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Student nurses' conceptions of computers in hospitals Abbott, Karen Elizabeth 1988

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STUDENT NURSES' CONCEPTIONS OF COMPUTERS IN HOSPITALS By KAREN ELIZABETH ABBOTT B.Sc.N., Lakehead University, 1975 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of Administrative, Adult And Higher Education We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA November, 1988 ®Karen Elizabeth Abbott, 1988 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada DE-6 (2/88) ABSTRACT The t r e n d t o w a r d i n c r e a s e d c o m p u t e r i z a t i o n i n Canadian h o s p i t a l s has p r o f o u n d i m p l i c a t i o n s f o r h o s p i t a l employed n u r s e s , t h e m a j o r i t y o f whom a r e educ a t e d i n community c o l l e g e n u r s i n g programs. E d u c a t o r s , i n response t o t h i s t r e n d , must be a t t e n t i v e t o t h e q u a l i t y o f s t u d e n t l e a r n i n g when p l a n n i n g f o r computer c o n t e n t i n n u r s i n g c u r r i c u l a . The purpose o f t h i s p h e n o m e n o l o g i c a l s t u d y was t o i d e n t i f y how s t u d e n t n u r s e s , e n r o l l e d i n a community c o l l e g e n u r s i n g program, c o n c e p t u a l i z e t h e impact o f computer use on h o s p i t a l employed n u r s e s . S t u d e n t s ' c o n c e p t i o n s were a n a l y z e d i n r e l a t i o n t o t h e i r : (a) a t t i t u d e t oward computers, and (b) l e n g t h o f c l i n i c a l e x p e r i e n c e . T h i r t y - f i v e (11 f i r s t - y e a r , 11 second-year and 13 t h i r d -year) s t u d e n t s e n r o l l e d i n t h e n u r s i n g program a t C a r i b o o C o l l e g e i n Kamloops, B r i t i s h Columbia, were i n t e r v i e w e d . Three b r o a d , and t e n f o r c e d - r e s p o n s e , q u e s t i o n s g e n e r a t e d b o t h q u a l i t a t i v e and q u a n t i t a t i v e d a t a , which were r e p o r t e d as p r i m a r y and secondary f i n d i n g s . Data a n a l y s i s , t h r o u g h use o f t h e c o n s t a n t c o m p a r a t i v e method, was c a r r i e d out on a f o r m a t i v e and summative b a s i s . F i n d i n g s i n d i c a t e d t h a t s u b j e c t s had l i t t l e awareness o f computer use by n u r s e s t o d a y . T h e i r knowledge o f how computers may be used by nur s e s i n t h e f u t u r e was a l s o l i m i t e d , and appeared t o c e n t e r around t h r e e b r o a d a r e a s : i i i nursing, communication, and administration. Subjects conceptions of the impact of computer use on hospital employed nurses f e l l into four categories: (a) nursing image, (b) professionalism, (c) patient care, and (d) workload. Their comments on these four categories were further c l a s s i f i e d into three:sub-categories, i n d i c a t i n g whether they f e l t that the increased use of computers would: (a) enhance, (b) detract from* or (c) both enhance and detract from, each category. It was found that subjects' conceptions d i f f e r e d i n complexity i n d i r e c t proportion to the year i n which they were enrolled i n the program and also the length of t h e i r c l i n i c a l experience. The majority of subjects had p o s i t i v e attitudes toward computer use. In addition, i t was found that there was a s i g n i f i c a n t relationship between complexity of conception and attitude. Students enter nursing programs with established conceptions and attitudes. The goal i n planning computer programs must be to sequence computer content through the use of a taxonomy of learning outcomes, so that quality of learning i s a p r i o r i t y , and p o s i t i v e attitudes are fostered. i v TABLE OF CONTENTS Tab l e o f C o n t e n t s .. i v L i s t o f T a b l e s i x L i s t o f F i g u r e s x i Acknowledgement x i i CHAPTER 1. INTRODUCTION . 1 BACKGROUND 4 A N a t i o n a l Study. 4 A P r o v i n c i a l P r o j e c t 7 L o c a l F a c t o r s . . . . . . . 8 PURPOSE 9 REASEARCH MODEL: NURSING INFORMATICS PYRAMID 11 RESEARCH QUESTIONS. 13 DEFINITION OF TERMS. .' 14 2. REVIEW OF LITERATURE.. 18 COMPUTERS IN HOSPITALS 19 E v o l u t i o n o f Computers i n H o s p i t a l s 19 Developments i n Canada 20 Developments i n B r i t i s h Columbia 22 Computer Support F o r N u r s i n g P r a c t i c e 26 I s s u e s C o n c e r n i n g Computer Use 28 ATTITUDES TOWARD COMPUTER USE 29 D e f i n i t i o n Of A t t i t u d e 30 H i s t o r i c a l Review Of S t u d i e s On Nurses' A t t i t u d e s Toward Computers 30 F a c t o r s A f f e c t i n g Usage 37 v LEARNING TO USE COMPUTERS 39 L e a r n i n g Need.... 40 L e a r n i n g Needs Of Nurses R e g a r d i n g Computers.... 42 Computer L i t e r a c y F o r Nurses 48 E v a l u a t i o n Of L e a r n i n g 52 SUMMARY. . . 56 3. METHODOLOGY 58 DESCRIPTION OF SUBJECTS . 59 Sample S e l e c t i o n . . . . . . •••• 59 S u b j e c t s ' Exposure To Computer Content 63 INSTRUMENTATION 66 PROCEDURES..... 68 Data C o l l e c t i o n . . .... 68 . R e s e a r c h e r ' s Role : 71 ANALYSIS OF INTERVIEWS 75 F o r m a t i v e A n a l y s i s 75 Summative A n a l y s i s 78 A n a l y s i s Of C o n c e p t u a l Data 79 A n a l y s i s Of A t t i t u d i n a l Data 86 A n a l y s i s Of Respondent P r o f i l e s 89 ESTABLISHING VALIDITY AND RELIABILITY 90 SUMMARY 93 v i FINDINGS . . 94 PRIMARY FINDINGS. . . 95 CONCEPTUAL FINDINGS 95 Awareness Of Computer Use By H o s p i t a l Employed Nurses Today 96 Knowledge Of How Computers May Be Used By H o s p i t a l Employed Nurses In The F u t u r e . . . . . . 102 C a t e g o r i e s Of C o n c e p t i o n s Of How Computers May Impact H o s p i t a l Employed Nurses I l l N u r s i n g Image;. . 112 P a t i e n t Care 116 Workload ,.. 121 P r o f e s s i o n a l i s m 126 C o m p l e x i t y Of C o n c e p t i o n s .... 131 R e l a t i o n s h i p Of C o n c e p t i o n To C l i n i c a l E x p e r i e n c e . . . . 135 ATTITUDINAL FINDINGS. 136 D e s i r e To Purchase A Computer Or To Take A Computer Course. 136 R a t i n g On An A t t i t u d e S c a l e . . . . . . . . . 138 R e l a t i o n s h i p Between C o n c e p t i o n And Attitude.-143 SECONDARY FINDINGS. . 146 DEMOGRAPHICS. ....... . . . . . . ... 147 Age. . . 147 Formal E d u c a t i o n P r i o r To E n t e r i n g The C a r i b o o C o l l e g e N u r s i n g Program 14 9 Amount Of E d u c a t i o n S p e c i f i c To Computers O b t a i n e d O u t s i d e The C a r i b o o C o l l e g e N u r s i n g Program 151 Environment F o r F i r s t Hands-On Computer E x p e r i e n c e . . . . . . . . 153 v i i Computer E x p e r i e n c e I n The C a r i b o o C o l l e g e N u r s i n g Program 155 Views On Computer Content I n The C a r i b o o C o l l e g e N u r s i n g Program 156 COMPUTER ACCESS AND . USAGE 159 Computer A c c e s s And Usage At C a r i b o o C o l l e g e . 1 5 9 Computer A c c e s s And Usage A t Home 163 F a m i l y Use - Other Than V i d e o Games......... 164 Spouse Or S i g n i f i c a n t Other 164 C h i l d r e n . . . . 164 SUMMARY OF PRIMARY AND SECONDARY FINDINGS 165 DISCUSSION, RECOMMENDATIONS, SIGNIFICANCE, AND CONCLUSION 168 DISCUSSION OF FINDINGS 168 DISCUSSION OF PRIMARY FINDINGS 169 Resea r c h Q u e s t i o n 1 169 Resea r c h Q u e s t i o n s (a) and (b) 179 Resea r c h Q u e s t i o n (c) 185 DISCUSSION OF SECONDARY FINDINGS 187 Demographics 187 Computer A c c e s s And Usage. 189 GENERALIZABILITY OF FINDINGS 190 LIMITATIONS OF THE STUDY. 191 RECOMMENDATIONS...... 193 Ge n e r a l Recommendations 193 L o c a l Recommendations. 194 v i i i SIGNIFICANCE OF RESEARCH 196 CONCLUSION 198 REFERENCES . . 200 APPENDICES A. COMPUTER SYSTEMS IN CANADIAN HOSPITALS 208 B. LETTER REQUESTING PERMISSION TO INTERVIEW 209 C. LETTER OF PERMISSION FROM CARIBOO COLLEGE .. 211 D. LETTER OF INTRODUCTION 212 E. CONSENT FORM. . . 213 F. INTERVIEW SCHEDULE 215 G. RESEARCH AUTHORIZATION. ... . 219 H. THEMES 220 I . CATEGORIES GROUPED 221 J . COMPUTER USE BY NURSES 222 ix LIST OF TABLES TABLES 1. STRUCTURE OF THE CARIBOO COLLEGE NURSING PROGRAM BY YEARS, SEMESTERS, AND CLINICAL ROTATIONS 15 2. NUMBER OF CLINICAL HOURS IN EACH SEMESTER AND YEAR OF THE CARIBOO COLLEGE NURSING PROGRAM . 17. 3. FREQUENCY OF MALE AND FEMALE STUDENTS IN THE ACCESSIBLE POPULATION OF CARIBOO COLLEGE NURSING STUDENTS FROM WHICH A SAMPLE WAS DRAWN . 63 4. SCHEDULED HOURS OF COMPUTER AWARENESS CONTENT IN EACH SEMESTER OF THE CARIBOO COLLEGE NURSING PROGRAM. 66 5. CHARACTERISTICS OF QUALITY OF CONCEPTION 84 6. FREQUENCY OF RESPONSE INDICATING STUDENTS' KNOWLEDGE OF HOW COMPUTERS WILL BE USED IN HOSPITAL NURSING IN THE FUTURE 107 7. RANKING OF CATEGORIES BY PERCENTAGE OF SUBJECTS' IN EACH YEAR WHO DISCUSSED THE CATEGORY 129 8. PERCENTAGE OF SUBJECTS WHO DISCUSSED EACH CATEGORY AND SUB-CATEGORY OF CONCEPTION 130 9. FREQUENCY OF HIGH AND LOW LEVEL RESPONSES INDICATING COMPLEXITY OF CONCEPTION 132 10. FREQUENCY OF RESPONSE INDICATING THE NUMBER OF CATEGORIES OF CONCEPTION DISCUSSED 133 11. FREQUENCY OF RESPONSE ;OF.RATINGS ON A FIVE POINT LIKERT-TYPE ATTITUDE SCALE 142 12. FREQUENCY OF RESPONSE OF SUBJECTS' ATTITUDES TOWARD COMPUTER USE IN HOSPITALS. . . . 143 13. FREQUENCY OF RESPONSE RELATING LEVEL OF CONCEPTION AND ATTITUDE 146 1.4. AGE RANGES OF SUBJECTS IN EACH YEAR OF THE CARIBOO COLLEGE NURSING PROGRAM 148 15. FORMAL EDUCATION PRIOR TO ENTERING THE CARIBOO COLLEGE NURSING PROGRAM. 150 16. AMOUNT OF FORMAL EDUCATION SPECIFIC TO COMPUTERS OBTAINED OUTSIDE THE CARIBOO COLLEGE NURSING PROGRAM. 151 X 17. SETTINGS OUTSIDE THE CARIBOO COLLEGE NURSING PROGRAM WHERE FORMAL COMPUTER EDUCATION WAS OBTAINED 153 18. INITIAL HANDS-ON COMPUTER EXPERIENCE IN NURSING AND NON-NURSING ENVIRONMENTS 154 19. PERCENTAGE OF SUBJECTS IN EACH YEAR WHO USE THE CARIBOO COLLEGE VAX SYSTEM 160 20. BARRIERS IDENTIFIED BY SUBJECTS TO USE OF THE CARIBOO COLLEGE VAX SYSTEM 161 21. FREQUENCY OF SUBJECTS WITH ACCESS TO A COMPUTER AT HOME 163 x i LIST OF FIGURES FIGURES 1. NURSING INFORMATICS (NI) PYRAMID 12 2. RELATIONGHIP OF SUB-CATEGORIES TO CATEGORIES OF CONCEPTION 166 3. NURSES AND TECHNOLOGY 199 x i i ACKNOWLEDGEMENTS I w i s h t o e x p r e s s my a p p r e c i a t i o n t o t h e members o f my t h e s i s committee: Dr. D a n i e l P r a t t , and Dr. H a r o l d R a t z l a f f f o r t h e i r a d v i c e and c o n s t r u c t i v e c r i t i c i s m . I a l s o w i s h t o thank t h e a d m i n i s t r a t i o n o f C a r i b o o C o l l e g e i n Kamloops, B r i t i s h Columbia f o r t h e i r monetary s u p p o r t , and my c o l l e a g u e s i n t h e N u r s i n g department f o r t h e i r u n d e r s t a n d i n g and encouragement. I owe a s i n c e r e debt t o t h e n u r s i n g s t u d e n t s a t C a r i b o o C o l l e g e f o r t h e i r w i l l i n g p a r t i c i p a t i o n i n t h e s t u d y . F i n a l l y , I owe a debt o f g r a t i t u d e t o my husband, C a r l , f o r h i s c o n s t a n t s u p p o r t and l o v i n g encouragement, and t o my c h i l d r e n , Mark and Suzanne f o r t h e i r p a t i e n c e and u n d e r s t a n d i n g . w i t h a Mom engaged i n graduate s t u d i e s over a f i v e y e a r p e r i o d . I thank my Dad, James Guppy, f o r h i s encouragement to w a r d advanced e d u c a t i o n e a r l y i n my c a r e e r , and my m o t h e r - i n - l a w , Grace A b b o t t , f o r t h e l o v i n g c a r e she p r o v i d e d my c h i l d r e n i n my absence. 1 CHAPTER 1 I n t r o d u c t i o n There i s l i t t l e doubt t h a t we a r e l i v i n g i n an i n c r e a s i n g l y t e c h n o l o g i c a l s o c i e t y , where i n f o r m a t i o n i s b e i n g g e n e r a t e d a t a p r e v i o u s l y unheard o f r a t e . T h i s t r e n d has p r o f o u n d i m p l i c a t i o n s f o r s o c i e t y , as attempts a r e made t o adapt t o t h e s e f o r c e d changes. The h e a l t h c a r e system i s moving toward i n c r e a s e d use o f computer t e c h n o l o g y as a means o f p r o c e s s i n g l a r g e volumes o f i n f o r m a t i o n . Movement i n t h i s d i r e c t i o n poses many q u e s t i o n s and c o n c e r n s , not o n l y f o r h e a l t h c a r e p r a c t i t i o n e r s t h e m s e l v e s , but f o r t h e i n s t i t u t i o n s where t h e s e p r a c t i t i o n e r s a re educated and t h e p r a c t i c e s e t t i n g s where t h e y a r e employed. I n B r i t i s h Columbia computers and computer a p p l i c a t i o n s o f t e c h n o l o g y have been q u i e t l y c r e e p i n g i n t o h e a l t h c a r e s e t t i n g s a t a s t e a d y r a t e over t h e l a s t decade. Nurses a r e t h e l a r g e s t s i n g l e group o f h e a l t h p r o f e s s i o n a l s employed i n h e a l t h c a r e s e t t i n g s i n t h i s . p r o v i n c e . The R e g i s t e r e d Nurses A s s o c i a t i o n Of B r i t i s h Columbia (R.N.A.B.C.) r e p o r t s t h a t t h e r e were 24,128 p r a c t i s i n g members i n May, 1988. Because o f t h e i r numbers, n u r s e s w i l l have a tremendous i n f l u e n c e on t h e a d o p t i o n o f t h e i n c r e a s e d use o f computers i n p r a c t i c e s e t t i n g s . I n d i v i d u a l a c c e ptance i s c r i t i c a l t o t h e s u c c e s s o r f a i l u r e o f any i n n o v a t i o n such as use o f computers ( H a l l & 2 Louckes, 1979). Some l i t e r a t u r e s u g g e s t s t h a t n u r s e s a r e w i l l i n g and ready t o b e g i n t h e e d u c a t i o n a l p r o c e s s o f l e a r n i n g t h e t e c h n i c a l s k i l l s r e q u i r e d f o r s a t i s f a c t o r y u t i l i z a t i o n o f computers (Krampf & Robinson, 1984). W h i l e a c q u i s i t i o n o f t e c h n i c a l s k i l l s i s v e r y i m p o r t a n t , i n s t i t u t i o n s must become concerned w i t h how t h e y can p r o v i d e a c o m f o r t a b l e f e e l i n g o f acce p t a n c e f o r t h e s e i n n o v a t i o n s (Krampf & Robinson, 1984). There i s l i t t l e i n f o r m a t i o n i n t h e l i t e r a t u r e about development o f t h e a f f e c t i v e domain o f u s e r s . Gaps e x i s t c o n c e r n i n g n u r s e s ' a t t i t u d e s t oward t h e use o f computers and how t h e use o f computers w i l l a f f e c t t h e i r r o l e . Most s u r v e y s on a c c e p t a b i l i t y have been conducted a f t e r computer systems have been implemented (Whitehouse, P r e s t o n , T o b i n , M i l l e r , & B a i l e y , 1975). I f nur s e s a r e t o be p r o a c t i v e , r a t h e r t h a n r e a c t i v e t o change, more e d u c a t i o n i s needed t o h e l p n u r s e s make w i s e c h o i c e s about t h e s e i n n o v a t i o n s w h i c h may i n t u r n , have impact upon t h e i r p r a c t i c e . The i n c r e a s i n g use o f computers i n h e a l t h c a r e has p r o f o u n d i m p l i c a t i o n s f o r n u r s i n g e d u c a t i o n (Ronald, 1983). There i s growing e v i d e n c e o f a surge o f i n t e r e s t by s c h o o l s o f n u r s i n g i n computer t e c h n o l o g y . T h i s i n t e r e s t presumably, i s due i n p a r t t o t h e i n c r e a s e d use o f computers i n n u r s i n g a d m i n i s t r a t i o n and p r a c t i c e ( P a r ks, Damrosch, H e l l e r , & Romano, 1986) . However, v e r y few a u t h o r s address t h e e d u c a t i o n a l needs r e l a t e d t o t h e use o f computers by h e a l t h 3 c a r e p r o f e s s i o n a l s , i n e i t h e r t h e i r i n i t i a l e d u c a t i o n a l programs, o r t h r o u g h c o n t i n u i n g e d u c a t i o n a c t i v i t i e s (Hannah, 1983) . There i s a d e a r t h o f i n f o r m a t i o n on what n u r s e s and n u r s i n g s t u d e n t s c u r r e n t l y . k n o w and d e s i r e t o know about computers (Parks e t a l , 1986). I t appears t h a t o n l y f o u r major American s t u d i e s i d e n t i f y i n g t h e l e a r n i n g needs o f n u r s e s have been r e p o r t e d i n t h e l i t e r a t u r e i n t h e l a s t decade (Walker, 1981; R o n a l d , 1983; H e l l e r , Romano, Damrosch, & P a r k s 1985; & P a r k s e t a l . 1986). R o n a l d (1983) f o c u s e d her a t t e n t i o n on t h e l e a r n i n g needs o f nurse e d u c a t o r s , w h i l e Walker (1981), H e l l e r e t a l . ;(1985) and P a r k s e t . a l . (1986), s t u d i e d t h e l e a r n i n g needs o f s t u d e n t n u r s e s e n r o l l e d i n b a c c a l a u r e a t e o r masters programs. . As a d i r e c t r e s u l t o f a t t e m p t s t o i d e n t i f y n u r s e s ' l e a r n i n g needs i n r e l a t i o n t o computers, a number o f p r e s c r i p t i v e a r t i c l e s and t e x t s have been w r i t t e n (Edmunds, 1982; S k i b a , 1983; R o n a l d , 1983; Hannah, 1983; & R o n a l d & S k i b a , 1987) . These a u t h o r s p r e s e n t s t e p by s t e p "how t o " approaches f o r c u r r i c u l u m p l a n n i n g and f o r c o n t e n t development. T h e i r w r i t i n g appears t o be f o c u s e d on t h e q u a n t i t y o r amount of c o n t e n t t o be i n c l u d e d when d e v e l o p i n g computer awareness c o u r s e s , r a t h e r t h a n on assessment o f t h e q u a l i t y o f l e a r n i n g . The absence o f r e p o r t e d s t u d i e s i s e v i d e n c e o f a v o i d o f i n f o r m a t i o n a v a i l a b l e on s t u d e n t s e n r o l l e d i n community 4 c o l l e g e n u r s i n g programs i n Canada i n terms o f t h e i r a t t i t u d e toward, knowledge o f , and l e a r n i n g needs, i n r e g a r d t o computers i n n u r s i n g . One must be c o g n i z a n t o f t h e f a c t t h a t g r a d u a t e s of t h e s e programs p r i m a r i l y work i n h o s p i t a l s . I n a d d i t i o n , i n f o r m a t i o n c o n c e r n i n g n u r s i n g s t u d e n t s ' c o n c e p t i o n s about t h e r o l e o f computers i n h o s p i t a l n u r s i n g and t h e q u a l i t y o f t h e i r c o n c e p t i o n s appears t o be non-e x i s t e n t i n t h e l i t e r a t u r e . Background A N a t i o n a l Study I n March 1987, The N a t i o n a l F e d e r a t i o n Of Nurses' Unions r e l e a s e d t h e r e s u l t s o f i t s t h i r t e e n month n a t i o n a l s t u d y . T h i s t h r e e p a r t s t u d y , e n t i t l e d I n f o s t a t , p r e p a r e d by p r i n c i p a l i n v e s t i g a t o r Kay Desborough, s t u d i e d r e g i s t e r e d n u r s e s c u r r e n t l y u s i n g computers i n Canadian h e a l t h c a r e a g e n c i e s . The purpose was t o document t h e e f f e c t s and i m p l i c a t i o n s o f p a t i e n t management systems on n u r s e s and n u r s i n g c a r e , and t o p r o v i d e n u r s i n g l e a d e r s w i t h q u a l i t a t i v e and q u a n t i t a t i v e i n f o r m a t i o n t o d i r e c t and s u p p o r t d e c i s i o n making f o r c u r r e n t use and f u t u r e development of t h e s e systems. Study 1 was a q u a l i t a t i v e r e s e a r c h s t u d y i n v o l v i n g t a p e d i n t e r v i e w s w i t h 45 r e g i s t e r e d n u r s e s from n i n e h e a l t h c a r e 5 a g e n c i e s i n E a s t e r n , C e n t r a l and Western Canada. Through t h e use o f t h e c o n s t a n t c o m p a r a t i v e a n a l y s i s t e c h n i q u e , f o u r c o n c e p t u a l c a t e g o r i e s emerged from t h e d a t a . These c a t e g o r i e s were: (a) t h e c o n t e x t (a s e t o f i n t e r r e l a t e d computer e d u c a t i o n , o r g a n i z a t i o n a l , computer system, and p e r s o n a l f a c t o r s ) i n which t h e computer system i s used; (b) t h e e f f e c t s on t h e n u r s e ; (c) t h e e f f e c t s on t h e d e l i v e r y o f n u r s i n g c a r e ; and (d) t h e e f f e c t s on t h e p a t i e n t . Study 1 g e n e r a t e d t h e h y p o t h e s i s t h a t t h e c o n t e x t i n which n u r s e s use c o m p u t e r i z e d p a t i e n t i n f o r m a t i o n management systems d e t e r m i n e s t h e e f f e c t s on n u r s e s , t h e d e l i v e r y o f n u r s i n g . c a r e , and on p a t i e n t s . Study 2 s e t out t o q u a n t i f y t h e f a c t o r s i d e n t i f i e d by s u b j e c t s i n Study 1 and t o determine t h e r e l a t i o n s h i p between c o n t e x t and t h e e f f e c t s o f computers on n u r s e s , t h e d e l i v e r y o f n u r s i n g c a r e , and p a t i e n t s . A 50 q u e s t i o n s u r v e y t o o l , c o m p i l e d u s i n g t h e f a c t o r s i d e n t i f i e d i n Study 1, was completed by 393 r e g i s t e r e d n u r s e s i n f o u r t e e n h e a l t h c a r e a g e n c i e s i n Canada. I t was found t h a t t h e c o n t e x t i n which t h e computer system i s used by n u r s e s d e t e r m i n e s t h e e f f e c t s on n u r s e s , t h e d e l i v e r y o f n u r s i n g c a r e , and p a t i e n t s . Of p a r t i c u l a r r e l e v a n c e i n s h a p i n g t h e f o c u s o f t h i s s t u d y were c o r r e l a t i o n a l f i n d i n g s i n d i c a t i n g : (a) a p o s i t i v e r e l a t i o n s h i p between computer e d u c a t i o n f a c t o r s and t h e n u r s e s ' p e r c e p t i o n s o f t h e e f f e c t s o f u s i n g computers on 6 n u r s e s , (b) a n e g a t i v e r e l a t i o n s h i p between computer system f a c t o r s and t h e n u r s e s ' p e r c e p t i o n s o f t h e e f f e c t s o f u s i n g computers on n u r s e s , (c) a p o s i t i v e r e l a t i o n s h i p between t h e use o f c l i n i c a l a p p l i c a t i o n s and t h e n u r s e s ' p e r c e p t i o n s o f t h e e f f e c t s o f u s i n g computers on t h e d e l i v e r y o f n u r s i n g c a r e and on p a t i e n t s , and (d) a s i g n i f i c a n t r e l a t i o n s h i p between t h e age o f t h e n u r s e and t h e n u r s e s ' p e r c e p t i o n s o f t h e adequacy of computer t r a i n i n g . In a d d i t i o n , comments from t h e n u r s e s i n d i c a t e d a number o f f i n d i n g s which were a l s o r e l e v a n t i n s h a p i n g t h i s s t u d y . R e l e v a n t f i n d i n g s were: (a) few n u r s e s have a b r o a d knowledge about computers, (b) many n u r s e s have problems w i t h e n t e r i n g d a t a from a keyboard, (c) n u r s e s f e e l uneasy about computer s e c u r i t y , (d) some n u r s e s were n e g a t i v e about computer system f a c t o r s , e s p e c i a l l y i n terms o f slow response t i m e , downtime, and t h e s t r u c t u r e and u s e f u l n e s s o f computer a p p l i c a t i o n s , (e) more o l d e r t h a n younger n u r s e s , r e p o r t e d t h a t t h e t r a i n i n g t o use t h e computer had been i n a d e q u a t e , (f) many n u r s e s r e p o r t e d s t r e s s , , f r u s t r a t i o n and d i s c o m f o r t a s s o c i a t e d w i t h u s i n g computers, (g) n u r s e s e x p r e s s e d concerns about t h e l e g a l and e t h i c a l i m p l i c a t i o n s a s s o c i a t e d w i t h u s i n g computers, (h) most n u r s e s were t o l d t h a t computer systems were e x p e c t e d t o i n c r e a s e e f f i c i e n c y and e f f e c t i v e n e s s , but i n s t e a d t h e y have added t o w o r k l o a d , and ( i ) n u r s e s c o m p l a i n e d t h a t computer systems t h a t were supposed t o save t i m e , a r e i n o r d i n a t e l y time-consuming. 7 P a r t 3 i n v o l v e d t h e d i s s e m i n a t i o n o f t h e f i n d i n g s from t h i s s t u d y t o Canadian n u r s e s . O v e r a l l f i n d i n g s o f t h e st u d y i n d i c a t e t h a t d e s p i t e a l a r g e number o f n e g a t i v e comments about t h e use o f computers by n u r s e s , 65.5% o f t h o s e sampled would recommend t h e use o f computers f o r managing p a t i e n t i n f o r m a t i o n . I m p l i c a t i o n s and recommendations from t h e s t u d y were i d e n t i f i e d f o r t h e Nurses Unions, N u r s i n g E d u c a t i o n , N u r s i n g P r a c t i c e , N u r s i n g A d m i n i s t r a t i o n , and N u r s i n g R e s e a r c h . The recommendation: t h a t t h o s e i n v o l v e d i n e d u c a t i n g p r o f e s s i o n a l n u r s e s c o l l a b o r a t e t o d e v e l o p g u i d e l i n e s f o r t r a i n i n g n u r s e s t o use computers f o r managing p a t i e n t i n f o r m a t i o n was a f a c t o r i n s h a p i n g t h i s s t u d y . A P r o v i n c i a l P r o j e c t I n March 1987, t h e M i n i s t r y o f Advanced E d u c a t i o n and Job T r a i n i n g i n B r i t i s h Columbia p r o v i d e d f u n d i n g s u pport t o th e B r i t i s h Columbia I n s t i t u t e o f Technology t o d e v e l o p c o u r s e m a t e r i a l s f o r n u r s e s and n u r s i n g s t u d e n t s , i n response t o t h e p e r c e i v e d need f o r nu r s e s t o l e a r n about computers. The p r o j e c t , e n t i t l e d , Computers In N u r s i n g P r o j e c t , began i n June, 1987. Data was c o l l e c t e d from f o u r s o u r c e s a t t h e o u t s e t o f t h e p r o j e c t : (a) r e v i e w o f e x i s t i n g m a t e r i a l s , (b) f o r m a l and i n f o r m a l i n t e r v i e w s w i t h n u rse e d u c a t o r s a t s e l e c t e d n u r s i n g programs, (c) i n f o r m a l i n t e r v i e w s w i t h n u r s i n g c o - o r d i n a t o r s o f h o s p i t a l computer systems i n v a r i o u s 8 Vancouver h o s p i t a l s , and (d) random s a m p l i n g o f t h e g e n e r a l n u r s i n g p o p u l a c e . Input from t h e s e s o u r c e s was used t o d e v e l o p a c u r r i c u l u m . The c u r r i c u l u m i n c l u d e d t h r e e modules: (a) b a s i c computer l i t e r a c y , .(b) an o v e r v i e w o f computer a p p l i c a t i o n s i n h e a l t h c a r e , and (c) l e g a l , e t h i c a l and p r o f e s s i o n a l i s s u e s . The t h r e e modules were d i s t r i b u t e d t o a l l n u r s i n g programs i n B r i t i s h Columbia i n May and June o f 1988, w i t h t h e e x p e c t a t i o n t h a t t h e y would be t a i l o r e d t o meet t h e needs o f i n d i v i d u a l programs, and i n c o r p o r a t e d i n t o n u r s i n g c u r r i c u l a i n September, 1988. L o c a l F a c t o r s C a r i b o o C o l l e g e c u r r e n t l y o f f e r s a R e g i s t e r e d Nurse (R.N.) d i p l o m a program i n n u r s i n g . I t s f a c u l t y , s u p p o r t e d by c o l l e g e a d m i n i s t r a t i o n , i s l o b b y i n g f o r degree g r a n t i n g s t a t u s i n response t o t h e Canadian Nurses A s s o c i a t i o n p o s i t i o n (adopted i n 1982) t h a t t h e b a c c a l a u r a t e degree s h o u l d be t h e o n l y e n t r y l e v e l t o p r o f e s s i o n a l n u r s i n g p r a c t i c e i n Canada by t h e y e a r 2000. A d d i t i o n a l l y , t h e C o l l e g e a d m i n i s t r a t i o n i s committed t o i m p l e m e n t i n g computer t e c h n o l o g y and i s e n c o u r a g i n g a l l i t s f a c u l t y and s t a f f t o become computer l i t e r a t e , by o f f e r i n g t a x b e n e f i t s t o t h o s e who p u r c h a s e computers, and by making c o u r s e s a v a i l a b l e f r e e o f charge. The C a r i b o o C o l l e g e n u r s i n g department i s 9 r e p r e s e n t e d by a f a c u l t y member on t h e Computers I n N u r s i n g  P r o j e c t . T h i s i n d i c a t e s t h e department's commitment t o ad v a n c i n g computer use amongst i t s s t u d e n t body. R o y a l I n l a n d H o s p i t a l , t h e o n l y a c u t e c a r e f a c i l i t y i n Kamloops, i s p r e s e n t l y i n t h e b e g i n n i n g s t a g e s o f imp l e m e n t i n g a h o s p i t a l p a t i e n t management system (HPMS) s u p p l i e d by T r a v e n o l H e a l t h c a r e I n f o r m a t i o n S e r v i c e s , Canada. The p r o j e c t e d p l a n i s f o r n u r s e s t o be u s i n g computers on t h e n u r s i n g u n i t s w i t h i n f i v e y e a r s . T h i s f a c i l i t y p r o v i d e s c l i n i c a l p lacements f o r C a r i b o o C o l l e g e n u r s i n g s t u d e n t s , as w e l l as p r o v i d i n g employment f o r t h e m a j o r i t y o f i t s n u r s i n g g r a d u a t e s . Purpose Developments c o n c e r n i n g computer t e c h n o l o g y on t h e Canadian n u r s i n g scene n a t i o n a l l y , p r o v i n c i a l l y and l o c a l l y , c o u p l e d w i t h i d e n t i f i e d gaps i n t h e l i t e r a t u r e , e s p e c i a l l y e v i d e n c e d by t h e l a c k o f r e s e a r c h i n v o l v i n g s t u d e n t n u r s e s e n r o l l e d i n community c o l l e g e n u r s i n g programs, s e r v e as i n d i c a t o r s o f t h e need f o r f u r t h e r s t u d y . I t would appear t h a t t h e s i t u a t i o n r e g a r d i n g t h e i m p l e m e n t a t i o n o f computers and computer t e c h n o l o g y i n n u r s i n g e d u c a t i o n i n B r i t i s h Columbia, a t t h e p r e s e n t t i m e , i s s o l e l y i n t h e hands o f p o l i t i c i a n s , a d m i n i s t r a t o r s , and f a c u l t y , who a l l c l a i m t o have t h e i n t e r e s t s o f t h e s t u d e n t and q u a l i t y e d u c a t i o n a t 10 h e a r t . U n f o r t u n a t e l y , t h i s does not a l l o w f o r i n p u t from n u r s i n g s t u d e n t s , who w i l l be d i r e c t l y a f f e c t e d by changes due t o t h e i n c r e a s e d use o f computers i n b o t h t h e e d u c a t i o n a l and t h e p r a c t i c e s e t t i n g s . The p r i m a r y purpose o f t h i s s t u d y i s t o i d e n t i f y how n u r s i n g s t u d e n t s , i n a community c o l l e g e n u r s i n g program, c o n c e p t u a l i z e t h e r o l e o f computers i n h o s p i t a l n u r s i n g . I t i s t h e r e s e a r c h e r ' s b e l i e f t h a t i n o r d e r t o s u c c e s s f u l l y implement computer content: i n t o n u r s i n g c u r r i c u l a i n t h i s p r o v i n c e and i n d e e d n a t i o n a l l y , an attempt must f i r s t be made t o u n d e r s t a n d t h e p e r s p e c t i v e , o f t h e s t u d e n t s f o r whom t h e c o n t e n t i s i n t e n d e d . By i d e n t i f y i n g how s t u d e n t s c o n c e p t u a l i z e t h e r o l e o f computers i n h o s p i t a l n u r s i n g and by a n a l y z i n g t h e i r c o m p l e x i t y i n r e l a t i o n t o t h e n u r s e ' s : (a) l e n g t h o f c l i n i c a l exposure, and (b) a t t i t u d e t oward computers, i t i s a n t i c i p a t e d t h a t d e c i s i o n s about when, and where t o i n c o r p o r a t e computer c o n t e n t i n t o t h e c u r r i c u l a o f community c o l l e g e s c h o o l s o f n u r s i n g may be f a c i l i t a t e d . The r e s e a r c h e r ' s u l t i m a t e g o a l i s t o promote p o s i t i v e a c c e ptance t o w a r d computer use i n h o s p i t a l n u r s i n g and t o i n c r e a s e t h e q u a l i t y o f s t u d e n t l e a r n i n g about computers i n n u r s i n g by r e s p o n d i n g t o a knowledge.of t h e s t u d e n t ' s p e r s p e c t i v e . A l t h o u g h i t i s r e c o g n i z e d t h a t b o t h t h e q u a n t i t y and q u a l i t y o f l e a r n i n g a r e e q u a l l y i m p o r t a n t , t h e main i s s u e i n t h i s t h e s i s i s q u a l i t y o f l e a r n i n g . R e s e a r c h Model: 11 N u r s i n g I n f o r m a t i c s P y r a mid In o r d e r t o more e f f e c t i v e l y i d e n t i f y i n i t i a l q u e s t i o n s , pose h y p o t h e s e s , and i n t e r p r e t r e s u l t s , a model f o r r e s e a r c h i n n u r s i n g i n f o r m a t i c s w i l l be used as a framework t o g u i d e t h i s s t u d y . N u r s i n g i n f o r m a t i c s (NI) i s t h e use o f i n f o r m a t i o n t e c h n o l o g i e s by n u r s e s i n r e l a t i o n t o t h e c a r e o f p a t i e n t s , o r t h e e d u c a t i o n a l p r e p a r a t i o n o f i n d i v i d u a l s t o p r a c t i c e t h e d i s c i p l i n e (Hannah, 1985). The NI P y ramid (see F i g u r e 1) i s one model f o r r e s e a r c h i n n u r s i n g i n f o r m a t i c s w hich p r o v i d e s a f o u r - d i m e n s i o n a l s t r u c t u r e , i n which t o d e v i s e and l o c a t e m e a n i n g f u l NI r e s e a r c h ( S c h w i r i a n , 1986). Three elements o f t h e model, i n f o r m a t i o n , t e c h n o l o g y , and u s e r s , are a r r a n g e d t o form t h e t r i a n g u l a r base o f t h e pyramid, d e p i c t i n g t h e f a c t t h a t t h e y i n t e r a c t t o form NI a c t i v i t y . The apex o f t h e p yramid i s t h e g o a l o r t h e o b j e c t i v e t oward which a l l t h e o t h e r elements are d i r e c t e d . The i n t e r a c t i v i t y o f a l l t h e elements i s b i d i r e c t i o n a l , i n n a t u r e a l l o w i n g an i n v e s t i g a t o r t o e n t e r t h e model at any p o i n t i n terms of p o s i n g r e s e a r c h q u e s t i o n s o r d e v e l o p i n g h y p otheses, w h i l e a t t h e same t i m e , a l l o w i n g t h e r e s e a r c h e r t o see where a p a r t i c u l a r s t u d y f i t s i n t o t h e l a r g e r scheme of knowledge r e l a t e d t o NI ( S c h w i r i a n , 1986). 12 GOAL COMPUTER  HARDWARE SOFTWARE 1 USER I  CONTEXT F i g u r e 1. N u r s i n g I n f o r m a t i c s (NI) Pyramid ( S c h w i r i a n , 1986, p. 135) Fo r t h e purposes o f t h i s s t u d y , USERS a r e f i r s t , second, and t h i r d y e a r n u r s i n g s t u d e n t s e n r o l l e d i n a community c o l l e g e n u r s i n g program which i s p r e p a r i n g them f o r employment i n h o s p i t a l s . INFORMATION i s t h e computer awareness c o n t e n t and s k i l l s t h a t s t u d e n t n u r s e s , e n r o l l e d i n community c o l l e g e n u r s i n g : p r o g r a m s , need t o work c o m f o r t a b l y and e f f e c t i v e l y w i t h computers i n h o s p i t a l s . TECHNOLOGY i s t h e a c c e s s i b i l i t y and a v a i l a b i l i t y o f computer hardware and s o f t w a r e t o f a c i l i t a t e b o t h (a) a c q u i s i t i o n o f computer s k i l l s , and (b) use i n t h e job s e t t i n g . GOALS are t w o - f o l d : (a) t h e p r i m a r y g o a l i s t o determine how st u d e n t n u r s e s c o n c e p t u a l i z e t h e r o l e and f u n c t i o n o f computers as th e y e f f e c t n u r s e s i n h o s p i t a l s , and (b) t h e secondary g o a l i s t o i d e n t i f y how t h e f i n d i n g s may be i n c o r p o r a t e d i n t o p l a n n i n g INFORMATION f o r i m p l e m e n t i n g computer c o n t e n t i n community c o l l e g e n u r s i n g c u r r i c u l a . R e s e a r c h Q u e s t i o n s One b r o a d and t h r e e s p e c i f i c q u e s t i o n s g u i d e d t h i s s t u d y : 1. How do n u r s i n g s t u d e n t s i n a community c o l l e g e n u r s i n g program c o n c e p t u a l i z e t h e r o l e o f computers i n h o s p i t a l n u r s i n g ? (a) I s t h e r e a d i f f e r e n c e i n c o m p l e x i t y among f i r s t , second, and t h i r d - y e a r n u r s i n g s t u d e n t s ' c o n c e p t i o n s o f t h e r o l e o f computers i n h o s p i t a l n u r s i n g ? (b) What i s t h e r e l a t i o n s h i p between n u r s i n g s t u d e n t s ' c o n c e p t i o n s of t h e r o l e o f computers i n h o s p i t a l n u r s i n g , and l e n g t h o f c l i n i c a l e x p e r i e n c e ? (c) What i s t h e r e l a t i o n s h i p between n u r s i n g s t u d e n t s ' c o n c e p t i o n s o f the. r o l e o f computers i n h o s p i t a l n u r s i n g , and t h e i r a t t i t u d e t oward computers i n h o s p i t a l n u r s i n g ? D e f i n i t i o n Of Terms The terms r e l e v a n t t o t h i s s t u d y a r e l i s t e d and d e f i n e d below. Community C o l l e g e N u r s i n g Program: N u r s i n g i n Canada i s t a u g h t i n t h r e e s e t t i n g s : h o s p i t a l , community c o l l e g e , and u n i v e r s i t y . T h i s s t u d y f o c u s e s on n u r s i n g programs based i n t h e community c o l l e g e s e t t i n g . More s p e c i f i c a l l y , t h i s s t u d y f o c u s e s on one c o l l e g e program: t h e C a r i b o o C o l l e g e N u r s i n g Program, i n Kamloops, B r i t i s h Columbia, Canada. C a r i b o o C o l l e g e N u r s i n g Program: The n u r s i n g program a t C a r i b o o C o l l e g e i s a t w e n t y - f o u r month program s p r e a d over t h r e e academic y e a r s . I t ' s mandate i s t w o - f o l d : (a) t o p r e p a r e s t u d e n t s t o s u c c e s s f u l l y complete t h e n a t i o n a l r e g i s t r a t i o n exams t o e n t e r t h e n u r s i n g p r o f e s s i o n , and (b) t o p r e p a r e s t u d e n t s t o meet m i n i m a l s t a n d a r d s o f n u r s i n g p r a c t i c e , as s p e c i f i e d by t h e R e g i s t e r e d Nurses A s s o c i a t i o n o f B r i t i s h Columbia, so t h a t t h e y may be employed i n a c u t e and l o n g term c a r e f a c i l i t i e s upon g r a d u a t i o n from t h e program. 