Advancing evidence-based practice and patient safety through integration of personal digital assistants into clinical nursing education
Article Outline
Since the turn of the century, clinicians, healthcare organizations, and educational institutions have increasingly recognized the potential role of mobile devices such as personal digital assistants (PDAs) and cellular telephones in advancing evidence-based practice and patient safety. A number of schools of nursing have embraced such technologies and integrated commercial and/or locally-developed programs for purposes such as documenting student clinical encounters through PDA-based student clinical logs, calculations (e.g., weight-based drug dosage, expected date of confinement), and accessing clinical practice guidelines and knowledge bases (e.g., Epocrates).1, 2, 3, 4
In this article, the authors summarize their experience in developing and implementing 3 generations of PDA-based clinical encounter logs for Advanced Practice Nursing (APN) students at the Columbia University School of Nursing (CUSON) and describe key lessons and implications for members of the American Academy of Nursing. The development has occurred within the context of curricular innovations and promotion of competencies in informatics and patient safety and the conduct of randomized, controlled trials of guideline-based decision support.5, 6
The decision to develop rather than buy a commercial program for documentation of clinical encounters was based on 2 major user-centered requirements. First, there was a need for a student clinical log application that would adequately capture (using standardized terminologies) the nursing as well as medical aspects of APN practice. Second, in terms of technology-task fit, the authors felt that it was imperative for the application to be consistent with the way that students in the CUSON APN programs are taught to document through creation of a 5-part APN plan of care: Diagnostics, Procedures, Prescriptions, Patient Teaching and Counseling, and Referrals. Although the application functionality has evolved through each generation, the initial design principles have remained consistent. These include: user-centered design, modular programming approaches, maintenance of content in the knowledge base rather than in the application, and use of standardized terminologies and other healthcare data exchange standards. The phases of development are illustrated with the examples of pediatric depression and smoking cessation.
In the first generation of PDA development and implementation, the focus was on supporting the collection of a set of encounter-level data elements tailored to each APN specialty.7 The application was developed using Satellite Forms and data elements that were represented in the knowledge base using standardized terminologies including Home Health Care Classification (now Clinical Care Classification) for nursing diagnoses, patient teaching and counseling, and referrals; International Classification of Diseases-Clinical Modification for medical diagnoses; and Physician’s Current Procedural Terminology for diagnostics and procedures.8 Student reports were generated to facilitate the APN students’ critical examination of their own practices over time and to provide a cumulative profile suitable for sharing with future employers.9 Faculty reports enabled evaluation of individual students and cohorts of students. Additionally, these reports provided useful targets for curricular development for improving quality of care (e.g., asthma, women’s health).9, 10 At the School level, the data were useful in documenting that CUSON APN students primarily delivered care to those without private health insurance.
In the second generation of application development, decision support for the screening, diagnosis, and initial management of smoking, obesity, and depression was added. These clinical content areas were chosen because they were relevant across age groups and APN specialties. Moreover, the conditions were amenable to initiation of interventions within the context of a single encounter. Advance Practice Nurse students were randomized to receive a reminder to screen for obesity from age 2, depression from age 7, or smoking from age 10. Key elements of the development in this phase were: (1) selection of the guideline and other sources of evidence upon which to base the decision support functionality, and (2) transforming these sources of evidence into knowledge that is both executable and actionable.6, 11, 12, 13 This resulted in a standardized assessment that generates an automated diagnosis and associated tailored plan of care (Figure 1) The tailored plan of care, which is organized as a document template, serves the dual purpose of displaying the relevant evidence-based care and supporting documentation of the selected interventions (i.e., the evidence is actionable). This version of the application was developed using AppForge.
Figure 1.
Pediatric Depression Screening and Management.
In the third generation of application development, referential knowledge was added to the categories of Patient Teaching and Counseling and Referrals through provision of context-specific links (infobuttons) to external information resources (Figure 2).14 This additional decision support approach facilitates access to up-to-date knowledge since the knowledge is maintained by the knowledge developer (e.g., the National Cancer Institute’s Cancer Information Service for the CUSON smoking cessation application) rather than by the application developer.15 The decision support provided to the APN student is complemented by a paper “information prescription” in either English or Spanish that refers patients to selected Cancer Information Service resources.
Figure 2.
Infobuttons in Smoking Cessation Application.
The American Academy of Nursing has recognized the important role of technology, including information and communication technologies, in improving the nursing work environment and subsequently patient safety.16 Consequently, it is vital that nursing students and APN students learn to use such technologies in association with the substantive content of their domain. Academy members should promote the implementation of innovative competency-based informatics curricula. The key lessons from the CUSON PDA experience may be useful in guiding such implementations. First, there must be buy-in from key stakeholders—the administration, faculty, and students—so that use of the PDAs is viewed as an essential part of the curriculum. At CUSON, faculty acceptance occurred incrementally and student use reflected the degree of faculty buy-in. Second, there must be a fit between the technology (e.g., the PDA student clinical log and decision support system) and the tasks to be achieved in the educational experience. Based on student and faculty feedback, the PDA applications and associated reports were iteratively refined through the years to better match the need to document and evaluate APN students’ clinical experiences. Third, user training, including booster training sessions and general technical support, is essential and the students’ needs will vary greatly dependent upon their level of familiarity with the technology chosen. In summary, the promise of PDAs to advance evidence-based practice and patient safety in clinical education is great; however, fulfillment of the promise requires a substantial commitment from key stakeholders.
The work described was supported through grants from the Health Services Resources Administration (HP00261, HP07346), National Institute of Nursing Research (R01NR008903), and National Cancer Institute (1R21CA126325). The authors thank the other members of the Informatics for Advanced Practice Nursing (i-APN) team for their role in the development and evaluation of the applications described.
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PII: S0029-6554(07)00295-3
doi:10.1016/j.outlook.2007.11.006
