Submitted by Jennifer Predhomme BScN University of Windsor
Personal Digital Assistants (PDAs) are pocket-sized computers that are capable of accessing the Internet, sending and receiving data, and storing textbooks worth of information. These tools have the potential to help nurses increase the quality of care that they provide in the hospital setting. PDAs have been shown to increase evidence-based practice and decrease medication errors by making relevant information available right at the point-of-care. PDAs have also been shown to save nurses’ time by increasing the efficiency and accuracy of electronic patient charting, and by decreasing the time that it takes nurses to research medication information. The integration of PDAs into nursing practice pose individual, technical, and financial challenges, as well as patient confidentiality and infection control concerns. However, as nurses and organizations begin to recognize the potential for PDAs, and as more nursing-focused software and resources continue to be developed, PDAs truly have the potential to revolutionize the way that nurses provide and record care.
How Personal Digital Assistants Can Increase the Quality of Nursing Care Provided in the Hospital Setting
Personal Digital Assistants (PDAs) are small pocket-sized computers that have traditionally been used as personal organizers. As technology has advanced, these devices are now able to store, send and receive significant amounts of data as well as to access the Internet. This effectively creates a resource that would allow nurses to carry textbooks of information right in their pockets, to access the information they are seeking in seconds, and to do so right at the point-of-care. Surveys of nurses with PDAs revealed that popular resources included drug reference programs, medical math calculators, medical texts, and practice guidelines (Stroud, Erkel, & Smith, 2005).
Although PDAs have become commonly used by physicians in the hospital setting (Garrity & El Emam, 2006), use by staff nurses continues to lag far behind (Thompson, 2005). This is unfortunate because PDAs could be useful in addressing many of the challenges that nurses face today, both as individual practitioners and as a joint profession. This article will explore how PDAs used as tools for practice can increase the quality of nursing care provided in the hospital setting. Furthermore, the challenges for integrating PDAs into nursing practice will be examined.
Increasing Evidence-Based Practice
One of the most prominent goals of modern nursing is to create a comprehensive evidence-based body of knowledge and to use this knowledge to guide and provide rationale for the best possible nursing care. Although the effort to build this knowledge base is advancing, the struggle to incorporate this knowledge into everyday nursing has been identified (Dawson & Thomas, 1999). PDAs have the ability to make evidence-based information available to nurses when and where they need it. This potential is being recognized by some professional organizations such as the Registered Nurses Association of Ontario and the American College of Physicians, both of which have created PDA friendly versions of their practice guidelines. It is also being recognized by the Ontario Government in their initiative currently in progress to provide PDAs to 2000 Ontario nurses. This initiative is expected to result in improved patient outcomes through increased use of evidence-based practice (Ministry of Health and Long-Term Care, 2008).
Research has shown that staff nurses without PDAs often seek information away from the bedside and that the most common source of information is nursing colleagues, who may or may not provide evidence-based advice. However, nurses using PDAs are far more likely to state that evidence-based practice guidelines are available to them versus those who do not (Doran & Mylopoulos, 2008). Physicians using PDAs have stated that the devices have increased their use of evidence-based practice (Hauser et al., 2007) and that the speed in which information could be obtained was critical to incorporating evidence at the point of care (Honeybourne, Sutton, & Ward, 2006).
Reducing Medication Errors
Medication errors are a serious threat to patient safety in healthcare systems worldwide. The Institute for Safe Medication Practices Canada has declared this to be a major public health issue (ISMP, 2001). In the United States, the Institute of Medicine (IOM) and the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), work diligently to identify the etiology of medication errors and to produce recommendations to prevent future errors. Research has shown that while errors may occur in any of the stages of the medication process, most errors occur in the ordering (56%) and administration stages (34%) (Bates et al.,1995). The following discussion will focus on the administration stage because it is a staff nursing function.
PDAs have the potential to reduce medication errors by providing a portable and convenient reference source for healthcare providers. Research into the etiology of medication errors has indicated that most errors occur due to lack of knowledge of patients’ clinical status and/or lack of knowledge of the medications being prescribed (Leape et al., 1995). However, with the rate at which new medication information is being produced, the IOM acknowledges that it is almost impossible for healthcare providers to have current knowledge of every medication they encounter. Therefore the IOM recommends a point-of-care reference source such as a PDA for all healthcare providers (Institute of Medicine, 2007).
PDAs can also decrease the amount of time that nurses spend seeking information about medications. A study has shown that nurses using PDAs are just as accurate and significantly more efficient than nurses researching medications in a text (Greenfield, 2007). This study was timed with nursing students sitting at a desk with either a PDA or a drug reference text in their hands. In the hospital setting time is lost when nurses must leave the medication carts or bedside areas to walk to the reference text locations. Thus, as well as being able to use their medication references more efficiently, nurses using PDAs would gain additional time by having the medication references on their PDAs with them at all times. Furthermore, although no studies are currently available, it is likely that the convenience that PDAs offer would make it more likely that nurses would research more of the medications they administer rather than relying on memory alone, which could also potentially decrease medication errors.