15 C a r i b o o C o l l e g e N u r s i n g Program S t r u c t u r e : The t w e n t y - f o u r month C a r i b o o C o l l e g e n u r s i n g program i s d i v i d e d i n t o t h r e e academic y e a r s and s i x se m e s t e r s . Each semester i s f u r t h e r d i v i d e d i n t o c l i n i c a l r o t a t i o n s as i n d i c a t e d i n Ta b l e 1. Tab l e 1. S t r u c t u r e Of The C a r i b o o C o l l e g e N u r s i n g Program By Y e a r s , Semesters, And C l i n i c a l R o t a t i o n s YEAR SEMESTER ROTATIONS 1 1 (September-December) 1 2 ( J a n u a r y - A p r i l ) 1 2 3 (September-December) 2 4 (J a n u a r y - A p r i 1 ) 2 3 5 (September-December) 2 6 ( J a n u a r y - A p r i l ) 2 H o s p i t a l N u r s i n g : Nurses p r a c t i s e n u r s i n g i n a v a r i e t y o f h o s p i t a l s e t t i n g s . Some h o s p i t a l s s e r v e c l i e n t s i n a s p e c i f i c age group, such as g e r i a t r i c o r p e d i a t r i c h o s p i t a l s . Others s e r v e t h e needs o f acu t e o r l o n g t erm c a r e c l i e n t s , and some a r e even s p e c i a l i z e d i n terms o f d i s e a s e p r o c e s s , such as r e h a b i l i t a t i o n and bur n h o s p i t a l s . The h o s p i t a l s e t t i n g r e f e r r e d t o i n t h i s s t u d y i s t h e g e n e r a l a c u t e c a r e h o s p i t a l . I n 1985, t h e m a j o r i t y o f nu r s e s p r a c t i s i n g i n B r i t i s h Columbia worked i n h o s p i t a l s 16 (76.5%) and p r i m a r i l y i n a c u t e c a r e f a c i l i t i e s (R.N.A.B.C. News, 1986, p. 16). A t t i t u d e s Toward Computers: A t t i t u d e s are l e a r n e d p r e d i s p o s i t i o n s which i n f l u e n c e how one responds, e i t h e r f a v o u r a b l y o r u n f a v o u r a b l y . A t t i t u d e s t oward computers may be o b s e r v e d i n t h e b e h a v i o u r o f an i n d i v i d u a l such as h i s \ h e r w i l l i n g n e s s o r r e s i s t a n c e t o use a computer. I n t h i s s t u d y , s t u d e n t a t t i t u d e was d e t e r m i n e d t o be p o s i t i v e , n e u t r a l , o r n e g a t i v e by a s s e s s i n g s t u d e n t s ' r a t i n g s on a f i v e p o i n t L i k e r t - t y p e a t t i t u d e s c a l e and by n o t i n g p o s i t i v e and\or n e g a t i v e comments d i r e c t e d t oward computers d u r i n g t h e i n t e r v i e w s C o n c e p t i o n s Of The R o l e Of Computers I n H o s p i t a l N u r s i n g : C o n c e p t i o n s e x p r e s s a b s t r a c t i o n s formed by g e n e r a l i z a t i o n s from p a r t i c u l a r s ( K e r l i n g e r 1986). Concepts a r e formed by our p a s t e x p e r i e n c e s and i n f l u e n c e our p e r c e p t i o n . P e o p l e l e a r n t o c o n c e p t u a l i z e t h e i r own r e a l i t y as t h e y grow up (Marton, 1981). S t u d e n t s ' c o n c e p t i o n s o r a b s t r a c t i o n s o f t h e r o l e o f computers i n h o s p i t a l n u r s i n g a r e t h e r e f o r e formed by g e n e r a l i z a t i o n s based on t h e i r : (a) awareness o f computer use i n h o s p i t a l n u r s i n g t o d a y , and (b) knowledge of how computers may be used by n u r s e s i n t h e f u t u r e . I n t h i s s t u d y , c o n c e p t i o n s were a n a l y z e d t o form c a t e g o r i e s o f c o n c e p t i o n . I n a d d i t i o n , t h e q u a l i t y o f s t u d e n t s ' 17 c o n c e p t i o n s were a s s i g n e d a r a t i n g o f h i g h o r low c o m p l e x i t y based on s p e c i f i c c h a r a c t e r i s t i c s . L ength Of C l i n i c a l E x p e r i e n c e : Length o f c l i n i c a l e x p e r i e n c e was measured i n ho u r s . I t v a r i e d f o r f i r s t , second, and t h i r d y e a r C a r i b o o C o l l e g e n u r s i n g s t u d e n t s as o u t l i n e d i n Table 2. Table 2. Number Of C l i n i c a l Hours I n Each Semester And Year Of The C a r i b o o C o l l e g e N u r s i n g Program YEAR SEMESTER SEMESTER HOURS YEAR HOURS 1 1 95 2 95 190 2 3 204 4 204 408 3 5 312 6 432 744 Because t h e number o f hours o f c l i n i c a l e x p e r i e n c e i n c r e a s e s s i g n i f i c a n t l y each y e a r , r e l a t i o n s h i p s between s u b j e c t s w i l l be d i s c u s s e d i n terms o f y e a r s i n t h e program thro u g h o u t t h e s t u d y . The e x c e p t i o n w i l l be when r e p o r t i n g and d i s c u s s i n g t h e answer t o r e s e a r c h q u e s t i o n number two. 18 CHAPTER 2 Review Of L i t e r a t u r e Review o f t h e l i t e r a t u r e w i l l be o r g a n i z e d i n t o t h r e e main s u b s e c t i o n s t o a l l o w f o r o r g a n i z a t i o n o f m a t e r i a l s i n t o a l o g i c a l p a t t e r n . The f i r s t s u b s e c t i o n "Computers In H o s p i t a l s , " i s aimed at p r o v i d i n g a c o n t e x t f o r t h e s t u d y . I t b e g i n s by t r a c i n g t h e g e n e r a l e v o l u t i o n o f computers w i t h i n h o s p i t a l s , and more s p e c i f i c a l l y , w i t h i n h o s p i t a l s i n B r i t i s h Columbia and t h e r e s t o f Canada. T h i s i s f o l l o w e d by an o v e r v i e w o f how computers a r e c u r r e n t l y b e i n g used i n h o s p i t a l s by n u r s e s , and t h e n by a b r i e f i n t r o d u c t i o n t o i s s u e s r a i s e d by n u r s e s c o n c e r n i n g computer use. The second s u b s e c t i o n " A t t i t u d e Toward Computer Use," i s aimed a t p r e s e n t i n g an o v e r v i e w o f one o f t h e v a r i a b l e s i n t h e s t u d y . The d i s c u s s i o n o f a t t i t u d e b e g i n s by l o o k i n g a t what i s meant by a t t i t u d e , and i s f o l l o w e d by an h i s t o r i c a l r e v i e w o f s t u d i e s on n u r s e s ' a t t i t u d e s t oward computer use. Then t h e f o c u s s h i f t s t o t h e : i d e n t i f i c a t i o n o f f a c t o r s a f f e c t i n g computer usage. The t h i r d s u b s e c t i o n " L e a r n i n g , " i s aimed a t p r e s e n t i n g l e a r n i n g as a change i n c o n c e p t i o n , t h e r e b y b r i n g i n g t h e o t h e r main v a r i a b l e o f t h e s t u d y i n t o f o c u s . The d i s c u s s i o n o f l e a r n i n g b e g i n s w i t h an attempt t o d e f i n e l e a r n i n g need, and t h e n t u r n s t o f o c u s on s t u d i e s w h i c h i d e n t i f y t h e l e a r n i n g needs o f n u r s e s w i t h r e g a r d t o computers. F i n a l l y , 19 t h e n o t i o n o f computer l i t e r a c y f o r n u r s e s i s d i s c u s s e d / and a taxonomy f o r e v a l u a t i n g q u a l i t y o f l e a r n i n g i s b r i e f l y d e s c r i b e d . Computers I n H o s p i t a l s The purpose o f t h i s s u b s e c t i o n i s f i v e f o l d , d e s i g n e d t o : (a) t r a c e t h e g e n e r a l h i s t o r i c a l e v o l u t i o n o f computer t e c h n o l o g y i n h o s p i t a l s , (b) put t h i s e v o l u t i o n i n t o a Canadian c o n t e x t , (c) i d e n t i f y t h e c u r r e n t s i t u a t i o n i n h o s p i t a l s i n B r i t i s h Columbia, (d) p r e s e n t a s h o r t o v e r v i e w o f t h e ways i n which computers are b e i n g used i n h o s p i t a l s t o s u p p o r t n u r s i n g p r a c t i c e , and (e) h i g h l i g h t i s s u e s c o n c e r n i n g computer use by n u r s e s w o r k i n g i n h o s p i t a l s . E v o l u t i o n Of Computers In H o s p i t a l s B a l l and Hannah (1984) note t h a t computers e n t e r e d h o s p i t a l s i n t h e 1950's, and a t t h a t t i m e were used o n l y f o r a d m i n i s t r a t i v e t a s k s such as c a l c u l a t i n g p a y r o l l , i n v e n t o r y c o n t r o l , t a b u l a t i n g p a t i e n t charges and g e n e r a t i n g and a n a l y z i n g m e d i c a l s t a t i s t i c s , They p o i n t out t h a t d u r i n g t h e 1960's, t h r e e f a c t o r s shaped developments toward i n c r e a s e d c o m p u t e r i z a t i o n : (a) h o s p i t a l a d m i n i s t r a t o r s were exposed t o t h e p o s s i b i l i t y o f a u tomating h e a l t h c a r e a c t i v i t i e s , (b) equipment became more r e f i n e d and s o p h i s t i c a t e d , and 20 (c) m a n u f a c t u r e r s r e c o g n i z e d t h e p o t e n t i a l f o r s a l e s i n t h e h e a l t h c a r e market. The 1970's saw t h e development and i n s t a l l a t i o n o f h o s p i t a l i n f o r m a t i o n systems, w i t h s p e c i a l - s e r v i c e computer f u n c t i o n s , d e v e l o p e d f o r s p e c i f i c h o s p i t a l departments such as: pharmacy, d i e t a r y , r a d i o l o g y , l a b o r a t o r y and e l e c t r o c a r d i o l o g y . The f o c u s o f development t h e n became one o f f i n d i n g a way f o r t h e s e i s o l a t e d s p e c i a l - s e r v i c e f u n c t i o n s t o communicate w i t h each o t h e r . The 1980's has brought t h e r e f i n e m e n t o f h o s p i t a l i n f o r m a t i o n systems and a b e t t e r u n d e r s t a n d i n g o f i n f o r m a t i o n needs o f n u r s e s , t h e development o f c o m p u t e r i z e d p a t i e n t c a r e p l a n n i n g , and t h e i n c r e a s e d use o f i n f o r m a t i o n d a t a bases and e x p e r t systems. Many a u t h o r s , i n c l u d i n g O'Brien (1984), n o te t h a t c o m p u t e r i z a t i o n has not advanced i n h e a l t h c a r e as q u i c k l y as once p r e d i c t e d , m a i n l y due t o : (a) t h e h i g h c o s t o f computer hardware, (b) h e a l t h p r o f e s s i o n a l s l a c k o f knowledge, (c) a s h o r t a g e o f p r o c e s s i n g e x p e r t s , and u n t i l r e c e n t l y (d) u n s o p h i s t i c a t e d t e c h n o l o g y . Developments I n Canada E f f o r t s a r e underway by a v a r i e t y o f p e o p l e t o d etermine t h e s t a t u s o f computing e f f o r t s i n h o s p i t a l s i n Canada. An a r t i c l e p u b l i s h e d i n t h e The Canadian Nurse i n June, 1988 r e p o r t e d t h e r e s u l t s o f a s u r v e y done by Karen Webber of 21 H a l i f a x i n March, 1987. She c o n t a c t e d 85 h o s p i t a l s and c h r o n i c c a r e a g e n c i e s i n a l l t h e Canadian p r o v i n c e s and t e r r i t o r i e s where computer t e r m i n a l s were i n p l a c e on n u r s i n g u n i t s . She found t h a t a computer system was f i r s t used on a n u r s i n g u n i t i n 1977. By March, 1987, t h i r t y s i t e s used computers f o r t h e management o f p a t i e n t i n f o r m a t i o n . The t h i r t y a g e n c i e s , t h e p r o v i n c e s where t h e y a re found, as w e l l as t h e hardware, and s o f t w a r e b e i n g used by each, were c o m p i l e d and p u b l i s h e d i n c h a r t form i n t h e a r t i c l e . A m o d i f i e d v e r s i o n o f t h i s c h a r t (see Appendix A) p r e s e n t s a sense o f t h e d i v e r s i t y o f systems b e i n g implemented a c r o s s t h e c o u n t r y and r a i s e s t h e q u e s t i o n o f how n u r s e s w i l l cope w i t h t h i s d i v e r s i t y as t h e y move from one employment s i t u a t i o n t o a n o t h e r . I n 1987, The Canadian N a t i o n a l H e a l t h Care Computer Survey was conducted by The Kennedy Group, an independent h e a l t h - c a r e i n f o r m a t i o n systems c o n s u l t i n g f i r m based i n San F r a n c i s c o . T h i s s u r v e y was t h e f i r s t major attempt t o c o l l e c t i n f o r m a t i o n on a l l Canadian h o s p i t a l s w i t h more t h a n 150 a c u t e c a r e beds. F i n d i n g s have r e c e n t l y been r e p o r t e d f o r 337 i n s t i t u t i o n s . One f i n d i n g i s o f p a r t i c u l a r i n t e r e s t t o t h i s s t u d y . I t was found t h a t t h e s t a t u s o f automation i n n i n e p a t i e n t c a r e a r e a s , ( w i t h t h e e x c e p t i o n o f a d m i s s i o n s \ d i s c h a r g e \ t r a n s f e r , c e n t r a l p a t i e n t i n d e x , m e d i c a l r e c o r d s , and pharmacy) i n t h e m a j o r i t y o f i n s t i t u t i o n s s u r v e y e d was l i m i t e d . 22 The Kennedy Group p r e d i c t e d t h a t a u t omation i n major p a t i e n t c a r e a r e a s was a n t i c i p a t e d t o be t h e most s i g n i f i c a n t growth i n t h e f u t u r e . They p o i n t e d out t h a t a l l n i n e major a r e a s , w h i c h impact on t h e d e l i v e r y o f p a t i e n t c a r e i n h o s p i t a l s a c r o s s t h e c o u n t r y , a r e a c t i v e l y p l a n n i n g f o r and s e l e c t i n g automated systems. N u r s i n g , as one o f t h e s e p a t i e n t c a r e a r e a s , i s p o i s e d t o i n i t i a t e t h e use o f such t e c h n o l o g y , which may w e l l i n t u r n , change t h e f a c e o f t h e p r o f e s s i o n . Developments I n B r i t i s h Columbia The i n t r o d u c t i o n o f computers i n t o h o s p i t a l s i n B r i t i s h Columbia appears t o have l a g g e d b e h i n d t h e r e s t o f Canada and i t appears t o have been i n f l u e n c e d d r a m a t i c a l l y by p o l i t i c s and power s t r u g g l e s (O'Brien, 1984). To i l l u s t r a t e t h i s s t r u g g l e , a b r i e f d e s c r i p t i o n f o l l o w s . I n t h e 1960's and e a r l y 1970's t h e f i r s t h o s p i t a l c o m p u t e r i z a t i o n o c c u r r e d i n B r i t i s h Columbia, a happening which was c o n s i s t e n t w i t h t h e r e s t o f t h e c o u n t r y . A t t h a t t i m e , Vancouver G e n e r a l H o s p i t a l (V.G.H.) and t h e B r i t i s h Columbia H e a l t h A s s o c i a t i o n (B.C.H.A.) a c q u i r e d main frame computers t o r u n f i n a n c i a l and p a y r o l l systems. As w e l l , by t h e e a r l y s e v e n t i e s , V.G.H. i n s t a l l e d computers i n i t s l a b o r a t o r y and r a d i o l o g y departments. By t h e m i d - s e v e n t i e s , f o u r o t h e r h o s p i t a l s i n t h e p r o v i n c e had i n s t a l l e d d i f f e r e n t 23 l a b o r a t o r y systems (Royal I n l a n d H o s p i t a l i n Kamioops i n c l u d e d ) . U n f o r t u n a t e l y , t h e r e was a b l o s s o m i n g o f a wide range o f minicom p u t e r s i n B r i t i s h Columbia h o s p i t a l s , w i t h o u t any j o i n t p l a n n i n g o r c o n s i d e r a t i o n o f f u t u r e needs. I n 1975, t h e p r o v i n c i a l government a p p o i n t e d a c o n s u l t i n g f i r m , Systemhouse, t o a d v i s e i t on h o s p i t a l - b a s e d computer p l a n n i n g . T h i s r e s u l t e d i n a committee, c o m p r i s e d o f d i r e c t o r s o f f i n a n c e from t e n h o s p i t a l s i n t h e p r o v i n c e , b e i n g formed t o f i n d a common, approach t o h o s p i t a l computer systems u s i n g I n t e r d a t a computers. By 1980 i t was c l e a r t h a t t h e I n t e r d a t a system had f a i l e d , due t o o u t - o f - d a t e hardware, l a b o r a t o r y systems, and i n a p p r o p r i a t e s o f t w a r e . A t t h i s p o i n t , O'Brien (1984) p o i n t s out t h a t l a c k o f f u n d i n g was a major problem, even though a g e n c i e s were w i l l i n g t o c o - o p e r a t e i n a common approach. C o n s e q u e n t l y , d i f f e r e n t approaches c o n t i n u e d t o be t a k e n by i n s t i t u t i o n s . The M i n i s t r y o f H e a l t h , i n 1980, formed a h o s p i t a l Computer A d v i s o r y Committee and a c o n s u l t a n t was h i r e d t o d e v e l o p a computer p l a n f o r f o u r d i f f e r e n t groups o f h o s p i t a l s : (a) h o s p i t a l s w i t h I n t e r d a t a systems,- (b) l a r g e n o n - t e a c h i n g h o s p i t a l s (Royal I n l a n d H o s p i t a l i n Kamioops i n c l u d e d ) , (c) v e r y s m a l l h o s p i t a l s , and (d) l a r g e t e a c h i n g h o s p i t a l s . Two Vancouver h o s p i t a l s , L i o n ' s Gate and The U n i v e r s i t y Of B r i t i s h Columbia (U.B.C.), embarked on a v e r y d i f f e r e n t c o u r s e t o w a r d c o m p u t e r i z a t i o n about t h i s t i m e . L i o n ' s Gate H o s p i t a l was p a r t o f a p i l o t p r o j e c t , whose o b j e c t i v e was t o 24 implement a h o s p i t a l - w i d e (IBM) p a t i e n t c a r e system, t h e f o c u s o f which was on p a t i e n t c a r e , p a r t i c u l a r l y i n n u r s i n g a r e a s . However, j u s t b e f o r e t h e t e r m i n a l s were t o be i n s t a l l e d , t h e p i l o t p r o j e c t was a b o r t e d . Meanwhile, t h e new M i n i s t r y Of H e a l t h formed t h e B r i t i s h Columbia H o s p i t a l s Shared Systems S o c i e t y , t o f u n d and d e v e l o p s h a r e d h o s p i t a l computer systems. T h i s system, a d e c e n t r a l i z e d one, which opposed t h e c e n t r a l system concept, was d e s i g n e d t o a c h i e v e c o s t c o n t r o l i n h o s p i t a l s by s h a r i n g systems. T h i s new system, a c c o r d i n g t o t h e M i n i s t r y ' s p l a n , was t o be implemented f i r s t i n departments which l e n d t h e m s e l v e s t o c o m p u t e r i z a t i o n , such as l a b o r a t o r y , pharmacy, a d m i t t i n g and d i s c h a r g e , and f i n a n c i a l s e r v i c e s . "Shared Systems" a l s o p l a n n e d t o implement n u r s i n g a p p l i c a t i o n s b u t , t o d a t e , t h i s has not m a t e r i a l i z e d . H o s p i t a l s who agreed t o a b i d e by t h e "Shared Systems" approach, would r e c e i v e f u n d i n g f o r a l l t h e n e c e s s a r y hardware. L i o n ' s Gate H o s p i t a l , f a c e d w i t h t h i s s i t u a t i o n , d e c i d e d t o go ahead w i t h t h e i r p l a n s f o r i n s t a l l i n g a complete p a t i e n t c a r e system. T h e i r d e c i s i o n was based on s e v e r a l : f a c t s : (a) t h e i r e x i s t i n g f i n a n c i a l system hardware and s o f t w a r e needed r e p l a c i n g , (b) t h e y were happy w i t h t h e w e l l p roven IBM system used by a t l e a s t t e n h o s p i t a l s i n Canada, and (c) t h e y had a h i g h l e v e l o f commitment from s t a f f . I n May, 1983, an IBM mainframe was i n s t a l l e d . 25 The B r i t i s h Columbia H e a l t h A s s o c i a t i o n (B.C.H.A.), r e p r e s e n t i n g t h e p r o v i n c e s ' h o s p i t a l s , had a l s o chosen, a t about t h e same t i m e , t o use IBM computers and have s i n c e c o n v e r t e d p a y r o l l s u p p o r t f o r i t s members onto an IBM mainframe. B.C.H.A. o f f e r s a c c e s s and computer s u p p o r t f o r members c h o o s i n g t o use t h e IBM p a t i e n t c a r e system, s i m i l a r t o t h e one a t L i o n ' s Gate. They e n v i s i o n e d o f f e r i n g t h e i r computer s e r v i c e s t o h o s p i t a l s t h r o u g h o u t t h e p r o v i n c e and t o date s e v e r a l members a r e u s i n g t h e i r s e r v i c e s . Meanwhile, c o m p u t e r i z a t i o n had been phased i n t o t h e U.B.C. H e a l t h S c i e n c e s C e n t e r H o s p i t a l s i n c e i t ' s o p e ning i n 1980. I t was, a t t h a t t i m e , t h e most c o m p u t e r i z e d h o s p i t a l i n Canada, due t o ready a v a i l a b i l i t y o f funds when i t was b u i l t . C o m p u t e r i z a t i o n t h e r e had i t s b e g i n n i n g s w i t h a l a b o r a t o r y system, f o l l o w e d by a d m i t t i n g , pharmacy, h e a l t h r e c o r d s , r a d i o l o g y , n u r s i n g s t a t i o n communication, and f i n a n c i a l systems. The system l i n k s t h e h o s p i t a l t o g e t h e r t h r o u g h 160 t e r m i n a l s and a l l o w s each n u r s i n g s t a t i o n t o communicate w i t h 15 departments, o t h e r n u r s i n g s t a t i o n s , and t h e n u r s i n g o f f i c e . Data G e n e r a l minicomputers which use M e d i t e c h s o f t w a r e , a r e used. As t h i s d i s c u s s i o n i l l u s t r a t e s , by u s i n g s e v e r a l h o s p i t a l s as examples, n u r s e s w o r k i n g i n l a r g e o r s m a l l h o s p i t a l s i n B r i t i s h Columbia f i n d t h emselves caught i n t h e m i d d l e o f t h r e e v a s t l y d i f f e r e n t approaches t o h o s p i t a l i n f o r m a t i o n systems: (a) c e n t r a l i z e d , (b) d e c e n t r a l i z e d , and 26 (c) i n d i v i d u a l department systems ( M i k u l e k y and L e d f o r d , 1987). To d a t e , n u r s e s i n many h o s p i t a l s i n B r i t i s h Columbia and a c r o s s t h i s c o u n t r y have not had a l o t o f i n p u t i n t o c h o i c e o f systems t h a t w i l l b e n e f i t n u r s i n g . C u r r e n t l y , b o t h h o s p i t a l a d m i n i s t r a t i o n s , and a l l h o s p i t a l departments, i n c l u d i n g n u r s i n g , a re b e i n g f a c e d w i t h making tough d e c i s i o n s as t o wh i c h approach t o t a k e , and are w e i g h i n g t h e pr o s and cons o f each, based on f i n a n c i a l c o n s t r a i n t s w i t h i n t h e i r r e s p e c t i v e i n s t i t u t i o n s . Computer Support F o r N u r s i n g P r a c t i c e Computer su p p o r t f o r n u r s i n g p r a c t i c e i s i n i t s i n f a n c y i n Canada, as i d e n t i f i e d i n t h e f i n d i n g s o f The Kennedy Group (1988). A l t h o u g h much has been w r i t t e n i n n u r s i n g l i t e r a t u r e , t h e i n t e n t o f t h e f o l l o w i n g d i s c u s s i o n i s merely t o p r e s e n t an o v e r v i e w o f how computers can be used by n u r s e s t o s u p p o r t t h e i r p r a c t i c e , and not t o d i s c u s s any one a p p l i c a t i o n i n d e t a i l . B a l l and Hannah (1984) d i s c u s s d i r e c t computer s u p p o r t f o r n u r s i n g p r a c t i c e under t h e f o l l o w i n g h e a d i n g s : p a t i e n t m o n i t o r i n g , documentation, p a t i e n t c a r e p l a n n i n g , s p e c i a l -s e r v i c e computer f u n c t i o n s , and h o s p i t a l i n f o r m a t i o n management systems. The use o f t h e computer f o r a d m i n i s t r a t i v e t a s k s such as q u a l i t y a s s u r a n c e , p a t i e n t c l a s s i f i c a t i o n systems f o r n u r s i n g w o r k l o a d d e t e r m i n a t i o n and 27 u n i t s t a f f i n g , and r e p o r t i n g , a l l a f f e c t t h e nurse i n an i n d i r e c t way. M i k u l e k l y and L e d f o r d (1987) n o t e d n u r s i n g a p p l i c a t i o n s f o r computers. They found t h a t n u r s e s use computers f o r a v a r i e t y o f f u n c t i o n s , which t h e y c a t e g o r i z e under t h e g e n e r a l a r e a s : (a) p a t i e n t c l a s s i f i c a t i o n and s t a f f i n g r e q u i r e m e n t s , (b) a d m i n i s t r a t i o n , ( f o r such t h i n g s as p e r s o n n e l r e c o r d s , . q u a l i t y a s s u r a n c e s t u d i e s , and b u d g e t i n g , and word p r o c e s s i n g f o r such t h i n g s as u p d a t i n g p o l i c i e s and p r o c e d u r e s ) , (c) n u r s i n g p r a c t i c e ( i n b o t h ; t h e c e n t r a l n u r s i n g s t a t i o n , and a t t h e b e d s i d e , f o r o r d e r e n t r y , r e s u l t s r e p o r t i n g , m o n i t o r i n g p a t i e n t ' s p h y s i o l o g i c a l f u n c t i o n s , g e n e r a t i n g n u r s i n g c a r e p l a n s , and m a i n t a i n i n g c l i n i c a l r e c o r d s ) , and (d) n u r s i n g e d u c a t i o n and r e s e a r c h . A l t h o u g h t h e m a j o r i t y o f n u r s e s w o r k i n g i n medium and s m a l l a c u t e c a r e h o s p i t a l s i n Canada a r e not p r e s e n t l y u s i n g many o f t h e s e a p p l i c a t i o n s , a l l a r e u s i n g p a t i e n t m o n i t o r i n g , and a number are u s i n g a t l e a s t one o r more o t h e r a p p l i c a t i o n s . The f u t u r e p r o m i s e s t o i n u n d a t e t h e nurse w i t h more computer a p p l i c a t i o n s , as a l l h o s p i t a l s s t r i v e f o r e f f i c i e n t i n f o r m a t i o n management, and q u a l i t y p a t i e n t c a r e . 28 I s s u e s C o n c e r n i n g Computer Use W i t h t h e p r e s e n t t r e n d o f s o c i e t y , t r a n s f o r m i n g from an i n d u s t r i a l t o an i n f o r m a t i o n s o c i e t y , many i s s u e s a r e b e i n g r a i s e d by n u r s e s about how t h i s change w i l l impact t h e i r p r a c t i c e o f n u r s i n g . B a l l and Hannah (1984) i d e n t i f y e i g h t b r o a d s o u r c e s o f r e s i s t e n c e t o computers i n h e a l t h c a r e , w hich can a l s o be viewed as i s s u e s i n n u r s i n g i n f o r m a t i c s : (a) o v e r s e l l by t h e vendor, (b) u s e r s ' u n r e a l i s t i c e x p e c t a t i o n s , (c) change i n t h e t r a d i t i o n a l p r o c e d u r e s and p r a c t i c e , (d) i n s u f f i c i e n t i n v o l v e m e n t o f n u r s e s , (e) i m p r o v i n g " o l d systems" v e r s u s s h i f t i n g t o new paradigms, (f) f e a r o f l e a v i n g t h e "Gutenberg C u l t u r e , " o r p r i n t e d word, (g) c u r r i c u l u m changes, and (h) f e a r o f t h e unknown. W h i l e each o f t h e s e e i g h t b r o a d i s s u e s d e s e r v e s s p e c i f i c a t t e n t i o n o n l y two i s s u e s w i l l be o u t l i n e d b r i e f l y i n t h i s s t u d y : (a) j o b e x p e c t a t i o n s , and (b) t e c h n o l o g y and t o u c h . Many n u r s e s a r e r a i s i n g t h e i s s u e t h a t t h e y a r e e x p e c t e d t o do e v e r y t h i n g t h e y d i d t h i r t y y e a r s ago, p l u s a g r e a t d e a l more (Hope, 1984) . Romano (1985) s t a t e s t h a t n u r s e s must l e t go o f c e r t a i n a r e a s w h i l e t a k i n g on new ones. She f e e l s we are no l o n g e r i n an i n d u s t r i a l s o c i e t y w i t h a f a c t o r y m e n t a l i t y , but r a t h e r , we are i n a knowledge i n t e n s i v e e r a and must p r a c t i s e a c c o r d i n g l y . I t seems t h a t even i f n u r s e s e x p e r i e n c e a s h i f t i n t h e i r own m e n t a l i t i e s , t o r e f l e c t t h e t r e n d s o f s o c i e t y , t h e y a re o f t e n l o c k e d i n t o employment 29 s i t u a t i o n s where t h e f a c t o r y m e n t a l i t y p r e v a i l s . S t r e s s and burnout a r e o f t e n t h e r e s u l t o f such s i t u a t i o n s . The p r o f e s s i o n o f n u r s i n g i s b o t h an a r t and a s c i e n c e , w i t h t h e s e two components f o r m i n g i t s c o r n e r s t o n e s . W i t h t h e advent o f computer t e c h n o l o g y i n t o h o s p i t a l s , many n u r s e s have v o i c e d concerns about t h e danger o f t h e p a t i e n t becoming dehumanized. John N a i s b i t t (1982) s u g g e s t s t h a t i n s t i t u t i o n s such as h o s p i t a l s s h o u l d c o n s i d e r "human b a l l a s t , " o r a h i g h t o u c h component, when t h e y i n t r o d u c e a new t e c h n o l o g y . He f e e l s t h a t t h e more t e c h n o l o g y around p e o p l e , t h e more p e o p l e need t h e human t o u c h . I s s u e s r e l a t i n g t o t h e i n c r e a s e d use o f t e c h n o l o g y by s o c i e t y i n g e n e r a l , and by n u r s e s i n p a r t i c u l a r , w i l l not go away by p r e t e n d i n g t h e y do not e x i s t . These i s s u e s must be d i s c u s s e d , debated, and c o n f r o n t e d by n u r s e s who w i s h t o break down e x i s t i n g b a r r i e r s o f r e s i s t a n c e toward computer t e c h n o l o g y . A t t i t u d e s Toward Computer Use The t h r e e f o l d purpose o f t h i s s u b s e c t i o n i s t o : (a) d i s c u s s what i s meant by a t t i t u d e , (b) p r e s e n t an h i s t o r i c a l r e v i e w o f r e p o r t e d s t u d i e s on n u r s e s ' a t t i t u d e s t o w a r d computers, and (c) i d e n t i f y f a c t o r s a f f e c t i n g computer usage. 30 D e f i n i t i o n Of A t t i t u d e A u n i v e r s a l l y a c c e p t e d d e f i n i t i o n o f a t t i t u d e does not appear i n t h e l i t e r a t u r e and, c o n s e q u e n t l y , t h e r e a r e a wide v a r i e t y o f p r o f e s s i o n a l uses and d e f i n i t i o n s o f t h e term. F o r t h e purposes o f t h i s s t u d y , t h e d e f i n i t i o n posed by F i s h b e i n and A j z e n (1975), d e s c r i b i n g a t t i t u d e as "a l e a r n e d p r e d i s p o s i t i o n t o respond i n a c o n s i s t e n t l y f a v o u r a b l e o r u n f a v o u r a b l e manner w i t h r e s p e c t t o a g i v e n o b j e c t " (p. 6) w i l l be adopted. The l i t e r a t u r e , as r e v i e w e d by Stronge and B r o d t (1985), i n d i c a t e s c e r t a i n g e n e r a l l y a c c e p t e d c h a r a c t e r i s t i c s o f a t t i t u d e s : (a) a t t i t u d e s a r e l e a r n e d , (b) once s o c i a l a t t i t u d e s a r e e s t a b l i s h e d , t h e y a r e c o n s i d e r e d t o be r e l a t i v e l y s t a b l e and e n d u r i n g , and (c) a t t i t u d e s a r e an antece d e n t o f b e h a v i o u r . I n c o n s i d e r i n g t h e s e c h a r a c t e r i s t i c s o f a t t i t u d e , i t became c l e a r t h a t p e r s o n s ' a t t i t u d e s t o w a r d computers a re l e a r n e d and i n f l u e n c e t h e i r w i l l i n g n e s s o r r e s i s t a n c e t o use computers. H i s t o r i c a l Review Of S t u d i e s On Nurses'  A t t i t u d e s Toward Computers A r e v i e w o f t h e l i t e r a t u r e on n u r s e s ' a t t i t u d e s t oward computers i n d i c a t e s a s h i f t i n a t t i t u d e . Nurses i n t h e 1960's and 1970's were v e r y n e g a t i v e , w h i l e n u r s e s i n t h e 31 1980's a r e becoming i n c r e a s i n g l y more p o s i t i v e . R e z n i k o f f , H o l l a n d , and S t r o b e l (1967) s u r v e y e d a l l f u l l - t i m e h o s p i t a l employees a t t h e I n s t i t u t e o f L i v i n g ( p s y c h i a t r i c h o s p i t a l ) i n H a r t f o r d , C o n n e c t i c u t , t o d e t e r m i n e t h e i r e x i s t i n g a t t i t u d e s t oward computers. They used a m o d i f i e d v e r s i o n o f a q u e s t i o n n a i r e d e v e l o p e d by K o b l e r , a t t h e U n i v e r s i t y o f Washington, which c o n s i s t e d o f 35 i t e m s , each r a t e d on a s i x - p o i n t s c a l e , r a n g i n g from " s t r o n g l y agree" t o " s t r o n g l y d i s a g r e e . " They r e p o r t e d t h a t o f a l l t h e employees, s t u d e n t n u r s e s were c o n s i s t e n t l y more n e g a t i v e t h a n t h e o t h e r o c c u p a t i o n a l groups. Because o f t h e f i n d i n g s o f R e z n i k o f f e t a l . (1967), a s e p a r a t e s t u d y o f t h e a t t i t u d e s o f s t u d e n t n u r s e s toward computers was u n d e r t a k e n . Rosenberg, R e z n i k o f f , S t r o e b e l , and E r i c s o n (1967) a d m i n i s t e r e d a q u e s t i o n n a i r e t o 54 j u n i o r and s e n i o r n u r s i n g s t u d e n t s f r o m . f i v e d i p l o m a programs, a t t h e b e g i n n i n g and t h e end o f t h e i r 3-month p s y c h i a t r i c r o t a t i o n , a t t h e I n s t i t u t e o f L i v i n g i n H a r t f o r d , C o n n e c t i c u t . The s t u d e n t s were e x p e c t e d t o use automated n u r s i n g n o t e s d u r i n g t h e i r r o t a t i o n a t t h a t i n s t i t u t i o n . The q u e s t i o n n a i r e used was d e v e l o p e d by K o b l e r , and m o d i f i e d by R e z n i k o f f e t a l . (1967). A t e s t - r e t e s t comparison of computer and non-computer groups was made. A l t h o u g h t h e r e was no s i g n i f i c a n t d i f f e r e n c e i n a t t i t u d e s between t h e two groups at t h e o u t s e t , f i n d i n g s a f t e r t h r e e months i n d i c a t e d t h a t exposure o f n u r s i n g s t u d e n t s t o automated n u r s i n g n o t e s 32 d u r i n g t h e i r p s y c h i a t r i c a f f i l i a t i o n l e d t o a f a v o u r a b l e change i n t h e i r a t t i t u d e t oward t h e use o f computers i n p a t i e n t c a r e . Chang (1984) p o i n t e d out t h a t i n t h e 1970's, o n l y a few nur s e s were i n v o l v e d i n computer a p p l i c a t i o n s i n n u r s i n g . S tartsman and Robinson (1972) d e v e l o p e d and a d m i n i s t e r e d a s h o r t a t t i t u d e s c a l e and an open-ended q u e s t i o n n a i r e t o 338 p h y s i c i a n s , p a r a m e d i c a l s t a f f , and s t u d e n t s a t a u n i v e r s i t y m e d i c a l c e n t r e . Of t h i s sample, 69 were s t u d e n t n u r s e s and 39 were s t a f f n u r s e s ( a p p r o x i m a t e l y 1/3 o f t h e sample). R e s u l t s i n d i c a t e d t h a t n u r s e s had a r e l a t i v e l y n e g a t i v e a t t i t u d e when compared t o t h e o t h e r groups. The r e l i a b i l i t y o f t h e a t t i t u d e s c a l e used was .87, u s i n g a s p l i t - h a l f c o r r e l a t i o n method. Because o f t h e i n c r e a s e d t r e n d toward automation i n t h e h e a l t h c a r e i n d u s t r y , seven y e a r s l a t e r , Melhorn, L e g l e r and C l a r k (1979) used a m o d i f i e d v e r s i o n o f t h e Startsman and . Robinson q u e s t i o n n a i r e . They s u r v e y e d a sample o f 180, t h i r t y o f whom were s t a f f n u r s e s and s i x o f whom were s t u d e n t n u r s e s ( a p p r o x i m a t e l y 1/6 o f t h e sample). They d i d not r e p o r t t h e r e l i a b i l i t y c o e f f i c i e n t o f t h i s m o d i f i e d t o o l . F i n d i n g s i n d i c a t e t h a t t h e respondents d i s p l a y e d a p o s i t i v e o v e r a l l a t t i t u d e t oward computers, as i n d i c a t e d by a w i l l i n g n e s s and even a d e s i r e t o l e a r n more about them i n t h e i r d a i l y work. The respondents who used t h e computer more e x t e n s i v e l y , and on a d a i l y b a s i s , were more p o s i t i v e . 33 R o n a l d (1983) s t u d i e d t h e l e a r n i n g needs and a t t i t u d e s o f 159 n u r s i n g f a c u l t y members w i t h a masters degree o r above, and who t a u g h t i n s c h o o l s o f n u r s i n g w i t h i n t h e c o n t i n e n t a l U n i t e d S t a t e s . She used Startsman and Robinson's a t t i t u d e s c a l e f o r t h e a t t i t u d e component o f t h i s s t u d y . The r e l i a b i l i t y o f t h e s c a l e on t h e s t u d y sample was .63, u s i n g c o e f f i c i e n t a l p h a . F i n d i n g s o f t h e s t u d y i n d i c a t e t h a t n u r s i n g e d u c a t o r s had p o s i t i v e a t t i t u d e s toward computers. T h e i r a t t i t u d e s were more p o s i t i v e w i t h r e s p e c t t o t h e computer's e f f i c i e n c y and importance t o s o c i e t y , and l e s s p o s i t i v e i n r e l a t i o n t o t h e i r w i l l i n g n e s s t o use and a c c e p t t h e use o f computers. Chang (1984) s u r v e y e d 156 v o l u n t e e r p a r t i c i p a n t s , a s s i g n e d u s i n g Houle's (1980) a d o p t i o n t o change t y p o l o g y , i n t o two groups: (a) t h e pace s e t t e r s , and (b) t h e m i d d l e m a j o r i t y . A l l s u b j e c t s had a t t e n d e d workshops conducted by Chang. T h i s s t u d y l o o k e d a t t h e d i f f e r e n c e between: (a) p a c e - s e t t e r s and t h e m i d d l e - m a j o r i t y i n t h e i r e x p e c t a t i o n s o f computer use w i t h r e s p e c t t o t h e i r p e r s o n a l l i v e s , r e l a t i o n s h i p s w i t h c l i e n t s , r e l a t i o n s h i p t o t h e p r o f e s s i o n , and view o f t h e h e a l t h c a r e system and h e a l t h c a r e c o s t s , and (b) t h e two groups i n t h e i r w i l l i n g n e s s t o i n t e r a c t w i t h t h e computer t o a c c o m p l i s h s p e c i f i c n u r s i n g a c t i v i t i e s . The Computer Use E x p e c t a t i o n s S c a l e (CUES) was used f o r d a t a c o l l e c t i o n i n t h e s t u d y . I t was d i v i d e d i n t o t h e 34 f o l l o w i n g two s e c t i o n s : (a) S e c t i o n 1 was r e l a t e d t o w i l l i n g n e s s t o i n t e r a c t w i t h computers. Nine i t e m s had an i n t e r n a l c o n s i s t e n c y u s i n g Cronbach's a l p h a o f .77, w h i l e s i x i t e m s examined s e p a r a t e l y had a r e l i a b i l i t y o f .78, and t h r e e had a r e l i a b i l i t y o f .83, and (b) S e c t i o n 2 o f t h i s t o o l was r e l a t e d t o t h e i n f l u e n c e o f computers. Chang found t h a t t h e group r e s p o n d i n g w i t h a g r e a t e r p e r c e n t a g e o f f a v o u r a b l e r esponses i n r e l a t i o n t o computer use ( p a c e s e t t e r s ) were a l s o s i g n i f i c a n t l y more w i l l i n g t o i n t e r a c t w i t h computers. She s u g g e s t s t h a t t h e e d u c a t i o n o f n u r s e s s h o u l d i n c l u d e i n c r e a s e d e x p e r i e n c e w i t h computer use and i n f o r m a t i o n management :in t h e f u t u r e . Merrow (1985) completed a d e s c r i p t i v e s t u d y i n o r d e r t o f a c i l i t a t e p l a n n i n g f u t u r e e d u c a t i o n i n t h e a r e a o f computer-based n u r s i n g p r a c t i c e . She a s s e s s e d n urse e d u c a t o r s ' and n u r s i n g s e r v i c e p e r s o n n e l s ' knowledge o f , and a t t i t u d e s toward, computer a p p l i c a b i l i t y t o n u r s i n g p r a c t i c e . A s t r a t i f i e d random sample of t w e l v e h o s p i t a l s and NLN-a c c r e d i t e d b a c c a l a u r e a t e s c h o o l s o f n u r s i n g i n New E n g l a n d was s e l e c t e d , from which t h r e e i n s t i t u t i o n s were chosen. T h i r t y - s i x s u b j e c t s were i n t e r v i e w e d , u s i n g an i n t e r v i e w s c h e d u l e which c o n s i s t e d o f b o t h d i r e c t and open ended q u e s t i o n s , aimed at c o l l e c t i n g d a t a i n t h r e e a r e a s : (a) a t t i t u d e , (b) knowledge, and (c) demographic and employment v a r i a b l e s . A l l o f t h e s u b j e c t s were r e g i s t e r e d n u r s e s , t h e m a j o r i t y o f whom were female (97.2%) and h e l d 35 m a s ters d e g r e e s . A t t h e c o n c l u s i o n o f t h e i n t e r v i e w , t h e r e s e a r c h e r s u b j e c t i v e l y a s s i g n e d each s u b j e c t an a t t i t u d e r a t i n g . F i n d i n g s suggest t h a t a l t h o u g h t h e r e were d i f f e r e n c e s i n t h e t y p e s o f s t a t e m e n t s made by v a r i o u s groups ( n u r s i n g s e r v i c e p e r s o n n e l and n urse e d u c a t o r s , p e o p l e w i t h e x p e r i e n c e u s i n g a computer i n n u r s i n g p r a c t i c e , and t h o s e w i t h o u t , and p e o p l e from v a r y i n g e d u c a t i o n a l programs), t h e m a j o r i t y o f n u r s e s i n t e r v i e w e d (22) were c o n s i d e r e d t o be p o s i t i v e , and e i g h t were n e u t r a l , i n t h e i r a t t i t u d e s t oward computer use i n n u r s i n g p r a c t i c e . S i x o f the: r e s p o n d e n t s were c o n s i d e r e d t o have a n e g a t i v e a t t i t u d e t o w a r d computer use i n n u r s i n g p r a c t i c e , w i t h t h e m a j o r i t y b e i n g n u r s i n g s e r v i c e p e r s o n n e l . The a v a i l a b i l i t y o f a r e l i a b l e , v a l i d t o o l d e s i g n e d s p e c i f i c a l l y t o measure n u r s e s ' a t t i t u d e s t oward computers was n o n e x i s t e n t f o r y e a r s , and r e s e a r c h e r s found t h e m s e l v e s e i t h e r : (a) u s i n g t o o l s d e s i g n e d f o r a l a r g e v a r i e t y o f a u d i e n c e s , (b) d e s i g n i n g t h e i r own t o o l s , o r (c) s u b j e c t i v e l y a s s i g n i n g s u b j e c t s an a t t i t u d e r a t i n g based on t h e d a t a g e n e r a t e d i n t h e i r s t u d i e s . The need was apparent f o r a t o o l d e s i g n e d f o r n u r s e s , and i n 1985, Stronge and B r o d t f o c u s e d t h e i r a t t e n t i o n on d e v e l o p i n g such a t o o l t o measure n u r s e s ' a t t i t u d e s t o w a r d computers. They d e v e l o p e d a L i k e r t - t y p e s c a l e t o measure n u r s e s ' a t t i t u d e s t oward c o m p u t e r i z a t i o n . S i x t y - s i x s t a t e m e n t s were o r i g i n a l l y i n c l u d e d i n t h e q u e s t i o n n a i r e . A f t e r o b t a i n i n g 36 i n d e x o f d i s c r i m i n a t i o n s c o r e s f o r a l l i t e m s , t h o s e above .50 were i n c l u d e d i n t h e f i n a l v e r s i o n o f t h e t o o l . The q u e s t i o n n a i r e was p i l o t e d by 60 p e o p l e , made up o f j u n i o r and s e n i o r n u r s i n g s t u d e n t s as w e l l as f a c u l t y a t M a r y c r e s t C o l l e g e i n Davenport, Iowa. The f i n a l twenty i t e m q u e s t i o n n a i r e i s b e l i e v e d t o be v a l i d and r e l i a b l e , w i t h r = .90 s p l i t - h a l f r e l i a b i l i t y c o e f f i c i e n t , u s i n g t h e Spearman-Brown prophecy f o r m u l a . In summary, t h e n , i t appears t h a t t h e a t t i t u d e s o f nu r s e s towards computers have become p r o g r e s s i v e l y more p o s i t i v e o v e r t h e y e a r s . R e c e n t l y , a s p e c i f i c t o o l has been deemed v a l i d and r e l i a b l e as a means o f c o l l e c t i n g q u a n t i t a t i v e a t t i t u d i n a l d a t a (Stronge & B r o d t , 1985) . I t s use by r e s e a r c h e r s i n v a r i o u s p a r t s o f t h e w o r l d s h o u l d a l l o w f o r t h e c o l l e c t i o n o f comparable q u a n t i t a t i v e d a t a , which ; w i l l p r o v i d e a more g e n e r a l sense o f n u r s e s ' a t t i t u d e s towards computers. A l t h o u g h a r e v i e w o f t h e n u r s i n g l i t e r a t u r e , w hich was thought t o r e f l e c t t h e major i s s u e s c o n c e r n i n g t h e use o f computers by n u r s e s , was t h e means used t o g e n e r a t e s t a t e m e n t s f o r i n c l u s i o n i n t h e t o o l , i t i s p o s s i b l e t h a t t h e r e were o t h e r i s s u e s i m p o r t a n t t o n u r s e s w hich were not r e p o r t e d i n t h e l i t e r a t u r e , and c o n s e q u e n t l y were e x c l u d e d . Even though a t o o l has been d e v e l o p e d which measures q u a n t i t a t i v e d a t a , t h e r e s t i l l appears t o be a d e a r t h o f q u a l i t a t i v e d a t a on n u r s e s ' and s t u d e n t n u r s e s ' a t t i t u d e s , t h u s l e a v i n g a sense o f not t r u l y knowing t h e 37 p e r s p e c t i v e o f t h e i n d i v i d u a l n u r s e o r s t u d e n t n u r s e . A c c o r d i n g l y / i n o r d e r t o t r u l y p r e s e n t an a c c u r a t e p i c t u r e o f t h e a t t i t u d e s o f n u r s e s t o w a r d computer use, t h e r e appears t o be a need t o mesh t h e two r e s e a r c h paradigms. F a c t o r s A f f e c t i n g Usage A t t i t u d e measurement i s an i n t e g r a l p a r t o f g a i n i n g an u n d e r s t a n d i n g o f an i n d i v i d u a l ' s b e h a v i o u r , i n v i e w o f t h e f a c t t h a t a t t i t u d e has a s i g n i f i c a n t i n f l u e n c e on an i n d i v i d u a l ' s r e s p o n s e . Stronge and B r o d t (1985) i n d i c a t e d t h a t i f an i n d i v i d u a l ' s a t t i t u d e t o a g i v e n o b j e c t (such as a computer) i s known, i t can be used i n c o n j u n c t i o n w i t h o t h e r v a r i a b l e s t o p r e d i c t and e x p l a i n r e a c t i o n s o f t h e i n d i v i d u a l t o t h a t o b j e c t . Demographic v a r i a b l e s / such as age, have been commonly thought t o i n f l u e n c e t h e r a t e o f a d o p t i o n o f i n n o v a t i o n s such as use o f computers (Chang, 1984). E x p e r t s have found t h a t i n d i v i d u a l s i n t h e i r m i d - t h i r t i e s and younger t e n d t o adapt q u i c k l y t o t h e computer, w h i l e t h o s e over f i f t y a r e more l i k e l y t o be i n t i m i d a t e d (Inman, 1983). I n a s u r v e y o f 237 f u l l - t i m e p r o f e s s i o n a l n u r s e s i n a m e t r o p o l i t a n h o s p i t a l i n n o r t h e a s t e r n Ohio, t h e f i n d i n g s o f Krampf and Robinson (1984) were i n c o n t r a d i c t i o n t o t h e f i n d i n g s o f most r e s e a r c h e r s . The age ranges and f r e q u e n c i e s o f t h e r e s p o n d e n t s i n t h e i r s t u d y were: 20-29 y e a r s 38 (n = 95)/ 30-39 y e a r s (n = 7 1 ) , 40-49 y e a r s (n = 41), and 50+ (n = 3 0 ) . W i t h t h e use o f a t w o - p a r t w r i t t e n q u e s t i o n n a i r e , t h e y found t h a t most o l d e r a d u l t s d i d not appear t o be t h r e a t e n e d by t h e computer. They a l s o found t h a t t h e o l d e r t h e a d u l t , t h e h i g h e r t h e l e v e l o f e d u c a t i o n , and t h e more e x t e n s i v e t h e exposure t o t h e computer, t h e more l i k e l y a computer problem would c h a l l e n g e , r a t h e r t h a n f r u s t r a t e , t h e r e s p o n d e n t s . A l t h o u g h t h e l i t e r a t u r e r e v e a l e d t h a t i n i t i a l computer r e s i s t a n c e i s f r e q u e n t l y a s s o c i a t e d w i t h an i n d i v i d u a l ' s p e r c e p t i o n s t h a t (a) a good mathematics background i s a p r e r e q u i s i t e f o r computer use, and (b) computers t e n d t o make numerous e r r o r s , Krampf and Robinsons' (1984) r e s u l t s were d i s p r o v i n g . S i x t y - s i x p e r c e n t o f t h e r e s p o n d e n t s i n t h e i r s u r v e y f e l t t h a t a mathematics background was not n e c e s s a r y f o r computer competency, w h i l e e i g h t y - s e v e n p e r c e n t i n d i c a t e d t h a t t h e y b e l i e v e d computers t o be r e l a t i v e l y e r r o r f r e e . Houle (1980) n o t e d t h a t t h e r a t e o f a d o p t i o n o f t h e use o f computers, as w i t h any o t h e r i n n o v a t i o n , i s p o s i t i v e l y c o r r e l a t e d w i t h f a v o u r a b l e p r e v i o u s e x p e r i e n c e and, from t h i s , Chang (1984) deduced t h a t p r e v i o u s use o f computers, whatever t h e s e t t i n g , may i n f l u e n c e n u r s e s ' e x p e c t a t i o n s . : The l i t e r a t u r e i n d i c a t e d a l a g between