgia. The system is easy to learn, does not require that an author learn a 
programming language, and allows an author to use whatever instructional strategy 
is appropriate to the learning need. Lessons developed using the system can be run 
on a variety of microcomputers. 

The lesson material will be available for purchase in 1984. Information can be 
obtained from Lucille Pogue, R.N., M.S.N., Department of Nursing, Talmadge Hospi- 
tal, Medical College of Georgia, Augusta, Georgia 30912. 



Report of Findings 

Audrey F. Spector, R.N., M.S.N. 
Nursing Programs Director, SREB 
Executive Director, SCCEN 

In early 1983, informal reports from schools of nursing in the South showed a 
surge of interest in computer technology, The Executive Committee of the 
Southern Council on Collegiate Education for Nursing had already planned that the 
next annual meeting of the Council would address the needs of deans and directors, 
as administrators, in using the technology. It was also believed that a special re- 
gional project should be planned, to assist the schools' faculties in using computer 
technology as an instructional tool. 

A questionnaire survey was conducted, therefore, to gather information as a 
basis for planning the meeting of deans and directors and a regional project for 
faculty. For practical reasons, the questionnaire was mailed only to deans and 
directors; they were asked to give their opinions about their faculty's knowledge, 
experience, and interests concerning computer instruction, and to report their per- 
sonal interest concerning the technology. The questionnaire was mailed on April 15, 
1983, to the nurse administrative heads of all associate degree and baccalaureate 
nursing programs in the South (342). By May 5, the deadline date, responses had 
been received from 75 percent of the schools as follows: 

This report summarizes the responses from these 257 nursing program administrators. 

Kathleen 3. Mikan, University of Alabama in Birmingham, assisted in the prep- 
aration of the questionnaire. Ethel Tatro, Georgia State University, handled the 
tabulation of responses and assisted in the analysis of findings. 

Associate degree programs 
Baccalaureate programs 
Schools offering both programs 









Most of the administrators (83 percent) reported that they had little or limited 
knowledge about computers; only nine persons rated themselves as highly knowl- 
edgeable. However, more than half said they have used the computer for some 
purpose, most commonly for administration and less often for research or instruc- 
tion. Only 13 percent of the individuals had not used computers for any purpose and 
did not plan to do so. A few (15 percent) had a personal computer at home. The 
majority said they would like a hands-on microcomputer demonstration at the 1983 
Council meeting. 

The nurse administrators reported that microcomputers are widely available 
on their college campuses, especially for use by non-nursing students, and are avail- 
able to a lesser, but growing, extent to nursing students. 

At 89 percent of the institutions, microcomputers were available for use by 
students enrolled in non-nursing majors (e.g., math, science, engineering). At 30 
percent of the institutions, nursing majors received some of their pre-nursing or 
non-nursing instruction through use of microcomputers. 

While only Kf percent of the schools reported that nursing majors receive some 
nursing instruction through microcomputers, many schools indicated they had re- 
cently purchased the machines and plan to use them for nursing instruction. 

Over a third of the nursing programs currently had microcomputers available for 
instruction in nursing courses, and half of the programs expected to have them within 
the next year. Some of the schools that did not have microcomputers commented 
"We have none because faculty don't know how to use computers;" "Individual 
faculty members have them, but the school cannot afford them." Some schools 
that already have micrccomputers said they plan to buy more, "as soon as the 
faculty learn to use them." 

The microcomputer hardware most commonly available in the nursing pro- 
grams is the Apple. The 93 nursing programs that currently have microcomputers 



62 6o 

reported a total of 331 Apples, 111 IBMs, 73 TRS-80s, 5 Commodores, 3 Digitals; 
there were 109 microcomputers of various other brands. The Apple is the brand that 
was named most often by schools that expect to purchase hardware within a year. 


As Table 1 shows, all of the responding schools reported that faculty have a 
moderate or great need to learn about the use of computer technology for education 
purposes. None of the schools said faculty did not need to learn computer use. (One 
school did not respond to this item.) A very high percentage of responders stated 
that the faculty have moderate to great need to learn about: developing software 
(96 percent), selecting appropriate software (98 percent), and overcoming fears of 
computer technology in instruction (88 percent). 


Schools Reporting that Faculty Have 
Moderate or Great Need Related to Microcomputers 





Learn Use 






of Computer 






Learn to 






Develop Software 






Learn to 






Select Software 






Overcome Fear 






of Computer 






*The tables show percentages of each type nursing program reporting that 
their faculty have moderate or great need to learn about microcomputers (Table 1), 
moderate or great interest (Table 2), no experience (Table 3), and the administrator 
has moderate or great expectations for faculty relative to microcomputer software 
(Table 4). Not all of the 257 schools that responded answered every item. 



The nurse administrative heads reported that faculty have a high level of 
interest in computer technology (see Table 2). The highest level of interest was in 
utilizing software (91 percent), selecting software for purchase (84 percent^ and 
evaluating software (82 percent). While developing software was of interest to 
fewer schools, 73 percent of the schools' faculties have moderate to great interest. 


Schools Reporting that Faculty Have 
Moderate or Great Interest in Microcomputer Software 



























(95%) , 


Selecting Softwa-e 






for Purchase 



















The schools reported that the vast majority of faculty have had no experience 
with microcomputer software. At 78 percent of the schools, faculty had no expe- 
rience in developing software; onJy two schools reported great experience* As ex- 
pected, faculty had somewhat more experience in using software, although only six 
schools reported great experience. Over 70 percent had no experience in selecting 
software for purchase or evaluating software (see Table 3). 

*See footnote, page 63. 

" 67 


Schools Reporting that Faculty Have 
No Experience with Microcomputer Software 






















Software ' 






Selecting Software 






for Purchase 



















Almost a third of the nurse administrators expected their faculty to develop 
software in the coming year. And, more than half expected that faculty will help 
select software for purchase, will use it, and will evaluate it (see Table 4). 


Schools Reporting 
Great or Moderate Expectations for Faculty 
Relative to Microcomputer Software 


















Selecting Software 
for Purchase 















* See footnote, page 63. 


Almost without exception, the deans and directors said their school is 
^ interested in participating in a regional project to help faculty Jearn to use com- 
puter technology as an instructional tool. They wanted their faculty to establish 
networks with others who have similar microcomputer interests, and believed their 
faculty would benefit from receiving periodic written reports about microcomputer 
activities within the region. They were also sure faculty v ould be interested in 
' attending workshops conducted by the project. 


Strong support for a proposed project was also expressed by directors of 
continuing education, who were contacted through a separate questionnaire. Of the 
36 CE directors who were contacted, 22 responded; only eight reported they had of- 
fered educational programs for faculty in the use of microcomputers for teaching. 

Note: Based on these findings of need and interest, plans were developed for a 
regional project to provide a continuing education program designed to strengthen 
the ability of nurse faculty in basic collegiate programs in using computer tech- 
nology as an instructional tool. Ai the time of this writing (spring, 1984), the pro- 
posal is under review by an outside agency. (AFS). 


erJc ♦ 6d