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This paper reports the progress of an educational innovation in an Undergraduate Nursing Education Program designed to strengthen conceptual links between the theory and practice components of the second year curriculum. The project involved installing a clinical database used in a major teaching hospital into a university computer laboratory. This extensive database contains the directions for all variations of nursing care implemented in the hospital and is constantly updated by clinicians providing an accurate description of current nursing practice. Students are given weekly hypothetical scenarios from which they develop plans of care using the database. These plans of care are later practised in a simulated laboratory setting. Students search the database to help identify and plan solutions for patient problems and are then required to develop rationales for the database content linking this to physiological and psychosocial theory as appropriate. The ongoing evaluation of the project is discussed in terms of students', clinicians' and educators' perceptions of the use of the database, the potential means of improving database use and the implications of considering database modification.Strategies for the evaluation of computer based teaching approaches are discussed and linked with the theoretical framework of the University Curriculum. Broader implications such as cooperation between institutions to produce high quality databases and the use of other workplace computer databases in education are introduced.
In response to this problem undergraduate nursing programs use a variety of measures in an attempt to link theory and practice, including the use of nursing skills laboratories and clinical teaching scenarios which provide students with problem solving activities and skills practice which simulate those situations encountered in the clinical setting. The project described in this paper is a further innovation in nursing education designed to address the need for appropriate and effective strategies to minimise the theory-practice gap. Specifically the project is concerned with addressing the problem of linking theory to practice through the integration of a hospital nursing care planning database into the undergraduate curriculum.
The major objectives of the project are to integrate the use of a clinical database into a problem-based learning (PBL) process in a manner which helps to bridge the theory-practice gap, to provide nursing students with the opportunity to use the type of software they would most frequently be using to plan patient care once they have graduated, and to provide feedback for other teachers and students on the effective use of computerised clinical databases as a learning resource for clinical subjects.
An approach to structuring the curriculum which involves confronting students with problems from practice which provide a stimulus for learning.The project commenced with the loading of the Excelcare computer program and the database of a large Adelaide public teaching hospital onto a pool of computers in the student computer laboratory. The Excelcare computer program is used by Registered Nurses and Nurse Managers to produce patient nursing care plans and provide the information required for management using the casemix system. Nursing care plans produced using the Excelcare program provide nurses with the instructions for carrying out patient care while enabling classification of patients in order to determine casemix based funding. A group of 25 second year undergraduate nursing students volunteered to be the first group to use the program. This group received initial instruction in the use of the Excelcare program to access the database. The subject chosen for the integration of the database was a second year undergraduate subject with an acute care focus.
Students in the volunteer group were engaged in a PBL process which involved, among other things, investigation of weekly clinical scenarios. The clinical scenarios include varied information ranging from medical diagnoses, symptoms and drug therapies to descriptions of social, cultural and spiritual backgrounds of fictitious patients. Students used the database to help them identify patient problems and developed nursing care plans which they then implemented in the skills laboratory setting. The use of the database was further embedded into the PBL process by requiring students to link the database to underlying pathophysiological and psychosocial theory. This was achieved by asking students to provide the rationale for the instructions for patient care generated by the database. In addition students were provided with scenarios describing changed patient progress over a period of time requiring students to modify the database. In this way the data base became much more than a static information resource linking theory to practice - providing students with experience in using computer databases for clinical problem solving.
Candy et al. (1994) highlight the use of computers in developing problem solving skills and indicate the advantages of interactive computer based education over passive educational media. By using the database to develop problem solving strategies students were preparing themselves well for a future health care environment where computers will play a greater role in both management and clinical decision making. Duguet (cited in Candy et al., 1994) emphasises the value of developing these life-long learning skills, identifying the use of computers to develop skills in problem solving, retrieval, synthesis, organisation and analysis of information.
A three week clinical placement in acute care hospitals followed completion of the University based component of the acute care nursing subject in order to consolidate the practical and theoretical development of students. Using a computer program students selected their own clinical placement from a number of hospital locations. In addition to the original group of 25 students another group of 20 students allocated themselves to the teaching hospital providing the database. These students were then included in the project and provided with instruction in the use of the Excelcare program. The inclusion of this group allowed investigation of an alternative approach to the use of the program with these students focusing only on the areas of the database directly linked to the specialty of their clinical placement. In this way students became familiar with the actual care plans in the hospital wards in which they would be working. The use of the database in this manner provided students with the opportunity to further individualise their own learning.
For this reason the project team adopted a primarily qualitative approach to evaluation which aimed to identify positive and negative aspects, with respect to the learning process, of the integration of the computer database. As the emphasis of the project was on student learning and the entire process was developed with an underlying philosophy which valued student input, student comments on the development of learning outcomes were used as a primary means of evaluation.
Further complexities in the evaluation process arose as a consequence of the varied expectations held by educators and clinicians in terms of student performance and student learning. The reasons for these varied expectations are complex and worthy of further research. As the database focused on nursing care planning, student ability to produce nursing care plans was clearly a major area of interest. However, there was very little agreement on what constituted a good nursing care plan. For example, the hospital database provided concise instructions for care while the recommended student texts often demanded use of predominantly North American based "jargon" and provided examples of very lengthy plans of care, impractical for use in the clinical setting. In view of these considerations the project required an evaluation process able to capture the input from the relevant participants or stakeholders.
A multifaceted evaluation was designed which included input from the key stakeholders who included all the major categories of persons with an interest in student learning including clinicians, senior clinicians, clinical facilitators, students and lecturers. The evaluation of the project was modelled on fourth generation evaluation developed by Guba and Lincoln (1989) who describe the construction of boundaries and parameters of the evaluation process as an interactive and responsive process. This approach contrasts with traditional evaluation methods which set boundaries and parameters prior to the commencement of the evaluation process. Koch (1994), discussing fourth generation evaluation in relation to nursing, describes the responsive focusing of this method with claims, issues and concerns from open-ended interviews fed back to other groups for comment, refutation or agreement. The characteristic of this approach to evaluation, is that input and comments from each category of key stakeholders are discussed by all other stakeholders thus capturing the diversity of views amongst stakeholders.