computer p o t e n t i a l and c u r r e n t l e v e l o f usage of computers i n n u r s i n g . P a r k s , e t a l . (1986) n o t e d t h a t f a c t o r s e v i d e n t i n t h e l i t e r a t u r e which might e x p l a i n t h i s phenomenon are s h o r t a g e o f n u r s i n g f a c u l t y w i t h computer e x p e r t i s e , r e l u c t a n c e o f f a c u l t y t o l e a r n computer s k i l l s and t o modify t h e c u r r i c u l u m t o i n c l u d e them, l i m i t e d c h o i c e o f computer s o f t w a r e and t e x t b o o k s , and l a c k o f consensus c o n c e r n i n g what s h o u l d be i n c l u d e d i n a computer e d u c a t i o n f o r n u r s e s . A l t h o u g h some a t t e n t i o n has been p l a c e d on a t t i t u d e and o t h e r f a c t o r s which may a f f e c t computer usage such a s : age, l e v e l o f e d u c a t i o n , and exposure t o a computer, t h e f i n d i n g s a r e o f t e n c o n t r a d i c t o r y . As more demand i s b e i n g p l a c e d on i n d i v i d u a l s , i n c l u d i n g n u r s e s , t o use computers i n t h e i r work, i t i s c l e a r t h a t much work remains t o be done. L e a r n i n g To Use Computers As p o i n t e d out t h u s f a r , whether n u r s e s a r e ready o r n o t , computer use i n n u r s i n g i s becoming a r e a l i t y . T h e r e f o r e , t h e onus w i l l be on n u r s i n g e d u c a t i o n programs t o p r o v i d e computer c o n t e n t i n t h e i r c u r r i c u l a , and a l s o on n u r s e s t o l e a r n how t o use t h i s new t e c h n o l o g y . P i v o t a l t o t h e development o f programs, i s t h e i d e n t i f i c a t i o n o f n u r s e s ' computer l e a r n i n g needs, and a means o f d e t e r m i n i n g whether t h e s e needs have been met. The purpose o f t h i s s u b s e c t i o n i s f o u r f o l d , d e s i g n e d t o : (a) d i s c u s s what i s meant by l e a r n i n g need, (b) h i g h l i g h t s t u d i e s about t h e l e a r n i n g needs o f n u r s e s w i t h r e g a r d t o computers, (c) d i s c u s s computer l i t e r a c y f o r n u r s e s , and (d) d i s c u s s e v a l u a t i o n o f l e a r n i n g , 40 and t h e n o t i o n o f a taxonomy t o det e r m i n e q u a l i t y o f l e a r n i n g . L e a r n i n g Need Houle (1972) d e f i n e d "need" as a c o n d i t i o n o r s i t u a t i o n i n w hich something n e c e s s a r y o r d e s i r a b l e i s r e q u i r e d o r wanted. He n o t e d t h a t i t i s o f t e n used t o e x p r e s s t h e d e f i c i e n c i e s o f an i n d i v i d u a l o r some c a t e g o r y o f p e o p l e , e i t h e r g e n e r a l l y , o r i n some s e t o f c i r c u m s t a n c e s . He i n d i c a t e d t h a t a need may be p e r c e i v e d by t h e p e r s o n o r pers o n s p o s s e s s i n g i t ( f e l t need), o r by some o b s e r v e r ( a s c r i b e d need). Knowles (1980) n o t e d t h a t an e d u c a t i o n a l need i s something p e o p l e ought t o l e a r n f o r t h e i r own good, f o r t h e good o f t h e o r g a n i z a t i o n , o r f o r t h e good o f s o c i e t y . He saw an e d u c a t i o n a l need as t h e d i s c r e p a n c y between what i n d i v i d u a l s , o r o r g a n i z a t i o n s , want t o be and what t h e y a r e ; o r , i n o t h e r words, t h e d i s t a n c e between an a s p i r a t i o n and a r e a l i t y . Boone (1985) d e f i n e d "need" as a d e f i c i e n c y , i m balance, l a c k o f adjustment, o r gap, between t h e p r e s e n t s i t u a t i o n and a s e t o f s o c i e t a l norms b e l i e v e d t o be more d e s i r a b l e . He i m p l i e d a gap between what i s and what ought t o be. B e a t t y (1981) r e f e r r e d t o t h e same phenomenon as a measurable d i s c r e p a n c y e x i s t i n g between a p r e s e n t s t a t e o f a f f a i r s and a 41 d e s i r e d s t a t e o f a f f a i r s as a s s e r t e d e i t h e r by an 'owner' o f need, o r by an ' a u t h o r i t y ' o f need. I t s h o u l d be o b v i o u s t h a t not a l l needs o f a d u l t s a r e e d u c a t i o n a l , and t h a t t h e r e f o r e , e d u c a t i o n cannot meet a l l needs. Need i s a vague t e r m , : p e r c e i v e d t o be d e a l i n g w i t h something e s s e n t i a l , r a t h e r t h a n a whim. A d u l t e d u c a t o r s would agree t h a t need p r o v i d e s a deep m o t i v a t i n g d r i v e f o r l e a r n i n g , even though t h e r e i s no u n i v e r s a l agreement as t o i t s d e f i n i t i o n . Because t h e d e f i n i t i o n o f need i s vague, so a l s o i s t h e d e f i n i t i o n o f t h e p r o c e s s o f needs assessment. Monette (1977) s t a t e d t h a t g e n e r a l l y , needs assessment i s c o n cerned w i t h l e a r n i n g needs. I t appears t o be a s y s t e m a t i c method f o r i d e n t i f y i n g and r e s p o n d i n g t o v a r i o u s p o s s i b l e r e q u i r e m e n t s f o r e d u c a t i o n a l a c t i o n . S c r i v e n (1978) s t a t e d t h a t needs assessment i s a d e t e r m i n a t i o n o f t h e d i f f e r e n c e between what i s and what ought t o be, o r between t h e a c t u a l and t h e i d e a l , o r between t h e g o a l s t a t e and t h e p r e s e n t s t a t e . Needs assessment i s b e l i e v e d , by many, t o be t h e f i r s t s t e p i n program p l a n n i n g , and t h e r e f o r e i t i s t h e essence o f a d u l t e d u c a t i o n . G r i f f i t h (1978) f e e l s t h a t even though i d e a l l y , needs assessment s h o u l d be t h e f i r s t s t e p i n programming, i n p r a c t i s e t h a t i s not o f t e n t h e c a s e . Many o t h e r f a c t o r s a f f e c t programming, i n c l u d i n g p o l i t i c a l power s t r u c t u r e s w i t h i n i n s t i t u t i o n s , t h e programmers' own b i a s , a t t e m p t s t o p r o f i t a b l y u t i l i z e unused 42 space, and a t t e m p t s t o i n c r e a s e revenues. A l t h o u g h o p i n i o n s d i f f e r as t o t h e d e f i n i t i o n o f need and needs assessment, t h e d e t e r m i n a t i o n o f need t h r o u g h t h e use o f a needs assessment i s b e l i e v e d by many t o be an i m p o r t a n t s t e p i n program p l a n n i n g , and as such, must be c o n s i d e r e d i n p l a n n i n g computer awareness and l i t e r a c y programs f o r n u r s e s . L e a r n i n g Needs Of Nurses R e g a r d i n g Computers Anderson, Gremy and Pages (1974) appear t o have done t h e b e g i n n i n g work i n t h e a r e a o f e d u c a t i o n o f h e a l t h p e r s o n n e l i n m e d i c a l i n f o r m a t i c s , i d e n t i f y i n g t h e n e c e s s i t y f o r more and b e t t e r e d u c a t i o n o f b o t h p r a c t i t i o n e r s and s t u d e n t s i n t h e h e a l t h c a r e d i s c i p l i n e s about m e d i c a l i n f o r m a t i c s . They proposed t h r e e l e v e l s of p r e p a r a t i o n : (a) The f i r s t would be a g e n e r a l l e v e l o f computer e d u c a t i o n , d e s i g n e d t o p r o v i d e a g e n e r a l knowledge of computers and d a t a p r o c e s s i n g , f o r a l l h e a l t h s e r v i c e u s e r s ; (b) t h e second would be d e s i g n e d f o r t h o s e who would keep t h e i r main o r i e n t a t i o n as members o f a p a r t i c u l a r h e a l t h c a r e d i s c i p l i n e , but who would be i n v o l v e d i n w o r k i n g w i t h e x p e r t s i n d a t a p r o c e s s i n g , on p r o j e c t s i n v o l v i n g b o t h t h e d e s i g n and i m p l e m e n t a t i o n o f systems; and (c) t h e t h i r d would i n v o l v e e x t e n s i v e t r a i n i n g f o r t h o s e c o n s i d e r e d t o be e x p e r t s i n b o t h t h e i r p a r t i c u l a r h e a l t h c a r e d i s c i p l i n e s and computer s c i e n c e , and who would spend t h e 43 major p a r t o f t h e i r t i m e i n v o l v e d i n t h e development and i n i t i a t i o n o f new computer systems. Hannah (1983) p o i n t e d out, t h a t t h e o n l y f l a w i n t h e r e s e a r c h o f Anderson e t a l . (1974) i s t h a t t h e i r model s u g g e s t s d e t a i l e d o b j e c t i v e s o n l y i n t h e c o g n i t i v e domain (Bloom e t a l . 1956), and c o m p l e t e l y o v e r l o o k s t h e a f f e c t i v e domain (Kr a t h w o h l , Bloom & M a s i a , 1964). S e v e r a l major s t u d i e s have been done i n t h e l a s t decade which i d e n t i f y computer l e a r n i n g needs f o r n u r s e s . Walker (1981) s u r v e y e d 193 r e g i s t e r e d n u r s e s from 29 s t a t e s i n t h e U n i t e d S t a t e s , who were r e c o g n i z e d as e x p e r t s i n n u r s i n g c o m p u t e r i z a t i o n , and asked them t o rank e l e v e n c a t e g o r i e s o f computer l e a r n i n g needs. She found t h a t t h e a r e a s i n which t h e d e s i r e d knowledge was h i g h e s t were t h o s e d i r e c t l y a s s o c i a t e d w i t h t h e n u r s e s ' c u r r e n t o r a n t i c i p a t e d r o l e s i n n u r s i n g . From t h i s she r e c o g n i z e d t h e need f o r d e v e l o p i n g e d u c a t i o n a l o b j e c t i v e s f o r n u r s i n g computer e d u c a t i o n . R o n a l d (1983) s u r v e y e d a n a t i o n a l sample o f 159 n u r s i n g e d u c a t o r s on t h e i r c u r r e n t and d e s i r e d l e v e l o f knowledge i n s i x t e e n computer a r e a s . She n o t e d t h a t t h e h i g h e s t p e r c e n t a g e o f respondents (50.9%) t a u g h t i n b a c c a l a u r e a t e programs, and t h e l o w e s t p e r c e n t a g e (8.2%) t a u g h t i n d i p l o m a programs. Both s c a l e s used t o measure n u r s i n g e d u c a t o r s ' c u r r e n t knowledge and d e s i r e d knowledge about computers had r e l i a b i l i t y c o e f f i c i e n t s o f .93, u s i n g c o e f f i c i e n t a l p h a . She found t h a t t h e n u r s i n g e d u c a t o r s who p a r t i c i p a t e d i n t h e s t u d y had an i d e n t i f i e d need t o l e a r n about computers. The s u b j e c t s p e r c e i v e d t h e m s e l v e s as h a v i n g a low l e v e l o f knowledge about computers, and w i s h e d t o have a h i g h l e v e l . R o n a l d r e p o r t e d t h a t t h e r e was a s i g n i f i c a n t d i f f e r e n c e i n t h e s u b j e c t s ' c u r r e n t knowledge and l e a r n i n g needs based on t h e t y p e o f program i n which t h e y t a u g h t . She found t h a t e d u c a t o r s t e a c h i n g i n gra d u a t e programs had t h e h i g h e s t l e v e l o f c u r r e n t knowledge and t h e l o w e s t l e a r n i n g need w i t h r e s p e c t t o computers. As i n Walker's s t u d y (1981), R o n a l d found t h a t t h e a r e a s i n which t h e d e s i r e d knowledge was h i g h e s t , was i n a r e a s d i r e c t l y a s s o c i a t e d w i t h t h e n u r s e s ' c u r r e n t o r a n t i c i p a t e d r o l e s . R o n a l d c o n c l u d e d t h a t a needs assessment o f each group o f l e a r n e r s s h o u l d be done, so t h a t programs c o u l d be d e v e l o p e d t o p r o v i d e l e a r n e r s w i t h o p p o r t u n i t i e s t o i d e n t i f y and meet t h e i r own i n d i v i d u a l l e a r n i n g needs. T h i s i s c o n s i s t e n t w i t h t h e b e l i e f s o f a d u l t e d u c a t i o n . H e l l e r e t a l . (1985) d e s c r i b e d t h e approach o f a t a s k f o r c e e s t a b l i s h e d a t t h e U n i v e r s i t y o f M a r y l a n d i n October, 1983, which s t u d i e d t h e c u r r i c u l u m i m p l i c a t i o n s o f computer a p p l i c a t i o n s i n n u r s i n g . The t a s k f o r c e was made up o f r e p r e s e n t a t i v e s o f f a c u l t y and s t u d e n t s , and completed i t s work i n A p r i l , 1984. Data was c o l l e c t e d from t h e l i t e r a t u r e , t h r o u g h n e t w o r k i n g and s i t e v i s i t s , as w e l l as a s u r v e y o f b a c c a l a u r e a t e n u r s i n g s t u d e n t s (n = 5 6 ) , masters n u r s i n g s t u d e n t s (n = 5 1 ) , and f a c u l t y members (n = 7 4 ) . 45 The q u e s t i o n n a i r e used f o r t h e s u r v e y was a m o d i f i e d v e r s i o n o f Ronald's (1983) i n s t r u m e n t , w i t h some ite m s from Walker's (1981) t o o l . I n t h e t o o l , as adapted by t h e a u t h o r s , t h e r e l i a b i l i t y ( c o e f f i c i e n t alpha) o f t h e r e v i s e d q u e s t i o n n a i r e was .96 f o r b a c c a l a u r e a t e s t u d e n t s ' d e s i r e d knowledge, .95 f o r masters s t u d e n t s ' d e s i r e d knowledge, .91 f o r f a c u l t i e s ' assessment o f d e s i r e d knowledge f o r b a c c a l a u r e a t e s t u d e n t s , and .91 f o r f a c u l t i e s ' assessment of d e s i r e d knowledge f o r masters s t u d e n t s . T h i s s u r v e y was t h e f i r s t t o measure what s t u d e n t s wanted t o know, and what f a c u l t y thought s t u d e n t s needed t o know. R e s u l t s o f t h e s u r v e y r e v e a l e d t h a t s t u d e n t s d e s i r e d a h i g h l e v e l o f knowledge. However, a d i s c r e p a n c y was e v i d e n t w i t h f a c u l t y e x p e c t a t i o n s . In some a r e a s , f a c u l t y thought t h a t b a c c a l a u r e a t e s t u d e n t s needed t o know l e s s t h a n s t u d e n t s wanted t o know. I n most areas f a c u l t y thought masters s t u d e n t s needed t o know more t h a n t h e y d e s i r e d t o know. The f i n d i n g s i n t h i s s t u d y were c o n s i s t e n t w i t h Ronald's (1983) and Walker's (1981) s t u d i e s , i n t h a t t h e a r e a s i n which t h e d e s i r e d knowledge was h i g h e s t , were t h o s e t h a t were most d i r e c t l y a s s o c i a t e d w i t h t h e n u r s e s ' c u r r e n t o r a n t i c i p a t e d n u r s i n g r o l e s . H e l l e r e t a l . (1985) c o n c l u d e t h e i r s t u d y by a d v o c a t i n g t h e need t o i n c l u d e c o n t e n t about computer c a p a b i l i t i e s and a p p l i c a t i o n s i n n u r s i n g i n t h e c u r r i c u l u m , and suggest s e v e r a l approaches t o t h i s end. They see f a c u l t y development as t h e c o r n e r s t o n e t o s u c c e s s f u l c u r r i c u l u m 46 i m p l e m e n t a t i o n . Merrow (1985), i n h e r s t u d y o f n u r s i n g e d u c a t o r s ' and n u r s i n g s e r v i c e p e r s o n n e l s ' knowledge o f and a t t i t u d e s t oward computer use i n n u r s i n g p r a c t i c e , found t h a t knowledge o f computer use i n n u r s i n g p r a c t i c e was r e l a t e d t o c u r r e n t computer use i n n u r s i n g p r a c t i c e . I n d i v i d u a l s i n h e r st u d y who were r a t e d as m i n i m a l l y knowledgeable about computer use i n n u r s i n g p r a c t i c e , never use a computer. A more r e c e n t s t u d y was conducted by P a r k s e t a l . (1986) at a l a r g e American urban u n i v e r s i t y s c h o o l o f n u r s i n g . Data was c o l l e c t e d as p a r t o f t h e work o f a Task F o r c e a p p o i n t e d by t h e Dean o f t h e S c h o o l o f N u r s i n g , t o determine what knowledge, r e l a t e d t o computer a p p l i c a t i o n s i n n u r s i n g , s h o u l d be i n c l u d e d i n t h e c u r r i c u l u m . The purpose o f t h e stu d y was two f o l d : (a) t o d e s c r i b e f a c u l t y (n = 71), b a c c a l a u r e a t e s t u d e n t s ' (n_ = 124) , and masters s t u d e n t s ' (n = 105) p e r c e p t i o n s o f t h e i r l e v e l o f c u r r e n t knowledge and t h e d e s i r e d l e v e l o f knowledge about a s p e c t s o f computer a p p l i c a t i o n s i n n u r s i n g , and (b) t o d e s c r i b e f a c u l t y p e r c e p t i o n s o f t h e l e v e l o f knowledge about computer a p p l i c a t i o n i n n u r s i n g o f b a c c a l a u r e a t e and masters s t u d e n t s . P a r k s e t a l . (1986) used two v e r s i o n s (one f o r f a c u l t y and one f o r s t u d e n t s ) o f an amalgam o f Ronald's (1983) t o o l and Walker's (1981) s c a l e . E i g h t major components o f t h e q u e s t i o n n a i r e p r o v i d e d e v i d e n c e o f h i g h i n t e r n a l c o n s i s t e n c y r a n g i n g from .91-.95, u s i n g c o e f f i c i e n t a l p h a . C o r r e l a t i o n s 47 between reported amounts of computer in s t r u c t i o n and perceived current knowledge, using Pearson's co r r e l a t i o n c o e f f i c i e n t , were .53 for baccalaureate students, .45 for masters students, and .50 for facuity. Data was c o l l e c t e d on f a c u l t i e s ' computer usage, for seven a c t i v i t i e s (e.g., s t a t i s t i c s , test scoring) through use of a 0-4 scale. The c o e f f i c i e n t alpha r e l i a b i l i t y for the possible range of scores, on the the seven items was .74. Response rate for students was 95-100%, but faculty had only 49%. The findings indicate that students and faculty had low levels of knowledge about computer applications, and desired high l e v e l s . This i s consistent with the finding of Ronald (1983), and Heller et a l . (1985). Faculty usage was shown to be p o s i t i v e l y associated with current knowledge. The authors claim t h i s research to be the f i r s t reported data on students' computer learning needs, from both faculty and student perspectives. However, Heller et a l . (1985) appear to have been the f i r s t to report such findings. They are not referenced by Parks et a l . (1986). It appears, from the l i t e r a t u r e reviewed, that nurses are making an attempt to understand the computer learning needs of various groups within the profession. 48 Computer L i t e r a c y F o r Nurses A l t h o u g h a t t e m p t s a r e b e i n g made t o d e t e r m i n e t h e . l e a r n i n g needs o f s t u d e n t s , p r a c t i s i n g n u r s e s , and n u r s e e d u c a t o r s , i n t e r e s t i n g l y enough, t h e r e appears t o be no c l e a r consensus on r e q u i r e d competencies i n computer knowledge o r usage. To compound m a t t e r s , t h e r e appears t o be no d e f i n i t i o n o f t h e term "computer l i t e r a c y " , which has g a i n e d w i d e s p r e a d a c c e p t a n c e . I t seems t h a t t h e term was f i r s t c o i n e d i n t h e 1960's, and s i n c e t h e n , numerous a u t h o r s have d e f i n e d i t i n a m u l t i t u d e o f ways and r e f e r e n c e s t o i t a r e abundant i n n u r s i n g l i t e r a t u r e . S k i b a (1983) d e f i n e d computer l i t e r a c y as "an u n d e r s t a n d i n g o f : computer c a p a b i l i t i e s (how t h e computer w o r k s ) ; computer a p p l i c a t i o n s (how computers can be used and t h e i r r e l a t i v e a d v a n t a g e s \ d i s a d v a n t a g e s ) ; and t h e knowledge of a l g o r i t h m d e s i g n (an i n t r o d u c t i o n t o t h e n o t i o n o f a l g o r i t h m s and t h e i r r e p r e s e n t a t i o n i n f l o w c h a r t s ) " (p. 8 ) . A 1more c o n c i s e d e f i n i t i o n i s one c o i n e d by M a r v i n and W i n t h e r (1983): "computer l i t e r a c y i s a s h i f t i n g s e t o f s k i l l s , s o c i a l l y d e f i n e d , i n response t o c h a n g i n g c i r c u m s t a n c e s " (p. 97). T h i s d e f i n i t i o n appears t o be congruent w i t h t h e i n t u i t i v e f e e l i n g s o f most e d u c a t o r s . P r a c t i t i o n e r s and e d u c a t o r s a l i k e d i s a g r e e as t o t h e e x t e n t o f l i t e r a c y n e c e s s a r y f o r d i f f e r e n t l e v e l s o f s t u d e n t s and p r a c t i s i n g n u r s e s . 49 W h i l e t h e r e i s disagreement over t h e l e v e l o f l i t e r a c y needed, most e d u c a t o r s would agree w i t h H a r d i n and S k i b a ' s (1982) f i n d i n g , i n t h e i r c o m p a r a t i v e a n a l y s i s o f computer l i t e r a c y e d u c a t i o n f o r n u r s e s , t h a t no s i n g l e e d u c a t i o n a l s t r a t e g y i s l i k e l y t o be e f f e c t i v e i n a c h i e v i n g computer l i t e r a c y f o r a l l n u r s e s . These a u t h o r s p r o v i d e d a c o n c e p t u a l framework f o r e x a m i n i n g computer l i t e r a c y components, and l o n g and s h o r t range g o a l s . f o r e d u c a t i n g n u r s i n g p e r s o n n e l . Many a u t h o r s a d d r e s s e d t h e n e c e s s i t y t o examine t h e n a t u r e o f l e a r n e r s e n r o l l e d i n n u r s i n g programs when d e s i g n i n g programs, p l a n n i n g c u r r i c u l a , and d e v e l o p i n g c o n t e n t f o r computer courses.. Krampf and Robinson (1984) s t a t e d t h a t e d u c a t i o n a l programs f o r n u r s e s must i n c o r p o r a t e l e a r n i n g a c t i v i t i e s which are c o n s i s t e n t w i t h t h e c h a r a c t e r i s t i c s o f a d u l t l e a r n e r s . Tarnow (1979) d e s c r i b e d some o f t h e s e c h a r a c t e r i s t i c s , which must be c o n s i d e r e d when w o r k i n g w i t h a d u l t l e a r n e r s . . They i n c l u d e d t h e : (a) l e a r n e r s ' r e a d i n e s s and c a p a b i l i t i e s , (b) r e l e v a n c e o f t h e m a t e r i a l t o be l e a r n e d , (c) s a t i s f a c t i o n d e r i v e d from t h e l e a r n i n g , (d) e f f e c t i v e n e s s o f immediacy o f a p p l i c a t i o n and t a n g i b l e rewards, and (e) o p p o r t u n i t y t o make m i s t a k e s and t o t a k e r i s k s . Krampf and Robinson (1984) f e l t t h a t a slow-paced, f l e x i b l e , f a i l - p r o o f , human i n t e r a c t i o n w i t h t h e computer i t s e l f i s t h e f i r s t s t e p i n t h e e d u c a t i o n a l p r o c e s s f o r a d u l t l e a r n e r s . They f e l t t h a t t h i s "hands-on" i n s t r u c t i o n s h o u l d 50 p r o g r e s s from s i m p l e t o complex. They a l s o f e l t t h a t a knowledgeable r e s o u r c e p e r s o n s h o u l d be a v a i l a b l e f o r t r o u b l e s h o o t i n g , as i t would seem t h a t , depending on t h e i n s t r u c t o r s approach, t h e a d u l t l e a r n e r s ' i n i t i a l e x p e r i e n c e l e a d s t o e i t h e r a p o s i t i v e o r n e g a t i v e a t t i t u d e , which tends t o p e r s i s t . R o n a l d (1979) documented i n t h e l i t e r a t u r e t h e f i r s t a t t e m p t s t o i n c o r p o r a t e m e d i c a l i n f o r m a t i c s i n t h e n u r s i n g c u r r i c u l u m . S i n c e t h e n a number o f p r e s c r i p t i v e a r t i c l e s and t e x t s have been w r i t t e n which p r e s e n t "how t o " approaches t o c u r r i c u l u m p l a n n i n g and c o n t e n t development (Edmunds, 1982; S k i b a , 1983; Ronald, 1983: Hannah,1983; & R o n a l d & S k i b a , 1987) A t t e n t i o n has been g i v e n by s e v e r a l a u t h o r s t o what s h o u l d be i n c l u d e d i n s p e c i f i c l e v e l s o f n u r s i n g e d u c a t i o n t o a l l o w n u r s e s t o a c h i e v e computer l i t e r a c y . Hannah (1983), f o r i n s t a n c e , f o c u s e d h e r d i s c u s s i o n on t h e p l a c e o f m e d i c a l i n f o r m a t i c s i n a b a c c a l a u r e a t e n u r s i n g c u r r i c u l u m . P a r k s e t a l . (1986) i d e n t i f i e d t h e f o l l o w i n g s p e c i f i c knowledge r e l a t e d t o computer a p p l i c a t i o n s i n n u r s i n g , which s h o u l d be i n c l u d e d i n two l e v e l s o f n u r s i n g programs. At t h e b a c c a l a u r e a t e l e v e l t h e y would i n c l u d e : (a) u s i n g computers t o h e l p n u r s e s c a r e f o r p a t i e n t s , (b) t h e computers' e f f e c t s on q u a l i t y o f h e a l t h c a r e , and (c) "hands-on" e x p e r i e n c e ; a t t h e masters l e v e l , c o n t e n t r e l a t e d t o a d m i n i s t r a t i o n , e d u c a t i o n and r e s e a r c h a p p l i c a t i o n s . 51 A l l o f t h e l i t e r a t u r e r e v i e w e d t o dat e i s American i n o r i g i n , w i t h t h e e x c e p t i o n o f Hannah (1983) a t t h e U n i v e r s i t y o f C a l g a r y , A l b e r t a , Canada. She r e p o r t e d t h e commitment o f t h e n u r s i n g f a c u l t y a t t h a t u n i v e r s i t y w i t h r e g a r d t o t h e development and i m p l e m e n t a t i o n o f m e d i c a l i n f o r m a t i c s , u s i n g a t h r e e f o l d approach, which i n c l u d e d community s e r v i c e , r e s e a r c h and t e a c h i n g . I t appears t h a t some a t t e n t i o n has been g i v e n t o a t t e m p t i n g t o u n d e r s t a n d what computer l i t e r a c y i s and how i t r e l a t e s t o n u r s e s , so t h a t programs can be d e s i g n e d t o address t h e i r computer l e a r n i n g needs. I n d o i n g so, i t appears t h a t some a t t e n t i o n has a l s o been g i v e n t o t h e l e a r n e r , t h e l e a r n i n g c o n t e x t and managing t h e l e a r n i n g e x p e r i e n c e . T o p i c s a d d r e s s e d i n c l u d e : c h a r a c t e r i s t i c s o f t h e a d u l t l e a r n e r , t e a c h i n g methods, t e c h n i q u e s and d e v i c e s , l e v e l l i n g o f c o n t e n t f o r s p e c i f i c groups o f n u r s e s , s e q u e n c i n g o f c o n t e n t and s t r a t e g i e s f o r i m p l e m e n t a t i o n o f computer c o n t e n t i n t o n u r s i n g c u r r i c u l a . However, l i t t l e o r no a t t e n t i o n has been g i v e n t o assessment o r e v a l u a t i o n o f e i t h e r t h e q u a n t i t y o r q u a l i t y o f t h e l e a r n i n g which r e s u l t s from t h e s e e f f o r t s . 52 E v a l u a t i o n Of L e a r n i n g D a h l g r e n (1978) d e s c r i b e s l e a r n i n g as a change i n c o n c e p t i o n . He f e e l s t h e r e i s a q u a l i t a t i v e s h i f t from one c o n c e p t i o n t o an o t h e r when l e a r n i n g has o c c u r r e d . E v a l u a t i o n o f l e a r n i n g o r change i n c o n c e p t i o n i n v o l v e s b o t h q u a n t i t a t i v e (how much) and q u a l i t a t i v e (how w e l l ) a s p e c t s (Marton & S a l j o , 1976). T h i s r e s e a r c h s t u d y i s f o c u s e d p r i m a r i l y on: (a) i d e n t i f y i n g t h e c o n c e p t i o n s o f s t u d e n t s e n r o l l e d i n a community c o l l e g e n u r s i n g program on t h e r o l e o f computers i n h o s p i t a l n u r s i n g , (b) a r r a n g i n g t h e i r c o n c e p t i o n s i n t o u n i t s o r c a t e g o r i e s , and (c) e v a l u a t i n g t h e c o m p l e x i t y o r q u a l i t y o f t h e s e c o n c e p t i o n s . T h e r e f o r e , t h i s d i s c u s s i o n w i l l f o c u s p r i m a r i l y on t h e q u a l i t a t i v e a s p e c t s o f t h e e v a l u a t i o n o f l e a r n i n g , even though i t i s r e c o g n i z e d t h a t b o t h t h e q u a n t i t a t i v e and q u a l i t a t i v e dimensions a re e q u a l l y i m p o r t a n t . There a r e few i n s t r u m e n t s f o r measuring t h e q u a l i t y o f l e a r n i n g . Four e v a l u a t i o n d e v i c e s w i l l be d e t a i l e d b r i e f l y . The most w i d e l y known i s Bloom's Taxonomy ( Bloom, E n g l e l h a r t , F u r s t , H i l l , & K r a t h w o h l , 1956) . A c c o r d i n g t o B i g g s and C o l l i s (1982), t h i s taxonomy was d e s i g n e d t o p r o v i d e t e a c h e r s w i t h a means o f o r d e r i n g items i n a h i e r a r c h i a l l e v e l o f q u a l i t y f o r t e s t i n g p u r p o s e s . The h i e r a r c h y s u b s c r i b e d t o by Bloom e t a l . c o n s i s t e d o f s i x l e v e l s : knowledge, comprehension, a p p l i c a t i o n , a n a l y s i s , 53 s y n t h e s i s , and e v a l u a t i o n . Most e d u c a t o r s a r e f a m i l i a r w i t h t h i s taxonomy, and even though i t has d e f i n i t e m e r i t s , most w i l l r e a d i l y admit i t s s h o r t c o m i n g s as b e i n g : (a) i t s i n t e n d e d use t o g u i d e t h e s e l e c t i o n o f items f o r c o n s t r u c t i n g t e s t s , r a t h e r t h a n as a means o f e v a l u a t i n g t h e q u a l i t y o f a s t u d e n t ' s response t o a p a r t i c u l a r i t e m , and (b) t h e d i f f i c u l t y o f d e v i s i n g i t e m s t o a s s e s s beyond t h e comprehension l e v e l o f t h e taxonomy. Sc h r o d e r , D r i v e r and S t r e u f e r t (1967) d e v e l o p e d an e v a l u a t i o n d e v i c e t o a s s e s s t h e q u a l i t y o f w r i t t e n e s s a y s i n terms o f f o u r l e v e l s o f c o n c e p t u a l s t r u c t u r e . Through t h e c o u r s e o f t h e i r r e s e a r c h , t h e y found t h a t low l e v e l s o f s t r u c t u r a l c o m p l e x i t y i n s t u d e n t s ' responses were not i n c o m p a t i b l e w i t h "good" marks, i n t h e terms o f r e c a l l o f f a c t u a l d e t a i l . Marton and S a l j o (1975) r e p o r t t h e f i n d i n g s o f a r e s e a r c h s t u d y t h e y d i d w i t h s t u d e n t s a t t h e U n i v e r s i t y o f Gothenburg. Two groups of twenty f i r s t - y e a r s t u d e n t s were asked t o r e a d t h r e e s e c t i o n s o f a t e x t b o o k . The s t u d e n t s i n each group were g i v e n two d i f f e r e n t t y p e s o f q u e s t i o n s a f t e r t h e y had r e a d t h e f i r s t two s e c t i o n s . W h i l e one group r e c e i v e d q u e s t i o n s r e q u i r i n g d e t a i l e d f a c t u a l answers, t h e o t h e r group r e c e i v e d q u e s t i o n s which demanded a t h o r o u g h meaning o f t h e passage. A common s e t o f b o t h t y p e s o f q u e s t i o n s was g i v e n a f t e r t h e f i n a l s e c t i o n had been r e a d . They found e v i d e n c e t o suggest t h a t s t u d e n t s adapt t h e i r way 54 o f l e a r n i n g a c c o r d i n g t o t h e i r c o n c e p t i o n s o f what was r e q u i r e d o f them and t h e i r i n d i v i d u a l c o n c e p t i o n s o f l e a r n i n g . Much o f t h e work on t h e e v a l u a t i o n o f q u a l i t y o f l e a r n i n g , l i k e t h e s t u d y j u s t c i t e d , has been done i n Sweden a t t h e U n i v e r s i t y o f Guthenberg, u s i n g a p h e n o m e n o l o g i c a l approach t o st u d y s t u d e n t l e a r n i n g . Marton and h i s c o l l e a g u e s a r e w o r k i n g w i t h i n a q u a l i t a t i v e approach t o l e a r n i n g , which assumes t h a t most human l e a r n i n g depends on meaning and i s d i r e c t e d t oward i t , and t h a t what a s t u d e n t l e a r n s can o n l y be gauged from t h e s t u d e n t ' s own p e r s p e c t i v e . They a r e i n t e r e s t e d i n "what," r a t h e r t h a n "how much," i s l e a r n e d . The g e n e r a l r e s e a r c h approach used by t h e s e r e s e a r c h e r s has been t o use s e m i - s t r u c t u r e d t a p e r e c o r d e d i n t e r v i e w s , which a r e t r a n s c r i b e d , t o p r o v i d e t h e d a t a t o be a n a l y z e d . The aim o f a n a l y s i s , i n t h i s t y p e o f r e s e a r c h , i s t o y i e l d d e s c r i p t i v e c a t e g o r i e s o f t h e q u a l i t a t i v e v a r i a t i o n found i n t h e e m p i r i c a l d a t a . These d e s c r i p t i v e c a t e g o r i e s form what t h e y c a l l t h e outcome space, which i s a k i n d o f an a n a l y t i c a l map o f v a r i a t i o n i n what has been l e a r n e d from a g i v e n l e a r n i n g t a s k . F u r t h e r r e s e a r c h by Marton and S a l j o (1976) r e p o r t e d t h a t s t u d e n t r esponses t o a l e a r n i n g e p i s o d e c o u l d be c l a s s i f i e d i n t o f o u r l e v e l s , showing i n c r e a s i n g g r a s p o f t h e c o m p l e x i t i e s o f t h e m a t e r i a l t h a t was t a u g h t . 55 The l e v e l s a r e o r d e r e d i n terms of c h a r a c t e r i s t i c s t h a t i n c l u d e p r o g r e s s i o n from c o n c r e t e t o a b s t r a c t , an i n c r e a s i n g number o f o r g a n i z i n g d i m e n s i o n s , i n c r e a s e d c o n s i s t e n c y , and use o f o r g a n i z i n g o r r e l a t i n g p r i n c i p l e s and h y p o t h e t i c a l p r i n c i p l e s used a t t h e most complex end (Biggs and C o l l i s , 1982, p 14). I n l o o k i n g a t t h e work o f Bloom (1956), S c h r o d e r e t a l . (1967), and Marton and S a l j o (1976), i t appears t h a t t h e r e i s agreement among t h e t h r e e t h a t q u a l i t a t i v e e v a l u a t i o n c o u l d p r o c e e d i n a h i e r a r c h y o f l e v e l s , i n i n c r e a s i n g s t r u c t u r a l q u a l i t y . A t t e n t i o n w i l l now be d i r e c t e d t o t h e work o f B i g g s and C o l l i s (1982), which i s s i m i l a r t o t h a t o f Marton and S a l j o , (1976). B i g g s and C o l l i s (1982) began t h e i r work w i t h t h e a ssumption t h a t t h e q u a l i t y o f l e a r n i n g depends on f a c t o r s , b o t h e x t r i n s i c and i n t r i n s i c t o t h e l e a r n e r . An example o f an e x t r i n s i c f a c t o r i s q u a l i t y o f i n s t r u c t i o n . I n t r i n s i c f a c t o r s i n c l u d e m o t i v a t i o n , ' d e v e l o p m e n t a l s t a g e , and p r i o r knowledge. A f t e r e x t e n s i v e a n a l y s i s , t h e y r e f u t e d d e v e l o p m e n t a l s t a g e as a frame of r e f e r e n c e , and r a t h e r , s u b s c r i b e d t o l e a r n i n g q u a l i t y , as a p o i n t o f d e p a r t u r e f o r t h e i r work. They d e v e l o p e d a taxonomy o f l e a r n i n g outcomes, c a l l e d t h e S t r u c t u r e o f Observed L e a r n i n g Outcomes (SOLO). T h e i r SOLO Taxonomy i s o r d e r e d i n terms of f i v e l e v e l s o f l e a r n i n g outcome: (a) p r e s t r u c t u r a l , (b) u n i s t r u c t u r a l , (c) m u l t i s t r u c t u r a l , (d) r e l a t i o n a l , and (e) extended a b s t r a c t . B i g g s and C o l l i s (1982). e m p h a t i c a l l y p o i n t out t h a t a l t h o u g h t h e y b e l i e v e t h e r e are n a t u r a l s t a g e s i n t h e 56 growth o f l e a r n i n g any complex m a t e r i a l o r s k i l l , t h e i r l e v e l s a r e s i m i l a r t o , but l o g i c a l l y d i s t i n c t from, t h e d e v e l o p m e n t a l s t a g e s s u b s c r i b e d t o by P i a g e t (1950) and o t h e r s . Those e s p o u s i n g t h e b e n e f i t s o f t h e SOLO Taxonomy h e r a l d i t as a u s e f u l t o o l t o h e l p e d u c a t o r s make judgements about t h e q u a l i t y o f l e a r n i n g t h a t t a k e s ; p l a c e i n t h e c o u r s e s t h e y t e a c h w i t h i n t h e i r c l a s s r o o m s . I t i s an attempt a t e m p i r i c a l c l a s s i f i c a t i o n o f l e v e l s o f l e a r n i n g outcome, i n a form which has w i d e s p r e a d a p p l i c a b i l i t y . I t appears t h a t t h e work o f e v a l u a t i n g t h e q u a l i t y o f l e a r n i n g i s on t h e i n c r e a s e , e s p e c i a l l y i n Sweden and A u s t r a l i a , and t h a t e d u c a t i o n a l r e s e a r c h e r s are s t r i v i n g t o p r o v i d e e d u c a t o r s i n g e n e r a l w i t h an u n d e r s t a n d i n g o f t h e concept o f q u a l i t y o f l e a r n i n g and a means of a s s e s s i n g t h a t q u a l i t y . There appears t o be l i t t l e , i f a n y t h i n g , r e p o r t e d i n n u r s i n g l i t e r a t u r e t o t h i s end. Summary Nurses w o r k i n g i n Canadian h o s p i t a l s are a l r e a d y o r a r e r a p i d l y becoming a f f e c t e d by i n c r e a s e d c o m p u t e r i z a t i o n , as n o t e d i n t h e f i n d i n g s o f The Kennedy Group Survey (1988) . A r e v i e w o f l i t e r a t u r e r e v e a l s a d e a r t h o f r e p o r t e d Canadian s t u d i e s , and o n l y a s m a l l number o f American s t u d i e s , d e a l i n g w i t h n u r s e s ' : (a) a t t i t u d e s t oward computer use, 57 (b) knowledge about computers, and (c) f a c t o r s a f f e c t i n g computer usage. The s t u d i e s r e v i e w e d f o c u s on n u r s e s i n p r a c t i c e , n u r s i n g e d u c a t o r s and b a c c a l a u r e a t e and masters l e v e l n u r s i n g s t u d e n t s , w i t h t h e o b v i o u s absence o f any r e c e n t l i t e r a t u r e on c o l l e g e p r e p a r e d n u r s i n g s t u d e n t s , t h e m a j o r i t y o f which a r e employed i n Canadian h o s p i t a l s . The l i t e r a t u r e does, however, p o i n t t o t h e need f o r computer e d u c a t i o n f o r a l l n u r s e s , w i t h much emphasis b e i n g p l a c e d on t h i s happening w i t h i n n u r s i n g e d u c a t i o n s e t t i n g s . W h i l e s e v e r a l "how t o " a r t i c l e s and t e x t s have been p u b l i s h e d t o a i d c o n t e n t development and i m p l e m e n t a t i o n o f computer c o u r s e s i n t o c u r r i c u l a o f n u r s i n g s c h o o l s , t h e r e appears t o have been l i t t l e t hought g i v e n t o a s s e s s i n g t h e q u a l i t y o f l e a r n i n g t h a t t a k e s p l a c e t h e r e . The i n d i c a t i o n , t h e n , f o r t h i s Canadian s t u d y o f t h e c o n c e p t i o n s o f n u r s i n g s t u d e n t s i n a community C o l l e g e based program, i s c l e a r . 