Increasing Efficiency and Accuracy of Nursing Documentation
Time saving measures, such as those offered by PDAs, have become very appealing to nurses in the modern hospital environment. In a pilot study of nurses, PDAs were found to be highly useful for collecting and documenting patient data (Doran & Mylopoulos, 2008). In the absence of PDAs many nurses are currently using personal “scrap” paper to record information at the point-of-care and later transcribing this into the patient record. This duplication of documentation could be eliminated with an interface that allows nurses to electronically send patients’ information from their PDAs directly to the organization’s electronic healthcare records (Di Pietro et al., 2008). It is also possible that such a system could eliminate transcription errors that may occur when nurses are manually transferring information from their personal papers into the health records.
As well as making documentation faster, research has shown that PDAs have the potential to make documentation more accurate (Stengel, Bauwens, Walter, Kopfer, & Ekkernkamp, 2004) and also more likely to include nursing interventions such as non-pharmacologic pain management (Doran & Mylopoulos, 2008). Furthermore, PDAs used in acute care settings were found to significantly improve communication between nurses and between nurses and other members of the healthcare team. This latter finding was based on the promptness of information transfer as well as the level of general communication reported by the healthcare team. However, more research is necessary in this area to prove that the improved communication was not related to factors other than PDA use (Doran & Mylopoulos, 2008).
Concerns and Challenges of Integrating PDAs into Nursing Practice
The challenges of integrating PDAs into nursing practice are multi-dimensional and include interrelated individual, organizational, and professional components. A descriptive study has found that individual challenges include inexperience with computers, difficultly changing habits, and difficulty accepting new technology. However, the same study showed that nurses with limited computer experience still found the software easy to use, and liked the small pocketsize of PDAs (Altmann & Brady, 2005). Additional individual challenges include the cost of PDAs and software when the devices are not being provided by organizations (Altmann & Brady, 2005).
Organizations face similar economic concerns but on a much larger scale. In addition to these economic concerns, organizations may have major technical challenges. These include compatibility of PDAs with the current computer system, availability of a wireless Internet network in all areas of the organization, and the need for an increase in technical support for staff (McAlearney, Schweikhart, & Medow, 2005).
Maintaining patient confidentiality is of major concern to both organizations (McAlearney, Schweikhart, & Medow, 2005) and nursing professionals. Although organizations should have policies and methods in place for PDA use, it is ultimately the nurse who is responsible to ensure that patient confidentiality is maintained. Therefore nurses should ensure that their PDAs are password protected and that a data encryption program is installed (CNO, 2008). These security measures are readily available for purchase and easily installed via the Internet. Nurses should also take the same precautions with patient information on their PDAs as they would with traditional paper records, such as not leaving the PDA in unauthorized areas to avoid theft, loss, and confidentiality breaches. Also, PDAs used for documentation should either be cleared of patient information before being brought out of the organization or kept in the workplace.
There is also concern over infection control with PDAs. Studies have shown that equipment such as stethoscopes and PDAs can be colonized with bacteria and thus have the potential to be vectors for nosocomial infections (Hassoun, Vellozzi, & Smith, 2004; Wright, Orr, & Porter, 1995). However, research has shown that the simple method of cleaning the PDA with one 70% isopropyl alcohol swab was effective in eliminating all bacteria in 75% of cases and significantly reduced the bacterial colonization in the other 25% of cases (Hassoun et al., 2004). Therefore, nurses must be diligent in cleaning their PDAs to maintain patient safety.
The concern over patients’ perceptions of nurses using PDAs in their care was recently explored through a descriptive study. Responses were varied with some patients expressing the opinion that PDAs likely increased the nurse’s work efficiency, while others stated indifference to PDAs as long as the quality of care remained high. However, many patients preferred that the nurse explain the function and purpose of the PDA to avoid confusion or misunderstanding. There was also some concern expressed over the accuracy and privacy of the data being recorded (Lee, 2007).
In conclusion, PDAs have been shown to have the potential to increase the quality of nursing care provided in the hospital setting by helping nurses better meet some of the major challenges that the profession faces today. PDAs have been shown to have the ability to increase evidence-based practice, decrease medication errors, and increase efficiency and accuracy of electronic patient charting. Furthermore, the portability, ease of use, and near instant access to information that PDAs provide makes them very appealing tools for nurses. As nurses and organizations begin to recognize the potential for PDAs, and as more nursing-focused software and resources continue to be developed, PDAs truly have the potential to revolutionize the way that nurses provide and record care.
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