The use of fourth generation evaluation also links to the theoretical underpinning of the acute care subject with journalling making up a major component of this evaluation tool. By adopting the model of fourth generation evaluation, dialogue between stakeholders is established as a part of the evaluation process and the evaluation process itself is likely to facilitate theory-practice links.
Less favourable comments received from students in the very early stages of the project included criticism of the database content for failing to provide rationale for nursing interventions and general dislike of computers. One insightful student indicated she was just producing printouts of care plans and not linking the content to theory and the rationale for the plan itself. This highlighted a common pitfall for educators using technology as an end in itself and not to assist in teaching and learning These problems appeared to be resolved by the restructuring of tutorials with students preparing plans of care integrated with theory and a supporting rationale and presenting them to the class groups.
While most students found the use of the database did provide an effective means of linking theory and practice, they only fully recognised the value of these links after they had completed clinical work. That is, they needed to use the clinical database in the clinical setting before really recognising its value. This finding is consistent with student experience of using the nursing skills laboratory, with students fully recognising the importance of clinical skills only after they see them applied in practice.
The project was dependent on the successful operation of hardware and software, and while problems in this area were minimal this was only because of very careful planning and highly competent technical support. Projects such as this require the availability of expensive and increasingly limited resources.
The initial trialling with a small number of students enabled early detection and resolution of technical problems without unduly disrupting student learning. However with large student numbers several potential problems arise. Increased demands are placed on hardware, software and printers. Each patient scenario will lead to care plan production with an average of 20 items per patient. In the hospital sector this has led to major problems with plans being excessively long. As there may be hundreds of nursing students involved, costs in paper use alone may be excessive and the demand for computer terminals may well exceed the available resources.
The level of student computer literacy is also a major factor for consideration when planning innovations such as this. Most students took 2-4 hours to learn to necessary parts of the program, however considerably more instruction time was needed for those students with less computer familiarity. Often educators do not take this into account assuming all students are computer literate and/or have access to computers.
In semester two of 1996 the project will expand to include 200 nursing students to assess whether it is feasible on a large scale. A system of rotation of students will be developed in an attempt to overcome logistic problems and to enable all students to use the database in weekly problem solving activities.
The quality of the clinical database is also of importance. Nursing care planning databases from the clinical setting are extremely useful as they provide instructions for nursing interventions. However, these databases are produced for instructional and management functions rather than specifically for education. While the instructional component has strong educational use, the databases would be improved if nursing instructions were linked to pathophysiological and psychosocial rationales.
The database was used to provide the core of the care plan design. In this way all teaching was firmly grounded in the realities of the practice setting with both the teacher and students being informed of the current nursing practice in the clinical setting. In a climate of rapid change and increasingly specialised clinical treatment, where texts and often lecturers are quickly outdated, the use of clinical databases may rapidly move from being an innovative approach to an essential part of nurse education.
While the use of this clinical database in University education has been successful, it is not necessarily "the" solution to bridging the theory-practice gap. Rather it is one step in further linking the University and clinical settings. This project has used instructional materials produced by hospitals in the University setting. Further collaboration between the University and the Hospital to produce improved databases with the University contributing to hospital care planning is the next logical step in the development of this innovation. This may later lead to establishing areas of expertise and cooperation in further database sharing and production between institutions. If centres of excellence were developed, able to produce high quality databases which could be shared internationally in an efficient and coordinated manner, then the potential for this type of education would be limitless.
Candy, P., Crebert, G. & O'Leary, J. (1994). Developing Lifelong Learners through Undergraduate Education. National Board of Employment Education and Training Commissioned Report number 28. Canberra, AGPS.
Doorley, J., Renner, A. & Corron, J. (1994). Creating care plans via modems: Using a hospital information system in nursing education. Computers in Nursing, 12(3), 160-163.
Guba, E. & Lincoln, Y. (1989). Fourth Generation Evaluation. Newbury Park California, Sage.
Hardy, J., Conrick, M., Foster, J., McGuiness, B. & Bostock, E. (1996). Computerised education for health professionals. In E. Hovenga, M. Kidd & B Cesnik (Eds), Health Informatics: An Overview. Melbourne, Churchill Livingstone.
Koch, T. (1994). Beyond measurement: Fourth generation evaluation in nursing. Journal of Advanced Nursing, 20, 1148-1155.
Magnus, M., Co, M. & Derkach, C. (1994). A first-level graduate studies experience in Nursing Informatics. Computers in Nursing, 12(4), 189-192.
Nursing education in Australian universities: Report of the National Review of Nurse Education in the Higher Education Sector - 1994 and beyond. (1994) Canberra, AGPS.
| Authors: Associate Professor Julianne Cheek PhD Faculty of Nursing, University of South Australia Mr David Gillham BSc, BN, RN, MNSt Faculty of Nursing, University of South Australia Tel: (08) 302 6233 Fax: (08) 302 6657 Email: David.Gillham@UniSA.edu.au Ms Patricia Mills RN, RM, DipT (Ned), BE, ME(HRS) Faculty of Nursing, University of South Australia Please cite as: Cheek, J., Gillham, D. and Mills, P. (1996). Facilitating students nurse learning via the integration of a clinical database into the undergraduate curriculum. Different Approaches: Theory and Practice in Higher Education. Proceedings HERDSA Conference 1996. Perth, Western Australia, 8-12 July. http://www.herdsa.org.au/confs/1996/cheek.html |