58 CHAPTER 3 Methodology The methodology used i n t h i s s t u d y i s based on t h e q u a l i t a t i v e r e s e a r c h t r a d i t i o n c a l l e d phenomenology, and i s aimed a t t h e g e n e r a t i o n o f t h e o r y . Phenomenology d e r i v e s from a p h i l o s o p h i c a l o r i e n t a t i o n t o w a r d human e x p e r i e n c e as t h e e x p e r i e n c e e x i s t s i n t h e c o n s c i o u s n e s s o f t h e i n d i v i d u a l . I t c o n s i d e r s s u b j e c t i v e r e a l i t y as t h e essence o f human e x p e r i e n c e . Phenomenology g u i d e s t h e g e n e r a t i o n and i n t e r p r e t a t i o n o f d a t a t o d e s c r i b e phenomena from t h e p o i n t o f v i e w o f t h e i n d i v i d u a l who knows t h e problem i n t i m a t e l y (Thorne, 1988). I t i s s u b s t a n c e - o r i e n t e d , and aimed a t d e s c r i p t i o n , a n a l y s i s , and u n d e r s t a n d i n g o f e x p e r i e n c e s (Marton,1981). T h i s s t u d y was d e s i g n e d t o seek an e m p a t h e t i c u n d e r s t a n d i n g o f s t u d e n t s ' c o n c e p t i o n s o f t h e r o l e o f computers i n h o s p i t a l n u r s i n g from s t u d e n t s ' d e s c r i p t i o n s o f what i t means t o them. Student c o n c e p t i o n s s e r v e d as t h e o b j e c t o f a n a l y s i s i n t h i s r e s e a r c h . A u d i o - t a p e d i n t e r v i e w s , u s i n g a s e m i - s t r u c t u r e d i n t e r v i e w , s c h e d u l e were conducted. T r a n s c r i p t s g e n e r a t e d from t h o s e i n t e r v i e w s were a n a l y z e d t o y i e l d d e s c r i p t i v e c a t e g o r i e s o f t h e q u a l i t a t i v e v a r i a t i o n s found i n t h e s u b j e c t s ' s t a t e m e n t s . I n summary, t h e n , t h e methodology used i n t h e st u d y was 59 phenomenology, and t h e p e r s p e c t i v e was t h a t o f t h e s t u d e n t . The components o f t h e method w i l l be d e s c r i b e d i n g r e a t e r d e t a i l i n t h e s e c t i o n s which f o l l o w . D e s c r i p t i o n Of S u b j e c t s Sample S e l e c t i o n The t a r g e t p o p u l a t i o n f o r t h i s r e s e a r c h was a l l n u r s i n g s t u d e n t s e n r o l l e d i n community c o l l e g e n u r s i n g programs i n B r i t i s h Columbia. Even though i t was r e c o g n i z e d t h a t t h e s e community c o l l e g e n u r s i n g programs v a r y i n l e n g t h , t h e y a l l have t h e same mandate t o p r e p a r e n u r s e s as b e g i n n i n g p r a c t i t i o n e r s and t h e i r programs are a l l o r g a n i z e d i n a s i m i l a r f a s h i o n i n terms o f semesters. The i d e n t i f i e d a c c e s s i b l e p o p u l a t i o n was a l l f i r s t , second, and t h i r d y e a r n u r s i n g s t u d e n t s e n r o l l e d i n C a r i b o o C o l l e g e ' s d i p l o m a n u r s i n g program i n t h e w i n t e r semester ( J a n u a r y - A p r i l ) o f 1988. The numbers o f s t u d e n t s i n each y e a r were: 57 i n f i r s t - y e a r , 47 i n second-year, and 67 i n t h i r d - y e a r , g i v i n g a t o t a l a c c e s s i b l e p o p u l a t i o n o f 171 s t u d e n t s . I t i s i m p o r t a n t t o note t h a t t h e t h i r d - y e a r c l a s s , c o n s i s t e d o f two v e r y d i s t i n c t groups. The f i r s t group was composed o f 51 so c a l l e d " r e g u l a r " s t u d e n t s , f o r which t h e d i p l o m a n u r s i n g program was d e s i g n e d . The second group was composed o f 16 r e g i s t e r e d p s y c h i a t r i c n u r s e s (R.P.N.'s), who 60 were e n r o l l e d i n an R.P.N. A c c e s s Program. These s t u d e n t s were t a k i n g a m o d i f i e d d i p l o m a n u r s i n g program t o supplement t h e i r p s y c h i a t r i c e d u c a t i o n and t o en a b l e them t o become r e g i s t e r e d n u r s e s . T h i s R.P.N, group j o i n e d t h e " r e g u l a r " s t u d e n t s i n September,1987, a t t h e b e g i n n i n g o f t h e t h i r d y e a r o f t h e program (semester 5 ) , and g r a d u a t e d i n March 1988, a p p r o x i m a t e l y one month b e f o r e t h e " r e g u l a r " s t u d e n t s . They were not i n c l u d e d i n t h e t h i r d - y e a r p o p u l a t i o n , as t h e y were u n c h a r a c t e r i s t i c o f t h a t group i n terms o f e d u c a t i o n a l e x p e r i e n c e , program l e n g t h and c u r r i c u l u m c o n t e n t m o d i f i c a t i o n . The " r e g u l a r " d i p l o m a n u r s i n g s t u d e n t p o p u l a t i o n , from which t h e sample was drawn, numbered 155 s t u d e n t s . W r i t t e n p e r m i s s i o n , a l l o w i n g t h e r e s e a r c h e r t o i n v i t e s e l e c t e d n u r s i n g s t u d e n t s t o p a r t i c i p a t e i n t h e s t u d y , was sought (see Appendix B) and o b t a i n e d (see Appendix C) i n January, 1988, from t h e V i c e - P r e s i d e n t o f C a r i b o o C o l l e g e . Because t h e a c c e s s i b l e p o p u l a t i o n was p r e d o m i n a n t l y female, (149 females and 6 m a l e s ) , i t was i n i t i a l l y d e c i d e d t o sample o n l y t h a t group. A t a b l e o f random numbers was used t o i d e n t i f y a sample o f t h i r t y female s t u d e n t s , t e n from each y e a r o f t h e program. These randomly s e l e c t e d female s t u d e n t s were approached t o p a r t i c i p a t e i n t h e s t u d y by means o f a l e t t e r o f i n t r o d u c t i o n , which o u t l i n e d t h e purpose o f t h e r e s e a r c h , p r o c e d u r e s t o be c a r r i e d o u t , and i t a s s u r e d them o f complete anonymity and c o n f i d e n t i a l i t y 61 (see Appendix D). They were r e q u e s t e d t o i n d i c a t e t h e i r w i l l i n g n e s s t o p a r t i c i p a t e i n t h e s t u d y by r e t u r n i n g a s i g n e d consent form (see Appendix E) t o t h e r e s e a r c h e r ' s m a i l b o x a t C a r i b o o C o l l e g e . Telephone c o n t a c t was t h e n made w i t h each s u b j e c t who had r e t u r n e d t h e s i g n e d consent/ t o s c h e d u l e a m u t u a l l y c o n v e n i e n t t i m e t o conduct t h e i n t e r v i e w . A l l second and t h i r d - y e a r female s u b j e c t s who were randomly s e l e c t e d were w i l l i n g t o p a r t i c i p a t e . One female f i r s t - y e a r s u b j e c t r e f u s e d t o p a r t i c i p a t e because she l i v e d out o f town and was una b l e t o s c h e d u l e t h e i n t e r v i e w f o r a m u t u a l l y c o n v e n i e n t t i m e . She made i t v e r y c l e a r t h a t she was i n t e r e s t e d i n t h e r e s e a r c h and v o l u n t e e r e d names o f c l a s s m a t e s who might be i n t e r e s t e d i n t a k i n g h e r p l a c e . However/ t h e s e names were : not used b u t , r a t h e r , t h e random numbers t a b l e was once a g a i n used t o s e l e c t t h i s t e n t h female s u b j e c t from f i r s t - y e a r . F l e x i b i l i t y and a d a p t a b i l i t y o f s e l e c t i o n and s a m p l i n g d e c i s i o n s , as w e l l as t h e i r i n t e g r a t i o n t h r o u g h o u t t h e r e s e a r c h p r o c e s s , a r e h a l l m a r k s o f q u a l i t a t i v e r e s e a r c h (Goetz & LaCompte,1984). As t h e stu d y u n f o l d e d / t h r o u g h t h e j o i n t p r o c e s s e s o f d a t a c o l l e c t i o n , c o d i n g , and a n a l y s i s o f d a t a , c o n c e p t i o n s based on t h e female s u b j e c t s ' p e r s p e c t i v e became v e r y a p p a r e n t . Thus, i t was d e c i d e d t o a l s o seek out c o n c e p t i o n s based on t h e male s t u d e n t s ' p e r s p e c t i v e . The s m a l l numbers o f male s t u d e n t s e n r o l l e d i n t h e C a r i b o o C o l l e g e n u r s i n g program r e f l e c t t r e n d s f o r males employed i n 62 n u r s i n g . "Less t h a n 2% (468 i n 1985) o f B.C. n u r s e s a r e male" (R.N.A.B.C. News, 1986, p 1 6 ) . F i v e o f t h e s i x male s t u d e n t s e n r o l l e d i n t h e program, (one i n each o f f i r s t and second-year and t h r e e i n t h i r d -year) , were approached by l e t t e r t o p a r t i c i p a t e i n t h e s t u d y . One male t h i r d - y e a r s t u d e n t was not approached, because he was d o i n g a c l i n i c a l p e r c e p t o r s h i p i n an o u t l y i n g h o s p i t a l , g e o g r a p h i c a l l y removed from Kamloops. T h i s g e o g r a p h i c d i s t a n c e made i t t o o d i f f i c u l t t o s c h e d u l e a m u t u a l l y c o n v e n i e n t i n t e r v i e w t i m e . Upon r e c e i v i n g t h e s i g n e d consent forms, t h e male s u b j e c t s were a l s o approached by t e l e p h o n e t o s c h e d u l e an appointment t i m e t o be i n t e r v i e w e d . A t t h a t p o i n t , t h e y were i n f o r m e d t h a t t h e y had not been randomly s e l e c t e d because o f t h e i r s m a l l numbers, but t h a t t h e y were i n t e n t i o n a l l y b e i n g i n v i t e d t o p a r t i c i p a t e . A l l f i v e r e a d i l y chose t o do so, even g i v e n t h o s e c i r c u m s t a n c e s . In summary, t h e t o t a l a c c e s s i b l e p o p u l a t i o n o f " r e g u l a r " d i p l o m a n u r s i n g s t u d e n t s y i e l d e d t h e st u d y sample breakdown i n terms o f y e a r and sex d e p i c t e d i n Table 3 on t h e f o l l o w i n g page. 63 T a b l e 3. Frequency Of Male And Female S t u d e n t s I n The A c c e s s i b l e P o p u l a t i o n Of C a r i b o o C o l l e g e N u r s i n g S t u d e n t s From Which A Sample Was Drawn ACCESSIBLE POPULATION SAMPLE YEAR CLASS FEMALE MALE TOTAL FEMALE MALE TOTAL 1 1990 56 1 57 10 1 11 2 1989 46 1 47 10 1 11 3 1988 47 4 51 10 3 13 TOTAL: 149 6 155 30 5 35 S u b j e c t s ' Exposure To Computer Content I n response t o t h e p e r c e i v e d i n c r e a s e d use o f computer t e c h n o l o g y i n n u r s i n g , a c o n s c i o u s e f f o r t has been made over t h e l a s t f o u r y e a r s t o i n c o r p o r a t e computer awareness c o n t e n t i n t o t h e n u r s i n g c u r r i c u l u m a t C a r i b o o C o l l e g e . T h i s c o n t e n t was p l a c e d i n t h e N u r s i n g P e r s p e c t i v e s Course, which i s t a u g h t i n each y e a r o f t h e program. The b r i e f c o n t e n t o u t l i n e w hich f o l l o w s i n d i c a t e s what was c o v e r e d i n each o f t h e t h r e e y e a r s . The f i r s t - y e a r s u b j e c t s ( c l a s s o f 1990), had a two hour seminar s c h e d u l e d i n semester 1, i n which t h e y were 64 i n t r o d u c e d t o t h e computer system a t C a r i b o o C o l l e g e , and g i v e n t h e o p p o r t u n i t y f o r a hands on e x p e r i e n c e . T h i s seminar was l e d by a p e r s o n employed i n computer s e r v i c e s and was h e l d i n a computer l a b . S u b j e c t s were encouraged t o send m a i l messages t o a n u r s i n g i n s t r u c t o r , t o e n a b l e them t o have some p r a c t i c a l use o f t h e computer. A handout was g i v e n t o each s u b j e c t w i t h i n f o r m a t i o n on how t o a c c e s s t h e C a r i b o o c o l l e g e system. I n a d d i t i o n , t h i s group a l s o had a two hour seminar l e d by a member o f t h e f i r s t - y e a r n u r s i n g f a c u l t y , i n which t h e y d i s c u s s e d : (a) t h e i r e x p e r i e n c e s w i t h computers, (b) t h e h i s t o r y o f computers i n h e a l t h c a r e , (c) t h e advantages and d i s a d v a n t a g e s o f computers, and (d) t h e i s s u e s c o n c e r n i n g n u r s e s w i t h i n c r e a s i n g c o m p u t e r i z a t i o n i n h e a l t h c a r e . The second-year s u b j e c t s ( c l a s s o f 1989), had s i m i l a r f o u r hour computer awareness seminars (as o u t l i n e d above) s c h e d u l e d f o r them w h i l e t h e y were e n r o l l e d i n semester one o f f i r s t y e a r . I n semester 4. o f second y e a r , t h e s e s u b j e c t s were r e q u i r e d t o r e a d c u r r e n t l i b r a r y r e a d i n g s on computers i n n u r s i n g as p a r t o f t h e i r N u r s i n g P e r s p e c t i v e s c o u r s e . The m a j o r i t y o f s u b j e c t s i n t e g r a t e d i n f o r m a t i o n from t h e s e a r t i c l e s i n t o a compulsory assignment about N u r s i n g I n The F u t u r e . Even though computer awareness c o n t e n t was not t a u g h t s p e c i f i c a l l y i n t h i s c o u r s e , i t came up i n c l a s s d i s c u s s i o n on s e v e r a l o c c a s i o n s . T h i r d - y e a r s u b j e c t s ( c l a s s o f 1988), were a l s o a l l 65 s c h e d u l e d , i n semester 1 o f f i r s t y e a r , t o a t t e n d a two hour computer awareness c o u r s e oh "Computers i n N u r s i n g , " f o l l o w e d by a two hour hands-on p r a c t i c a l s e s s i o n on a c c e s s i n g and u s i n g C a r i b o o C o l l e g e ' s computer system. As w i t h t h e second-year s u b j e c t s , t h e s e s u b j e c t s r e c e i v e d no s t r u c t u r e d hands-on computer e x p e r i e n c e w h i l e e n r o l l e d i n t h e second y e a r o f t h e program, however, d i s c u s s i o n on t h e e f f e c t s o f computer t e c h n o l o g y on n u r s i n g p r a c t i c e was i n t e g r a t e d i n t o t h e N u r s i n g P e r s p e c t i v e s c o u r s e . I n semester 5 o f t h i r d y e a r , s e v e r a l s u b j e c t s d i d r e s e a r c h papers on t e c h n o l o g y i n n u r s i n g as a r e q u i r e d assignment i n t h e N u r s i n g P e r s p e c t i v e s c o u r s e . I n a d d i t i o n , semester 6 s u b j e c t s were i n t r o d u c e d t o a computer a s s i s t e d i n s t r u c t i o n (C.A.I.) program e n t i t l e d Nurse S t a r , which i s a c o m p u t e r i z e d exam t e s t bank. The i n t e n t i n i n t r o d u c i n g s t u d e n t s t o t h i s program was t o promote i t s use i n p r e p a r i n g f o r t h e i r r e g i s t r a t i o n exams. A t t h e t i m e of t h e s t u d y , t h i s was t h e o n l y n u r s i n g r e l a t e d C.A.I, program owned by t h e n u r s i n g department a t C a r i b o o C o l l e g e . . I n summary, a l i m i t e d amount of c o n t e n t i n computer awareness was made a v a i l a b l e t o a l l s u b j e c t s e n r o l l e d i n t h e n u r s i n g program at C a r i b o o C o l l e g e . T h i s c o n t e n t was i n c o r p o r a t e d i n t o t h e N u r s i n g P e r s p e c t i v e s Course, w i t h t h e e x c e p t i o n o f t h i r d - y e a r . I n t h i r d - y e a r , s u b j e c t s were a l s o o f f e r e d one i n s t r u c t i o n a l s e s s i o n w i t h a C.A.I, t e s t bank package. T h i s package was d e s i g n e d t o g i v e s t u d e n t s p r a c t i c e i n a n s w e r i n g m u l t i p l e c h o i c e q u e s t i o n s as p r e p a r a t i o n f o r 66 w r i t i n g t h e n a t i o n a l r e g i s t r a t i o n e x a m i n a t i o n s . T a b l e 4 d e p i c t s how t h e computer awareness c o n t e n t i s d i s p e r s e d t h r o u g h o u t t h e program. T a b l e 4. Sche d u l e d Hours Of Computer Awareness Content I n Each Semester Of The C a r i b o o C o l l e g e N u r s i n g Program SCHEDULED HOURS SEMESTER FIRST YEAR SECOND YEAR THIRD YEAR 4 4 4 P e r s p e c t i v e s P e r s p e c t i v e s - P e r s p e c t i v e s Nurse S t a r 1 2 3 4 5 6 I n s t r u m e n t a t i o n An i n t e r v i e w s c h e d u l e (see Appendix F) was d e v e l o p e d by th e r e s e a r c h e r i n which t h r e e s e m i - s t r u c t u r e d q u e s t i o n s formed t h e framework f o r c o l l e c t i n g q u a l i t a t i v e d a t a t o answer t h e b r o a d and s p e c i f i c r e s e a r c h q u e s t i o n s . The t h r e e i n t e r v i e w q u e s t i o n s were aimed a t : (a) g a t h e r i n g d e s c r i p t i v e d a t a from which c a t e g o r i e s o f s t u d e n t c o n c e p t i o n s o f t h e r o l e 67 of computers i n h o s p i t a l n u r s i n g c o u l d be g e n e r a t e d , and (b) d e t e r m i n i n g each s t u d e n t ' s a t t i t u d e t oward t h e r o l e o f computers i n h o s p i t a l n u r s i n g . I n a d d i t i o n , i n o r d e r t o o b t a i n q u a n t i t a t i v e demographic d a t a and d a t a on computer usage, a respondent p r o f i l e s h e e t , c o n s i s t i n g o f t e n f o r c e d -response and open-ended q u e s t i o n s , was d e v e l o p e d and i n c l u d e d at t h e end o f each i n t e r v i e w s c h e d u l e . The i n t e r v i e w s c h e d u l e was f i r s t p i l o t e d i n January 1988, w i t h two second-year n u r s i n g s t u d e n t s , and r e s u l t e d i n f u r t h e r f o c u s e d q u e s t i o n s . I t a l s o p r o v i d e d an o p p o r t u n i t y t o c r i t i q u e t h e r e s e a r c h e r ' s i n t e r v i e w i n g s k i l l s . N e c e s s a r y r e v i s i o n s t o t h e t o o l and i n t e r v i e w i n g s t y l e were a d d r e s s e d . The r e v i s e d i n t e r v i e w s c h e d u l e was a g a i n p i l o t e d i n F e b r u a r y 1988, w i t h two d i f f e r e n t second-year s t u d e n t s . M i n o r r e v i s i o n s were made and i t was f e l t a t t h a t t i m e t h a t i t was ready f o r use. Second-year s t u d e n t s were chosen f o r t h e p i l o t s , because t h e r e s e a r c h e r had e a s i e r a c c e s s t o t h a t group o f s t u d e n t s on a r e g u l a r b a s i s , and second y e a r was between t h e o t h e r two y e a r s . The i n t e r v i e w s c h e d u l e and accompanying respondent p r o f i l e were s c r e e n e d by t h e U n i v e r s i t y o f B r i t i s h Columbia B e h a v i o r a l S c i e n c e s S c r e e n i n g Committee F o r Rese a r c h and Other S t u d i e s I n v o l v i n g Human S u b j e c t s . A p p r o v a l on e t h i c a l grounds f o r t h i s r e s e a r c h s t u d y (#B88-058) i n v o l v i n g human s u b j e c t s was o b t a i n e d on March 10, 1988 (see Appendix G). 68 P r o c e d u r e s Data C o l l e c t i o n T h i r t y - f i v e a u d i o t a p e d i n t e r v i e w s , r a n g i n g i n l e n g t h from 30-45 minutes, were conducted i n March and A p r i l , 1988. These too k p l a c e a t m u t u a l l y c o n v e n i e n t s c h e d u l e d t i m e s w i t h i n t h e p r i v a c y o f t h e r e s e a r c h e r ' s o f f i c e . I n t e r v i e w t i m e s were s t a g g e r e d w i t h o n l y one or two i n t e r v i e w s s c h e d u l e d p e r day, on a l t e r n a t e days, so as not t o j e o p a r d i z e t h e q u a l i t y o f t h e i n t e r v i e w s w i t h i n t e r v i e w e r f a t i g u e . On one o c c a s i o n , t h r e e i n t e r v i e w s were h e l d on one day because o f t h e l a c k o f a v a i l a b i l i t y o f t h e s u b j e c t s due t o f i n a l e x a m i n a t i o n s c h e d u l e s a t t h e end o f t h e semester. A t t h e o u t s e t o f each i n t e r v i e w , s u b j e c t s were asked i f t h e y agreed t o t h e i n t e r v i e w b e i n g t a p e r e c o r d e d , and a l l s u b j e c t s r e a d i l y agreed. A s e m i - s t r u c t u r e d i n t e r v i e w s c h e d u l e (see Appendix F) was used, which e n a b l e d t h e r e s e a r c h e r t o g a t h e r comparable d a t a between s u b j e c t s w i t h i n t h e same and d i f f e r e n t y e a r s o f th e n u r s i n g program (Bogdan & B i k l e n 1982). A l l q u e s t i o n s were asked i n t h e o r d e r o u t l i n e d i n t h e s c h e d u l e and w i t h o n l y minor r e w o r d i n g s o f t h e q u e s t i o n s t o make them c o n s i s t e n t w i t h t h e i n t e r v i e w e r ' s and s u b j e c t s ' s t y l e . Q u e s t i o n s were reworded when i t was n e c e s s a r y t o c l a r i f y t h e i r meaning t o s u b j e c t s . P r o b i n g f o r a d d i t i o n a l i n f o r m a t i o n and c l a r i f i c a t i o n o f answers t o o k p l a c e i n each 69 i n t e r v i e w . I f a s u b j e c t a d d r e s s e d a q u e s t i o n b e f o r e i t was asked, t h e q u e s t i o n was s t i l l asked i n sequence but t h e i n t e r v i e w e r acknowledged t h a t t h e q u e s t i o n had been a d d r e s s e d . T h i s communicated t o t h e s u b j e c t t h a t t h e i n t e r v i e w e r had been l i s t e n i n g but i n a d d i t i o n , p r o v i d e d t h e s u b j e c t w i t h t h e o p p o r t u n i t y t o expand on what had been s a i d p r e v i o u s l y , and a l s o p r e c l u d e d o m i s s i o n o r c u r s o r y i n v e s t i g a t i o n o f a q u e s t i o n by t h e i n t e r v i e w e r ( K n a f r , P e t t e n g i l l , B e v i s , & K i r c h h o f f , 1988). The r e s e a r c h e r was c o g n i z a n t o f " p u t t i n g words i n t h e s u b j e c t ' s mouth," and c o n s c i o u s l y a t t e m p t e d t o a v o i d t h i s , as i t was o b s e r v e d t o be a weakness i n t h e f i r s t two o f t h e f o u r p i l o t i n t e r v i e w s . D u r i n g d a t a c o l l e c t i o n , a t t e m p t s were made t o e l i c i t and m a i n t a i n t h e uniqueness o f each s u b j e c t ' s i n t e r p r e t a t i o n o f h i s o r her e x p e r i e n c e ( M u n h a l l , 1982). At t h e c o n c l u s i o n o f each i n t e r v i e w , s u b j e c t s were thanked f o r t h e i r p a r t i c i p a t i o n , and asked i f t h e y would l i k e t o r e c e i v e a copy o f t h e i r t r a n s c r i p t . Only one s u b j e c t , a f i r s t y e a r s t u d e n t who had c o n s i d e r a b l e e x p e r i e n c e w i t h computers, i n d i c a t e d she would l i k e a copy. The r e a c t i o n o f t h e o t h e r s u b j e c t s was one o f , " I know what I've s a i d , so i t i s not n e c e s s a r y t o have a copy." Tapes were i d e n t i f i e d w i t h a number i n d i c a t i n g t h e : (a) y e a r o f t h e program i n which t h e s t u d e n t was e n r o l l e d , and (b) s u b j e c t w i t h i n each y e a r . Numbers from 1-10 were 70 used t o i d e n t i f y female s u b j e c t s and 11-13 t o i d e n t i f y male s u b j e c t s . Immediately a f t e r each i n t e r v i e w , t h e r e s e a r c h e r wrote a s h o r t summary o f t h o u g h t s , f e e l i n g s and r e a c t i o n s t o t h e i n t e r v i e w . These i n i t i a l t h o u g h t s e n a b l e d t h e r e s e a r c h e r t o b e g i n t h e p r o c e s s o f a n a l y s i s s i m u l t a n e o u s l y w i t h t h e d a t a c o l l e c t i o n phase o f t h e r e s e a r c h . I n t h i s s t u d y , t h e o r y was g e n e r a t e d by t h e j o i n t o p e r a t i o n s o f d a t a c o l l e c t i o n , c o d i n g , and a n a l y s i s o f d a t a . G l a s e r and S t r a u s s (1967) p o i n t out t h a t t h e g e n e r a t i o n o f t h e o r y , c o u p l e d w i t h t h e n o t i o n o f t h e o r y as p r o c e s s , r e q u i r e s t h a t a l l o p e r a t i o n s be done t o g e t h e r as much as p o s s i b l e and i n t e r t w i n e d c o n t i n u a l l y from t h e b e g i n n i n g o f t h e s t u d y t o t h e end. A d i c t a p h o n e was used t o t r a n s c r i b e t h e a u d i o t a p e s v e r b a t i m i n t o a computer i n o r d e r t o g e n e r a t e t r a n s c r i p t s o f t h e i n t e r v i e w s . O r i g i n a l s o f t h e t r a n s c r i p t s were s t o r e d i n a s a f e p l a c e f o r f u r t h e r r e f e r e n c e l a t e r as t h e st u d y u n f o l d e d . P h o t o c o p i e s o f t h e o r i g i n a l s were t a k e n and were used as w o r k i n g documents from which t h e a n a l y s i s was g e n e r a t e d . These t r a n s c r i p t i o n s , t o g e t h e r w i t h t h e w r i t t e n r e a c t i o n s t o t h e i n t e r v i e w s , p r o v i d e d 455 pages o f d a t a . D u r i n g t h e two month p e r i o d o f ti m e when s t u d e n t i n t e r v i e w s , t r a n s c r i p t i o n o f t a p e s , c o d i n g and b e g i n n i n g a n a l y s i s was o c c u r r i n g , i n f o r m a l d i s c u s s i o n s were a l s o h e l d w i t h : (a) members o f t h e Computers In N u r s i n g I n t e r e s t Group o f t h e R.N.A.B.C., (b) t h e s t e e r i n g committee members f o r t h e 71 Computers I n N u r s i n g P r o j e c t , and (c) c o l l e a g u e s a t C a r i b o o C o l l e g e N u r s i n g f a c u l t y . The i n t e n t o f t h e s e d i s c u s s i o n s was t o d e t e r m i n e t h e c l i m a t e and p r e s e n t s t a t e o f t h e a r t o f computers i n b o t h h o s p i t a l and e d u c a t i o n a l s e t t i n g s w i t h i n B r i t i s h Columbia. I n a d d i t i o n , a s c h e d u l e d i n f o r m a t i o n g a t h e r i n g i n t e r v i e w was h e l d w i t h t h e D i r e c t o r o f P a t i e n t Care S e r v i c e s a t R o y a l I n l a n d H o s p i t a l i n Kamloops t o d e t e r m i n e : (a) t h e s t a t u s o f computer i m p l e m e n t a t i o n a t t h e l o c a l h o s p i t a l , (b) t h e degree o f n u r s i n g i n p u t i n t o system s e l e c t i o n , and (c) p l a n s f o r e d u c a t i n g n u r s e s t o use i t . These i n f o r m a l d i s c u s s i o n s p r o v i d e d t h e r e s e a r c h e r w i t h a sense o f t h e p r e s e n t s t a t e o f t h e a r t o f computer use by n u r s e s i n h o s p i t a l s i n Kamloops and t h e r e s t o f B r i t i s h Columbia, and a l s o a sense o f how n u r s e s and s t u d e n t n u r s e s are b e i n g e d u c a t e d t o use t h e s e computers. The i n f o r m a t i o n g l e a n e d from t h e s e d i s c u s s i o n s , as w e l l as from t h e r e v i e w o f t h e l i t e r a t u r e , p r o v i d e d a c o n t e x t f o r i n t e r p r e t a t i o n and d i s c u s s i o n o f t h e f i n d i n g s from t h i s s t u d y . R e s e a r c h e r ' s R o l e Because t h e n a t u r e o f t h i s s t u d y was b o t h i n d u c t i v e , and g e n e r a t i v e , d e s i g n e d t o d i s c o v e r a n a l y t i c c o n s t r u c t s or c a t e g o r i e s , i t was e x p e c t e d t h a t t h e s u b j e c t i v i t y o f t h e r e s e a r c h e r would i n f l u e n c e t h e a n a l y s i s (Goetz & LeCompte 1984). Bogdan and B i k l e n (1982) p o i n t out t h a t t h e 72 r e s e a r c h e r i s t h e key i n q u a l i t a t i v e r e s e a r c h . At t h e t i m e o f t h e s t u d y , t h e r e s e a r c h e r was a member o f t h e n u r s i n g f a c u l t y a t C a r i b o o C o l l e g e and as such, was k e e n l y aware o f v a r i a b l e s i m p i n g i n g on t h i s s t u d y from t h a t unique p e r s p e c t i v e . I t was a n t i c i p a t e d t h a t d a t a a n a l y s i s would be improved by t h e r e s e a r c h e r ' s i n s i g h t , from her e x p e r i e n c e as a p r a c t i s i n g n u r s e , a second-year n u r s i n g t h e o r y and c l i n i c a l i n s t r u c t o r , and a g r a d u a t e s t u d e n t i n a d u l t e d u c a t i o n a t t h e U n i v e r s i t y o f B r i t i s h Columbia. I t c o u l d be argued t h a t t h e d u a l r o l e o f i n s t r u c t o r \ r e s e a r c h e r put t h e r e s e a r c h e r i n a p o s i t i o n which c o u l d be p e r c e i v e d by t h e s u b j e c t s t o be i n c o n g r u e n t and p o s s i b l y u n c o m f o r t a b l e . A: r a p p o r t had been e s t a b l i s h e d between t h e i n s t r u c t o r \ r e s e a r c h e r and t h e p r e s e n t second-year c l a s s . These s t u d e n t s had a l l been t a u g h t by t h e i n s t r u c t o r \ r e s e a r c h e r , who was c a r r y i n g a f u l l t e a c h i n g l o a d i n n u r s i n g t h e o r y t h r o u g h o u t t h e y e a r . As w e l l , s i x t e e n o f t h e second-year s t u d e n t s were t a u g h t c l i n i c a l l y i n t h e f a l l semester, (September-December, 1987) by t h e i n s t r u c t o r \ r e s e a r c h e r , p r i o r t o her c l i n i c a l r e l e a s e d u r i n g t h e w i n t e r semester ( J a n u a r y - A p r i l , 1988). Because of s t a f f i n g changes i n t h e n u r s i n g department a t C a r i b o o C o l l e g e , s t u d e n t s e n r o l l e d i n t h e t h i r d - y e a r c l a s s were a l l t a u g h t n u r s i n g t h e o r y by t h e i n s t r u c t o r \ r e s e a r c h e r i n b o t h t h e i r f i r s t and second y e a r s o f t h e program. A d d i t i o n a l l y , o v er h a l f t h e t h i r d - y e a r c l a s s had been t a u g h t 73 by t h e i n s t r u c t o r \ r e s e a r c h e r i n t h e c l i n i c a l a r e a over t h e p a s t two y e a r s . S e v e r a l s t u d e n t s had a l s o had t h e i n s t r u c t o r \ r e s e a r c h e r as a c l i n i c a l i n s t r u c t o r , b o t h i n f i r s t and second y e a r . I t was f e l t t h a t t h e f a m i l i a r i t y and r a p p o r t t h a t e x i s t e d between t h e i n s t r u c t o r \ r e s e a r c h e r and b o t h second and t h i r d - y e a r students,-compensated f o r any r o l e i n c o n g r u e n c y s u b j e c t s might have f e l t and t h a t i n s t e a d o f b e i n g a d e t e r r e n t , i t enhanced d a t a c o l l e c t i o n , because t h e comfort l e v e l s o f s u b j e c t s and c o o p e r a t i o n were i n c r e a s e d . One t h i r d - y e a r s u b j e c t had r e c e i v e d a p r o b a t i o n a r y c l i n i c a l e v a l u a t i o n from t h e r e s e a r c h e r i n a second y e a r c l i n i c a l r o t a t i o n . A t t h e t i m e she was v e r y angry, but a t t h e b e g i n n i n g o f h e r t h i r d y e a r she came back and t h a n k e d t h e r e s e a r c h e r f o r h e l p i n g h e r t o c o r r e c t h er weaknesses. T h i s s u b j e c t was not r e p l a c e d by an o t h e r f o r two r e a s o n s : (a) I t was f e l t t h a t t h e i s s u e had happened l o n g enough p r i o r t o t h e stu d y and had been d e a l t w i t h s u f f i c i e n t l y so t h a t i t d i d not i n t e r f e r e w i t h t h e s u b j e c t ' s a b i l i t y t o p a r t i c i p a t e , and (b) t h e t i m i n g o f t h e i n t e r v i e w was c l o s e t o t h e end o f t h e semester, and many o f t h e o t h e r t h i r d - y e a r s t u d e n t s had f i n i s h e d t h e i r p r a c t i c u m and were not a v a i l a b l e . Throughout t h e i n t e r v i e w i n g phase o f t h e s t u d y , t h e i n s t r u c t o r \ r e s e a r c h e r was c o g n i z a n t o f her own b i a s e s r e g a r d i n g p r e v i o u s knowledge o f s u b j e c t s ' performance i n t h e n u r s i n g program and a c c o r d i n g l y , t r i e d t o c o n s c i o u s l y check 74 a g a i n s t t h i s . F o r example, one t h i r d - y e a r s u b j e c t , whom t h e r e s e a r c h e r knew p r e v i o u s l y as q u i t e n e g a t i v e , came a c r o s s i n t h e i n t e r v i e w as b e i n g v e r y p o s i t i v e towards computers. The f i r s t - y e a r s u b j e c t s who had not had any c o n t a c t w i t h t h e r e s e a r c h e r , had a d i f f e r e n t r e l a t i o n s h i p . These s u b j e c t s were not f a m i l i a r w i t h t h e r e s e a r c h e r as an i n s t r u c t o r , and i t was f e l t t h a t p e r c e i v e d i n c o n g r u e n c y o f r o l e would t h e r e f o r e be reduced o r n o n - e x i s t e n t . T h i s posed a v e r y d i f f e r e n t c o n s i d e r a t i o n f o r t h e r e s e a r c h e r . A c c o r d i n g l y , she worked e s p e c i a l l y h a r d a t i n c r e a s i n g t h e comfort l e v e l o f t h e s e s u b j e c t s , so t h a t t h e y f e l t r e l a x e d enough t o r e v e a l complete d a t a i n t h e i n t e r v i e w s . Time was spent g e t t i n g a c q u a i n t e d and i n r a p p o r t b u i l d i n g w i t h each f i r s t - y e a r s u b j e c t p r i o r t o t h e commencement o f each i n t e r v i e w . The r e s e a r c h e r was a l s o c o g n i z a n t o f h e r own p o s i t i v e a t t i t u d e t o w a r d computer use i n h o s p i t a l s , and c o n s c i o u s l y t r i e d not t o r e v e a l t h a t p o s i t i v e b i a s t o t h e s u b j e c t s . S e v e r a l s u b j e c t s asked t h e r e s e a r c h e r t o r e v e a l how she f e l t about computer use by n u r s e s , a f t e r t h e i r i n t e r v i e w had t e r m i n a t e d . The f a c t t h a t t h e y posed t h a t q u e s t i o n , a t t h a t p o i n t i n t h e i r i n t e r a c t i o n , s e r v e d as an i n d i c a t i o n t h a t s u b j e c t s were unable t o d e t e c t o r respond t o r e s e a r c h e r b i a s d u r i n g t h e a c t u a l a u d i o - t a p e d i n t e r v i e w . 75 A n a l y s i s Of I n t e r v i e w s Two s t r a t e g i e s were employed i n a n a l y z i n g d a t a g e n e r a t e d from t h e i n t e r v i e w s . A l t h o u g h t h e p r o c e s s o f a n a l y s i s o f d a t a was ongoing o r f o r m a t i v e t h r o u g h o u t t h e s t u d y , t h e more f o r m a l o r summative a n a l y s i s was done a f t e r a l l o f t h e d a t a was c o l l e c t e d and a l l t h e i n t e r v i e w s were t r a n s c r i b e d (Bogdan & B i k l e n , 1982). F o r t h e sake o f c l a r i t y o f d i s c u s s i o n , f o r m a t i v e and summative a n a l y s i s w i l l be d i s c u s s e d s e p a r a t e l y . F o r m a t i v e A n a l y s i s F o r m a t i v e a n a l y s i s i n c l u d e d what G l a s e r and S t r a u s s (1967) d e s c r i b e as t h e c o n s t a n t c o m p a r a t i v e method o f a n a l y s i s . T h i s i s a p r o c e s s whereby comparisons o f d a t a a r e made between and among s u b j e c t s from each y e a r sampled. I n t e r v i e w s were s c h e d u l e d t o ensure t h a t d a t a from f i r s t , second, and t h i r d - y e a r s t u d e n t s was c o l l e c t e d c o n c u r r e n t l y , so t h a t d i f f e r e n c e s i n c o n c e p t i o n s ( i f any) between, and ; among t h e y e a r s c o u l d be t e s t e d . Immediately a f t e r each i n t e r v i e w , and p r i o r t o t r a n s c r i b i n g t h e a u d i o t a p e s , t h e r e s e a r c h e r wrote a s h o r t summary o f t h o u g h t s , f e e l i n g s , and r e a c t i o n s t o t h e i n t e r v i e w , as w e l l as any u n u s u a l c i r c u m s t a n c e s which c o u l d i n f l u e n c e t h e q u a l i t y o f t h e s u b j e c t ' s r e s p o n s e s . D u r i n g an 76 i n t e r v i e w , one f i r s t - y e a r female s u b j e c t , r e v e a l e d t h a t she was not t h i n k i n g s t r a i g h t because she had j u s t found out t h a t h e r Dad had c a n c e r . A second-year s u b j e c t , even though she had j u s t found out she was pr e g n a n t , d i d not appear t o l e t t h i s news a f f e c t h e r r e s p o n s e s . A c i r c u m s t a n c e w i t h a d i f f e r e n t e m o t i o n a l component o c c u r r e d i n an i n t e r v i e w w i t h a t h i r d - y e a r female s u b j e c t . She had j u s t come from a j o b i n t e r v i e w where she had s u c c e s s f u l l y o b t a i n e d h e r f i r s t j o b as a n u r s e . She was v e r y n o t i c e a b l y e x c i t e d a t t h e o u t s e t o f t h e i n t e r v i e w , and gave v e r y s h o r t , t o - t h e - p o i n t answers u n t i l she s e t t l e d down about f i v e minutes i n t o t h e i n t e r v i e w , and t h e n o f f e r e d more d e t a i l e d r e s p o n s e s . D u r i n g t h e t r a n s c r i p t i o n , p r o c e s s , which i n v o l v e d l i s t e n i n g t o t h e t a p e s and t y p i n g t h e d i a l o g u e d i r e c t l y i n t o t h e computer, t h o u g h t s and a s s o c i a t i o n s between t r a n s c r i p t d a t a and i n s i g h t s which came t o t h e r e s e a r c h e r were a l s o r e c o r d e d as o b s e r v e r comments. Both t h e i n i t i a l o b s e r v e r comments, and t h o s e made d u r i n g t h e t r a n s c r i p t i o n p r o c e s s , were r e c o r d e d under t h e b r o a d headings o f : (a) c o n c e p t i o n s , and (b) a t t i t u d e . T h i s s e r v e d t o f o c u s t h e a n a l y s i s around t h e a r e a s o f i n t e r e s t i d e n t i f i e d by t h e r e s e a r c h q u e s t i o n s g u i d i n g t h e s t u d y . As t h e c o n c u r r e n t p r o c e s s o f d a t a c o l l e c t i o n and ongoing a n a l y s i s proceeded, i t became n e c e s s a r y t o s t o p p e r i o d i c a l l y and r e f l e c t on what appeared t o be emerging from t h e d a t a . Data g e n e r a t e d from s i x s u b j e c t s (two from each year) 77 c o n s i s t i n g o f t h e t r a n s c r i p t s and a l l o b s e r v e r comments were r e a d once a g a i n and a memo or summary was w r i t t e n o f what appeared t o be emerging. The t e c h n i q u e o f c o n s t a n t comparison between, and among y e a r s was used i n w r i t i n g t h e s e memos. T h i s p r o c e s s o f memo w r i t i n g was c a r r i e d out a f t e r each group o f s i x i n t e r v i e w s . T r a n s c r i p t s appeared w e l l used as t h e r e s e a r c h u n f o l d e d and each one had i d e a s j o t t e d i n margins, i m p o r t a n t s e c t i o n s u n d e r l i n e d , and key words and p h r a s e s used by s u b j e c t s c i r c l e d . A l l d a t a , i n c l u d i n g t r a n s c r i p t s , o b s e r v e r comments, and memos g e n e r a t e d when comparing each group o f s i x i n t e r v i e w s , were i d e n t i f i e d by number and f i l e d s y s t e m a t i c a l l y i n o r d e r t o f a c i l i t a t e r e t r i e v a l f o r use l a t e r i n t h e p r o c e s s o f a n a l y s i s . Ideas were t e s t e d w i t h s u b j e c t s , i n each y e a r , who were known by f a c u l t y t o be p e r c e p t i v e and a r t i c u l a t e . T h i s h e l p e d t o advance t h e f o r m a l a n a l y s i s o f t h e s t u d y (Bogdan & B i k l e n , 1982). A l t h o u g h t h e q u e s t i o n s oh t h e i n t e r v i e w s c h e d u l e c o n t i n u e d t o be asked as o r i g i n a l l y o u t l i n e d , more f o c u s e d p r o b i n g was used t o t e s t out hunches. Review o f t h e l i t e r a t u r e c o n t i n u e d f o r t h e purpose o f enhancing t h e a n a l y s i s and t h e g e n e r a t i o n o f t h e o r y . 78 Summative A n a l y s i s F o l l o w i n g t h e c o n c e n t r a t e d f o r m a t i v e p r o c e s s o f d a t a c o l l e c t i o n and a n a l y s i s , a s h o r t break was t a k e n from t h e st u d y t o a l l o w f o r r e f l e c t i o n and s y n t h e s i s o f i n f o r m a t i o n p r i o r t o t h e commencement o f summative a n a l y s i s . The overwhelming volume o f t r a n s c r i p t s , n o t e s , and memos i n d i c a t e d t h e need t o o r g a n i z e t h e d a t a i n t o a more manageable form, so t h a t r e l a t i o n s h i p s c o u l d be examined more r e a d i l y . I n i t i a l l y , t h e t r a n s c r i p t o f one s u b j e c t a t a ti m e was examined t o c a p t u r e t h e f u l l range and d i v e r s i t y o f t h e d a t a g e n e r a t e d by t h a t s u b j e c t . Then, a t t e n t i o n was f o c u s e d on i d e n t i f y i n g d a t a from t h a t i n d i v i d u a l s t r a n s c r i p t , under t h e two main b r o a d headings o f t h e st u d y , c o n c e p t i o n s and a t t i t u d e . A f t e r a t t i t u d i n a l and c o n c e p t i o n a l d a t a were i d e n t i f i e d from each o f t h e t h i r t y - f i v e t r a n s c r i p t s , a t t e n t i o n was t h e n . d i r e c t e d toward i d e n t i f y i n g r e l a t i o n s h i p s : (a) between t h e two br o a d h e a d i n g s , and (b) w i t h i n and between s u b j e c t s e n r o l l e d i n each y e a r o f t h e program. M a n i p u l a t i o n o f d a t a was f a c i l i t a t e d by use o f a computer. A s e p a r a t e computer f i l e was made f o r each s u b j e c t , under each o f t h e two b r o a d headings ( c o n c e p t i o n s and a t t i t u d e ) . Data s u p p o r t i n g each b r o a d h e a d i n g was p u l l e d from t h e s u b j e c t ' s t r a n s c r i p t and t y p e d i n t o t h e f i l e . A c o n s c i o u s attempt was made t o p r e s e r v e t h e s u b j e c t s ' 79 • p e r s p e c t i v e by u s i n g h i s \ h e r e x a c t words. As t h e s e f i l e s were dev e l o p e d , i t became c l e a r t h a t d a t a s u p p o r t i n g each h e a d i n g f u r t h e r s e p a r a t e d i t s e l f i n t o sub-headings. Hard c o p i e s o f t h e a t t i t u d e and c o n c e p t i o n f i l e s f o r each s u b j e c t were p r i n t e d and became w o r k i n g documents f o r f u r t h e r a n a l y s i s . F o r c l a r i t y o f p r e s e n t a t i o n , t h e p r o c e s s o f d a t a r e d u c t i o n and a n a l y s i s o f d a t a p e r t a i n i n g t o each o f t h e two br o a d h e a d i n g s , as w e l l as t h e respondent p r o f i l e s , a r e d i s c u s s e d s e p a r a t e l y . A n a l y s i s Of C o n c e p t u a l Data Because t h i s phenomenologic r e s e a r c h i s o f t h e second o r d e r p e r s p e c t i v e , aimed a t d e s c r i p t i o n , a n a l y s i s , and u n d e r s t a n d i n g o f s u b j e c t s ' views on computers i n h o s p i t a l s , t h e i r v iews were c o n s i d e r e d as c a t e g o r i e s o f d e s c r i p t i o n (Marton 1981). S e v e r a l s t e p s were i n v o l v e d i n g e n e r a t i n g c a t e g o r i e s which were grounded i n t h e d a t a . The f i r s t s t e p i n v o l v e d t h e g a t h e r i n g o f d a t a from each s u b j e c t ' s t r a n s c r i p t t h a t p e r t a i n e d t o h i s \ h e r . v i e w o r c o n c e p t i o n o f t h e r o l e o f computers i n h o s p i t a l n u r s i n g . T h i s d a t a was t y p e d i n t o a computer f i l e e n t i t l e d " c o n c e p t i o n s , " and t h e d a t a was c l e a r l y i d e n t i f i e d by u s i n g t h e same number as t h e s u b j e c t ' s t r a n s c r i p t . The second s t e p , aimed a t t h e g e n e r a t i o n o f c a t e g o r i e s o f c o n c e p t i o n , was t h e o r g a n i z a t i o n o f t h e c o n c e p t u a l d a t a 80 under t h e f o l l o w i n g f i v e sub-headings, which emerged from e a r l i e r a n a l y s i s : (a) awareness o f computer use i n h o s p i t a l n u r s i n g t o d a y , (b) knowledge o f how computers w i l l be used by nu r s e s w o r k i n g i n h o s p i t a l s i n t h e f u t u r e , (c) views on how computers may a f f e c t t h e j o b \ r o l e o f t h e nurse w o r k i n g i n a h o s p i t a l , (d) views on how computers may b e n e f i t n u r s e s w o r k i n g i n h o s p i t a l s , and (e) views on how computers may l i m i t n u r s e s w o r k i n g i n h o s p i t a l s . On f u r t h e r e x a m i n a t i o n o f a l l t h e d a t a on c o n c e p t i o n s , from each s u b j e c t , i t became e v i d e n t t h a t t h i s breakdown, a l t h o u g h u s e f u l f o r s t a r t i n g t o determine c a t e g o r i e s o f c o n c e p t i o n , a l t e r n a t e l y r e s u l t e d i n f r a g m e n t i n g t h e d a t a . To reduce t h i s f r a g m e n t a t i o n o f d a t a , which c o u l d l e a d t o i n a c c u r a t e a n a l y s i s and i n t e r p r e t a t i o n o f f i n d i n g s , a more g l o b a l approach t o t h e a n a l y s i s o f t h e d a t a on c o n c e p t i o n s was s u b s e q u e n t l y t a k e n . I t was d e c i d e d t o s e p a r a t e t h e d a t a on s u b j e c t s ' : (a) awareness o f computer use i n h o s p i t a l s ; t o d a y , and (b) knowledge o f how computers may be used by h o s p i t a l employed n u r s e s i n t h e f u t u r e , from t h e c o n c e p t i o n ' s f i l e . As i t was f e l t t h a t t h e s e f i n d i n g s would p r o v i d e t h e backbone o r c o n t e x t f o r s u b j e c t s ' o t h e r c o n c e p t i o n s c o n c e r n i n g computers i n h o s p i t a l n u r s i n g , t h e s e d a t a were a n a l y z e d , and r e p o r t e d s e p a r a t e l y . The r e s u l t i n g c a t e g o r i e s of d e s c r i p t i o n o f s u b j e c t ' s c o n c e p t i o n s o f t h e r o l e o f computers i n h o s p i t a l n u r s i n g , t h u s emerged from t h e r e m a i n i n g d a t a i n t h e c o n c e p t i o n f i l e . 