ED 248 748
HE 017 606
Computer Technology and Nursing Education.
Southern Council on Collegiate Education for Nursing,
Atlanta, GA.; Southern Regional Education Board,
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 -
MF01/PC03 Plus Postage.
Authoring Aids (Programing); * Computer Assisted
Instruction; * Computer Oriented Programs; Delivery
Systems; Higher Education; "Information Systems;
Microcomputers; "Nursing; "Nursing Education;
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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COMPUTER TECHNOLOGY AND NURSING EDUCATION
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.
COMPUTER TECHNOLOGY AND NURSING EDUCATION
COMPUTERS IN NURSING: WHERE ARE THE LEADERS?
Richard E. Pogue
BASICS OF COMPUTER TECHNOLOGY: CLEARING THE CRYSTAL BALL 15
Gary D. Hales
DEAN'S USE OF COMPUTER TECHNOLOGY IN
ADMINISTERING A NURSING PROGRAM 27
Billye J. Brown
COMPUTER-ASSISTED INSTRUCTION IN NURSING EDUCATION 37
Donna E. Larson
COMPUTER USE IN NURSING SERVICE 47
Carol A. Romano
NURSING EDUCATION MODULE AUTHORING SYSTEM 57
DRUG THERAPY COURSE 59
Lucille M. Pogue
SURVEY OF MICROCOMPUTER USE IN SOUTHERN NURSING EDUCATION 61
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
Southern Council on Collegiate
Education for Nursing
COMPUTER TECHNOLOGY IN NURSING: WHERE ARE THE LEADERS?
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
with computers. AN INSTRUCTOR WHO IS LESS SKILLED THAN HIS
STUDENTS IN THIS IMPORTANT AREA WILL BE AT A PSYCHOLOGI-
CAL AS WELL AS AT A FUNCTIONAL DISADVANTAGE. (Emphasis
Let's approach our topic in another way— through scenarios which illustrate
uses of computer technology within nursing.
SCENARIOS ILLUSTRATING COMPUTER USE
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.
A SCENARIO FOR THE FUTURE
, 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.
EVENTS IN SOCIET Y
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
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,
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.
HOW DO WE DEVELOP OUR LEADERS IN NURSING?
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
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
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.
WHERE ARE THE LEADERS IN THE USE OF COMPUTERS IN NURSING?
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.
BASICS OF COMPUTER TECHNOLOGY: CLEARING THE CRYSTAL BALL
Gary D. Hales, Ph.D.
Computer Consultant for Nursing, Health Care,
Education, and Small Businesses, Houston, Texas
Editor-in-Chief, Computers in Nursing
BASIC COMPUTER TERMINOLOGY
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
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
COMPUTER SYSTEM DESIGN
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.
COSTING THE SYSTEM
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
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
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
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
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.
USING COMPUTER TECHNOLOGY IN ADMINISTERING NURSING PROGRAM
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
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-
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
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-
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
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.
COMPLi 1 fcK-ASSISTETTINSTRUCTION INTVURSING-EDUCATION-
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
ADVANTAGES OF COMPUTER-ASSISTED INSTRUCTION IN NURSING
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).
SPECIFIC TEACHING AND
CO NTINUING EDUCATION APPLICATIONS
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
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.
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Bitzer, M., Boudreaus, M., & Avner, R. A. (1973). Computer-based instruction of
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Burson, J. (1981). A ten point-seven criteria CAI materials appraisal process. In J.
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COMPUTER USE IN NURSING SERVICE
Carol A. Romano, R.N.
Nursing Information System Specialist
Clinical Center Nursing Department
National Institutes of Health
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-
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
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
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,
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
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,
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
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 .
NURSING EDUCATION MODULE AUTHORING SYSTEM (NEMAS)
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.
DRUG THERAPY COURSE
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
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.
SURVEY OF MICROCOMPUTER USE IN
SOUTHERN NURSING EDUCATION, 1983
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
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
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
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
*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
FACULTY EXPERIENCE WITH SOFTWARE
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.
Schools Reporting that Faculty Have
No Experience with Microcomputer Software
TOT A I
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).
Great or Moderate Expectations for Faculty
Relative to Microcomputer Software
* See footnote, page 63.
INTEREST IN REGIONAL ACTIVITIES
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).
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