81 Once a g a i n , t h e t r a n s c r i p t s , o b s e r v e r comments, and memos were r e v i e w e d , a l o n g w i t h t h e r e v i s e d c o n c e p t i o n s f i l e , and t o p i c s and t h o u g h t s which had been i n t r o d u c e d by t h e s u b j e c t s were i d e n t i f i e d . E x t e n s i v e l i s t s were made o f words, p h r a s e s , and s e n t e n c e s from t h e t h i r t y - f i v e i n t e r v i e w s w h i c h seemed t o d e s c r i b e t h e s u b j e c t s ' way o f t h i n k i n g . These l i s t s were t h e n reduced t o 43 themes (see Appendix H). These 43 themes were re-examined and r e l a t e d themes were grouped, r e s u l t i n g i n t h e emergence o f f o u r c a t e g o r i e s . The c a t e g o r i e s were named t o r e f l e c t t h e o v e r a l l n a t u r e o f t h e themes t h e y r e p r e s e n t e d (see Appendix I ) . A t t h i s p o i n t , i t became apparent t h a t s u b j e c t responses stemmed from c o n c e p t i o n s o f how computers impact h o s p i t a l employed n u r s e s , r a t h e r t h a n c o n c e p t i o n s o f t h e r o l e o f computers i n h o s p i t a l n u r s i n g . The b r o a d r e s e a r c h q u e s t i o n posed a t t h e o u t s e t o f t h e s t u d y was r e v i s e d t o r e a d : How do n u r s i n g s t u d e n t s i n a community c o l l e g e n u r s i n g program c o n c e p t u a l i z e t h e impact o f computers on h o s p i t a l employed n u r s e s ? The word p r o c e s s i n g f u n c t i o n o f t h e computer f a c i l i t a t e d o r g a n i z a t i o n o f d a t a under each o f t h e f o u r f i n a l c a t e g o r i e s o f c o n c e p t i o n s . Subsequent r e v i e w o f t h e d a t a d e t e r m i n e d t h e p r o p e r t i e s o r a t t r i b u t e s c h a r a c t e r i s t i c o f each c a t e g o r y , and t h e s e were grounded i n t h e d a t a t h r o u g h t h e use o f d i r e c t examples t a k e n from t h e t r a n s c r i p t s . T h i s w i l l be d i s c u s s e d i n some d e t a i l i n Chapter 4. Through t h e p r o c e s s o f c o n s t a n t comparison i t became 82 o b v i o u s t h a t some s u b j e c t s f o c u s e d t h e i r a t t e n t i o n on o n l y two c a t e g o r i e s o f c o n c e p t i o n s , w h i l e o t h e r s r e a d i l y d i s c u s s e d t h r e e o r f o u r . I t a l s o became e v i d e n t t h a t some s u b j e c t s chose t o d i s c u s s e i t h e r a l l p o s i t i v e o r n e g a t i v e c h a r a c t e r i s t i c s o f t h e c a t e g o r i e s chosen, w h i l e o t h e r s p r e s e n t e d b o t h . Comments from each s u b j e c t ' s t r a n s c r i p t were t h e n o r g a n i z e d a c c o r d i n g t o s u b - c a t e g o r i e s i n d i c a t i n g whether t h e s u b j e c t saw t h e use o f computers by h o s p i t a l employed n u r s e s as (a) enhancing, (b) d e t r a c t i n g from, o r (c) b o t h e n h a n c i n g and d e t r a c t i n g from t h a t c a t e g o r y . I n t u i t i v e l y , t h e r e s e a r c h e r c o u l d a s c e r t a i n a d i f f e r e n c e i n t h e q u a l i t y o f i n d i v i d u a l s u b j e c t s ' c o n c e p t i o n s and sought a means o f measuring t h i s . : Q u a n t i t a t i v e measures c o u l d be det e r m i n e d f o r : (a) t h e number o f c a t e g o r i e s o f c o n c e p t i o n s d i s c u s s e d by each s u b j e c t , and (b) whether t h e y saw each c a t e g o r y enhancing o r d e t r a c t i n g from t h e r o l e o f h o s p i t a l employed n u r s e s . I t became apparent t h a t t h e s e q u a n t i t a t i v e measures might s e r v e as one means o f d e t e r m i n i n g t h e c o m p l e x i t y o r q u a l i t y o f t h e s u b j e c t s ' c o n c e p t i o n s , and o f drawing comparisons between s u b j e c t s e n r o l l e d i n each y e a r o f t h e program.' The f i r s t s p e c i f i c r e s e a r c h q u e s t i o n posed a t t h e o u t s e t o f t h e s t u d y was s u b s e q u e n t l y r e v i s e d t o r e a d : I s t h e r e a d i f f e r e n c e i n c o m p l e x i t y between f i r s t , second, and t h i r d -y e a r n u r s i n g s t u d e n t s ' c o n c e p t i o n s o f t h e impact o f computers on h o s p i t a l employed n u r s e s ? 83 In an attempt t o answer t h i s r e v i s e d f i r s t s p e c i f i c r e s e a r c h q u e s t i o n , once a g a i n t h e t r a n s c r i p t s were r e v i s i t e d , but t h i s t i m e , t h e r e s e a r c h e r s e a r c h e d each t r a n s c r i p t f o r c o m p l e x i t y o f c o n c e p t i o n s , o r a q u a l i t a t i v e measure, t o deter m i n e how t h e c a t e g o r i e s and t h e i r p r o p e r t i e s were l i n k e d . D e t e r m i n a t i o n o f q u a l i t y o f c o n c e p t i o n s was made f i r s t l y by r e a d i n g a l l t h e c o n c e p t u a l d a t a from each s u b j e c t and i n t u i t i v e l y a r r a n g i n g them i n t h r e e p i l e s : h i g h , medium, and low l e v e l s o f c o n c e p t i o n . Secondly, t h e r e s e a r c h e r d e t e r m i n e d c o m m o n a l i t i e s w i t h i n each group o f t r a n s c r i p t s which prompted t h e r e s e a r c h e r t o r a t e them i n a c e r t a i n way. I t was d e c i d e d t h a t t h e r e was o f t e n a f i n e l i n e between t h e mi d d l e r a t i n g , and t h a t o f e i t h e r h i g h o r low. T h e r e f o r e , i t was d e c i d e d t o use j u s t t h e two o p p o s i t e r a t i n g s o f h i g h , and low l e v e l s o f c o m p l e x i t y o f c o n c e p t i o n s , i n o r d e r t h a t c l e a r d i s t i n c t i o n s might be found between s u b j e c t s i n each y e a r . A number o f c h a r a c t e r i s t i c s were used t o r a t e s u b j e c t s as h a v i n g e i t h e r h i g h o r low l e v e l s o f c o n c e p t i o n . S u b j e c t s w i t h low l e v e l c o n c e p t i o n s d i s c u s s e d t h e c a t e g o r i e s and whether t h e y f e l t t h e y would be enhanced o r d e t r a c t e d from, but d i d so i n s h o r t , " t o - t h e - p o i n t " answers, w i t h l i t t l e attempt t o q u a l i f y t h e i r s t a t e m e n t s . They t a l k e d about computers i n s i m p l i s t i c , m a g i c a l terms, o f t e n p o r t r a y i n g t h e f e e l i n g o f d i s b e l i e f . L i t t l e o r no attemp t s were made t o draw r e l a t i o n s h i p s between t h e i r e x p e r i e n c e s i n t h e c l i n i c a l s e t t i n g , o r t o r e f e r t o happenings i n o t h e r f i e l d s . They 84 o f t e n spoke as i f t h e y were removed from t h e s i t u a t i o n , and seemed r e l u c t a n t t o v o i c e o p i n i o n s o r s u g g e s t i o n s . S u b j e c t s who were r a t e d as h a v i n g h i g h l e v e l s o f c o n c e p t i o n appeared much more r e a l i s t i c i n t h e i r o p i n i o n s , and went beyond j u s t t a l k i n g about t h e c a t e g o r y t o o f f e r s u g g e s t i o n s and v o i c e p e r s o n a l views on i t . They tended t o d i s c u s s t r e n d s i n n u r s i n g , and s o c i e t y i n g e n e r a l , as w e l l as t o r e l a t e t h e d i s c u s s i o n t o t h e i r own c l i n i c a l e x p e r i e n c e s . Table 5 shows, d i a g r a m a t i c a l l y , what c h a r a c t e r i s t i c s were i n c l u d e d i n each l e v e l o f q u a l i t y o f c o n c e p t i o n . T a b l e 5. C h a r a c t e r i s t i c s Of Q u a l i t y Of C o n c e p t i o n LOW HIGH C a t e g o r i e s And S u b - C a t e g o r i e s H y p o t h e s i z e d About C a t e g o r i e s M a g i c a l , S i m p l i s t i c Q u a l i t y R e a l i s t i c D e t a i l e d Q u a l i t y Few R e l a t i o n s h i p s R e l a t e d To C l i n i c a l And Other Few O p i n i o n s O p i n i o n s And S u g g e s t i o n s D i s t a n c e d From S i t u a t i o n P e r s o n a l i z e d S i t u a t i o n The s u b j e c t s i n each y e a r , who f e l l i n t h e m i d d l e were e i t h e r moved t o h i g h e r , o r l o w e r , l e v e l s o f c o n c e p t i o n by r e v i e w i n g t h e i r t r a n s c r i p t s c o n s i d e r i n g t h e f o l l o w i n g : (a) t h e number o f c a t e g o r i e s d i s c u s s e d , (b) d i s c u s s i o n o f 85 whether each c a t e g o r y was enhanced o r d e t r a c t e d from, (c) t h e number o f c h a r a c t e r i s t i c s ( h i g h o r low) o f q u a l i t y o f c o n c e p t i o n , and (d) comparing t h e q u a l i t y o f t h e i r c o n c e p t i o n s w i t h t h o s e o f o t h e r s u b j e c t s i n t h e h i g h and low groups. Two f i r s t - y e a r s u b j e c t s , who f e l l i n t h e m i d d l e , w i l l s e r v e as examples o f t h i s p r o c e s s . The d e c i s i o n t o move one o f t h e s e f i r s t - y e a r s u b j e c t s t o t h e h i g h l e v e l o f c o n c e p t i o n was based on t h e f o l l o w i n g : (a) t h r e e c a t e g o r i e s d i s c u s s e d ; (b) b o t h enhancement and d e t r a c t i o n s o f two c a t e g o r i e s , and o n l y enhancement o f t h e t h i r d were d i s c u s s e d ; (c) made one r e f e r e n c e t o an i n c i d e n t e x p e r i e n c e d i n t h e h o s p i t a l , and t h i s i n c i d e n t was d i s c u s s e d i n r e l a t i o n t o how i t would be a f f e c t e d by computer use; (d) gave one o p i n i o n and s u g g e s t i o n f o r what might be done; (e) p e r s o n a l i z e d t h e d i s c u s s i o n on one o c c a s i o n ; and (f) t h e q u a l i t y o f c o n c e p t i o n was more congruent w i t h t h o s e o f s u b j e c t s p l a c e d i n t h e h i g h l e v e l . The d e c i s i o n t o move t h e o t h e r f i r s t - y e a r s u b j e c t who f e l l i n t h e m i d d l e t o t h e low l e v e l o f c o n c e p t i o n was based on t h e f o l l o w i n g : (a) t h r e e c a t e g o r i e s were d i s c u s s e d ; (b) b o t h enhancement and d e t r a c t i o n s o f two c a t e g o r i e s , and o n l y t h e d e t r a c t i o n s o f t h e t h i r d were d i s c u s s e d ; (c) one r e f e r e n c e o n l y t o h e r c l i n i c a l e x p e r i e n c e ; (d) one o p i n i o n i n r e l a t i o n t o employment i n a g l o b a l sense; (e) d i s t a n t from t h e s i t u a t i o n ; and (f) t h e q u a l i t y o f c o n c e p t i o n s was more congruent w i t h t h o s e o f s u b j e c t s p l a c e d i n t h e low l e v e l . 86 Frequency co u n t s and c h i - s q u a r e d i s t r i b u t i o n s were used t o d e t e r m i n e t h e r e l a t i o n s h i p between h i g h and low l e v e l o f c o n c e p t i o n s and s u b j e c t s ' : (a) y e a r i n t h e program, and (b) l e n g t h o f c l i n i c a l e x p e r i e n c e . These f i n d i n g s w i l l be p r e s e n t e d i n Chapter 4. A n a l y s i s Of A t t i t u d i n a l Data The f i r s t s t e p o f a n a l y s i s o f s u b j e c t s ' a t t i t u d e t oward t h e r o l e o f computers i n h o s p i t a l n u r s i n g , was i d e n t i f i c a t i o n o f d a t a i n t h e t r a n s c r i p t s which i n d i c a t e d a t t i t u d e . F i r s t l y , a computer f i l e named " a t t i t u d e " was c r e a t e d , and s e c o n d l y , s u b - f i l e s , c l e a r l y i d e n t i f i e d by number, were made f o r each s u b j e c t . At t h e b e g i n n i n g s t a g e o f a n a l y s i s , a t t i t u d i n a l d a t a was t a k e n v e r b a t i m from each t r a n s c r i p t and t y p e d i n t o each s u b j e c t ' s sub f i l e under th e f o l l o w i n g f o u r a r e a s : (a) i n i t i a l e x p e r i e n c e , (b) subsequent e x p e r i e n c e , (c) b a r r i e r s t o use, and (d) g e n e r a l a t t i t u d i n a l comments. O r g a n i z a t i o n o f t h e a t t i t u d i n a l d a t a i n t h i s manner, a t t h e o u t s e t , f a c i l i t a t e d t h e p r o c e s s o f d a t a r e d u c t i o n under headings which were more r e l e v a n t t o t h i s s t u d y . On f u r t h e r e x a m i n a t i o n o f t h e d a t a , i t became c l e a r t h a t t h e f i r s t t h r e e a r e a s , a l t h o u g h h e l p f u l i n terms of o r g a n i z i n g t h e volume of d a t a c o l l e c t e d , and i n p r e s e n t i n g a c l e a r p i c t u r e o f t h e s u b j e c t ' s e x p e r i e n c e w i t h computers, c o u l d not be used i n a s s e s s i n g s u b j e c t ' s a t t i t u d e toward t h e 87 role of computers i n hospital nursing. Although i t was inte r e s t i n g to know i f a subject's i n i t i a l and subsequent experiences with a computer were p o s i t i v e or negative, and to know the circumstances surrounding the development of these attitudes, these personal experiences were a l l unrelated to hospital nursing. The l i t e r a t u r e points to a co r r e l a t i o n between a subject's i n i t i a l and subsequent computer experience and his\her attitude toward a computer, but t h i s study did not set out to test such correlations. Subjects indicated a number of l o c a l b a r r i e r s to use of the Cariboo College VAX computer system. On r e f l e c t i o n , these were f e l t to be misplaced under the heading, "Analysis Of A t t i t u d i n a l Data". Data supporting barriers to computer usage was subsequently analyzed with other computer usage data i n the respondent p r o f i l e analysis section. A l l the data i d e n t i f i e d under the two areas: i n i t i a l experience, and subsequent experience with a computer, were not f e l t to be d i r e c t l y related to t h i s study. However, they provided the researcher with an indication of where each of the subjects were i n terms of t h e i r own personal comfort l e v e l and growth of attitude toward computer use i n general. This data was f e l t to influence the study i n d i r e c t l y , so i t was analyzed using frequency counts, and used to provide background information about the subjects enrolled i n each year of the program. The findings are reported i n Chapter 4 under the heading "Secondary Findings," and are also 88 d i s c u s s e d i n Chapter 5 i n terms o f making l o c a l recommendations as an outcome o f t h i s s t u d y . Three main sub-headings were c o n s i d e r e d i n d e t e r m i n i n g each s u b j e c t ' s a t t i t u d e t o w a r d t h e r o l e o f computers i n h o s p i t a l n u r s i n g . F i r s t l y , a l l s u b j e c t s r a t e d t hemselves on a f i v e p o i n t L i k e r t - t y p e a t t i t u d e s c a l e , f o r w hich a r a t i n g o f "1" was c o n s i d e r e d t o be n e g a t i v e , "2" m o d e r a t e l y n e g a t i v e , "3" n e u t r a l , "4" mo d e r a t e l y p o s i t i v e , and "5" p o s i t i v e . I f s t u d e n t s gave a range o f s c o r e s , o r r a t e d t h e m s e l v e s between t h e whole numbers on t h e s c a l e , t h e lo w e r number was c o n s i s t e n t l y t a k e n as t h e r a t i n g . S e c o n d l y , i t was n o t e d whether s u b j e c t s i n d i c a t e d a d e s i r e t o purchase a home computer, o r t a k e a computer c o u r s e . A p o s i t i v e response t o e i t h e r o f t h e s e q u e s t i o n s might i n d i c a t e a p o s i t i v e a t t i t u d e t oward computers, as i t i n d i c a t e d t h e s u b j e c t ' s d e s i r e t o commit t i m e and money toward l e a r n i n g t o use a computer. T h i s s t u d y d i d not s e t out t o determine i f s u b j e c t s ' : a t t i t u d e s toward computers i n g e n e r a l were c o n s i s t e n t w i t h t h e i r a t t i t u d e t oward computer use i n h o s p i t a l n u r s i n g . However, i t was i n t u i t i v e l y f e l t t h a t i f a s u b j e c t had a p o s i t i v e a t t i t u d e t oward computers i n g e n e r a l , he\she might a l s o have a p o s i t i v e a t t i t u d e t o w a r d computer use i n h o s p i t a l n u r s i n g . T h i r d l y , b o t h t h e t r a n s c r i p t s - and h a r d c o p i e s o f each s u b j e c t ' s a t t i t u d e f i l e made a t t h e o u t s e t o f t h e a n a l y s i s were r e v i s i t e d . A l l comments i n d i c a t i n g t h e s u b j e c t ' s 89 attitude toward the role of computers i n hospital nursing were examined, and examples of comments were c i t e d from the tra n s c r i p t s to ground the researcher's subjective rating of the subject's attitude i n the data. The outcome of t h i s process was to rate each subject as being either p o s i t i v e , neutral, or negative about computer use i n hospital nursing. Once an attitude rating was determined for each subject, attention was turned to answering the t h i r d research question. Like the others, t h i s one was also revised to read: What i s the relationship between nursing students' conceptions of the impact of computers on hospital employed nurses, and students' attitudes toward computers? Frequency counts, and percentages that had been determined e a r l i e r i n the study, were used as measures of high or low lev e l s of conception and p o s i t i v e or negative attitude. The s t a t i s t i c a l significance of relationships was tested between the two variables by using the chi-square d i s t r i b u t i o n . These findings are presented i n Chapter 4. Analysis of Respondent P r o f i l e s Frequency counts, means, and percentages were used to analyze the data generated from the respondent p r o f i l e s . Demographic data was analyzed, including: (a) age, (b) educational experience p r i o r to entering the Cariboo College nursing program, (c) education s p e c i f i c to computing 90 ( e x c l u d i n g e x p e r i e n c e i n t h e C a r i b o o C o l l e g e n u r s i n g program), and (d) a c c e s s t o a computer a t home. Computer usage d a t a was a n a l y z e d i n c l u d i n g : (a) use a t home, (b) use a t C a r i b o o C o l l e g e , (c) b a r r i e r s t o use, and (d) f a m i l y use ( o t h e r t h a n v i d e o games). F i n d i n g s from t h i s d a t a p r o v i d e d t h e r e s e a r c h e r w i t h a c l e a r e r p i c t u r e o f t h e backgrounds o f C a r i b o o C o l l e g e s u b j e c t s i n terms of t h e i r computer knowledge and use. F i n d i n g s from t h e respondent p r o f i l e s a r e r e p o r t e d i n C h a pter 4 . under t h e h e a d i n g "Secondary F i n d i n g s . " E s t a b l i s h i n g V a l i d i t y And R e l i a b i l i t y A number of s t r a t e g i e s were employed t o enhance v a l i d i t y and r e l i a b i l i t y t h r o u g h each s t e p o f t h i s s t u d y . R e l i a b i l i t y i s c oncerned w i t h t h e r e p l i c a b i l i t y o f r e s e a r c h f i n d i n g s , and v a l i d i t y i s concerned w i t h t h e a c c u r a c y o f t h o s e f i n d i n g s . R e l i a b i l i t y and v a l i d i t y w i l l be d i s c u s s e d i n terms of e s t a b l i s h i n g b o t h e x t e r n a l and i n t e r n a l c o n t r o l s f o r each. A number o f c o n t r o l s were employed t o enhance e x t e r n a l r e l i a b i l i t y , o r t h e e x t e n t t o which independent r e s e a r c h e r s w o r k i n g i n t h e same or s i m i l a r c o n t e x t would o b t a i n c o n s i s t e n t r e s u l t s . A t t h e o u t s e t , c a r e was t a k e n t o d e s c r i b e t h e s t r u c t u r e o f t h e n u r s i n g program i n t h e community c o l l e g e where t h e s t u d y t o o k p l a c e , and t o i d e n t i f y i t s s t r u c t u r e i n terms of l e n g t h , and t h e number of c l i n i c a l h ours i n each y e a r . The p r o c e s s o f t h e s e l e c t i o n o f s u b j e c t s 91 i n c l u d e d such d e t a i l s as how t h e y were c o n t a c t e d , and t h e r o l e o f t h e r e s e a r c h e r i n r e l a t i o n t o them. The s e t t i n g and c o n d i t i o n s under which t h e i n t e r v i e w s t o o k p l a c e , t h e i n t e r v i e w t o o l , and d e t a i l s o f how t h e i n t e r v i e w s were conducted were a l s o d e s c r i b e d i n d e t a i l . I n a d d i t i o n , an o u t l i n e o f t h e computer c o n t e n t i n each semester o f t h e n u r s i n g program was i n c l u d e d . A n a l y s i s o f i n t e r v i e w s , i n terms o f b o t h f o r m a t i v e and summative a n a l y s i s , and a d e t a i l e d d e s c r i p t i o n o f how c a t e g o r i e s o f d e s c r i p t i o n were a r r i v e d a t , was g i v e n c o n s i d e r a b l e a t t e n t i o n . I n t e r n a l r e l i a b i l i t y , o r t h e q u e s t i o n o f whether, w i t h i n a s i n g l e s t u d y , m u l t i p l e o b s e r v e r s would agree (LeCompte & Goetz, 1982) was d e a l t w i t h i n a number o f ways. I n t e r v i e w s were t a p e r e c o r d e d t o p r e s e r v e a l l d a t a and t h e i n t e r v i e w s were s u b s e q u e n t l y t r a n s c r i b e d v e r b a t i m . To determine i n t e r -r a t e r r e l i a b i l i t y , c l e a n c o p i e s o f t h e same f o u r i n t e r v i e w t r a n s c r i p t s , and c o p i e s o f t h e d r a f t s g e n e r a t e d d u r i n g each s t e p o f t h e d a t a r e d u c t i o n p r o c e s s were g i v e n t o b o t h t h e s i s a d v i s o r s . Each a d v i s o r was asked t o r e a d t h e d a t a and t o i n d e p e n d e n t l y a s s e s s t h e r e s e a r c h e r ' s a n a l y s i s o f i t , w i t h t h e r e s u l t t h a t each a d v i s o r c o n c u r r e d w i t h t h e r e s e a r c h e r ' s assessment. I n a d d i t i o n , t h e r e s e a r c h e r used v e r b a t i m comments from s u b j e c t ' s t r a n s c r i p t s t o support f i n d i n g s . V a l i d i t y i s b e l i e v e d t o be a s t r e n g t h o f t h i s t y p e o f r e s e a r c h (LeCompte & Goetz, 1982). To enhance i n t e r n a l v a l i d i t y i n terms o f h i s t o r y and m a t u r a t i o n , a l l i n t e r v i e w s 92 were conducted i n a two month p e r i o d (March and A p r i l , 1988) Observer e f f e c t s were c o n t r o l l e d i n t h e f o l l o w i n g ways: (a) s u b j e c t s were i n f o r m e d t h a t t h e i r s t a t u s as s t u d e n t s a t C a r i b o o C o l l e g e would i n no way be a f f e c t e d by t h e i r p a r t i c i p a t i o n o r n o n - p a r t i c i p a t i o n i n t h e s t u d y ; (b) observe comments, which i n c l u d e d o b s e r v a t i o n s o f s u b j e c t ' s b e h a v i o r d u r i n g t h e i n t e r v i e w were w r i t t e n a f t e r each i n t e r v i e w , and t h e s e o b s e r v a t i o n s were n o t e d where i t was f e l t t o have a f f e c t e d t h e f i n d i n g s ; and (c) s u b j e c t s were o f f e r e d c o p i e s o f t h e i r t r a n s c r i p t s . S e l e c t i o n and s a m p l i n g f o l l o w e d r i g o r o u s i d e n t i f i c a t i o n o f subgroups w i t h i n t h e t o t a l s t u d e n t p o p u l a t i o n , and t h e n d e c i s i o n s were made t o i n c l u d e an e q u a l number of f i r s t , second, and t h i r d - y e a r female s u b j e c t s , because t h e m a j o r i t y o f s t u d e n t s i n each c l a s s was female, and t h e c l a s s s i z e s were r e l a t i v e l y e q u a l . As each c l a s s had male s t u d e n t s , i t was t h e n d e c i d e d t o i n c l u d e them t o enhance t h e v a l i d i t y o f t h e f i n d i n g s . The r e g i s t e r e d p s y c h i a t r i c n u rse (R.P.N.) group was e x c l u d e d , because t h a t group would not be i n c l u d e d i n p o p u l a t i o n s o f n u r s i n g s t u d e n t s i n o t h e r programs. M o r t a l i t y was not a problem i n t h i s s t u d y . T h r e a t s t o e x t e r n a l v a l i d i t y a re t h o s e e f f e c t s t h a t o b s t r u c t o r reduce a s t u d y ' s c o m p a r a b i l i t y and g e n e r a l i z a b i l i t y . The r e s e a r c h e r i d e n t i f i e d t h e audience t o which t h e s e r e s u l t s might be g e n e r a l i z e d e a r l y i n t h e r e s e a r c h as b e i n g community c o l l e g e n u r s i n g programs, and 93 acknowledged t h e f a c t t h a t even though t h e s e programs d i f f e r i n terms of. l e n g t h and r e q u i r e d number o f c l i n i c a l h o u r s , t h e y share a common mandate. Care was t a k e n t o use common n u r s i n g t e r m i n o l o g y t o d e f i n e c a t e g o r i e s which would have meaning i n any n u r s i n g e d u c a t i o n a l s e t t i n g . S u b j e c t s were a l l a sked t h e same q u e s t i o n s , i n t h e o r d e r l i s t e d i n t h e i n t e r v i e w s c h e d u l e , t o a l l o w f o r comparisons t o be drawn a c r o s s and between y e a r s . Summary In summary, d a t a a n a l y s i s f o r t h i s s t u d y was c a r r i e d out b o t h on a f o r m a t i v e and a summative b a s i s . A c o m b i n a t i o n o f s t r a t e g i e s f o r a n a l y s i s was employed when a n a l y z i n g i n t e r v i e w t r a n s c r i p t s . These s t r a t e g i e s i n c l u d e d : (a) a n a l y t i c i n d u c t i o n , (b) c o n s t a n t comparison, (c) t y p o l o g i c a l a n a l y s i s , and (d) enumeration (Gpetz & LeCompte, 1984). A n a l y t i c i n d u c t i o n was used i n i t i a l l y t o scan t h e d a t a f o r c o d i n g c a t e g o r i e s and f o r r e l a t i o n s h i p s among c a t e g o r i e s . Constant comparison a c r o s s c a t e g o r i e s was used t h r o u g h o u t , and t y p o l o g i c a l a n a l y s i s was used t o a n a l y z e c o n c e p t u a l d a t a i n o r d e r t o p l a c e i t i n a taxonomy. In a d d i t i o n , enumeration, o r t h e use o f f r e q u e n c y c o u n t s , was employed t o add a q u a n t i t a t i v e d i m e n s i o n t o t h e d a t a , so t h a t comparisons between s u b j e c t s i n each y e a r c o u l d be made. 94 CHAPTER 4 F i n d i n g s As t h e r e s e a r c h u n f o l d e d , i t became e v i d e n t t h a t t h e f i n d i n g s d i v i d e d n a t u r a l l y i n t o two d i s t i n c t groups: (a) p r i m a r y f i n d i n g s , o r t h o s e f i n d i n g s r e l a t e d t o t h e r e s e a r c h q u e s t i o n s posed a t t h e o u t s e t , and (b) secondary f i n d i n g s , o r t h o s e r e l a t e d t o t h e s u b j e c t s ' i n d i v i d u a l computer use and computer e x p e r i e n c e s w h i l e e n r o l l e d as s t u d e n t s i n t h e C a r i b o o C o l l e g e d i p l o m a n u r s i n g program. P r i m a r y f i n d i n g s w i l l be p r e s e n t e d by u s i n g t h e r e s e a r c h q u e s t i o n s as a g u i d e . F o r c l a r i t y o f p r e s e n t a t i o n , f i n d i n g s i n r e l a t i o n t o c o n c e p t i o n s w i l l be d i s c u s s e d f i r s t , because r e l a t i o n s h i p s a r e drawn l a t e r between c o n c e p t i o n s and o t h e r v a r i a b l e s . F i n d i n g s under t h e h e a d i n g " C o n c e p t u a l F i n d i n g s " w i l l be o r g a n i z e d under f i v e sub-headings: (a) awareness o f computer use by h o s p i t a l employed n u r s e s t o d a y , (b) c o n c e p t i o n s o f how computers w i l l be used by h o s p i t a l employed n u r s e s i n t h e f u t u r e , (c) c a t e g o r i e s o f c o n c e p t i o n s o f how computers impact h o s p i t a l employed n u r s e s , (d) c o m p l e x i t y o f c o n c e p t i o n s , and (e) r e l a t i o n s h i p o f c o n c e p t i o n t o c l i n i c a l e x p e r i e n c e . F i n d i n g s under t h e he a d i n g " A t t i t u d i n a l F i n d i n g s " w i l l be a d d r e s s e d under t h r e e sub-headings: (a) d e s i r e t o purchase a computer o r t o t a k e a c o u r s e , (b) r a t i n g on an a t t i t u d i n a l s c a l e , and (c) r e l a t i o n s h i p between c o n c e p t i o n 95 and a t t i t u d e . Secondary f i n d i n g s w i l l be p r e s e n t e d under two sub-h e a d i n g s : (a) demographics, and (b) computer a c c e s s and usage. The c h a p t e r c o n c l u d e s w i t h a summary o f b o t h t h e p r i m a r y and secondary f i n d i n g s . P r i m a r y F i n d i n g s C o n c e p t u a l F i n d i n g s The b r o a d r e s e a r c h q u e s t i o n was r e v i s e d as t h e s t u d y u n f o l d e d , t o r e a d : How do n u r s i n g s t u d e n t s i n a community c o l l e g e n u r s i n g program c o n c e p t u a l i z e t h e impact o f computers on h o s p i t a l employed n u r s e s ? C o n c e p t i o n s , o r t h o u g h t s , a r e formed by b o t h our knowledge o f p r e s e n t happenings and our e x p e c t a t i o n s o f f u t u r e e v e n t s . T h e r e f o r e , as a p o i n t o f d e p a r t u r e i n a d d r e s s i n g t h i s q u e s t i o n , d e s c r i p t i v e d a t a and f r e q u e n c y c o u n t s o f s u b j e c t s ' responses w i l l be r e p o r t e d t o i l l u s t r a t e t h e i r : (a) awareness o f computer use i n h o s p i t a l n u r s i n g today, and (b) knowledge o f how computers w i l l be used by h o s p i t a l employed n u r s e s i n t h e f u t u r e . 96 Awareness Of Computer Use By H o s p i t a l Employed Nurses Today Computer t e r m i n a l s were not a v a i l a b l e on n u r s i n g u n i t s a t R o y a l I n l a n d H o s p i t a l a t t h e t i m e o f t h e s t u d y (March and A p r i l , 1988). T h e r e f o r e , s u b j e c t s d i d not see n u r s e s u s i n g computer t e r m i n a l s as t h e y c a r r i e d out t h e i r j o b s \ r o l e s . E i g h t f i r s t - y e a r , n i n e second-year, and f i v e t h i r d - y e a r s u b j e c t s commented on t h i s f a c t . One f i r s t - y e a r s u b j e c t s t a t e d : " I c a n ' t even p i c t u r e i n my mind where t h e computers would be set-up...how t h e y would have i t . " S i x f i r s t - y e a r , s i x second-year, and seven t h i r d - y e a r s u b j e c t s i n d i c a t e d awareness t h a t computers were b e i n g used i n t h e l a b a t t h e l o c a l h o s p i t a l . S e v e r a l s u b j e c t s d i s c u s s e d t h e f a c t t h a t : c o m p u t e r i z e d l a b r e s u l t s a f f e c t e d t h e n urse i n d i r e c t l y . I t p r o v i d e d him\her w i t h l e g i b l e r e s u l t s t h a t were a v a i l a b l e q u i c k l y . Norms p r i n t e d on t h e r e p o r t s a i d e d t h e n u r s e i n d o i n g p a t i e n t assessments. Three t h i r d - y e a r s u b j e c t s c i t e d computers which a r e c onnected d i r e c t l y t o t h e l a b , t o f a c i l i t a t e speed i n r e p o r t i n g r e s u l t s t o such c r i t i c a l c a r e a r e a s as, t h e i n t e n s i v e c a r e u n i t (I.C.U.) and i n t e n s i v e c a r e n u r s e r y (I.C.N.) u n i t , a t R o y a l I n l a n d H o s p i t a l . I t i s i m p o r t a n t t o note t h a t s u b j e c t s i n a l l t h r e e y e a r s o f t h e program had l a b t o u r s s c h e d u l e d as p a r t o f t h e i r c l i n i c a l e x p e r i e n c e when t h e y were e n r o l l e d i n semester 2 o f t h e program. S u b j e c t s mentioned s e v e r a l o t h e r a r e a s i n t h e l o c a l 97 h o s p i t a l where t h e y thought computers were b e i n g used. Two f i r s t - y e a r , and f o u r t h i r d - y e a r s u b j e c t s n o t e d t h a t computers were b e i n g used i n t h e A d m i t t i n g Department. One f i r s t - y e a r and one second-year s u b j e c t thought t h e y were b e i n g used i n the r e c o r d s department, w h i l e one second-year s t u d e n t n o t e d t h e i r use i n X-ray. One f i r s t , one second, and t h r e e t h i r d -y e a r s u b j e c t s n o t e d t h e i r use i n t h e Pharmacy Department. The h o s p i t a l ' s a d m i n i s t r a t i v e f u n c t i o n s were f e l t by one f i r s t - y e a r and f i v e second-year s u b j e c t s t o be c o m p u t e r i z e d . T h i r d - y e a r s u b j e c t s d i d not mention t h e h o s p i t a l ' s a d m i n i s t r a t i v e f u n c t i o n s , a l t h o u g h t h e y a r e p r e s e n t l y c o m p u t e r i z e d . S p e c i f i c examples o f a d m i n i s t r a t i v e uses n o t e d by s u b j e c t s i n c l u d e d : o p e r a t i n g room (OR) s c h e d u l i n g , p a y r o l l , s t o c k t a k i n g , d a t a s t o r a g e o f r e c o r d s , and bed a v a i l a b i l i t y . One f i r s t , one second, and no t h i r d - y e a r s u b j e c t s i d e n t i f i e d m o n i t o r s , c o m p u t e r i z e d (IVAC) thermometers, and c o m p u t e r i z e d i n t r a v e n o u s (IMED) c o n t r o l l e r s as ways computers were b e i n g used a t t h e h o s p i t a l . S u b j e c t s v a r i e d i n t h e i r awareness t h a t t h e l o c a l h o s p i t a l was i n t h e b e g i n n i n g p r o c e s s o f i m p l e m e n t i n g a t o t a l h o s p i t a l computer system. One f i r s t - y e a r s u b j e c t n o t e d t h a t she was not r e a l l y t o o s u r e o f what was happening w i t h computers r i g h t now i n t h e h o s p i t a l , w h i l e a n o t h e r f e l t , " they a r e coming." One second-year s u b j e c t mentioned t h a t she had h e a r d t h a t , "they a r e coming and I f e e l t h a t from t h e way p e o p l e are t a l k i n g , computers are moving i n t o t h e system 98 f a s t . " A second-year s u b j e c t , who had worked i n t h e M e d i c a l Records Department o f t h e h o s p i t a l , knew t h a t t h e h o s p i t a l was c h a n g i n g over t o a computer system. T h i r d - y e a r s u b j e c t s seemed more i n f o r m e d , but gave a v a r i e t y o f r e s p o n s e s , i n terms o f t h e t i m e frame f o r i m p l e m e n t a t i o n . One t h i r d - y e a r s u b j e c t n o t e d , " T h e y ' l l be o n l i n e a t t h e end o f t h e summer o r something...I t h i n k t h a t i s t h e p l a n . " A n o t h e r s t a t e d , " I t h i n k t h a t h o p e f u l l y t h e y w i l l be g e t t i n g them i n t h e new wing, which i s s c h e d u l e d t o open i n t h e summer." Two s u b j e c t s n o t e d t h a t i t l o o k e d l i k e we were f i v e y e a r s away from g e t t i n g them on t h e f l o o r s . O thers were l e s s s p e c i f i c as i n d i c a t e d by t h e f o l l o w i n g comments: (a) " I t i s g o i n g t o come i n t o our h o s p i t a l " , (b) " q u i t e a ways i n t h e f u t u r e , " and (c) "the p l a n i s d e f i n i t e l y i n t h e f u t u r e f o r R.I.H. t o become c o m p u t e r i z e d . " F i r s t , second, and t h i r d - y e a r s u b j e c t s were not v e r y aware of what was happening i n h o s p i t a l s o u t s i d e o f Kamloops, as i n d i c a t e d by t h e s e t e n examples o f t h e i r comments: 1. I'm not aware o f them b e i n g used i n o t h e r c e n t e r s . 2. I'm not aware of a l o t t h a t i s happening i n n u r s i n g w i t h computers t o d a y . 3. I'm not aware of them b e i n g used by n u r s e s . 4. I'm not r e a l l y aware of what's happening o r what's b e i n g done w i t h computers i n n u r s i n g e l s e w h e r e . 5. I don't know how comprehensive o t h e r h o s p i t a l s a r e . 6. I'm not aware of what i s g o i n g on. I don't r e a l l y know t h a t much about i t . 7. I'm not aware of a n y t h i n g happening i n t h e p r o v i n c e . 8. I haven't r e a l l y thought about, i t or d i s c u s s e d i t w i t h anybody. 9. I don't know enough about t h e f i e l d . 10. I don't know what i s g o i n g on anywhere e l s e . S e v e r a l s u b j e c t s made r e f e r e n c e t o happenings w i t h i n B r i t i s h Columbia, but t h e i r awareness o f p r o v i n c i a l happenings was m i n i m a l . A f i r s t - y e a r s u b j e c t n o t e d t h a t her husband had undergone h e a r t s u r g e r y a t S t . P a u l ' s ' H o s p i t a l i n Vancouver, and s p e c u l a t e d t h a t computers were i n v o l v e d i n h i s c a r e , even though she i n d i c a t e d t h a t n e i t h e r she nor her husband was aware t h a t "the h o s p i t a l was i n v a d e d by computers." A second-year s u b j e c t s t a t e d , " I imagine t h e y a r e b e i n g used i n p l a c e s l i k e C h i l d r e n ' s b u t , I'm t a k i n g b i g quesses h e r e . " Another second-year s u b j e c t n o t e d t h a t h e r mother worked as a n urse i n V i c t o r i a and used computers, but t h a t she had never d i s c u s s e d i t w i t h h e r . One t h i r d - y e a r s u b j e c t n o t e d t h a t t h e Pharmacy i n Salmon Arm H o s p i t a l where she d i d h e r p e r c e p t o r s h i p had a computer, w h i l e a n o t h e r thought t h e y would not have computers i n s m a l l e r h o s p i t a l s . A n o t h e r t h i r d - y e a r s u b j e c t n o t e d t h a t t h e h o s p i t a l s i n Nanaimo and a l l t h e d o c t o r ' s o f f i c e s were b e i n g c onnected t o a c e n t r a l computer, w h i l e another thought t h a t t h e y were b e i n g used i n h o s p i t a l s "back e a s t i n T o r o n t o . " S u b j e c t s ' awareness of computer use by n u r s e s i n o t h e r p r o v i n c e s o f Canada was a l s o m i n i m a l . One second-year s u b j e c t s t a t e d t h a t she had h e a r d a w h i l e ago t h a t t h e h o s p i t a l s i n Newfoundland were b e i n g l i n k e d by computer t o t r y i t o u t , and she s p e c u l a t e d t h a t t h i s would s p r e a d r i g h t a c r o s s t h e c o u n t r y . S u b j e c t s ' seemed s l i g h t l y more aware o f happenings i n t h e U n i t e d S t a t e s . A f i r s t - y e a r s u b j e c t 100 v a g u e l y r e c a l l e d t h a t one o f t h e t e a c h e r s had spoken t o them i n c l a s s about computers i n a h o s p i t a l i n C a l i f o r n i a . Two second-year s u b j e c t s r e f e r r e d t o t h e v i d e o about a t o t a l h o s p i t a l system t h a t t h e y had seen w h i l e i n t h e f i r s t y e a r o f t h e n u r s i n g program. I t showed a p a t i e n t a d m i t t e d t o a h o s p i t a l i n C a l i f o r n i a , and how computers had i n f l u e n c e d h i s c a r e . T h i r d - y e a r s u b j e c t s made t h e f o l l o w i n g comments: 1. I know t h a t t h e r e a r e h o s p i t a l s i n t h e S t a t e s t h a t are almost e n t i r e l y run by computers. 2. I've h e a r d t h a t some h o s p i t a l s i n t h e S t a t e s have computers and t h e y use them a t t h e b e d s i d e a l s o . 3. They a r e i n t h e n u r s i n g s t a t i o n s . I know t h a t ' s happening now, somewhere i n t h e S t a t e s . 4. I b e l i e v e t h a t computers are used by n u r s e s i n t h e S t a t e s . 5. They a r e used a l o t more i n t h e S t a t e s and t h a t t h e y w i l l e v e n t u a l l y be coming up t o Canada. E v i d e n c e s u g g e s t e d t h a t a s m a l l number of s u b j e c t s had r e a d a r t i c l e s p e r t a i n i n g t o computers i n n u r s i n g . D u r i n g t h e c o u r s e o f t h e i n t e r v i e w s , t h r e e f i r s t - y e a r s u b j e c t s made r e f e r e n c e t o t h i n g s t h e y had r e a d . One second-year s u b j e c t commented, "I ' v e done t h e r e a d i n g s t h a t were p e r t i n e n t t o t h e papers we handed i n i n t h e P e r s p e c t i v e s Course on n u r s i n g i n t h e f u t u r e , but t h a t was a l l . I d i d n ' t get i n t o any e x t r a s . " That same s u b j e c t made t h e comment, "my background i s l a c k i n g , but I am a s t u d e n t . " Two t h i r d - y e a r s u b j e c t s r e v e a l e d t h a t t h e y had r e a d a number of a r t i c l e s and s u b s e q u e n t l y w r i t t e n papers on Computers In N u r s i n g . B o t h brought t h e i r papers t o t h e i n t e r v i e w and one s u b j e c t r e a d from h i s paper t o i l l u s t r a t e a p o i n t b e i n g made i n t h e i n t e r v i e w . Two o t h e r t h i r d - y e a r s u b j e c t s made r e f e r e n c e t o 101 a r t i c l e s t h e y had r e a d . Only two s u b j e c t s had a c t u a l l y seen a computer used by n u r s e s o r had used one p e r s o n a l l y i n a h o s p i t a l s e t t i n g . A f i r s t - y e a r s u b j e c t had worked as a candy s t r i p e r i n a h o s p i t a l i n V i c t o r i a , and she had seen computers t h a t were b e i n g p i l o t e d i n a n u r s i n g s t a t i o n t o keep t r a c k o f p a t i e n t ' s room as s i g n m e n t s . A second-year s u b j e c t had r e c e i v e d a week's t r a i n i n g , and she had d i r e c t work e x p e r i e n c e w i t h t h e o r i g i n a l computers i n t h e m e d i c a l r e c o r d s department a t R o y a l I n l a n d H o s p i t a l . Her comment was, "I'm o n l y j u s t aware o f what I've worked w i t h i n m e d i c a l r e c o r d s . " A t t h i s p o i n t i n t i m e , s u b j e c t s d i d not seem t o p e r s o n a l i z e t h e use o f computers i n t h e h o s p i t a l s e t t i n g , as e v i d e n c e d by t h e s e two comments from f i r s t - y e a r s u b j e c t s : " I t i s not r e a l l y i m p a c t i n g me r i g h t now," and "I'm not r e a l l y aware o f any b i g impact on me as a n u r s e . " One second-year s u b j e c t commented, " I don't f e e l l i k e I have much t o do w i t h them. I don't t h i n k i t p e r t a i n s t o me a t a l l . " O t h ers n o t e d : 1. I t h i n k t h e y a r e good f o r l a b r e s u l t s but t h e y don't d i r e c t l y r e l a t e t o me a t a l l a t t h i s p o i n t . My work ...what I'm d o i n g i n t h e h o s p i t a l i s not b e i n g h e l p e d by computers,I don't t h i n k . You see v e r y l i t t l e o f i t i n n u r s i n g . 2. I'm not r e a l l y aware of how t h e y a r e i m p a c t i n g me i n d i r e c t l y . 3. A p p l y i n g them t o my j o b i s h a r d f o r me t o say because I'm not r e a l l y w o r k i n g w i t h them p e r se. Computers have not impacted me as f a r as a p r a c t i c a l f a s h i o n i n t h e c l i n i c a l s e t t i n g . 4. I haven't had enough exposure t o know much more. 5. I've never r e a l l y seen t h e a p p l i c a t i o n . 102 I n summary, s u b j e c t s ' awareness o f computer use i n h o s p i t a l s t o d a y appeared t o c e n t e r m a i n l y around t h e i r l o c a l e x p e r i e n c e s . D i r e c t hands-on e x p e r i e n c e by s u b j e c t s t o computers i n t h e h o s p i t a l s e t t i n g was n o n - e x i s t e n t . A l t h o u g h s e v e r a l s u b j e c t s n o t e d a r t i c l e s t h e y had r e a d and a v i d e o t h e y had been shown i n f i r s t y e a r n u r s i n g , t h e m a j o r i t y o f s u b j e c t s were unaware o f happenings on b o t h t h e p r o v i n c i a l and n a t i o n a l scene. A s m a l l number o f s u b j e c t s were v a g u e l y aware t h a t h o s p i t a l s i n t h e U n i t e d S t a t e s were more advanced i n terms o f t e c h n o l o g y . S u b j e c t s ' awareness d i d not appear t o i n c r e a s e d r a m a t i c a l l y as t h e y p r o g r e s s e d i n t h e program, a l t h o u g h t h i r d y e a r s u b j e c t s p r o v i d e d more d e t a i l e d d e s c r i p t i o n s o f t h e i r c o n c e p t i o n s . I t appears t h e n t h a t a l l t h i r t y - f i v e s u b j e c t s have next t o no awareness o f computer use i n h o s p i t a l s l o c a l l y , p r o v i n c i a l l y , o r n a t i o n a l l y . Knowledge Of How Computers May Be Used By H o s p i t a l Employed  Nurses I n The F u t u r e S u b j e c t s ' knowledge o f how computers may be used by h o s p i t a l employed nu r s e s i n t h e f u t u r e , c e n t e r e d around t h r e e b r o a d a r e a s : (a) n u r s i n g , (b) a d m i n i s t r a t i o n , and (c) communication. Two o f t h e s e a r e a s i n v o l v e d i r e c t computer use by n u r s e s , w h i l e t h e o t h e r i n v o l v e s i n d i r e c t use. Appendix J d e t a i l s t h e items c i t e d by s u b j e c t s i n t h e i r i n t e r v i e w s , under each o f t h e s e t h r e e b r o a d a r e a s . In 103 a d d i t i o n , s e v e r a l s u b j e c t s r e p o r t e d t h e i r t h o u g h t s o f where, and when computers might be p h y s i c a l l y p l a c e d on t h e n u r s i n g u n i t s . F i r s t l y , f i n d i n g s o f s u b j e c t s ' views o f how computers may be used by h o s p i t a l employed n u r s e s i n t h e f u t u r e w i l l be r e p o r t e d , f o l l o w e d , s e c o n d l y , by f i n d i n g s r e l a t e d t o s u b j e c t s ' t h o u g h t s o f where, and when t h i s might o c c u r . The f i r s t b r o a d a r e a " n u r s i n g , " i n c l u d e d d i r e c t computer use by t h e n u r s e : (a) as a t e a c h i n g t o o l , (b) f o r p h y s i o l o g i c a l m o n i t o r i n g , (c) f o r documentation, (d) f o r p l a n n i n g n u r s i n g c a r e , and (e) as a r e f e r e n c e s o u r c e . Computer use by n u r s e s f o r documentation purposes was t h e one ar e a t h a t t h e m a j o r i t y o f s u b j e c t s n o t e d (91% f i r s t - y e a r , 91% second-year, and 69% t h i r d - y e a r ) . One t h i r d - y e a r s u b j e c t however, s t a t e d t h a t she d i d not t h i n k we'd see a whole l o t of t h e n a r r a t i v e and f l o w c h a r t i n g done on computers f o r some t i m e , and h e r r a t i o n a l e was t h a t t h e system p r e s e n t l y used i s "good and f a s t " . Others however, thought t h a t " a l l documentation and a l o t o f t h e c l e r i c a l s t u f f c o u l d be on computers." A l l e l e v e n f i r s t - y e a r (100%), t e n t h i r d - y e a r ( 7 7 % ) , but o n l y f o u r second-year (36%) s u b j e c t s n o t e d t h e use o f computers as r e f e r e n c e t o p i s . The one a r e a t h a t t h e m a j o r i t y o f t h e s e s u b j e c t s mentioned was as a sour c e f o r drug i n f o r m a t i o n and c o m p a t i b i l i t i e s . Computer use f o r p h y s i o l o g i c a l m o n i t o r i n g o f p a t i e n t s was n o t e d by a v e r y s m a l l number o f s u b j e c t s i n each y e a r : 104 f i r s t - y e a r (n = 3 ) , second-year (n = 5 ) , and t h i r d - y e a r (n = 3 ) . One second-year s u b j e c t , even though she thought t h e y would be used more f o r p a t i e n t m o n i t o r i n g f u n c t i o n s , s t a t e d : " I don't t r u s t them, so I would s t i l l be c h e c k i n g t h e t h i n g e v e r y t e n m i n u t e s . " A n o t h e r n o t e d t h a t as t e c h n o l o g y moves i n t o t h e h o s p i t a l , p a t i e n t m o n i t o r i n g w i l l not o n l y be e v i d e n t i n t h e c r i t i c a l c a r e a r e a s , but w i l l become more r o u t i n e on t h e r e g u l a r f l o o r s . Four f i r s t - y e a r , f i v e t h i r d - y e a r , and no second-year s u b j e c t s n o t e d t h e use o f computers as a t e a c h i n g t o o l . A f i r s t - y e a r s u b j e c t s t a t e d t h a t t h e r e i s n ' t much t e a c h i n g b e i n g done r i g h t now by n u r s e s , because o f t h e t i m e f a c t o r . She thought t h a t more might be done i f computers a r e used because: "computers have a l l day i f you want t o spend w i t h i t . . . i t doesn't r u s h t h i n g s a l o n g . " O n e - t h i r d y e a r s u b j e c t s t a t e d t h a t t h e computer would have t o be r e a s o n a b l y f r i e n d l y , and t h a t he c o u l d not see t h e computer t e a c h i n g t h e p a t i e n t t o g i v e h i s \ h e r own i n s u l i n . He f e l t t h a t i t c o u l d not do t h e a c t u a l i n j e c t i o n , which i s t h e " s c a r i e s t p a r t . " He thought t h a t t h e computer c o u l d p r o v i d e t h e i n f o r m a t i o n , but t h a t t h e human c o n t a c t s t i l l had t o be t h e r e . The f i n a l a r e a under n u r s i n g uses i d e n t i f i e d by s u b j e c t s was use o f t h e computer t o g e n e r a t e n u r s i n g c a r e p l a n s , and t h i s was n o t e d by o n l y a s m a l l number o f f i r s t - y e a r (n = 3 ) , second-year (n = 2 ) , and t h i r d - y e a r (n = 2 ) , s u b j e c t s . One second-year s u b j e c t s a i d , "computers might be used t o 105 g e n e r a t e n u r s i n g c a r e p l a n s i n some e x p e r i m e n t a l h o s p i t a l s . " A t h i r d - y e a r s u b j e c t s a i d , "you c o u l d use t h e computer t o draw up a b e t t e r c a r e p l a n , by i n d i v i d u a l i z i n g a s t a n d a r d c a r e p l a n . " The second b r o a d a r e a "communication," i n c l u d e d d i r e c t computer use by t h e nurse f o r communication w i t h : (a) o t h e r n u r s e s , (b) d o c t o r s , (3) p a t i e n t s , (4) h o s p i t a l departments, and (5) o t h e r h o s p i t a l s . Use o f t h e computer t o f a c i l i t a t e communication between n u r s e s r e c e i v e d m i n i m a l a t t e n t i o n by s u b j e c t s i n a l l t h r e e y e a r s . One f i r s t - y e a r s u b j e c t s a i d t h a t when she shows up f o r work i n t h e f u t u r e , she w i l l have a number, and when she e n t e r s t h a t i n t o t h e computer, she w i l l r e c e i v e a whole p r i n t - o u t o f not o n l y who she i s t o c a r e f o r , but a l s o , t h e p a t i e n t s l i s t e d i n o r d e r o f p r i o r i t y o f c a r e . The p r i n t - o u t would a l s o i n d i c a t e n o t e s on t h e p a t i e n t ' s c o n d i t i o n , and what i s e x p e c t e d as f a r as p a t i e n t c a r e f o r t h a t s h i f t . Most o f t h e s u b j e c t s who d i s c u s s e d communication between n u r s e s f o c u s e d t h e i r d i s c u s s i o n around communication a t t h e change o f s h i f t and w i t h u p d a t i n g t h e n u r s i n g Kardex. Use o f computers t o f a c i l i t a t e communication w i t h d o c t o r s a l s o r e c e i v e d m i n i m a l a t t e n t i o n , and t h e s u b j e c t s who mentioned i t f o c u s e d on d o c t o r s u s i n g i t t o communicate l e g i b l e d o c t o r s ' o r d e r s . Only one f i r s t - y e a r s u b j e c t n o t e d t h e use o f computers by p a t i e n t s t o f a c i l i t a t e communication w i t h t h e n u r s e . She i l l u s t r a t e d h e r p o i n t w i t h an example o f 106 an a p h a s i c p a t i e n t . W h i l e o n l y a v e r y s m a l l number o f f i r s t (n = l j and second (n=3), y e a r s u b j e c t s mentioned communication between h o s p i t a l departments, t h e m a j o r i t y o f t h i r d (n = 9) y e a r s u b j e c t s chose t o d i s c u s s t h i s a r e a o f usage. Communication between h o s p i t a l s was not mentioned by any f i r s t - y e a r , and o n l y a. m i n i m a l number o f second and t h i r d - y e a r , s u b j e c t s . One t h i r d - y e a r s u b j e c t s t a t e d t h a t she f e l t p e o p l e s ' m e d i c a l h i s t o r i e s were g o i n g t o be c a r r i e d around on l i t t l e c a r d s , and n u r s e s would be a b l e t o a c c e s s them and update t h e i n f o r m a t i o n wherever t h e p a t i e n t goes a c r o s s t h e c o u n t r y . The t h i r d b r o a d a r e a " a d m i n i s t r a t i o n , " i n c l u d e d i n d i r e c t use by t h e nu r s e f o r : (a) s c h e d u l i n g , (b) f i n a n c e , and (c) s t a t i s t i c s . L e s s t h a n 25% o f s u b j e c t s i n each y e a r n o t e d t h e s e a d m i n i s t r a t i v e uses. One second-year s u b j e c t n o t e d , "I'm sure t h e y w i l l be used more on t h e a d m i n i s t r a t i v e s i d e ' and e v e n t u a l l y t r i c k l e down i n t o t h e wards, but I c a n ' t see t h a t f o r a l o n g t i m e . " A t h i r d - y e a r s u b j e c t s a i d , "computers would h e l p w i t h b i l l i n g p a t i e n t s , i f we e v e r get down t o c h a r g i n g f o r e v e r y tongue d e p r e s s o r b e i n g used, as t h e y do i n t h e U n i t e d S t a t e s . " T a b l e 6 p r e s e n t s a summary o f t h e t h r e e a r e a s d i s c u s s e d by s u b j e c t s i n d i c a t i n g t h e i r knowledge o f how computers may be used i n h o s p i t a l n u r s i n g i n t h e f u t u r e . 107 Tab l e 6. Frequency Of Response I n d i c a t i n g S t u d e n t s ' Knowledge Of How Computers May Be Used I n H o s p i t a l N u r s i n g I n The F u t u r e YEAR FIRST SECOND THIRD COMPUTER USE = 11) (n = I D (n = 13) IN THE FUTURE f <%) f (%) f (%) NURSING documentation 10 (91) 10 (91) 9 (69) r e f e r e n c e s o u r c e 11 (100) 4 (36) 10 (77) p h y s i o l o g i c a l m o n i t o r i n g 3 (27) 5 (45) 3 (23) t e a c h i n g t o o l 4 (36) 0 (0) 5 (38) n u r s i n g c a r e p l a n s 3 (27) 2 (18) 2 (15) COMMUNICATION h o s p i t a l departments 1 (9) 3 (27) 9 (69) n u r s e s 4 (36) 3 (27) 1 (8) d o c t o r s 2 (18) 5 (45) 5 (38) o t h e r h o s p i t a l s 0 (0) 1 (9) 1 (8) p a t i e n t s 1 (9) 0 (0) 0 (0) ADMINISTRATIVE f i n a n c e 2 (18) 2 (18) 3 (23) s t a t i s t i c s 1 (9) 1 (9) 3 (23) s c h e d u l i n g 1 (9) 1 (9) 2 (15) 108 S e v e r a l s u b j e c t s , i n a l l y e a r s , s p e c u l a t e d as t o when t h e y thought computers would be p h y s i c a l l y p l a c e d i n h o s p i t a l s f o r use by n u r s e s . Two f i r s t - y e a r s u b j e c t s made t h e f o l l o w i n g g l o b a l s t a t e m e n t s : (a) " I n f i v e y e a r s , t h e y w i l l be everywhere," and (b) " I t h i n k t h e r e w i l l be a l o t o f them." Two second-year s u b j e c t s were more s k e p t i c a l w i t h t h e i r o b s e r v a t i o n s : (a) " I don't t h i n k t h e y a r e g o i n g t o move as f a s t as I have been r e a d i n g about. They w i l l be i n a l o t o f h o s p i t a l s but I don't t h i n k t h e y ' r e g o i n g t o be i n ev e r y h o s p i t a l . P e o p l e get t o o e x c i t e d t o o soon," and (b) " I can' t r e a l l y see a g r e a t d e a l more computers coming i n f o r a l o n g t i m e . " S p e c u l a t i o n about where computers would be p l a c e d i n t h e h o s p i t a l f o r use by n u r s e s o c c u r r e d . S e v e n t y - t h r e e p e r c e n t o f t h e f i r s t - y e a r , t h i r t y - s i x p e r c e n t o f t h e second-year, and t h i r t y - e i g h t p e r c e n t o f t h e t h i r d - y e a r s u b j e c t s thought t e r m i n a l s would be s i t u a t e d a t t h e n u r s i n g s t a t i o n . Three s u b j e c t s were s p e c i f i c when s p e c u l a t i n g about t h e number of t e r m i n a l s a t t h e desk: 1. P r o b a b l y one o r two maximum-per ward as t h e r e a re two R.N's w o r k i n g a t one t i m e so t h a t t h e y can each use them. 2. I'm t r y i n g t o t h i n k o f t h e n u r s i n g s t a t i o n on t h e f l o o r I'm on w i t h two t e r m i n a l s on e i t h e r s i d e and a keyboard i n f r o n t o f them and one a t t h e desk w i t h a c c e s s t o whatever you need f o r your p a t i e n t . 3. Two computers a t each n u r s i n g s t a t i o n and one by t h e drug c o u n t e r . Four s u b j e c t s p o i n t e d out t h a t t h e head nurse would have a t e r m i n a l i n h e r o f f i c e . A second-year s u b j e c t s t a t e d , 109 " I would be r e a l l y s u r p r i s e d i f t h e head nurse d i d n ' t have one s i t t i n g on h e r desk, so she c o u l d scan p a t i e n t s ' f i l e s , because she l i k e s an o v e r a l l p i c t u r e o f t h e p a t i e n t s on h e r ward." A t h i r d - y e a r s u b j e c t s a i d , "the head nurse would have one on h e r desk, but d o c t o r s w i l l p r o b a b l y get them b e f o r e us...you know, t h e y ' l l say t h e y need them, t h a t ' s t y p i c a l . " Computers at t h e b e d s i d e were mentioned by t h r e e f i r s t -y e a r , seven t h i r d - y e a r , but no second-year s u b j e c t s . The s u b j e c t s who d i s c u s s e d computers a t t h e b e d s i d e d i d so i n terms o f e i t h e r i t s use as a m o n i t o r i n g d e v i c e , o r as a v e h i c l e f o r d a t a e n t r y and r e t r i e v a l a t t h e b e d s i d e . S e v e r a l s u b j e c t s t a l k e d i n terms of c o n s t a n t p h y s i o l o g i c a l m o n i t o r i n g o f t h e p a t i e n t , w h i l e one : f i r s t - y e a r s u b j e c t n o t e d t h a t you. would t a k e t h e p a t i e n t ' s v i t a l s i g n s and e n t e r t h e r e a d i n g s d i r e c t l y i n t o t h e t e r m i n a l a t t h e b e d s i d e . She went on t o s p e c u l a t e t h a t "the u l t i m a t e " would be h a v i n g t h e thermometer and b l o o d p r e s s u r e c o n n e c t e d t o t h e t e r m i n a l , so t h a t t h e r e a d i n g s would j u s t be e n t e r e d a u t o m a t i c a l l y . One t h i r d - y e a r s u b j e c t f e l t t h e r e would be a t e r m i n a l between two beds and each n u r s e would have an a c c e s s code t o get i n t o i t t o c h a r t r i g h t t h e r e as c a r e i s completed. A n o t h e r t h i r d - y e a r s u b j e c t t a l k e d about s c r e e n s and m i n i t y p i n g pads at e v e r y b e d s i d e . A p a r t i c u l a r l y e n t h u s i a s t i c t h i r d - y e a r s u b j e c t s t a t e d , " I hope t h e y a r e a t t h e b e d s i d e ! " Not a l l s u b j e c t s were as o p t i m i s t i c or e n t h u s i a s t i c , n o t i n g t h a t computers would not be a t t h e b e d s i d e f o r a " l o t o f y e a r s . " 110 Four s u b j e c t s n o t e d a number of c r e a t i v e ways computers may i n f l u e n c e t h e n u r s e s ' j o b o f m e d i c a t i o n a d m i n i s t r a t i o n i n t h e f u t u r e . These were not i n c l u d e d w i t h t h e t h r e e b r o a d ar e a s o f usage, as t h e y were t h e o n l y comments s p e c i f i c t o m e d i c a t i o n a d m i n i s t r a t i o n , and a l l comments r e l a t e d t o methods c o n s i d e r e d t o be u n c o n v e n t i o n a l and q u i t e f u t u r i s t i c i n terms o f how t e c h n o l o g y i s b e i n g used t o d a y . Three f i r s t -y e a r s u b j e c t s i n d i c a t e d t h a t p o s s i b l y r o b o t s would be used f o r m e d i c a t i o n a d m i n i s t r a t i o n i n t h e f u t u r e . One s u b j e c t s t a t e d , "Maybe we won't be g i v i n g t h e m e d i c a t i o n s p e r s o n a l l y , i n s t e a d r o b o t s would be a t t a c h e d t o computers g i v i n g t h e m e d i c a t i o n s . " A t h i r d - y e a r s u b j e c t thought t h a t p a t i e n t s would be a b l e t o p r e s s a b u t t o n on a c o m p u t e r i z e d pharmacy machine and t h e p i l l s would be t h e r e . She n o t e d t h a t she f e l t most p a t i e n t s were c a p a b l e of t a k i n g t h e i r own m e d i c a t i o n s , because t h e y do so a t home. In summary, s u b j e c t s c o n c e p t u a l i z e d t h r e e b r o a d a r e a s o f computer use by h o s p i t a l employed n u r s e s i n t h e f u t u r e . These a r e a s i n c l u d e d d i r e c t use by t h e n u rse f o r n u r s i n g and communication, and i n d i r e c t use f o r a d m i n i s t r a t i v e f u n c t i o n s . One f i n d i n g under t h e b r o a d a r e a o f n u r s i n g use s t a n d s a l o n e . The m a j o r i t y o f s u b j e c t s i n a l l t h r e e y e a r s e n v i s i o n computer use by n u r s e s f o r documentation purposes (91% f i r s t - y e a r , 91% second-year, 69% t h i r d - y e a r ) . A n o t h e r i n t e r e s t i n g f i n d i n g i n t h e n u r s i n g a r e a was t h a t a l l f i r s t - y e a r (100%), and t h e m a j o r i t y o f t h i r d - y e a r s u b j e c t s (77%) n o t e d t h e use o f I l l computers by n u r s e s as a r e f e r e n c e s o u r c e . Only one f i n d i n g was p a r t i c u l a r l y n oteworthy, i n terms of i t ' s importance t o t h e s u b j e c t s , i n t h e a r e a o f communication. The m a j o r i t y o f t h i r d - y e a r s u b j e c t s (69%) n o t e d t h e use o f computers by t h e n u rse f o r i n t e r d e p a r t m e n t a l communication. The a d m i n i s t r a t i v e use o f computers was not o f p a r t i c u l a r i n t e r e s t t o s u b j e c t s w i t h l e s s t h a n 25% i n each y e a r n o t i n g t h i s a p p l i c a t i o n . A v e r y s m a l l number of s u b j e c t s d i s c u s s e d where, and when computers would be p l a c e d i n t h e h o s p i t a l s e t t i n g . The m a j o r i t y o f f i r s t - y e a r s u b j e c t s (73%) d i s c u s s e d computers a t t h e n u r s i n g s t a t i o n , w h i l e a number o f t h i r d -y e a r s (46%) d i s c u s s e d computers a t t h e b e d s i d e . C a t e g o r i e s Of C o n c e p t i o n s Of How Computers May Impact  H o s p i t a l Employed Nurses The t h i r t y - f i v e n u r s i n g s u b j e c t s r e a d i l y d i s c u s s e d t h e i r c o n c e p t i o n s o f how computers may impact h o s p i t a l employed n u r s e s . Lengthy e x h a u s t i v e l i s t s t h a t were made o f comments, i d e a s and words g e n e r a t e d from t h e t r a n s c r i p t s , e a r l y i n t h e a n a l y s i s p r o c e s s , were e v e n t u a l l y reduced t o 43 themes (see Appendix H). These themes were f u r t h e r reduced t o t h e f o l l o w i n g f o u r c a t e g o r i e s o f c o n c e p t i o n : (a) n u r s i n g image, ;(b) p a t i e n t c a r e , (c) w o r k l o a d , and (d) p r o f e s s i o n a l i s m (see Appendix I ) . Four s t e p s were used t o note t h e f i n d i n g s f o r each c a t e g o r y . F i r s t l y , each c a t e g o r y was d e f i n e d , and 112 s e c o n d l y , examples t a k e n from t h e i n t e r v i e w t r a n s c r i p t s were used t o s u p p o r t t h e e x i s t e n c e o f t h e c a t e g o r y . T h i r d l y , t h e examples c i t e d i n each c a t e g o r y were grouped i n terms o f t h e s u b - c a t e g o r i e s o f whether t h e y enhanced o r d e t r a c t e d from t h e j o b \ r o l e o f h o s p i t a l employed n u r s e s . L a s t l y , f r e q u e n c y c o u n t s and p e r c e n t a g e s were r e p o r t e d , b o t h i n d e s c r i p t i v e form t h r o u g h o u t t h e s e c t i o n , and i n T a b l e s 7 and 8 a t t h e c o n c l u s i o n o f t h e s e c t i o n . These q u a n t i t a t i v e f i n d i n g s p r o v i d e a sense o f t h e number of s u b j e c t s i n each y e a r who commented on each main and sub c a t e g o r y . N u r s i n g Image. N u r s i n g image has r e c e i v e d c o n s i d e r a b l e a t t e n t i o n i n t h e n u r s i n g l i t e r a t u r e i n r e c e n t y e a r s . N u r s i n g image r e f e r s t o how o t h e r s see n u r s e s and how t h e n urse sees h e r s e l f . The husband and w i f e n u r s i n g r e s e a r c h team o f B e a t r i c e and P h i l i p K a l i s c h , a t t h e U n i v e r s i t y Of M i c h i g a n , have w r i t t e n e x t e n s i v e l y o f t h e i r r e s e a r c h f i n d i n g s on n u r s i n g image. They note t h a t n u r s i n g i s a n : u n d e r r a t e d p r o f e s s i o n i n N o r t h A m e r i c a which i s p o r t r a y e d n e g a t i v e l y i n t h e media ( K a l i s c h & K a l i s c h , 1983). In an attempt t o d i s p e l t h i s n e g a t i v e media image, t h e p r o f e s s i o n a l a s s o c i a t i o n i n B r i t i s h Columbia has a c t i v e l y u n d e r t a k e n a n a t i o n a l media campaign t o p o r t r a y n u r s i n g i n a p o s i t i v e way t o t h e p u b l i c . N u r s i n g has matured as a p r o f e s s i o n i n r e c e n t y e a r s . 113 I n response t o s o c i a l and t e c h n o l o g i c a l changes i n n u r s i n g p r a c t i c e , and an improved t h e o r y base, t h e i s s u e o f s p e c i a l i z a t i o n has g a i n e d momentum (Lane,1985). However, t h e t r a d i t i o n a l image i s one o f t h e nurse as a g e n e r a l i s t . As t h e s p e c i a l i z a t i o n i s s u e i s debated by n u r s e s , i n t h e i r p r o f e s s i o n a l a s s o c i a t i o n s a c r o s s t h e c o u n t r y , t h e e f f e c t s t e c h n o l o g y , and more s p e c i f i c a l l y , computer use, w i l l have on t h e n u r s e s ' t r a d i t i o n a l g e n e r a l i s t image as a c a r e g i v e r w i l l u n d o u b t l y s u r f a c e . Appendix I g i v e s a breakdown o f themes i n c l u d e d i n t h i s category.. Twenty d i r e c t q u o t a t i o n s have been drawn from s u b j e c t s ' i n t e r v i e w s t o i l l u s t r a t e t h e i r c o n c e p t i o n s o f t h e impact o f computers on h o s p i t a l employed n u r s e s , i n terms o f t h e image t h e y p o r t r a y . F o r c l a r i t y o f p r e s e n t a t i o n , t h e s e q u o t a t i o n s have been o r g a n i z e d i n t o t h e two s u b c a t e g o r i e s : enhancement o f , and d e t r a c t i o n from, t h e image o f t h e n u r s e . Q u o t a t i o n s 1-5 were f e l t t o i l l u s t r a t e s u b j e c t s ' c o n c e p t i o n s o f how t h e t r a d i t i o n a l c a r e g i v i n g image o f t h e nurse might be enhanced by use o f computers i n h o s p i t a l s . Q u o t a t i o n s 6 - 2 0 were . f e l t t o i l l u s t r a t e t h e i r c o n c e p t i o n s o f how computer use might d e t r a c t from t h e n u r s e s ' t r a d i t i o n a l c a r e g i v i n g image. Computers ENHANCE The C a r e g i v i n g Image 1. Most n u r s e s a re n u r s e s because t h e y l i k e t h e p e r s o n a l c a r e . The computer i s o n l y a t o o l t o h e l p h er l o o k a f t e r p e o p l e . They w i l l a l l o w h er t o do her j o b , and t o be a b e t t e r more e f f i c i e n t n u r s e . 2. N u r s i n g i s such a hands-on t h i n g . That can not change. P e o p l e w i l l s t i l l need t o be ba t h e d and have t h e i r 114 d r e s s i n g s changed. That's what t h e y t h i n k about when t h e y t h i n k o f n u r s e s . Computers w i l l g i v e n u r s e s more t i m e f o r t h o s e t h i n g s , which i s what p e o p l e want. 3. The p u b l i c ' s esteem would go up and n u r s e s would be seen as b e i n g modern and updated. 4. Computers w i l l never do b a s i c p a t i e n t c a r e . They w i l l e n a b l e t h e n u r s e t o spend more t i m e a t t h e b e d s i d e . The p a t i e n t wants t h e human t o u c h a l o n g w i t h t h e computer. 5. You c a n ' t s u b s t i t u t e t h e human element. The n u r s e ' s t o u c h i s i m p o r t a n t t o t h e p a t i e n t but he a l s o wants t h e a c c u r a c y p r o v i d e d by modern t e c h n o l o g y . Computers DETRACT FROM The C a r e g i v i n g Image 6. P a t i e n t s might t h i n k t h a t computers are a v e r y i m p e r s o n a l way o f d o i n g t h i n g s . 7. The d i v i s i o n o f work would change...and so perhaps you would have t h e w o r l d segmented, and somebody would know a l l about one l i t t l e s m a l l a r e a and somebody would know an o t h e r , but who would i n t e g r a t e i t a l l and r e a l l y know t h e human b e i n g as a whole person? 8. I e n v i s i o n two groups o f nurses..one d o i n g a l o t o f t h e t e c h n i c a l t h i n g s and t h e o t h e r d o i n g t h e c a r e - g i v i n g . 9. More e x p e c t e d o f you computer-wise and l e s s e x p e c t e d o f you i n p a t i e n t c a r e . 10. Maybe a p p e a r i n g more as a t e c h n i c i a n o r a p e r s o n who works a computer, i n s t e a d o f a p e r s o n who i s by t h e b e d s i d e as a n u r s e . 11. Nurses w i l l j u s t be an e x t e n s i o n o f t h e computer. 12. A l l h i g h t e c h and low t o u c h . 13. Computer j o b a l m o s t . . y o u ' r e d e a l i n g w i t h a machine, not a p e r s o n . 14. P a t i e n t s w i l l see us as s e c r e t a r i e s . 15. Nurses w i l l be more t e c h n i c a l . 16. They might d e p e r s o n a l i z e n u r s i n g . 17. Nurses may l o s e t h e i r c a r i n g a t t i t u d e . 18. Now you're not j u s t n u rse b u t , computer t e r m i n a l o p e r a t o r . 19. Two l e v e l s of w o r k e r s , t h o s e who are computer l i t e r a t e and t h o s e who are n o t . 20. N u r s i n g w i l l become m a c h i n e - o r i e n t e d . A l t h o u g h a l a r g e m a j o r i t y of second-year s u b j e c t s (91%) commented on image o f t h e n u r s e , 50% o f t h o s e s u b j e c t s f o c u s e d t h e i r comments on t h e s u b - c a t e g o r y o f t h e n u r s e s image, b e i n g d e t r a c t e d from or seen as l e s s p o s i t i v e w h i l e 115 o n l y 10% f o c u s e d t h e i r comments on t h e s u b - c a t e g o r y o f t h e n u r s e s image b e i n g enhanced. The r e m a i n i n g 40% d i s c u s s e d b o t h s u b - c a t e g o r i e s : enhancement, and d e t r a c t i o n . Seventy-seven p e r c e n t o f t h e t h i r d - y e a r s u b j e c t s made i m a g e - r e l a t e d comments and, as w i t h t h e second-year s u b j e c t s , more s u b j e c t s (40%) f o c u s e d t h e i r a t t e n t i o n o n l y on how t h e n u r s e ' s image would be d e t r a c t e d from r a t h e r t h a n enhanced ( 2 0 % ) . The r e m a i n i n g 40% d i s c u s s e d b o t h s u b - c a t e g o r i e s . A s m a l l e r p e r c e n t a g e (55%) o f f i r s t - y e a r s u b j e c t s commented on image. Of t h o s e who commented, 50% d i s c u s s e d o n l y how t h e n u r s e ' s image would be d e t r a c t e d from, and no s u b j e c t s d i s c u s s e d o n l y how i t would be enhanced. H a l f (50%) d i s c u s s e d b o t h sub-c a t e g o r i e s . Comments from two s u b j e c t s c o n t r a s t e d t h e image seemingly p o r t r a y e d t o s u b j e c t s about t h e d i f f e r e n c e s between c r i t i c a l c a r e and g e r i a t r i c n u r s e s : 1. I have t h i s g r e a t f e a r o f n u r s i n g becoming a l l h i g h - t e c h and no-touch. You can see i t i n t h e a d m i r a t i o n we h o l d f o r i n t e n s i v e c a r e n u r s e s who spend most o f t h e i r t i m e w i t h machinery. We l o o k down on t h e l o n g - t e r m c a r e n u r s e s who spend most o f t h e i r t i m e w i t h p a t i e n t s . 2. The b a s i c d i f f e r e n c e between your g e r i a t r i c n u r se w i t h no equipment and your I.C.U. n u r s e . The p u b l i c i s i n awe o f t h e I.C.U. nurse because o f t h e equipment she i s a b l e t o h a n d l e and c o n t r o l because t h e y f e e l overwhelmed by i t . Comments from f o u r s u b j e c t s i l l u s t r a t e t h e i r c oncerns about n u r s e s n e e d i n g t o c o n t i n u e t o p o r t r a y a c a r i n g image, where human t o u c h remains i m p o r t a n t , as t h e use o f computers becomes more w i d e s p r e a d i n h o s p i t a l s : 116 1. The image o f t h e nu r s e as a c a r e g i v e r would remain t h e domain o f t h e nurse because humans need humans. 2. P e o p l e need human t o u c h . 3. There are some p e o p l e who a r e b e t t e r w i t h machines and t h e r e a r e some p e o p l e who even though t h e y a r e good w i t h machines/ don't c a r e t o g i v e t h e i r l i f e t o t h a t k i n d o f work...they p r e f e r t o g i v e t h e i r l i f e t o c a r i n g f o r p e o p l e . I n summary, t h e c a t e g o r y n u r s i n g image was d i s c u s s e d m a i n l y by second (91 % ) , f o l l o w e d by t h i r d ( 7 7 % ) , and t h e n f i r s t - y e a r (55%) s u b j e c t s . The m a j o r i t y o f s u b j e c t s , from each y e a r , who d i s c u s s e d t h i s c a t e g o r y f o c u s e d t h e i r a t t e n t i o n on how t h e t r a d i t i o n a l c a r e g i v i n g image o f h o s p i t a l employed n u r s e s might be d e t r a c t e d from by i n c r e a s e d computer use. S u b j e c t s ' concerns about t h e n u r s e s ' image b e i n g a f f e c t e d / appeared t o c e n t e r around a concern f o r n u r s e s l o s i n g t h e c a r i n g , h u m a n i s t i c q u a l i t i e s which have t r a d i t i o n a l l y been c e n t r a l ' t o t h e image t h e y ' v e p o r t r a y e d . P a t i e n t C are. Nurses w o r k i n g i n t h e h o s p i t a l s e t t i n g c o n s i s t e n t l y r e p o r t t h a t t h e i r main a r e a o f f o c u s i s p a t i e n t c a r e . The p u b l i s h e r s o f N u r s i n g magazine's f i r s t i s s u e i n November, 1971 echoed t h i s when t h e y p r o m i s e d t h a t t h e magazine would f o c u s on "the t r u e s i d e o f n u r s i n g . . p a t i e n t c a r e . " F i f t e e n y e a r s l a t e r , t h e same magazine p u b l i s h e d an a r t i c l e e n t i t l e d , "What's Happened To The Essence Of N u r s i n g : P a t i e n t Care? " The a u t h o r o f t h a t a r t i c l e , O l i v e B urner, f o c u s e d h er 117 a t t e n t i o n on t h e n e g l e c t o f t h e b e d s i d e n u r s e , t h e s i l e n t m a j o r i t y o f w o r k i n g n u r s e s . S t r i v i n g t o promote optimum q u a l i t y o f p a t i e n t c a r e i s t h e s t a t e d g o a l o f a l l h e a l t h c a r e w o r k e r s ; however, B u r n e r (1986) f e e l s t h a t l i t t l e a t t e n t i o n i s g i v e n t o t h e i n t r i n s i c w o r t h o f t h e n u rse who c a r e s f o r t h e s i c k and promotes w e l l n e s s . She e x p r e s s e s c o n c e r n t h a t n u r s i n g i s moving away from t h e t r u e a r t and s c i e n c e o f p r o v i d i n g b a s i c b e d s i d e c a r e . W i t h t h e i n c r e a s e d use o f computer t e c h n o l o g y by n u r s e s , o t h e r s echo t h e s e same concerns ( B a l l & Hannah, 1984; & Romano, 1985). Through t h e i d e n t i f i c a t i o n o f t h e i s s u e s and concerns r e l a t e d t o t h e use o f computers by n u r s e s , and by e n c o u r a g i n g n u r s e s t o o p e n l y d i s c u s s t h e s e i s s u e s , a t t e m p t s are b e i n g made t o b r i n g t h e f o c u s o f n u r s i n g back t o i t s t r u e s i d e . . . p a t i e n t c a r e . The c a t e g o r y of p a t i e n t c a r e r e f e r s t o f u n c t i o n s o f t h e n u r s e s ' j o b o r r o l e i n v o l v e d i n b o t h d i r e c t hands-on p a t i e n t c a r e , and t h o s e t h a t a f f e c t her c a r e t o t h e p a t i e n t i n an i n d i r e c t way. D i r e c t hands-on c a r e i n c l u d e n u r s i n g p r o c e d u r e s , p a t i e n t t e a c h i n g , and communication w i t h p a t i e n t s . P a t i e n t c a r e i s a f f e c t e d i n d i r e c t l y by such t h i n g s as communication w i t h o t h e r departments and c o l l e a g u e s , t h e n u r s e s ' knowledge base, and a t t i t u d e toward t h e j o b . Appendix I g i v e s a breakdown of themes i n c l u d e d i n t h i s c a t e g o r y . T h i r t y d i r e c t q u o t a t i o n s have been drawn from s u b j e c t s ' i n t e r v i e w s t o i l l u s t r a t e t h e i r c o n c e p t i o n s of t h e impact o f 118 computers on h o s p i t a l employed n u r s e s , i n terms o f t h e d e l i v e r y o f p a t i e n t p a t i e n t c a r e . These q u o t a t i o n s have been o r g a n i z e d i n t o two s u b - c a t e g o r i e s : enhancement o f , and d e t r a c t i o n from, t h e d e l i v e r y o f p a t i e n t c a r e . Q u o t a t i o n s 1-18 were f e l t t o i l l u s t r a t e how computer use by t h e n urse would enhance h e r d e l i v e r y o f p a t i e n t c a r e . Q u o t a t i o n s 19-30 were f e l t t o i l l u s t r a t e how computer use by t h e n urse would d e t r a c t from h e r d e l i v e r y o f p a t i e n t c a r e . Computers ENHANCE The D e l i v e r y Of P a t i e n t Care 1. Less o f t h e m o n i t o r i n g l e v e l o f f u n c t i o n and more o f t h e i n t e r p r e t a t i o n and a n a l y s i s o f d a t a . 2. Up-to-date i n f o r m a t i o n would be r e a d i l y a v a i l a b l e . 3. Readable p r i n t w i l l mean l e s s d e c i p h e r i n g e r r o r s and t i m e saved. I t i s annoying t o t r y and d e c i p h e r d o c t o r s ' o r d e r s . 4. Computers would keep your knowledge about t h e p a t i e n t c u r r e n t . 5. I t would f a c i l i t a t e communication between d o c t o r s and n u r s e s , because now i t seems t h a t d o c t o r s a r e j u s t r u n n i n g i n and out and you are supposed t o c a t c h them whenever you can. I t i s h i t and m i s s . 6. I t c o u l d a l e r t n u r s e s t o c e r t a i n t h i n g s ( e l e v a t e d b l o o d w o rk). 7. The computer c o u l d f a c i l i t a t e t h e development o f n u r s i n g c a r e p l a n s from s t a n d a r d c a r e p l a n s . 8. I t would be l i k e h a v i n g a t e a c h e r on t h e ward a l l t h e t i m e . You c o u l d go t o i t and ask q u e s t i o n s . 9. P a t i e n t ' s would be c o n f i d e n t t h a t t h e y c o u l d get i n f o r m a t i o n t o t h e d o c t o r . Now t h e y have t o t e l l t h e n u r se and i f she f o r g e t s , i t ' s a problem. She c o u l d j u s t punch i t i n t o t h e computer. 10. The computer c o u l d a n a l y z e i n f o r m a t i o n t h a t i t has and g i v e s e v e r a l p o s s i b l e n u r s i n g d i a g n o s e s and t h e n t h e n u r s e c o u l d go t o t h e p a t i e n t and t h e n come back and compare i t w i t h what t h e computer i s t e l l i n g them. I t would f o r c e t h e n urse t o go t o t h e p a t i e n t . 11. I n f o r m a t i o n would be r e a d i l y a c c e s s i b l e and a v a i l a b l e (about new drugs and t h i n g s t h e n urse needs t o know t o c a r e f o r t h e p a t i e n t ) . 12. I t would be a s o u r c e o f back-up i n f o r m a t i o n ( a l e r t i n g t h e n u rse t o a d m i n i s t e r m e d i c a t i o n s i f she f o r g e t s ) . 119 13. P a t i e n t s would f e e l s a f e r and more r e l a x e d w i t h m o n i t o r i n g d e v i c e s r a t h e r t h a n w o r r y i n g i f t h e n u rse i s g o i n g t o pop i n . 14. The n u rse would have an o v e r a l l p i c t u r e o f t h e p a t i e n t and what t h e i r s t a t u s i s . 15. There would be more community h e a l t h t i e s , w hich c o u l d l e a d t o e a r l i e r d i s c h a r g e s . 16. I t h i n k t h e r e would be more time w i t h t h e p a t i e n t f o r b e d s i d e n u r s i n g and l e s s t i m e w r i t i n g a l l o f t h e t h i n g s i n t h e c h a r t s . 17. The p a t i e n t would be more i n f o r m e d i f you used i t f o r spur-of-the-moment t e a c h i n g . 18. They would c a t c h l i t t l e e r r o r s . I f you were c h a r t i n g t h e m e d i c a t i o n s you gave and you f o r g o t t o c h a r t one, i t would s a y . . h o l d i t t h e r e . You m i s s e d t h a t m e d i c a t i o n . Computers DETRACT FROM The D e l i v e r y Of P a t i e n t Care 19. The b i g g e s t problem I see i s a c c u r a c y or p u t t i n g i n t h e c o r r e c t d a t a . That's a mind s e t . You are e i t h e r l i k e t h a t or you are n o t . 20. A l l t h a t might be r e q u i r e d o f t h e n u rse might be t h e n u r s i n g p r o c e d u r e s t h e m s e l v e s , not t h e i n t e r a c t i o n anymore w i t h t h e p a t i e n t . 21. Nurses would be i n t e r a c t i n g w i t h t h e computer, not t h e i r c o l l e a g u e s , about t h e i r p a t i e n t s . 22. As l o n g as t h e p a t i e n t s don't become numbered, you s t i l l have t h a t q u a l i t y o f c a r e . I'm a f r a i d we won't know them as p e o p l e , but r a t h e r j u s t as f i l e s . 23. The n u rse might have t h e tendency not t o come i n and check on them so many t i m e s a s h i f t . 24. We might be tempted t o see what t h e computer says, i n s t e a d o f r e l y i n g on your own judgment ( f o r p a t i e n t a s s e s s m e n t ) . 25. Time away from t h e b e d s i d e . I can j u s t see t h e e x t r a t i m e saved b e i n g spent s i t t i n g around gabbing and b e i n g a t t h e n u r s e s s t a t i o n . 26. We might be communicating more w i t h t h e computer t h a n t h e p a t i e n t . 27. A b a r r i e r might be s e t up between t h e n u rse and t h e p a t i e n t , w i t h t h e p a t i e n t f e e l i n g a n x i o u s about t h e machinery. 28. Maybe your assessment s k i l l s would get r u s t y , because you are depending on t h e computer more th a n you a r e depending on y o u r s e l f t o a s s e s s . 29. F o r most p e o p l e who r e s i s t change t h e y w i l l be an e x t r a headache, and t h e problem you W i l l s t a r t t o run i n t o w i l l be i n r e g a r d t o q u a l i t y o f c a r e . 30. Too much s t e r e o t y p i n g , i n t h e sense t h a t you have a p a t i e n t come i n w i t h C.O.P.D. ( c h r o n i c o b s t r u c t i v e pulmonary d i s e a s e ) , and t h e y would have a c a r e p l a n f o r 120 t h e C.O.P.D. p a t i e n t and i t w i l l be g e n e r a l i z e d and not s p e c i f i c t o t h e i n d i v i d u a l . Over 90% o f t h e s u b j e c t s i n each y e a r (100% f i r s t , 91% second, and 92% t h i r d - y e a r ) made comments under t h e p a t i e n t c a r e c a t e g o r y . The m a j o r i t y o f f i r s t ( 6 4 % ) , second (80 % ) , and t h i r d (67%) y e a r s u b j e c t s who commented on t h i s c a t e g o r y made comments i n r e l a t i o n t o computer use b o t h enhancing, and d e t r a c t i n g from t h e d e l i v e r y o f p a t i e n t c a r e . E i g h t e e n p e r cent o f t h e f i r s t - y e a r s u b j e c t s commented o n l y on computer use e n hancing p a t i e n t c a r e , and a l s o e i g h t e e n p e r c e n t commented o n l y on computer use d e t r a c t i n g from p a t i e n t c a r e . Twenty p e r cent o f t h e second-year s u b j e c t s commented o n l y on t h e s u b - c a t e g o r y , enhancement o f p a t i e n t c a r e , and none o f t h e second-year s u b j e c t s mentioned o n l y d e t r a c t i o n from p a t i e n t c a r e . T w e n t y - f i v e p e r cent o f t h e t h i r d - y e a r s u b j e c t s commented o n l y on computer use enhancing p a t i e n t c a r e , w h i l e e i g h t p e r c e n t mentioned o n l y how i t ' s use would d e t r a c t from p a t i e n t c a r e . S e v e r a l s u b j e c t s i n each y e a r s p e c u l a t e d as t o whether t h e n u r s e would use t h e t i m e t h a t might be f r e e d up from paperwork t o f o c u s on p a t i e n t c a r e . Comments i n c l u d e d : 1. You c o u l d be f r e e d up t o spend more t i m e a t t h e b e d s i d e , but whether o r not t h e y d i d t h a t i s something e l s e . 2. I t depends on t h e i n d i v i d u a l whether t h e y use t h a t t i m e w i t h t h e p a t i e n t . 3. I t a l l comes back t o t h e n u r s e ' s p e r s o n a l i t y (how she spends her t i m e ) . 4. Q u a l i t y t i m e w i t h t h e p a t i e n t i s up t o t h e i n d i v i d u a l n u r s e . 5. Some n u r s e s w i l l make t h e a d j u s t m e n t s and some won't. 6. I t w i l l f r e e up t h e nurse t o go t o t h e b e d s i d e , but 121 whether o r not t h e nurse w i l l go t o t h e b e d s i d e i s an o t h e r m a t t e r . 7. I'm t h i n k i n g I w i l l go t o t h e p a t i e n t . That's my p e r s o n a l i t y . 8. I t i s an i n d i v i d u a l t h i n g . You c a n ' t guarantee i t (how ti m e i s spent) f o r everybody. 9. I would hope t h a t n u r s e s would use t h e t i m e not s i t t i n g around t h e desk g o s s i p i n g , but t o s i t and t a l k t o p a t i e n t s . In summary, t h e c a t e g o r y o f p a t i e n t c a r e was d i s c u s s e d by a l l f i r s t - y e a r (100%), and n e a r l y a l l second ( 9 1 % ) , and t h i r d (92%) y e a r , s u b j e c t s . I t appears t h a t t h e m a j o r i t y o f s u b j e c t s i n a l l y e a r s can r e a d i l y i d e n t i f y how p a t i e n t c a r e would be enhanced w i t h t h e use o f computers by h o s p i t a l employed n u r s e s (82% f i r s t - y e a r , 100% second-year, 92% t h i r d -year) . There i s a d e f i n i t e c o n c e r n among s u b j e c t s i n a l l t h r e e y e a r s i n terms o f m a i n t a i n i n g q u a l i t y o f p a t i e n t c a r e w i t h t h e i n c r e a s e d use o f computers. There seemed t o be a consensus among t h e s u b j e c t s t h a t a t t i t u d e and p e r s o n a l i t y a f f e c t how t h e i n d i v i d u a l nurse would choose t o spend t h e e x t r a t i m e t h a t might be f r e e d up by i n c r e a s e d c o m p u t e r i z a t i o n . Workload. Workload i s a u n i v e r s a l i s s u e i n any j o b , and n u r s i n g i s no e x c e p t i o n . I n t h e c u r r e n t economic m i l i e u o f B r i t i s h Columbia, a r t i c l e s on n u r s i n g s h o r t a g e s a re f r e q u e n t l y f e a t u r e d i n t h e media. The R e g i s t e r e d Nurses A s s o c i a t i o n o f B r i t i s h Columbia (R.N.A.B.C.) s u r v e y s 167 f a c i l i t i e s monthly 122 t o o b t a i n d a t a on n u r s i n g v a c a n c i e s i n t h e p r o v i n c e . A l t h o u g h t h e number o f v a c a n c i e s f l u c t u a t e from month t o month, t h e d a t a g i v e s a c l e a r sense o f t r e n d s . I n May, 1988, t h e r e were 474 v a c a n c i e s . Of t h o s e , 175 were i n g e n e r a l duty n u r s i n g , 108 i n c r i t i c a l c a r e , 85 i n o t h e r s p e c i a l t i e s , 75 i n l o n g t e r m - c a r e r e l a t e d p o s i t i o n s , and 31 i n a d m i n i s t r a t i o n and o t h e r . T h i s i s s u e o f n u r s i n g s h o r t a g e i s uppermost i n t h e minds of most n u r s e s and s t u d e n t n u r s e s , and i s d i s c u s s e d i n N u r s i n g P e r s p e c t i v e s c o u r s e s t h r o u g h o u t t h e C a r i b o o C o l l e g e n u r s i n g program. N u r s i n g s h o r t a g e s are caused by v a r i a b l e s such as: not enough g r a d u a t e s t o f i l l n u r s i n g v a c a n c i e s , and l o s s o f p r a c t i s i n g n u r s e s due t o burnout, l a c k o f r e c o g n i t i o n and reward f o r b e d s i d e n u r s i n g , and low s a l a r y s c a l e s . Workload r e f e r s t o t h e amount o f work performed o r e x p e c t e d t o be performed by an employee. I t seems r e a s o n a b l e t o e x pect t h a t t h e c u r r e n t n u r s i n g s h o r t a g e would a f f e c t t h e w o r k l o a d o f p r a c t i s i n g n u r s e s . In a d d i t i o n , t h e n a t u r e o f a n u r s e ' s work and t h e a c t u a l w o r k l o a d i s c h a n g i n g . "Today's nurse i s w o r k i n g l o n g e r and v e r y d i f f e r e n t l y t h a n she d i d even f i v e y e a r s ago" (Banning, 1987, p . 3 ) . Appendix I l i s t s t h e themes i n c l u d e d i n t h i s c a t e g o r y . T h i r t y d i r e c t q u o t a t i o n s have been drawn from s u b j e c t s ' i n t e r v i e w s , t o i l l u s t r a t e t h e i r c o n c e p t i o n s o f t h e impact o f computers on t h e w o r k l o a d o f h o s p i t a l employed n u r s e s . Q u o t a t i o n s 1-8 were f e l t t o i l l u s t r a t e t h e i r c o n c e p t i o n s o f 123 how computer use by nurses would enhance, (i . e . , have a po s i t i v e e f f e c t on) t h e i r workload. Quotations 9-30 were f e l t to i l l u s t r a t e subjects' conceptions of how computer use by nurses would detract from (i . e . , have a negative ef f e c t on) t h e i r workload. Computers ENHANCE Workload (Positive Effect) 1. It cuts down on a l o t of recording time. 2. It w i l l save time as far as looking through masses of books. 3. Computers could be a time management to o l , cutting out a l o t of unnecessary running around. 4. There would be an increase of s t a f f at the outset to input data but i t won't be R.N.'s. 5.' They w i l l not replace nurses. They didn't replace teachers. 6. It could shorten the paperwork that the nurse has to do. 7. Computers are a t o o l to help you do your job more e f f i c i e n t l y . o r to save time. 8. In a twelve hour s h i f t , how many times do you have to wait for a chart? How many times do you have to wait for a phone order or to get results phoned from the lab. If you add a l l of that time up, i t i s r e a l l y phenomenal. A computer w i l l save a l o t of time. Computers DETRACT FROM Workload (Negative Effect) 9. It i s f a i r l y important that nurses who are going to use the system have input into the system. Nurses know the nursing role and must work with the programmer, or i t increases nursing workload, not decreases i t . 10. You'd d e f i n i t e l y need more than one terminal. If we have to wait around to use i t , i t won't help us. 11. You spend the money and bring i n a computerized system, therefore you don't need s t a f f (less s t a f f might increase workload). 12. Downtime. Things do go wrong with computers. It adds to the nurses' work. 13. It i s n ' t cheap but i t ' s cheaper than paying s t a f f (less s t a f f would be employed and the workload would increase). 14. Are they going to have the money to replace the equipment? Old, faulty equipment means more hassle for the nurse. 15. If you are keying i n data with the expectation that 124 you're going to get information back i n some manner that you can use, then i f i t doesn't come back i n that way, you tend to get frustrated and not use the system. 16.. The cost would be astronomical to have enough terminals 1 available to be actually e f f e c t i v e . Unless there are enough, the work w i l l increase. 17. It w i l l probably take me ten minutes to chart now and one half an hour on a computer, u n t i l I get used to i t . 18. Power f a i l u r e . . I know people who have lo s t s t u f f they are working on because somebody has pulled out the plug. 19. I can see a l o t of things f a l l i n g on the shoulders of the nurse. 20. They w i l l occupy a lot; of time at the beginning for the nurses learning how to use them and getting user f r i e n d l y . 21. You'd have to learn how to type. 22. If things were more computerized, there would be less need for nurses, because the nurse could then do things quicker and maybe they would cut back on s t a f f and instead of being able to spend more time, you wouldn't have more time. They're going to say, you used to be able to do i t before with t h i s many nurses and now you can do i t with less because there i s less to do. 23. The nurse using a l o t of computers might be expected to look after more patients. 24. If you are going to have to s i t there and wait your turn to chart, they w i l l not decrease the nurses' workload. 25. You almost wonder i f you are getting to the point where you spread a nurse too t h i n . Everyone w i l l be f e e l i n g overworked and can't work to t h e i r f u l l p o t e n t i a l . People leave the f i e l d or i t gets to the point where even the r e a l l y dedicated ones lose interest or just get that negative attitude. 26. Work w i l l get heavier i f the nurse i s responsible for putting i n the data because we'll have more c l e r i c a l duties than we have now. 27. With computers comes the.idea that everything should be more streamlined and therefore you'11 probably be required to maybe even do more charting than we do. They w i l l say.."you have a computer, you should be faster!" 28. The perception w i l l be that your workload has decreased but i t w i l l have increased. 29. It w i l l be a l i t t l e more s t r e s s f u l , because i t ' s just one more thing that you have to do. 30. Roles w i l l be cut and taken over by computers. The more of a good thing you get the more you expect and the more the government expects and the more everybody expects. The demands w i l l be.great on the nurse; just p o l i t i c a l you know. Instead of being at the bedside, you w i l l have to keep up with the l a t e s t systems. 125 , The c a t e g o r y o f w o r k l o a d was d i s c u s s e d by a l l s u b j e c t s e n r o l l e d i n a l l y e a r s o f t h e program. The m a j o r i t y o f s u b j e c t s i n each y e a r commented on b o t h t h e p o s i t i v e , and n e g a t i v e e f f e c t s o f computer use on t h e w o r k l o a d o f h o s p i t a l employed n u r s e s (91% f i r s t - y e a r , 55% second-year, and 92% t h i r d - y e a r ) . N ine p e r c e n t o f s u b j e c t s i n b o t h f i r s t and second-year, and none i n t h i r d - y e a r , commented o n l y on t h e computer enhancing t h e n u r s e s ' w o r k l o a d . None o f t h e s u b j e c t s i n f i r s t - y e a r , and o n l y a s m a l l number i n second-y e a r (36%) and t h i r d - y e a r ( 8 % ) , commented o n l y on how computer use by t h e nurse may have n e g a t i v e e f f e c t s on h e r w o r k l o a d . A l a r g e m a j o r i t y o f s u b j e c t s i n a l l t h r e e y e a r s c i t e d t h e f a c t t h a t i f n u r s e s : have t o l e a r n t o use computers i n t h e w o r k p l a c e , i t may i n c r e a s e t h e i r w o r k l o a d . In summary, w o r k l o a d was t h e one c a t e g o r y d i s c u s s e d by 100% o f s u b j e c t s i n a l l t h r e e y e a r s . W h i l e a l l f i r s t - y e a r s u b j e c t s commented on how computer use may enhance t h e n u r s e s ' w o r k l o a d , a l l t h i r d - y e a r , and a number o f second-year s u b j e c t s , d i s c u s s e d d e t r i m e n t s t o t h e n u r s e , i n terms o f i n c r e a s i n g w o r k l o a d . S u b j e c t s appeared t o f e e l t h a t i n i t i a l l y t h e nurse w i l l have her w o r k l o a d i n c r e a s e d by l e a r n i n g t o use computers but t h a t once she becomes p r o f i c i e n t , w o r k l o a d may be d e c r e a s e d , u n l e s s management d e c i d e s t o c u t s t a f f o r i n c r e a s e p a t i e n t c a r e a s s i g n m e n t s . 126 P r o f e s s i o n a l i s m . The debate over whether o r not n u r s i n g i s a p r o f e s s i o n has, p r e v a i l e d i n n u r s i n g c i r c l e s f o r y e a r s . F o r t h e purpose o f t h i s s t u d y , i t i s assumed t h a t n u r s i n g i s a p r o f e s s i o n , and, as such, has a s p e c i f i c body o f knowledge, adheres t o a f o r m a l code o f e t h i c s and i s governed by a p r o f e s s i o n a l a s s o c i a t i o n . I n a d d i t i o n , Standards o f N u r s i n g P r a c t i c e were approved by The Canadian Nurses A s s o c i a t i o n (C.N.A.) i n J u l y , 1979, and by The R e g i s t e r e d Nurses A s s o c i a t i o n Of B r i t i s h Columbia (R.N.A.B.C.) i n September, 1984. The assumption i s th e n made t h a t t h e nurse i s a p r o f e s s i o n a l , governed by a l l r u l e s and r e g u l a t i o n s o f t h e p r o f e s s i o n . Appendix I o u t l i n e s t h e themes i n c l u d e d i n t h i s c a t e g o r y . Twenty-four d i r e c t q u o t a t i o n s have been drawn from s u b j e c t s ' i n t e r v i e w s t o i l l u s t r a t e t h e i r c o n c e p t i o n s o f t h e p o s s i b l e impact o f computers on h o s p i t a l employed n u r s e s , i n terms o f t h e i r p r o f e s s i o n a l i s m . Q u o t a t i o n s 1-12 were f e l t t o i l l u s t r a t e s u b j e c t s ' c o n c e p t i o n s o f how t h e use o f computers might enhance t h e n u r s e s ' p r o f e s s i o n a l i s m . Q u o t a t i o n s 13-24 were f e l t t o r e l a t e t o t h e i r c o n c e p t i o n s o f how t h e use of; computers by h o s p i t a l employed n u r s e s , might d e t r a c t from t h e i r p r o f e s s i o n a l i s m . Computers ENHANCE P r o f e s s i o n a l i s m 1. I t may be e a s i e r t o d e t e c t n u r s e s who don't p e r f o r m t h e i r t a s k s p r o p e r l y . 127 2. E t h i c a l dilemmas w i l l be easier to solve through computers because there i s that b a r r i e r that separates people. 3. Accountability may change. 4. I guess they can b u i l d safeguards into computers to maintain the individual's right to privacy. 5. There i s going to be more emphasis placed on nursing decisions; not necessarily nursing diagnosis. 6. I'm r e a l l y not too concerned about the legal aspects of i t because I'm sure that somebody w i l l work that out because i t i s a very high concern for a majority of people. 7. It would decrease the potential for drug abuse to some degree, because of inventory control. 8. I think that to some degree you'd see more accountability with regards to time management, wastage of supplies. 9. Messages would be documented. I'm just concerned about having everything documented, i n case i t i s your word . against the pharmacist. 10. Information i n the computer would be accepted practice within the i n s t i t u t i o n . 11. It would be nice to have some leg a l and e t h i c a l scenarios written on the computer that a nurse could access, for review, when faced with a s i t u a t i o n . 12. You could use i t to cut down on legal problems because you are able to streamline what you are supposed to be saying because everybody would be speaking the same language. Computers DETRACT FROM Professionalism 13. I don't understand how you are going to avoid going back to edit your patient care notes that are two days old. 14. Right now you r e l y on the doctor's written orders to protect you i n every way. What happens i f the system becomes i n f i l t r a t e d by human viruses and the orders are lost? 15. The patient's privacy might be invaded. 16. There might be less r e s p o n s i b i l i t y i n some ways as far as patient care goes, you can always say i t was the computer's f a u l t . 17. Computers do make errors. They're not perfect and i f something goes wrong, who do you blame? 18. When doctors hand write orders, i f there i s an error, . then that's t h e i r error. If i t ' s on the computer, then you say i t ' s the computer's f a u l t . 19. It won't stand up as well as a chart that was hand written i n court because: you can a l t e r a computer f i l e , whereas you r e a l l y can't a l t e r a chart. 20. Big Brother watching over you! 21. People entering into the computer system that have no 128 r i g h t . 22. Computers can keep t r a c k o f each i n d i v i d u a l n u r s e and how he\she spend t h e i r day. You w i l l no l o n g e r have t h e nurse who i s a b l e t o s i t down and have a l o n g c h a t and not f e e l g u i l t y t h a t she i s c h a r g i n g t h e p a t i e n t X number of d o l l a r s a minute t h a t you a r e s i t t i n g t h e r e . 23. I'd be r e a l l y c oncerned about b e i n g a b l e t o convey e x a c t l y what I want t o say on t h e n a r r a t i v e c h a r t i n t h e computer, t h a t i t remains as c o n c i s e , and t h a t i t says what I want i t t o say. 24. K e e p i n g t r a c k o f n u r s e s by t h e employer. I t i s g o i n g t o be l i k e a b i g c l u b h e l d over your head. A s m a l l e r number o f s u b j e c t s i n each y e a r commented on computers as t h e y r e l a t e t o t h e nurse as a p r o f e s s i o n a l (64% f i r s t and second-year, 62% t h i r d - y e a r ) . Most of t h e subjects< who commented, d i d so m a i n l y i n r e l a t i o n t o o n l y t h e d e t r a c t i o n s p l a c e d on t h e nurse as a p r o f e s s i o n a l (86% f i r s t -y e a r , 71% second-year, 44% t h i r d - y e a r ) by t h e use o f computers i n her j o b \ r o l e . No f i r s t - y e a r , t w e n t y - n i n e p e r c e n t o f second-year, and e l e v e n p e r c e n t o f t h i r d - y e a r , s u b j e c t s , who d i s c u s s e d t h i s c a t e g o r y , commented on how t h e p r o f e s s i o n a l i s m o f t h e nurse might be enhanced t h r o u g h t h e use o f computers. F o u r t e e n p e r cent o f f i r s t - y e a r , no second-year, and f o r t y - f o u r p e r c e n t o f t h i r d - y e a r s u b j e c t s , d i s c u s s e d t h e c a t e g o r y i n terms o f how p r o f e s s i o n a l i s m might be b o t h enhanced, and d e t r a c t e d from t h r o u g h computer use. In summary, t h e c a t e g o r y o f p r o f e s s i o n a l i s m was commented on by s l i g h t l y more t h a n h a l f o f t h e s u b j e c t s i n a l l t h r e e y e a r s . The o v e r a l l f o c u s by s u b j e c t s commenting on t h i s c a t e g o r y , was i n r e l a t i o n t o l e g a l and e t h i c a l i s s u e s , as w e l l as p r o f e s s i o n a l r e s p o n s i b i l i t y and a c c o u n t a b i l i t y . 129 Two male s u b j e c t s d i s c u s s e d n u r s i n g a c c o u n t a b i l i t y w i t h t h e computer b e i n g used as " b i g b r o t h e r . " T a b l e 7 below i n d i c a t e s t h e r a n k i n g o f c a t e g o r i e s as d e t e r m i n e d by t h e p e r c e n t a g e o f s u b j e c t s i n each y e a r who commented on each c a t e g o r y . Number "1" i n d i c a t e s t h e h i g h e s t rank and number "4" t h e l o w e s t . Workload was t h e major c a t e g o r y , and p a t i e n t c a r e t h e second c a t e g o r y d i s c u s s e d by s u b j e c t s e n r o l l e d i n a l l t h r e e y e a r s . Image and p r o f e s s i o n a l i s m a l t e r n a t e d between t h i r d and f o u r t h p l a c e f o r b o t h f i r s t , and t h i r d - y e a r s u b j e c t s . Note t h a t second-year s u b j e c t s commented e q u a l l y on p a t i e n t c a r e and image, and t h a t each was ranked as number "2," t h e r e b y e l i m i n a t i n g t h e number "3" r a n k i n g . T a b l e 7. Ranking Of C a t e g o r i e s By P e r c e n t a g e Of S u b j e c t s In Each Year Who D i s c u s s e d The Categ o r y YEAR FIRST SECOND THIRD CATEGORY (n = 11) (n = 11) (n = 13) WORKLOAD PATIENT CARE IMAGE PROFESSIONALISM 1 (100%) 1 2 (100%) 2 4 (55%) 2 3 (64%) 4 (100%) 1 (100%) (91%) 2 (91%) (91%) 3 (77%) (64%) 4 (62%) 130 T a b l e 8 p r o v i d e s an o v e r a l l q u a n t i t a t i v e summary o f t h e f i n d i n g s d i s c u s s e d i n t h i s s e c t i o n on s u b j e c t s ' c a t e g o r i e s o f c o n c e p t i o n . I t a l l o w s one t o see a t a g l a n c e t h e p e r c e n t a g e s o f s u b j e c t s e n r o l l e d i n each y e a r who d i s c u s s e d each c a t e g o r y and s u b - c a t e g o r y . T a b l e 8. Pe r c e n t a g e Of S u b j e c t s Who D i s c u s s e d Each Cat e g o r y And Sub-Category Of C o n c e p t i o n CATEGORY AND SUB-CATEGORY FIRST (n = 11) YEAR SECOND (n = 11) THIRD (n = 13) WORKLOAD (TOTAL) 100 . enhance 9 d e t r a c t 0 b o t h 91 PATIENT CARE (TOTAL) 100 enhance 18 d e t r a c t 18 b o t h 64 IMAGE (TOTAL) 55 enhance 0 d e t r a c t 50 b o t h 50 PROFESSIONALISM (TOTAL) 64 enhance 0 d e t r a c t 86 b o t h 14 100 91 91 64 9 36 55 20 0 80 10 50 40 29 71 0 100 92 77 62 0 8 92 25 8 67 20 40 40 11 44 44 131 C o m p l e x i t y Of C o n c e p t i o n The f i r s t s p e c i f i c r e s e a r c h q u e s t i o n was: I s t h e r e a d i f f e r e n c e i n c o m p l e x i t y between f i r s t , second, and t h i r d y e a r n u r s i n g s t u d e n t s ' c o n c e p t i o n s o f t h e impact o f computers on h o s p i t a l employed n u r s e s ? D u r i n g t h e a n a l y s i s p r o c e s s o f t h e s t u d y , i t became o b v i o u s t o t h e r e s e a r c h e r t h a t s u b j e c t s ' c o n c e p t i o n s d i f f e r e d i n terms of t h e i r q u a l i t y o r c o m p l e x i t y . T h i s i s not an o r i g i n a l o b s e r v a t i o n , and f i n d i n g s were i n f l u e n c e d by t h e work o f Marton e t . a l . ( 1 9 8 4 ) i n Sweden on q u a l i t y o f l e a r n i n g , and B i g g s and C o l l i s (1982) i n A u s t r a l i a on e v a l u a t i n g t h e q u a l i t y o f l e a r n i n g t h r o u g h use o f t h e SOLO Taxonomy. F i n d i n g s w i l l now be p r e s e n t e d t o answer t h i s q u e s t i o n . A l l s u b j e c t s r esponses were r a t e d as h a v i n g e i t h e r a h i g h o r low l e v e l o f c o m p l e x i t y based on g e n e r a l c r i t e r i a o u t l i n e d i n C hapter 3, and s p e c i f i e d c h a r a c t e r i s t i c s p r e s e n t e d i n T a b l e 5. Three f i r s t - y e a r (27%), seven second-y e a r ( 6 4 % ) , and n i n e t h i r d - y e a r (69%), s u b j e c t s were r a t e d as h a v i n g h i g h l e v e l c o n c e p t i o n s , w h i l e e i g h t f i r s t - y e a r ( 7 3 % ) , f o u r second-year (3 6 % ) , and f o u r t h i r d - y e a r ( 3 1 % ) , s u b j e c t s were r a t e d as h a v i n g low l e v e l c o n c e p t i o n s , i n terms o f t h e c o m p l e x i t y o r q u a l i t y o f t h e i r r e s p o n s e s . O v e r a l l , n i n e t e e n (54%) o f t h e s u b j e c t s were r a t e d h i g h , and s i x t e e n (46%) low. T a b l e 9 g i v e s an i n d i c a t i o n o f how s u b j e c t s w i t h i n each y e a r were r a t e d . 132 T a b l e 9. Frequency Of Hig h And Low L e v e l Responses I n d i c a t i n g C o m p l e x i t y Of C o n c e p t i o n YEAR FIRST SECOND THIRD TOTAL COMPLEXITY (n = 11) (n = 11) (n = 1 3 ) N = 35 OF CONCEPTION f (%) f (%) f (%) f (%) HIGH 3 (27) 7 (64) 9 (69) 19 (54) LOW 8 (73) 4 (36) 4 (31) 16 (46) TOTAL 11 (100) 11 (100) 13 (100) 35 (100) The number o f c a t e g o r i e s o f c o n c e p t i o n s d i s c u s s e d by s u b j e c t s i n each y e a r was a l s o t a b u l a t e d , and a r e p r e s e n t e d on t h e f o l l o w i n g page i n Table 10. I t appears t h a t t h e m a j o r i t y o f second (55%) and t h i r d - y e a r (54%) s u b j e c t s , d i s c u s s e d f o u r c a t e g o r i e s w h i l e most (45%) of t h e f i r s t - y e a r s u b j e c t s d i s c u s s e d t h r e e . The d i s t r i b u t i o n f o r t h e t o t a l sample o f t h i r t y - f i v e s u b j e c t s was: 14% d i s c u s s e d two c a t e g o r i e s , 37% d i s c u s s e d t h r e e , and 49% d i s c u s s e d f o u r c a t e g o r i e s . 133 T a b l e 10. Frequency Of Response I n d i c a t i n g The Number Of C a t e g o r i e s Of C o n c e p t i o n D i s c u s s e d YEAR FIRST SECOND THIRD TOTAL NUMBER OF (n = 11) (n = 11) (n = 1 3 ) N = 35 CATEGORIES f (%) f (%) f (%) f (%) 2 2 (18) 1 (9) 2 (15) 5 (14) 3 5 (45) 4 (36) 4 (31) 13 (37) 4 4 (36) 6 (55) 7 (54) 17 (49) TOTAL 11 (99) 11 (100) 13 (100) 35 (100) F i r s t l y , f i n d i n g s were examined t o see i f t h e r e was any r e l a t i o n s h i p between t h e number o f c a t e g o r i e s d i s c u s s e d by s u b j e c t s (see T a b l e s 9 and 10), and t h e c o m p l e x i t y o f t h e i r c o n c e p t i o n s . Three p o i n t s a re r e l e v a n t i n making comparisons between s u b j e c t s ' c o m p l e x i t y o f c o n c e p t i o n , and t h e number o f c a t e g o r i e s t h e y d i s c u s s e d : (a) t h e number o f c a t e g o r i e s cannot be t a k e n on i t s own as a measure o f c o m p l e x i t y o f c o n c e p t i o n , (b) not a l l s u b j e c t s r a t e d as h a v i n g h i g h l e v e l s o f c o n c e p t i o n d i s c u s s e d f o u r c a t e g o r i e s , and (c) some s u b j e c t s r a t e d as h a v i n g low l e v e l s o f c o n c e p t i o n d i s c u s s e d f o u r c a t e g o r i e s . 134 It was Interesting to note that o v e r a l l , the majority of second (64%), and t h i r d (69%) year subjects, had a high l e v e l of conception about the impact of computers on h o s p i t a l employed nurses. The majority of subjects e n r o l l e d i n those years also discussed four categories (55% second-year, 54% t h i r d - y e a r ) . Of the seven, second-year subjects rated as conceptualizing at a high l e v e l , four discussed four categories, and the remainding three, discussed three categories. Seven of the nine, third-year subjects, rated as conceptualizing at a high l e v e l , discussed four categories of conception, while the remaining three discussed three. Only one of the three f i r s t - y e a r subjects rated as conceptualizing at a high l e v e l , discussed four categories, while the other two discussed three. Secondly, the findings of subjects' l e v e l of complexity of conceptions (see Table 9), and t h e i r year i n the program were examined to determine possible r e l a t i o n s h i p s . Using a chi-square d i r e c t i o n a l t e s t for s t a t i s t i c a l s ignificance, i t appears that, subjects' responses i n d i c a t i n g t h e i r l e v e l of conception are d i r e c t l y proportional to t h e i r year i n the program (X = 4.90, p_ <.05) . F i r s t year subjects conceptualized at a lower l e v e l , then second, and third-year subjects. There appears to be a s i g n i f i c a n t difference i n the complexity of conceptions of f i r s t and third-year subjects (X 2 = 4.21, p_<.05), and f i r s t and second-year subjects (X 2 = 2.94, p_<.05). However, there appears to be no 135 s i g n i f i c a n t difference i n the complexity of conceptions of second and third-year subjects (X 2= .066, p_>.05). To answer the research question then, there does appear to be a difference i n complexity between f i r s t , second, and third-year students' conceptions of the impact of computers on h o s p i t a l employed nurses. In addition, a l l subjects with high l e v e l s of conception about the impact of computers on hospital employed nurses, discussed either three or four categories of conception. Relationship Of Conception To C l i n i c a l Experience The second s p e c i f i c research question was: What i s the r e l a t i o n s h i p between nursing students' conceptions of the impact of computers on ho s p i t a l employed nurses, and the length of the students' c l i n i c a l experience? C l i n i c a l experience increases each year students are enrolled i n the Cariboo College nursing program (190 hours f i r s t - y e a r , 408 hours second-year, 744 hours thi r d - y e a r ) . As reported i n the previous paragraphs, the complexity of students' conceptions of the impact of computers on ho s p i t a l employed nurses appears to be d i r e c t l y proportional to the students' year i n the program. Then, the complexity of students' conceptions about the impact of computers on h o s p i t a l employed nurses also appears to be d i r e c t l y proportional to the length of the students' c l i n i c a l experience. 136 A t t i t u d i n a l Findings Another question posed at the outset of t h i s study was: Is there a re l a t i o n s h i p between nursing students' conceptions of the role of computers i n hos p i t a l nursing and t h e i r attitude toward computers? As noted i n Chapter 3/ t h i s question was revised as the research unfolded to be: Is there a re l a t i o n s h i p between nursing students' conceptions of the impact of computers on hospital employed nurses, and students' attitudes toward computers? Because attitude i s believed to be r e f l e c t e d i n one's behavior (Stronge & Brodt, 1985), the f i r s t f i n ding relates to the subject's expressed desire to purchase a home computer or to take a computer course. The second finding indicates subjects' r a t i n g on a f i v e point Likert-type attitude scale. Descriptive comments from the subjects' t r a n s c r i p t s are included to support these ratings. The t h i r d finding supports a rel a t i o n s h i p between subjects' conceptions and t h e i r attitudes toward computer use i n hospital nursing. Desire To Purchase A Computer Or To Take A Computer Course Six of the t h i r t y - f i v e subjects (17%) reported a desire to purchase a home computer sometime i n the future. Of the six, three were f i r s t , one second, and two third-year subjects, the following six quotations were taken d i r e c t l y 137 from s u b j e c t s ' t r a n s c r i p t s : 1. We a r e l o o k i n g a t p u r c h a s i n g one t h i s summer f o r September f o r t h e s c h o o l season. 2. I'd l i k e t o buy my own. 3. I wouldn't mind h a v i n g my own. 4. We've t a l k e d about b u y i n g a computer f o r our home but r i g h t now we c a n ' t a f f o r d i t , b u t maybe one day. 5. I'm t h i n k i n g o f g e t t i n g one i n t h e f u t u r e . 6. There a r e s e v e r a l t h a t I want t o buy b u t I don't have t h e money now. Maybe a f t e r I g r a d u a t e . Only f i v e o f t h e t h i r t y - f i v e s u b j e c t s (14%) e x p r e s s e d a d e s i r e t o t a k e a computer c o u r s e . Of t h e f i v e , two were f i r s t , and t h r e e were t h i r d - y e a r s t u d e n t s . No second-year s u b j e c t s e x p r e s s e d a d e s i r e t o t a k e a computer c o u r s e . The f o l l o w i n g f i v e q u o t a t i o n s were t a k e n d i r e c t l y from s u b j e c t s ' t r a n s c r i p t s : 1. I would l i k e t o l e a r n more about computers p e r s o n a l l y / even i f I have t o t a k e an e x t r a c o u r s e . I l o o k e d i n t o i t t o t a k e a c o u r s e t h i s summer, j u s t an i n t r o d u c t i o n , and t o use t h e w o r d - p r o c e s s o r and t h e d i f f e r e n t packages t h a t you can use. 2. I'm c o n s i d e r i n g t h a t I might t a k e a computer c o u r s e t h i s summer i f I can f i t i t i n t o work. 3. I've t r i e d t o t a k e a computer c o u r s e , b u t w i t h s c h o o l you c a n ' t , and i n t h e summertime I work, so I haven't had t h e o p p o r t u n i t y . I r e a l l y would l i k e t o l e a r n how t o use one! I t i s not t h a t I don't want t o l e a r n . Some p e o p l e may j u s t shy away from i t i f t h e y don't know how, b u t not me, I would l i k e t o l e a r n how t o use i t . 4. I ' d l i k e t o t a k e a c o u r s e and l e a r n more about them. 5. One o f my g o a l s , once I get my d i p l o m a , i s t o do a c o u r s e i n computing j u s t t o l e a r n how t o use i t and be e l o q u e n t i n i t . A v e r y s m a l l number o f s u b j e c t s e n r o l l e d i n a l l t h r e e y e a r s o f t h e n u r s i n g program e x p r e s s e d a d e s i r e t o p u r c h a s e a home computer. No second-year, and o n l y a v e r y s m a l l number o f f i r s t and t h i r d - y e a r s u b j e c t s , e x p r e s s e d a d e s i r e t o t a k e 138 a computer course. Of those who did comment, time and money appear to be b a r r i e r s preventing achievement of t h e i r stated desire. Rating On An Attitude Scale A l l subjects when, asked to rate t h e i r attitude toward computers i n hospital nursing, on a f i v e point Likert-type scale, did so without hesitation. A score of "1" was considered to be negative, "2" moderately negative, "3" neutral, "4" moderately,positive, and "5" p o s i t i v e . A score of "1" (negative) was not chosen by a subject enrolled i n any year of the program. One second-year subject gave two ratings and q u a l i f i e d her answer with the following statement, "If you look at e f f i c i e n c y i t would be "4.5," but i f you look at the threat of decreased interaction with the patient, i t would be about "1.5." As long as i t i s kept r e a l i s t i c , I think i t w i l l be very good." Because of the very p o s i t i v e comments throughout the interview, t h i s subject was rated a "3." Only six of the t h i r t y - f i v e subjects (17%) rated t h e i r a t titude as "2" (moderately negative). Three of those subjects were i n f i r s t - y e a r , three in second-year, and none were i n t h i r d year. A l l were female. The f i r s t - y e a r subjects who rated t h e i r attitude as "2" made these comments: 139 1. I'm not very p o s i t i v e . I think t h e y ' l l be more accurate and up to date but I think a l o t more mistakes are going to be made. 2. I don't l i k e i t ! I have not had a p o s i t i v e experience with a computer up to t h i s point. I f they were introduced into the h o s p i t a l at f i r s t I would be a l i t t l e resentful u n t i l I got used to i t and more experienced. Then i t would depend on what kind of teaching I had. I don't r e a l l y l i k e s t r i c t teaching where you are penalized for every mistake. I'd have to be forced to use i t u n t i l I got interested. I'm just not interested i n computers at a l l . 3. I just think that as f a r as the h o s p i t a l goes, the b i g thing i s the hands-on care. You can never replace the human touch with anything, and I can see from my l i t t l e experience how much a good nurse a f f e c t s the well being of the patient. It would take a l o t away from the nurses. One second-year subject became visably agitated as she looked at the computer on the researcher's desk during the interview. She said, "I look over there at your computer now and I think, oh God! It looks so t y p i c a l . It's just looking at you. I'm t r y i n g to describe i t but i t ' s hard. It looks f u t u r i s t i c . I can't explain i t . You want to take a step back instead of a step forward up to computers." When asked what would t r i g g e r her to take a step forward toward computers she commented, "Knowing i t would help me. Knowing that:red l i g h t s flashed a l l over i t and I would know what to do. I'm negative because of my past experiences with computers, lack of use of computers, and I can't see any need for i t at the moment." Another second-year subject, who chose "2" on the attitude scale, made these comments: " I f I wanted to get into computers, I would have taken "Computers.". The people 140 who go i n t o n u r s i n g u s u a l l y l i k e p e o p l e and want t o t a l k t o p e o p l e . I don't t h i n k I e n j o y t h e t e c h n i c a l t h i n g s . I don't mean t o sound n e g a t i v e , b u t p e r s o n a l l y , I j u s t don't want t o f e e l t h a t I have t o l e a r n them. I don't l i k e them. I ' d r a t h e r p u t my e x t r a energy l e a r n i n g about a p r o t o t y p e b e f o r e I l e a r n e d about t h e computer. B u t, a f t e r y e a r s o f c l i n i c a l work, I might want t o because I might want t h e s t i m u l a t i o n . " The t h i r d s econd-year s u b j e c t who was n e g a t i v e n o t e d : " I guess I'm n e g a t i v e about computers b u t , j u s t a t home on t h e one we have, h a l f t h e t i m e t h e t h i n g doesn't work and I j u s t have t h a t f e a r t h a t i t w i l l be t h e same t h i n g w i t h computers and n u r s i n g . I j u s t don't t r u s t them." E l e v e n o f t h e s u b j e c t s (31%) r a t e d t h e i r a t t i t u d e as "3" ( n e u t r a l , w a i t and s e e ) . The m a j o r i t y o f s u b j e c t s i n t h i s c a t e g o r y , Were i n t h i r d - y e a r ( 5 4 % ) . Comments made by t h e s e s u b j e c t s i n c l u d e d : 1. I r e a l l y don't know y e t . I ' l l have t o g e t i n and work w i t h them m y s e l f . I guess I'm a w a i t and see. 2. I'm not t o t a l l y a g a i n s t h a v i n g computers. I guess I w i l l e v e n t u a l l y f e e l c o m f o r t a b l e w o r k i n g w i t h computers i f I am exposed t o them f o r a l o n g enough p e r i o d . 3. I'm i n f a v o u r o f them b e i n g t h e r e , but I'm not knowledgeable enough t o r e a l l y know what's g o i n g on t o know what a r e g o i n g t o be t h e problems w i t h them y e t . 4. Computers do have a p l a c e , i t ' s j u s t t h e a n x i e t y towards them. T h i r t e e n o f t h e s u b j e c t s (37%) r a t e d t h e i r a t t i t u d e as "4" ( m o d e r a t e l y p o s i t i v e ) . F r e q u e n c i e s o f t h o s e r a t i n g t h e m s e l v e s a t "4" were d i s t r i b u t e d almost e v e n l y amongst t h e t h r e e y e a r s , w i t h f o u r i n b o t h f i r s t and second-year, and 141 f i v e i n t h i r d - y e a r . Comments t a k e n d i r e c t l y from t h e t r a n s c r i p t s o f t h e s e s u b j e c t s i n c l u d e d : 1. On t h e whole I'm p o s i t i v e . L e t ' s use i t where i t has dem o n s t r a t e d t h a t i t i s d e f i n i t e l y o f v a l u e , and l e t ' s not t r y t o f o r c e i t i n t o a r e a s where i t h a s n ' t been d e m o n s t r a t e d t h a t i t i s good. 2. I t h i n k t h e y w i l l be more b e n e f i c i a l t h a n t h e y w i l l be n e g a t i v e . 3. I t h i n k computers w i l l be p o s i t i v e and t h e y w i l l come. 4.1 t h i n k t h e y a r e coming and t h e r e i s no g e t t i n g away from them. I f e e l I've come a l o n g way s i n c e my f i r s t e x p e r i e n c e . 5. I don't t h i n k we have much c h o i c e i n t h e m a t t e r . They a r e g o i n g t o come and I t h i n k t h a t i f you can j u s t r e a l i z e t h a t and not f i g h t i t , y o u ' l l be ahead o f t h e game because you can a t l e a s t go i n t o i t w i t h an a t t i t u d e . . . okay t h i s i s g o i n g t o be p a r t o f my j o b and I ' l l have t o l e a r n i t , so I might as w e l l l e a r n i t as b e s t I can. 6. I t h i n k t h a t i f I t o o k t i m e and I had t i m e t o l e a r n , I would l i k e i t . 7. I would r e a l l y l i k e t o see them come i n t o our h o s p i t a l . 8 . 1 would be p o s i t i v e i f t h e y were t o come i n t o t h e c l i n i c a l s e t t i n g . F i v e s t u d e n t s s a i d t h e i r a t t i t u d e was "5" ( p o s i t i v e ) . Three were i n f i r s t - y e a r , one was i n second-year, and a l s o one was i n t h i r d - y e a r . Comments made by t h e s e f i v e s u b j e c t s were: 1. I t h i n k i t i s a v e r y p o s i t i v e t h i n g . -2. I 'd r e a l l y l i k e i t i n t h e h o s p i t a l . 3. D e f i n i t e l y p o s i t i v e ! 4. I am j u s t gung-ho on t h i s ! I f e e l my t h o u g h t s a r e so p o s i t i v e about h a v i n g computers, u s i n g i t t o i t s f u l l e s t advantage so t h a t I can have more t i m e w i t h my p a t i e n t . I t i s j u s t so m o t i v a t i n g f o r me! 5. I l i k e computers v e r y much. I t h i n k i t would be a g r e a t a s s e t t o n u r s i n g . T a b l e 11 p r o v i d e s a summary o f t h e f r e q u e n c i e s and p e r c e n t a g e s o f response on a f i v e p o i n t L i k e r t - t y p e a t t i t u d e s c a l e f o r s u b j e c t s i n each y e a r . 142 T a b l e 11. Frequency Of Response Of R a t i n g Oa A F i v e P o i n t L i k e r t - T y p e A t t i t u d e S c a l e YEAR FIRST SECOND THIRD TOTAL RATING* (n = 11) (n = 11) (n = 13) N = 35 f (%) f (%) f (%) f (%) 1 0 (0) 0 (0) 0 (0) 0 (0) 2 3 (27) 3 (27) 0 (0) 6 (17) 3 1 (9) 3 (27) 7 (54) 11 (31) 4 4 (36) 4 (36) 5 (38) 13 (37) 5 3 (27) 1 (9) 1 (8) 5 (9) * 1 = n e g a t i v e , 2 = m o d e r a t e l y n e g a t i v e , 3 = n e u t r a l / 4 = m o d e r a t e l y p o s i t i v e , 5 = p o s i t i v e The o v e r a l l a t t i t u d e o f s u b j e c t s was p o s i t i v e t o w a r d computers i n h o s p i t a l n u r s i n g , w i t h e i g h t e e n ( 5 1 ) % o f t h e s u b j e c t s s a y i n g t h e i r a t t i t u d e was p o s i t i v e ("4" o r " 5 " ) . E l e v e n (31%) were n e u t r a l ("3"), and o n l y s i x o f t h e t h i r t y -f i v e s u b j e c t s (17%) were c o n s i d e r e d t o be n e g a t i v e ("1" o r " 2 " ) . One o f t h e male s u b j e c t s r a t e d h i s a t t i t u d e as "3", and t h e o t h e r f o u r were a l l p o s i t i v e . T a b l e 12 p r o v i d e s a summary o f s u b j e c t s ' a t t i t u d e s ( n e g a t i v e , n e u t r a l , p o s i t i v e ) t o w a r d computer use i n h o s p i t a l s . 143 T a b l e 12. Frequency Of Response Of S u b j e c t s ' A t t i t u d e s Toward Computer Use I n H o s p i t a l s YEAR FIRST SECOND THIRD TOTAL (n = 11) (n = 11) (n = 13) N = 35 ATTITUDE RATING* f (%) f (%) f (%) f (%) NEGATIVE 3 (27) 3 (27) 0 (0) 6 (17) NEUTRAL 1 (9) 3 (27) 7 (54) 11 (31) POSITIVE 7 (64) 5 (45) 6 (46) 18 (51) * R a t i n g s on a f i v e - p o i n t L i k e r t - t y p e a t t i t u d e s c a l e were combined t o p r o v i d e t h e f i n d i n g s ( n e g a t i v e = " 1 " and "2", n e u t r a l = "3", p o s i t i v e = "3" and " 4 " ) . R e l a t i o n s h i p Between C o n c e p t i o n And A t t i t u d e A t h i r d q u e s t i o n posed a t t h e o u t s e t o f t h e s t u d y was r e v i s e d t o be: What i s t h e r e l a t i o n s h i p between n u r s i n g s t u d e n t s ' c o n c e p t i o n s o f t h e impact o f computers on h o s p i t a l employed n u r s e s , and s t u d e n t ' s a t t i t u d e s t o w a r d computers? I n o r d e r t o a s s e s s t h e r e l a t i o n s h i p between c o n c e p t i o n and a t t i t u d e , i t was i n i t i a l l y d e c i d e d t o f o c u s on s u b j e c t s who were r a t e d as n e g a t i v e , because t h e m a j o r i t y o f s u b j e c t s i n t h e s t u d y were p o s i t i v e about computers coming i n t o t h e 144 ho s p i t a l setting, and also p o s i t i v e about the nurse becoming more involved with them. Measures of attitude were the subject's r a t i n g on the a t t i t u d i n a l scale. Measures of conceptions were: (1) r a t i n g of the l e v e l of complexity of conceptions, and (2) the number of categories of conception discussed by each subject. These ratings have been reported e a r l i e r i n t h i s chapter (Tables 9, 10, 11 and 12). F i r s t l y , findings on the number of categories of conceptions discussed by the s i x (three f i r s t , and three second-year) subjects with negative attitudes, were examined to determine possible r e l a t i o n s h i p s . It appears that one of the subjects had discussed two categories, three had discussed three, and two had discussed four. There does not appear to be an obvious r e l a t i o n s h i p between the number of categories discussed and a t t i t u d e . Secondly, findings on i n d i v i d u a l subjects' complexity of conceptions and attitudes were examined to determine re l a t i o n s h i p s . It appears that a l l six subjects with negative attitudes toward computer use i n hospitals, conceptualize the use of computers at a low l e v e l . On the other hand, of the eight subjects i n f i r s t - y e a r considered to have low l e v e l conceptions, three had negative attitudes, and f i v e had p o s i t i v e attitudes. Of the four subjects i n second-year with a low l e v e l of conception, three had negative attitudes, and one had a p o s i t i v e a t t i t u d e . A l l four of the third-year subjects with low l e v e l conceptions had p o s i t i v e 145 a t t i t u d e s . I n e x a m i n i n g s u b j e c t s r a t e d as h a v i n g a h i g h l e v e l o f c o n c e p t i o n , i t appears t h a t a l l ( t h r e e f i r s t - y e a r , seven second-year, n i n e t h i r d - y e a r ) t h e s e s u b j e c t s , a l s o have p o s i t i v e a t t i t u d e s t o w a r d computer use i n h o s p i t a l s . There appears t o be a s i g n i f i c a n t r e l a t i o n s h i p between c o n c e p t i o n and a t t i t u d e (X 2= 7.25, p_<.01). A l l s u b j e c t s w i t h a h i g h l e v e l o f c o n c e p t i o n have p o s i t i v e a t t i t u d e s . S u b j e c t s w i t h a low l e v e l o f c o n c e p t i o n a r e d i v i d e d i n terms o f h a v i n g a p o s i t i v e o r n e g a t i v e a t t i t u d e . However, a l l s i x s u b j e c t s who were i d e n t i f i e d i n t h e s t u d y as h a v i n g a n e g a t i v e a t t i t u d e , have a low l e v e l o f c o n c e p t i o n . T a b l e 13 summarizes l e v e l s o f c o n c e p t i o n and a t t i t u d e t o w a r d computers. 146 Table 13. Frequency of Response Relating Level Of Conception And Attitude YEAR CONCEPTION AND FIRST SECOND THIRD TOTAL ATTITUDE (n = 11) (n = 11) (n = 13) N = 35 HIGH CONCEPTION: POSITIVE ATTITUDE 3 7 9 19 NEGATIVE ATTITUDE 0 0 0 0 LOW CONCEPTION: POSITIVE ATTITUDE 5 1 4 10 NEGATIVE ATTITUDE 3 3 0 6 TOTAL 11 11 13 35 Secondary Findings Secondary findings were generated through analysis of the questions on the respondent p r o f i l e section of the interview schedule. Two types of questions were used: (a) forced-response, requiring subjects to select a . response from two or more alt e r n a t i v e s ; and (b) open-ended, allowing subjects to construct the responses. Because the questions on the p r o f i l e were designed to obtain an understanding of 147 t h e b ackground o f t h e s u b j e c t s , t h e y sought i n f o r m a t i o n on a v a r i e t y o f s e e m i n g l y u n r e l a t e d f a c t s . C o n s e q u e n t l y , t h i s s e c ondary f i n d i n g s s e c t i o n , appears a t t i m e s t o be a d i s j o i n t e d c o l l e c t i o n o f u n r e l a t e d f a c t s . The r e l a t i o n s h i p o f s e c ondary f i n d i n g s t o p r i m a r y f i n d i n g s w i l l be a d d r e s s e d i n C h a p t e r 5. I n o r d e r t o p r e s e n t t h e secondary f i n d i n g s i n a s u c c i n c t f a s h i o n , t h e y w i l l be p r e s e n t e d under two h e a d i n g s : (a) demographics, ( s u b - s e c t i o n s A - F ) , and (b) computer a c c e s s and usage, ( s u b - s e c t i o n s A-C). Demographics A. Age A t t h e t i m e o f t h e i n t e r v i e w s (March & A p r i l , 1988), t h e m a j o r i t y o f s u b j e c t s , (60%) were between t h e ages o f e i g h t e e n and t w e n t y - f o u r . The n e x t l a r g e s t age group was between t w e n t y ^ f i v e and t w e n t y - n i n e ( 2 0 % ) . One second-year s u b j e c t was between ages f o r t y and f o r t y - n i n e , and one f i r s t - y e a r was between ages f i f t y and f i f t y - n i n e . ; The t o t a l " r e g u l a r " s t u d e n t p o p u l a t i o n who were between t h e ages o f e i g h t e e n and t w e n t y - f o u r i n March and A p r i l , 1988 were d i s t r i b u t e d as f o l l o w s : 49% f i r s t - y e a r , 57% second-year, and 43% t h i r d -y e a r . T a b l e 14 i n d i c a t e s t h e breakdown o f s u b j e c t s w i t h i n each y e a r , i n terms o f age range. 148 Table 14. Age Ranges Of Subjects In Each Year Of The Cariboo College Nursing Program YEAR FIRST SECOND THIRD TOTAL (n = 11) (n = 11) (n = 13) N = 35 AGE RANGE f (%) f (%) f (%) f (%) 18 - 24 5 (45) 8 (73) 8 (62) 21 (60) 25 - 29 3 (27) 1 (9) 3 (23) 7 (20) 30 - 39 2 (18) 1 (9) 2 (15) 5 (14) 40 - 49 0 (0) 1 (9) 0 (0) 1 (3) 50 - 59 1 (9) 0 (0) 0 (0) 1 (3) TOTAL 11 (99) 11 (100) 13 (100) 35 (100) In summary, the majority of subjects who p a r t i c i p a t e d i n the study, i n a l l three years, were between the ages of eighteen and twenty-four. The age group that ranked second for a l l three years was twenty-five to twenty-nine. The majority of subjects i n a l l three years (80%) ranged i n age between eighteen and twenty-nine as did the majority (68%) i n the "regular" nursing population. The age range of the sample appears to be representative of the t o t a l student population enrolled i n each year of the program. 149 B. Formal E d u c a t i o n P r i o r To E n t e r i n g The C a r i b o o C o l l e g e N u r s i n g Program T w e n t y - s i x s u b j e c t s (74%) have had f o r m a l e d u c a t i o n a l e x p e r i e n c e beyond t h e h i g h s c h o o l l e v e l p r i o r t o e n t e r i n g t h e C a r i b o o C o l l e g e n u r s i n g program. These e d u c a t i o n a l e x p e r i e n c e s i n c l u d e d : u n i v e r s i t y t r a n s f e r c o l l e g e c o u r s e s , n o n - u n i v e r s i t y t r a n s f e r c o l l e g e c o u r s e s , u n i v e r s i t y d e g r e e s , non-degree u n i v e r s i t y c o u r s e s , and o t h e r c o u r s e s , such as c o r r e s p o n d e n c e and work r e l a t e d c o u r s e s . Only n i n e s u b j e c t s (26%) e n t e r e d n u r s i n g d i r e c t l y from h i g h s c h o o l . S i x t e e n s u b j e c t s (46%) had t a k e n u n i v e r s i t y t r a n s f e r c o l l e g e c o u r s e s , and t h r e e s u b j e c t s (9%) had u n i v e r s i t y degrees p r i o r t o e n t e r i n g t h e program. W h i l e f o u r t e e n s u b j e c t s (40%) w i t h e x p e r i e n c e beyond h i g h s c h o o l had one f o r m a l e d u c a t i o n a l e x p e r i e n c e p r i o r t o e n t e r i n g t h e n u r s i n g program, e l e v e n (31%) had two e x p e r i e n c e s . One f i r s t - y e a r s u b j e c t was not t y p i c a l o f t h e sample, i n t h a t she had a l a r g e v a r i e t y o f e d u c a t i o n a l e x p e r i e n c e s from f o u r o f t h e c a t e g o r i e s . T a b l e 15 i n d i c a t e s a breakdown o f t h e l e v e l o f f o r m a l e d u c a t i o n a l e x p e r i e n c e o f s u b j e c t s p r i o r t o e n t e r i n g t h e C a r i b o o C o l l e g e n u r s i n g program. 150 Table 15. Formal Education P r i o r To Entering The Cariboo College Nursing Program YEAR FIRST SECOND THIRD TOTAL (n = 11) (n = 11) (n = 13) N = 35 FORMAL EDUCATION f (%) f (%) f (%) f (%) HIGH SCHOOL 1 (9) 4 (36) 4 (31) 9 (26) U.T. COLLEGE 5 (45) 4 (36) 7 (54) 16 (46) NON U.T. COLLEGE 2 (18) 2 (18) 5 (38) 9 (26) UNIVERSITY DEGREE 2 (18) 1 (9) 0 (0) 3 (9) UNIVERSITY NON DEGREE 3 (27) 1 (9) 0 (0) 4 (11) OTHER 3 (27) 1 (9) 4 (31) 8 (23) TOTAL * 16 13 20 * The frequency counts reported i n these columns do not t o t a l the i d e n t i f i e d n's for each year, as twelve subjects indicated more than one educational experience. The majority of subjects who p a r t i c i p a t e d i n t h i s study had educational experience beyond the high school l e v e l p r i o r to entering the Cariboo College nursing program. Only one f i r s t - y e a r , and four second and third-year subjects entered d i r e c t l y from high school. 151 C. Amount Of Education S p e c i f i c To Computers Obtained Outside The Cariboo College Nursing Program Fourteen subjects (40%) had no education s p e c i f i c to computing p r i o r to entering the nursing department. Of the twenty-one who had, nineteen (54%) had only one formal experience, while one f i r s t - y e a r subject had two. Another f i r s t - y e a r subject had a number of univers i t y and college courses, as well as a long history of varied experiences, with computers i n the workplace. She was considered to be an EXPERT. Table 16 i l l u s t r a t e s the amount of formal computer education subjects have had outside the nursing department. Table 16. Amount Of Formal Education S p e c i f i c To Computers Obtained Outside The Cariboo College Nursing Program YEAR AMOUNT OF FIRST SECOND THIRD TOTAL FORMAL COMPUTER (n = 11) (n = 11) (n = 13) N = 35 EDUCATION f (%) f (%) f (%) f (%) NONE 3 (27) 3 (27) 8 (62) 14 (40) ONE EXPERIENCE 6 (55) 8 (73) 5 (38) 1? (54) TWO EXPERIENCES 1 (9) 0 (0) 0 (0) 1 (3) MORE THAN TWO 1 (9) 0 (0) 0 (0) 1 (3) 152 These e d u c a t i o n a l e x p e r i e n c e s w i t h computers t o o k p l a c e i n a v a r i e t y o f t y p e s o f s e t t i n g s i n c l u d i n g : u n i v e r s i t y , c o l l e g e , t h e s c h o o l system, and t h e w o r k p l a c e . Only one s u b j e c t had t a k e n u n i v e r s i t y l e v e l computer c o u r s e s , w h i l e two had t a k e n c o l l e g e l e v e l c o u r s e s . Twelve s u b j e c t s (34%) had t a k e n computing c o u r s e s w h i l e i n t h e s c h o o l system i n e i t h e r e l e m e n t a r y , j u n i o r h i g h o r h i g h s c h o o l . Of t h e s e t w e l v e , s i x were second-year s u b j e c t s , w h i l e t h r e e were f i r s t h a n d t h r e e were t h i r d - y e a r . I t appeared from d i s c u s s i o n s w i t h t h o s e s u b j e c t s who had t a k e n computer c o u r s e s i n t h e s c h o o l system, t h a t t h e f o c u s o f t h e s e c o u r s e s was on programming. A t o t a l o f t h r e e s u b j e c t s t o o k computer c o n t e n t i n c o r p o r a t e d w i t h programs o t h e r t h a n n u r s i n g , w h i l e s i x t o o k o t h e r t y p e s o f c o u r s e s , such as c o r r e s p o n d e n c e and w o r k - r e l a t e d c o u r s e s . T a b l e 17 summarizes t h e f r e q u e n c y and p e r c e n t a g e o f s u b j e c t s i n each y e a r , who o b t a i n e d f o r m a l e d u c a t i o n s p e c i f i c t o computers, i n s e t t i n g s o u t s i d e t h e C a r i b o o C o l l e g e n u r s i n g program. 153 Table 17. Settings Outside The Cariboo College Nursing Program Where Formal Computer Education Was Obtained YEAR FIRST SECOND THIRD TOTAL FORMAL COMPUTER (n = ID (n = 11) (n = 13) (N = 35) EDUCATION f (%) f (%) • f (%) f (%) UNIVERSITY COURSE 1 (9) 0 (0) 0 (0) 1 (3) COLLEGE COURSE 2 (18) 0 (0) 0 (0) 2 (6) SCHOOL SYSTEM 3 (27) 6 (55) 3 (23) 12 (34) INCORPXCOURSE 2 (18) 0 (0) 1 (8) 3 (9) CORRESP\WORK 3 (27) 2 (27) 1 (8) 6 (17) TOTAL* 11 8 5 24 *Total frequency does not equal n as several subjects had obtained formal education s p e c i f i c to computers i n more than one type of set t i n g . D. Environment For F i r s t Hands-On Computer Experience Subjects reported that t h e i r i n i t i a l experience with a computer (other than with video games) took place i n a variety of environments. A large majority of the t h i r t y - f i v e subjects (91%) had t h e i r i n i t i a l experience with a computer 154 p r i o r t o e n t e r i n g t h e C a r i b o o C o l l e g e N u r s i n g program. Of t h a t number, e i g h t e e n , (56%) d e s c r i b e d t h e i r i n i t i a l e x p e r i e n c e p o s i t i v e l y . Only t h r e e s u b j e c t s had n o t had a computer hands-on e x p e r i e n c e p r i o r t o t h e one i n t h e n u r s i n g program. These t h r e e were a l l e n r o l l e d i n t h i r d - y e a r . T a b l e 18 p r e s e n t s a summary o f t h e f r e q u e n c y and p e r c e n t a g e o f s u b j e c t s who had t h e i r i n i t i a l e x p e r i e n c e w i t h computers i n n u r s i n g o r n o n - n u r s i n g e n v i r o n m e n t s . T a b l e 18. I n i t i a l Hands-On Computer E x p e r i e n c e I n N u r s i n g And Non-N u r s i n g Environments ENVIROMENT FREQUENCY PERCENTAGE NON NURSING s c h o o l / u n i v e r s i t y 11 49 work 6 17 home 5 14 c o l l e g e - n o n - n u r s i n g 4 11 NURSING c o l l e g e - n u r s i n g 3 9 TOTAL 35 100 155 E. Computer E x p e r i e n c e I n The C a r i b o o C o l l e g e N u r s i n g  Program Computer c o n t e n t i s i n c o r p o r a t e d i n t o t h e C a r i b o o C o l l e g e n u r s i n g c u r r i c u l u m , m a i n l y i n t h e N u r s i n g P e r s p e c t i v e s Course, as o u t l i n e d i n C h a p t e r t h r e e (Table 4 ) . S e v e r a l s u b j e c t s s p o n t a n e o u s l y v o i c e d o p i n i o n s on t h e c o n t e n t p r e s e n t l y b e i n g t a u g h t i n t h e program, even though t h e y were not a s ked a d i r e c t q u e s t i o n t o e l i c i t s p e c i f i c i n f o r m a t i o n . These o p i n i o n s u s u a l l y came i n t h e c o u r s e o f s u b j e c t s d e s c r i b i n g t h e i r i n i t i a l and subsequent e x p e r i e n c e s w i t h a computer. A l l s u b j e c t s i n each y e a r were exposed t o s e m i n a r s i n semester one o f f i r s t - y e a r . N i n e f i r s t - y e a r s u b j e c t s (82%) mentioned t h e s e m i n a r s , and s i x o f t h e n i n e c o n s i d e r e d them t o be p o s i t i v e . Seven second-year s u b j e c t s (64%) mentioned t h e s e m i n a r s , and f o u r o f t h e seven c o n s i d e r e d them t o be p o s i t i v e . I n c l u d i n g t h e t h r e e s u b j e c t s who had t h e i r i n i t i a l e x p e r i e n c e w i t h a computer i n t h e f i r s t y e a r s e m i n a r s , o n l y s i x t h i r d - y e a r s u b j e c t s (46%) mentioned t h e computer s e m i n a r s . Of t h o s e s t u d e n t s , f o u r r e c a l l e d them as b e i n g p o s i t i v e l e a r n i n g e x p e r i e n c e s . O v e r a l l , 62% o f a l l s u b j e c t s mentioned t h e f i r s t y e a r s e minars as a computer e x p e r i e n c e . F i f t y - n i n e p e r c e n t o f t h o s e m e n t i o n i n g t h e f i r s t y e a r e x p e r i e n c e f o u n d i t t o be p o s i t i v e . Twelve t h i r d - y e a r s u b j e c t s (92%) mentioned t h e Nurse 156 Star program. Of that number, only four found the experience to be p o s i t i v e . The main reason seemed to be f a u l t y programs, which were a source of student f r u s t r a t i o n . F. Views On Computer Content In The Cariboo College Nursing  Program Subjects spontaneously voiced t h e i r opinions on computer content i n the Cariboo College nursing program. Twenty-two subjects (63%) f e l t that computer content should be included i n the nursing program, either as a separate course, or incorporated into the nursing course. The numbers of subjects (55% f i r s t - y e a r , 63% second-year, 69% third-year) wanting more computer content i n the nursing program increased with each succeeding year. One male subject thought that a computing course should be a pre-requisite to nursing. One female f i r s t - y e a r subject stated that she would force herself to go u n t i l she got interested. A third-year subject who has used computers i n a job setting, stated, "I d e f i n i t e l y would say you r e a l l y need that t r a i n i n g program." A variety of opinions were expressed when subjects were asked to describe how they l i k e to learn to use a computer. Eleven subjects (31%) expressed the desire to learn on t h e i r own i n a s e l f - d i r e c t e d fashion. One third-year subject f e l t that faculty should make sure that everybody does i t , by keeping a l i s t . Another subject f e l t she could be s e l f -157 d i r e c t e d once she r e a c h e d a c e r t a i n p o i n t i n terms o f p r o f i c i e n c y . T e a c h i n g t e c h n i q u e s were d i s c u s s e d by s e v e r a l s u b j e c t s . T h i r t e e n s u b j e c t s (37%) e x p r e s s e d t h e d e s i r e t o have a d e m o n s t r a t i o n as p a r t o f t h e method o f t e a c h i n g . Three s u b j e c t s e x p r e s s e d a d e s i r e f o r one-to-one i n s t r u c t i o n . One s u b j e c t s t a t e d e m p h a t i c a l l y t h a t i t s h o u l d DEFINITELY be one-to - o n e . That p a r t i c u l a r s u b j e c t was v e r y n e g a t i v e towards computers t h r o u g h o u t h e r i n t e r v i e w . A n o t h e r s u b j e c t i n d i c a t e d she d i d n ' t want t o be s i t t i n g t h e r e f o r h a l f an hour w a i t i n g f o r h e l p and not p r o g r e s s i n g . " I j u s t don't have t h a t k i n d o f p a t i e n c e , " she s a i d . T h i r t e e n s u b j e c t s (37%) e x p r e s s e d t h e d e s i r e t o have a manual o r a b o o k l e t . One male s u b j e c t s t a t e d t h a t he l i k e d t o l e a r n by r e a d i n g and by t r i a l and e r r o r , but he n o t e d t h a t i t i s f r u s t r a t i n g when t h e book i s i n c o r r e c t . Twenty-one o f t h o s e sampled ( 6 0 % ) , s t a t e d t h e y l i k e d a s u p e r v i s e d p r a c t i s e , o r h a v i n g t h e i n s t r u c t o r a v a i l a b l e t o them, w h i l e t h e y used t h e computer. One female s u b j e c t s t a t e d she wanted t h e i n s t r u c t o r t o be honest and s t r a i g h t w i t h h e r . S e v e r a l s u b j e c t s s t a t e d t h e y p r e f e r r e d a p e r s o n r a t h e r t h a n a book. A n o t h e r s t a t e d she l i k e d t o be c o r r e c t e d as she went, as she saw no p o i n t , i n d o i n g something wrong two o r t h r e e t i m e s because i t ' s more d i f f i c u l t t o c o r r e c t an e r r o r when you've e s t a b l i s h e d a p a t t e r n . One s u b j e c t s t a t e d , " I l i k e always h a v i n g someone t h e r e you can ask: What am I d o i n g wrong?" 158 Sixteen subjects (46%) stated they would l i k e hands-on experience. As one subject noted, "I learn by doing." Nine subjects (26%) stated they l i k e d a step by step approach, from simple to more complex. Opinions varied as well on the amount of theory and practice needed i n programs. Nine subjects (26%) stated they would l i k e theory on computers. One f i r s t - y e a r female subject stated that she d i d not want the t e c h n i c a l i t i e s , but rather, she wanted a p r a c t i c a l a p p l i c a t i o n that she could use right away. A second-year subject stated she believes that you should know the reason why you are h i t t i n g a c e r t a i n key, rather than having whatever happens. While six f i r s t and second-year subjects expressed a desire for the p r a c t i c a l application, the t h i r d year subjects d i d not mention t h i s . One f i r s t - y e a r subject expressed a desire to learn how to edit essays. Subjects also discussed the rate for learning and the expectations placed on them. F i f t e e n subjects (43%) stated that they would l i k e to work at t h e i r own speed. One second year subject stated that a l o t of computer teachers have been using them so long that they don't understand that you don't know how, so they just rush along. Six subjects (17%) expressed the desire for a p o s i t i v e successful experience when learning about computers. One female second year subject stated she did not want to " f e e l l i k e an i d i o t . " She said: "It's better i f I don't touch i t at a l l , rather than 159 admit t h a t I don't know what I'm d o i n g . I h a t e b e i n g out o f c o n t r o l . " S e v e r a l s u b j e c t s n o t e d t h e d e s i r e t o have a c o u r s e f r e e from g r a d e s . I n summary, when asked how t h e y l i k e t o l e a r n about computers, s u b j e c t s e x p r e s s e d a v a r i e t y o f o p i n i o n s . I t appears t h a t t h e m a j o r i t y o f s u b j e c t s (63%) f e l t t h a t computer c o n t e n t s h o u l d be i n c l u d e d i n t h e program e i t h e r as a s e p a r a t e c o u r s e o r i n c o r p o r a t e d i n t o e x i s t i n g n u r s i n g c o u r s e s , but t h e r e d i d not appear t o be concensus among s u b j e c t s about: (a) p r e f e r r e d t e a c h i n g t e c h n i q u e s , (b) p a c i n g o f c o n t e n t , and (c) e v a l u a t i o n o f l e a r n i n g . Computer A c c e s s And Usage A. Computer A c c e s s And Usage A t C a r i b o o C o l l e g e A l l C a r i b o o C o l l e g e s t u d e n t s have f r e e a c c e s s t o t h e C o l l e g e VAX main frame system by v i r t u e o f t h e i r s t u d e n t s t a t u s . However, 71% o f t h e n u r s i n g s t u d e n t s sampled do not use t h e system. T a b l e 19 i n d i c a t e s t h e breakdown o f s u b j e c t s by y e a r , i n d i c a t i n g t h e i r use o f t h e C a r i b o o C o l l e g e Vax system. Of t h e t e n s u b j e c t s who use i t , e i g h t (80%) use i t f o r word p r o c e s s i n g , and two f o r m a i l messages o n l y . 160 Table 19. Percentage Of Subjects In Each Year Who Use The Cariboo College VAX System YEAR FIRST SECOND THIRD TOTAL (n = 11) (n = 11) (n = 13) (N = 35) VAX USE f (%) f (%) f (%) f (%) YES 3 (27) 2 (18) 5 (38) 10 (29) NO 8 (73) 9 (82) 8 (62) 25 (71) Even though subjects have free access to the Cariboo College Vax system, they i d e n t i f i e d nine b a r r i e r s preventing them from using the system. However, one f i r s t - y e a r , one second-year and three third-year subjects d i d not i d e n t i f y any b a r r i e r s . These subjects a l l use the system for word processing. Table 20 indicates a summary of the b a r r i e r s , arranged i n descending order of frequency of response, noted by subjects i n each year which prevent them from using the Cariboo College VAX system. 161 Table 20. Barriers I d e n t i f i e d By Subjects To Use Of The Cariboo College VAX System YEAR FIRST SECOND THIRD TOTAL (n = 11) (n = 11) (n = 13) N = 35 BARRIERS f (%) f <%') f (%) f (%) TIME\WORKLOAD 5 (45) 5 (45) 7 (54) 17 (49) ACCESSNAVAIL 4 (36) 5 (45) 5 (38) 14 (40) LACK OF KNOWLEDGE 4 (36) 3 (27) 6 (46) 13 (37) NO NEED TO USE 3 (27) 3 (27) 4 (31) 10 (29) NEGATIVE ATTITUDE 1 (9) 3 (27) 3 (23) 10 (29) PHYSICAL 4 (36) 0 (0) 3 (23) 7 (20) FEAR OF UNKNOWN 1 (9) 3 (27) 3 (23) 7 (20) NOT MECHANICAL 2 (18) 2 (18) 1 (8) 5 (14) TYPING ABILITY 2 (18) 0 (0) 0 (0) 2 (6) It i s interesting'to note that some p a r a l l e l s may be drawn between what subjects i d e n t i f y as b a r r i e r s to computer use i n the college, and what they discussed i n terms of t h e i r conceptions of the impact of computer use on hos p i t a l employed nurses. The major b a r r i e r (49%) to use of the Cariboo College VAX computer appears to be time and workload. A l l subjects (100%) discussed workload as a category of 162 c o n c e p t i o n / i n terms o f t h e impact computers may have on t h e w o r k l o a d o f h o s p i t a l employed n u r s e s . Many s u b j e c t s n o t e d t h a t t h e w o r k l o a d o f t h e h o s p i t a l employed n u r s e would be i n c r e a s e d w h i l e he\she was l e a r n i n g t o use a computer. A c c e s s a b i l i t y , and a v a i l a b i l i t y / w h i c h was t h e b a r r i e r r a n k e d second by t h e s u b j e c t s , was a l s o d i s c u s s e d by many i n terms o f p o s s i b l y i n c r e a s i n g t h e n u r s e ' s w o r k l o a d i n t h e h o s p i t a l . Lack o f knowledge was n o t e d as a b a r r i e r by 37% o f t h e s u b j e c t s ; t h i r t e e n o f whom were i n t h i r d - y e a r . T y p i n g a b i l i t y was n o t e d as a b a r r i e r t o use by o n l y two s u b j e c t s , b o t h o f whom were f i r s t y e a r , but was not mentioned i n t h e d i s c u s s i o n o f c a t e g o r i e s o f c o n c e p t i o n . A n e g a t i v e a t t i t u d e t o w a r d computers was n o t e d by seven (one f i r s t - y e a r , t h r e e s e cond-year, t h r e e t h i r d - y e a r ) s u b j e c t s as a b a r r i e r i n u s i n g t h e C a r i b o o C o l l e g e system. S i x s u b j e c t s r a t e d t h e m s e l v e s on a f i v e - p o i n t L i k e r t - t y p e s c a l e as h a v i n g a n e g a t i v e a t t i t u d e t o w a r d computer use i n h o s p i t a l n u r s i n g ( t h r e e f i r s t - y e a r , t h r e e s e c o n d - y e a r ) . I t appears t h a t , w i t h t h e e x c e p t i o n o f t h e second y e a r s u b j e c t s , some s u b j e c t s o n l y have n e g a t i v e a t t i t u d e s towards t h e use o f a computer i n s p e c i f i c s e t t i n g s . 163 B. Computer A c c e s s And Usage A t Home E i g h t y p e r c e n t o f s u b j e c t s do not have a c c e s s t o a computer a t home. T h i s means 28 s u b j e c t s e i t h e r have no computer i n t h e i r home, o r no ready a c c e s s t o t h a t o f a f r i e n d o r r e l a t i v e . T a b l e 21 i n d i c a t e s t h e s u b j e c t s i n each y e a r w i t h a c c e s s t o a computer a t home. T a b l e 21. Frequency Of S u b j e c t s W i t h A c c e s s To A Computer A t Home YEAR FIRST ,SECOND THIRD TOTAL (n = 11) (n = 11) (n = 13) N = 35 HOME ACCESS f. (%) f (%) f (%) f (%) YES 3 (27) 2 (18) 2 (15) 7 (20) NO 8 (73) 9 (82) 11 (85) 28 (80) Of t h e seven s u b j e c t s who have a c c e s s t o a computer a t home, f o u r (57%) a r e u s i n g them, and t h r e e (43%) a r e n o t . One o f t h e non-users i s a second-year s u b j e c t who r a t e d h e r s e l f as h a v i n g a n e g a t i v e a t t i t u d e t o w a r d computers. The o t h e r two non-users s t a t e d t h e y were i n t e r e s t e d i n u s i n g them, but c o u l d n o t f i n d t h e t i m e t o l e a r n . 164 G. F a m i l y Use - Other Than V i d e o Games Spouse Or S i g n i f i c a n t O t h e r . S i x o f t h e spouses o r s i g n i f i c a n t o t h e r s o f f i r s t - y e a r S u b j e c t s ( 5 5 % ) , f i v e o f second-year s u b j e c t s ( 4 5 % ) , and t h r e e o f t h i r d - y e a r s u b j e c t s (23%) use computers. T h i s g i v e s a t o t a l o f f o u r t e e n o f t h e spouses o r s i g n i f i c a n t o t h e r s (40%) o f s u b j e c t s u s i n g computers. The number u s i n g computers i s i n v e r s e l y p r o p o r t i o n a l t o s u b j e c t s ' y e a r i n t h e program. C h i l d r e n Twenty-seven o f t h e s u b j e c t s (77%) sampled have no c h i l d r e n . Of t h e e i g h t s u b j e c t s w i t h c h i l d r e n , t h r e e a r e i n f i r s t - y e a r and t h e i r c h i l d r e n a l l use computers a t s c h o o l . One second-year s u b j e c t e m p h a t i c a l l y s t a t e d t h a t she v a l u e d a music e d u c a t i o n f o r h e r c h i l d r e n o v e r computers. A c c e s s t o computers a t home i s not a r e a l i t y f o r most s u b j e c t s e n r o l l e d i n t h e C a r i b o o C o l l e g e N u r s i n g Program. Even though t h i s group does have f r e e a c c e s s t o t h e c o l l e g e ' a main frame VAX system, as s t u d e n t s , a number o f b a r r i e r s were n o t e d by t h e s u b j e c t s w h i c h p r e v e n t t h e m a j o r i t y from u s i n g i t t o any g r e a t e x t e n t . The main b a r r i e r s appear t o be w o r k l o a d , and a c c e s s a b i l i t y and a v a i l a b i l i t y . I t appears t h a t t h e spouses and c h i l d r e n o f s u b j e c t s a r e moderate computer u s e r s . 165 Summary Of P r i m a r y And Secondary F i n d i n g s F i n d i n g s were r e p o r t e d as b e i n g e i t h e r p r i m a r y o r s e c o n d a r y . P r i m a r y f i n d i n g s i n d i c a t e t h a t t h e t y p i c a l s u b j e c t ' s awareness o f computer use i n h o s p i t a l s t o d a y i s m i n i m a l / and p r i m a r i l y f o c u s e d on h i s \ h e r e x p e r i e n c e s i n t h e l o c a l c l i n i c a l agency (R . I . H . ) . The m a j o r i t y o f s u b j e c t s were not aware o f happenings p r o v i n c i a l l y and n a t i o n a l l y i n Canada, but s e v e r a l seemed t o f e e l t h a t h o s p i t a l s i n t h e U n i t e d S t a t e s were more advanced i n terms o f t e c h n o l o g y . S u b j e c t s ' knowledge o f how computers w i l l be used by h o s p i t a l employed n u r s e s i n t h e f u t u r e c e n t e r e d around t h r e e b r o a d a r e a s o f usage: (a) n u r s i n g , (b) communication and (c) a d m i n i s t r a t i o n . The m a j o r i t y o f s u b j e c t s i n a l l t h r e e y e a r s n o t e d t h e use o f computers f o r d o c u m e n t a t i o n p u r p o s e s . S u b j e c t s ' c o n c e p t i o n s o f how computers w i l l impact on h o s p i t a l employed n u r s e s f e l l i n t o f o u r c a t e g o r i e s : (a) n u r s i n g image, (b) p a t i e n t c a r e , (c) w o r k l o a d , and (d) p r o f e s s i o n a l i s m . S u b j e c t s ' comments, w i t h i n each o f t h e s e f o u r c a t e g o r i e s , were f u r t h e r c l a s s i f i e d i n t o t h r e e s u b - c a t e g o r i e s i n d i c a t i n g whether s u b j e c t s f e l t t h a t t h e i n c r e a s e d use o f computers would: (a) enhance, (b) d e t r a c t from o r ! ( c ) b o t h enhance and d e t r a c t from t h e c a t e g o r y . The r e l a t i o n s h i p o f s u b - c a t e g o r i e s t o c a t e g o r i e s i s r e p r e s e n t e d i n F i g u r e 2. 166 Categories Detract Nursing image Patient care Workload Professionalism Enhance F i g u r e 2. R e l a t i o n s h i p Of S u b - C a t e g o r i e s To C a t e g o r i e s Of C o n c e p t i o n A l l s u b j e c t s commented on e i t h e r two, t h r e e , o r f o u r c a t e g o r i e s o f c o n c e p t i o n but o v e r a l l , t h e m a j o r i t y o f second and t h i r d - y e a r s u b j e c t s d i s c u s s e d a l l f o u r c a t e g o r i e s . S u b j e c t ' s c o n c e p t i o n s d i f f e r e d i n c o m p l e x i t y o r q u a l i t y , i n d i r e c t p r o p o r t i o n t o t h e y e a r i n which t h e y were e n r o l l e d i n the program. A v e r y s m a l l number o f s u b j e c t s s p o n t a n e o u s l y e x p r e s s e d a d e s i r e t o purchase a computer, o r t o t a k e a computer c o u r s e . The o v e r a l l a t t i t u d e o f s u b j e c t s t oward computers i n h o s p i t a l n u r s i n g was p o s i t i v e . A l l s i x o f t h e s u b j e c t s who were r a t e d as h a v i n g n e g a t i v e a t t i t u d e s were female. Three were i n f i r s t - y e a r and t h r e e were i n second-year. I n a d d i t i o n , t h e r e appears t o be a r e l a t i o n s h i p between a s u b j e c t ' s c o m p l e x i t y o f c o n c e p t i o n , and h i s \ h e r a t t i t u d e . A l l s i x s u b j e c t s w i t h n e g a t i v e a t t i t u d e s had a low l e v e l o f c o n c e p t i o n , and a l l s u b j e c t s w i t h a h i g h l e v e l o f c o n c e p t i o n 167 had p o s i t i v e a t t i t u d e s . Secondary f i n d i n g s i n d i c a t e t h a t t h e m a j o r i t y o f s u b j e c t s were between t h e ages o f e i g h t e e n and t w e n t y - f o u r , and had e d u c a t i o n beyond t h e h i g h s c h o o l l e v e l . P r i o r t o e n t e r i n g t h e C a r i b o o C o l l e g e n u r s i n g program, t h e m a j o r i t y o f s u b j e c t s had a hands-on computer e x p e r i e n c e ( e x c l u d i n g v i d e o games). However, 40% had no. f o r m a l computing e d u c a t i o n . A number o f s u b j e c t s e x p r e s s e d v i e w s , b o t h p o s i t i v e and n e g a t i v e , about t h e e x p e r i e n c e t h e y had w i t h computers i n t h e i r n u r s i n g program, w i t h some even making s u g g e s t i o n s f o r change. W h i l e a c c e s s t o computers a t home i s not a r e a l i t y f o r most s u b j e c t s (80%), a l l s u b j e c t s , as s t u d e n t s have f r e e a c c e s s t o t h e C a r i b o o C o l l e g e VAX computer system, but few are u s i n g t h i s system ( 2 1 % ) . A number o f b a r r i e r s were c i t e d f o r t h i s l a c k o f use; w o r k l o a d (4 9 % ) , a c c e s s i b i l i t y and a v a i l a b i l i t y o f t e r m i n a l s (40%), and l a c k o f knowledge (37%) appear t o be paramount. 168 CHAPTER 5 D i s c u s s i o n , Recommendations, S i g n i f i c a n c e , And C o n c l u s i o n s D i s c u s s i o n Of F i n d i n g s T h i s s t u d y s e t out to.answer one broad, and t h r e e s p e c i f i c r e s e a r c h q u e s t i o n s . . As a n t i c i p a t e d a t t h e o u t s e t , due t o t h e phenomenologic n a t u r e o f t h e s t u d y , t h e q u e s t i o n s were r e f i n e d d u r i n g t h e d a t a c o l l e c t i o n and a n a l y s i s phase t o r e a d : 1. How do n u r s i n g s t u d e n t s i n a community c o l l e g e n u r s i n g program c o n c e p t u a l i z e t h e impact o f computers on h o s p i t a l employed n u r s e s ? (a) I s t h e r e a d i f f e r e n c e i n c o m p l e x i t y between f i r s t , second, and t h i r d - y e a r n u r s i n g s t u d e n t s ' c o n c e p t i o n s : o f t h e impact o f computers on h o s p i t a l employed n u r s e s ? (b) What i s t h e r e l a t i o n s h i p between n u r s i n g s t u d e n t s ' c o n c e p t i o n s o f t h e impact o f computers on h o s p i t a l employed n u r s e s , and t h e l e n g t h o f s t u d e n t s ' c l i n i c a l e x p e r i e n c e ? 169 (c) I s t h e r e a r e l a t i o n s h i p between n u r s i n g s t u d e n t s ' c o n c e p t i o n s o f t h e impact o f computers on h o s p i t a l employed n u r s e s , and s t u d e n t s ' a t t i t u d e t oward computers? F i n d i n g s were p r e s e n t e d i n Chapter 4 as e i t h e r p r i m a r y o r secondary. In t h i s c h a p t e r , p r i m a r y f i n d i n g s a r e d i s c u s s e d by f o c u s i n g on each o f t h e r e f i n e d r e s e a r c h q u e s t i o n s s e p a r a t e l y . T h i s i s f o l l o w e d by a d i s c u s s i o n o f secondary f i n d i n g s on demographics, and computer usage. Then, t h e g e n e r a l i z a b i l i t y : o f t h e f i n d i n g s , as w e l l as t h e l i m i t a t i o n s , and s i g n i f i c a n c e o f t h e s t u d y are a d d r e s s e d . F i n a l l y , t h e c h a p t e r ends w i t h b o t h g e n e r a l , and l o c a l recommendations and c o n c l u s i o n s . D i s c u s s i o n Of P r i m a r y F i n d i n g s R e s e a r c h Q u e s t i o n 1 Because c o n c e p t i o n s a r e formed by one's awareness o f "what i s , " and by a knowledge o f "what may be," q u e s t i o n s were asked a t t h e o u t s e t o f t h e s t u d y t o determine s u b j e c t s ' : (a) awareness o f computer use i n h o s p i t a l n u r s i n g t o d a y , and (b) knowledge o f how computers may be used by h o s p i t a l employed n u r s e s i n t h e f u t u r e . These views p r o v i d e d a c o n t e x t f o r u n d e r s t a n d i n g s t u d e n t s ' c o n c e p t i o n s about t h e 170 impact o f computers on h o s p i t a l employed n u r s e s . O v e r a l l , i t appears t h a t s u b j e c t s e n r o l l e d i n t h e C a r i b o o C o l l e g e n u r s i n g program, have a l a c k o f awareness o f computer use i n h o s p i t a l n u r s i n g t o d a y . S u b j e c t s ' l a c k o f awareness may be p a r t i a l l y e x p l a i n e d by t h e f a c t t h a t n u r s e s a r e not p r e s e n t l y u s i n g computers at R o y a l I n l a n d H o s p i t a l (R.I.H.), t h e f a c i l i t y where t h e m a j o r i t y o f t h e i r c l i n i c a l e x p e r i e n c e t a k e s p l a c e . I n t h a t l o c a l f a c i l i t y , a t t h e t i m e o f t h e i n t e r v i e w s , computer use c o n s i s t e d o f i n d i v i d u a l department systems i n n o n - n u r s i n g a r e a s . I n a d d i t i o n , s u b j e c t s ' l a c k o f awareness appears t o i n d i c a t e t h a t t h e computer awareness c o n t e n t p r e s e n t l y i n c l u d e d i n t h e N u r s i n g P e r s p e c t i v e s c o u r s e i n the ; C a r i b o o C o l l e g e n u r s i n g program i s i n a d e q u a t e . Most s u b j e c t s were aware o f t h e p r e s ence o f computers i n t h e l a b a t R.I.H.. T h i s f i n d i n g i s not s u r p r i s i n g , as a l l s u b j e c t s have a c c e s s t o , and r e f e r t o t h e c o m p u t e r i z e d l a b r e p o r t s i n p a t i e n t c h a r t s d u r i n g t h e i r c l i n i c a l e x p e r i e n c e . The T r a v e n o l H o s p i t a l P a t i e n t Management System i s e x p e c t e d t o be p i l o t e d a t R.I.H. i n t h e a d m i t t i n g , p a y r o l l , m e d i c a l r e c o r d s , and b u s i n e s s departments i n October, 1988. A l t h o u g h d a t a i s p r e s e n t l y b e i n g e n t e r e d i n t o t h e system, s u b j e c t s d i d not seem t o be aware o f t h a t f a c t , however s e v e r a l s u b j e c t s d i d know t h a t t h e r e were p l a n s f o r t h e i n s t a l l a t i o n o f a t o t a l p a t i e n t system at R.I.H sometime i n t h e f u t u r e . Because o f t h e i r p r e s e n t l a c k o f d i r e c t hands-on use of 171 computers i n t h e h o s p i t a l , s u b j e c t s a t t h i s p o i n t i n t h e i r c a r e e r , do not appear t o r e l a t e p e r s o n a l l y t o t h e use o f computers i n n u r s i n g . W h i l e a l l s u b j e c t s a r e exposed t o c o m p u t e r i z e d equipment such as i n t r a v e n o u s c o n t r o l l e r s , thermometers and m o n i t o r s , d u r i n g t h e i r c l i n i c a l e x p e r i e n c e , most do not appear t o r e l a t e t h i s t o computer use. I n s t e a d , t h e y d i s c u s s e d computers i n r e l a t i o n t o a c t u a l t e r m i n a l s w i t h keypads. Perhaps t h i s i s so because s u b j e c t s have not been i n f o r m e d r e g a r d i n g v a r i o u s t y p e s o f computers, and computer a p p l i c a t i o n s p r e s e n t l y b e i n g used. I t was i n t e r e s t i n g t o note t h a t many o f t h e s u b j e c t s , p r i o r t o t h e commencement o f t h e i n t e r v i e w s , made b l a n k e t s t a t e m e n t s i n f o r m i n g t h e r e s e a r c h e r o f t h e f a c t t h a t t h e y knew n o t h i n g about computers, and f o r h e r not t o expect them t o know much i n t h e i n t e r v i e w . A f t e r t h e i n t e r v i e w , many o f t h e s e same s u b j e c t s , - e x p r e s s e d t h a n k s f o r t h e o p p o r t u n i t y t o e x p r e s s t h e i r v i e w s , and s e v e r a l e x p r e s s e d s u r p r i s e t h a t t h e y had so many views t o o f f e r . One second-year s u b j e c t s a i d , " I d i d n ' t t h i n k I knew much. You made me t h i n k . " T h i s was an u n a n t i c i p a t e d outcome o f t h e r e s e a r c h , and i n d e e d i t p r o b a b l y s e r v e d t o h e i g h t e n t h e awareness o f a number o f s u b j e c t s by drawing t h e i r a t t e n t i o n t o computer use by h o s p i t a l employed n u r s e s . S e v e r a l s u b j e c t s e x p r e s s e d an i n t e r e s t i n s e e i n g t h e st u d y when i t was completed. Even though a g e n e r a l i n t r o d u c t i o n t o computer use i n n u r s i n g i s p a r t o f t h e computer seminars i n semester one, and 172 computer use i s d i s c u s s e d i n f o r m a l l y i n t h e N u r s i n g P e r s p e c t i v e s c o u r s e , s u b j e c t s i n a l l y e a r s l a c k e d knowledge of computer use by n u r s e s i n o t h e r p a r t s o f t h e p r o v i n c e , and t h e c o u n t r y . These f i n d i n g s a r e c o n s i s t e n t w i t h t h o s e o f o t h e r r e s e a r c h e r s who s t u d i e d n u r s e s w i t h d i f f e r e n t t y p e s o f e d u c a t i o n a l backgrounds and work e x p e r i e n c e ( H e l l e r e t a l . , 1985; R o n a l d , 1983; & P a r k e s e t a l . , 1986). Most C a r i b o o C o l l e g e n u r s i n g s t u d e n t s do not s u b s c r i b e t o The Canadian Nurse p u b l i c a t i o n and, even i f t h e y had a c c e s s t o i t , one p a r t i c u l a r l y r e l e v a n t a r t i c l e (Webber, 1988) which n o t e d t h e h o s p i t a l s i n Canada which a r e c o m p u t e r i z e d , was not p u b l i s h e d u n t i l a f t e r t h e s u b j e c t s had been i n t e r v i e w e d . S u b j e c t s were v a g u e l y aware of happenings i n t h e U n i t e d S t a t e s , p r o b a b l y due t o t h e f a c t t h a t most o f t h e a r t i c l e s , and books p e r t a i n i n g t o computers i n n u r s i n g are American i n o r i g i n . The f i l m t h a t has been used y e a r l y i n t h e semester one seminar on computer awareness d i s c u s s e s t h e t o t a l h o s p i t a l system at an American h o s p i t a l , E l Camino M e d i c a l C e n t e r i n C a l i f o r n i a . Two f i r s t - y e a r s u b j e c t s r a i s e d t h e p o i n t o f not y e t knowing t h e r o l e o f t h e n u r s e . T h i s r a i s e s t h e q u e s t i o n o f how, and when t o sequence computer c o n t e n t i n t h e n u r s i n g program. I t might be t o o e a r l y t o i n t r o d u c e s t u d e n t s t o use o f a t o t a l h o s p i t a l system i n semester one, as t h e y : (a) have o n l y had a v e r y l i m i t e d number of c l i n i c a l hours (95 h o u r s ) , (b) do not c u r r e n t l y see a system i n o p e r a t i o n a t R.I.H., and 173 (c) a r e j u s t b e g i n n i n g t o be s o c i a l i z e d i n t o t h e r o l e o f a n u r s e . I f a s t u d e n t i s unsure o f what h i s \ h e r r o l e as a h o s p i t a l employed nurse w i l l be, i t i s d i f f i c u l t t o see h i m s e l f \ h e r s e l f i n t h a t r o l e , and t o know how computers might be used, t o a s s i s t him\her i n c a r r y i n g out t h a t r o l e . S u b j e c t s ' knowledge o f how computers may be used by h o s p i t a l employed n u r s e s i n t h e f u t u r e , c e n t e r e d around t h r e e b r o a d a r e a s o f usage: (a) n u r s i n g , (b) communication, and (c) a d m i n i s t r a t i o n . The most f r e q u e n t l y mentioned uses were i n t h e a r e a o f n u r s i n g . Computer use f o r documentation purposes was c i t e d by t h e m a j o r i t y o f s u b j e c t s i n a l l t h r e e y e a r s . T h i s i s not s u r p r i s i n g because o f : (a) t h e emphasis p l a c e d on t h e importance o f documentation, and (b) t h e e x p e c t a t i o n t h a t a l l s t u d e n t s document t h e c a r e t h e y g i v e t h e i r p a t i e n t s from t h e i r f i r s t c l i n i c a l e x p e r i e n c e , t o t h e i r l a s t , w h i l e e n r o l l e d i n t h e program. Students i n a l l y e a r s , h i s t o r i c a l l y , c o m p l a i n about not h a v i n g s u f f i c i e n t t i m e t o document t h e c a r e t h e y g i v e as soon as i t i s completed. When bombarded by a d v e r t i s i n g i n t h e media t o u t i n g t h e e f f i c i e n c y of computers f o r i n f o r m a t i o n management, i t i s easy t o see how s u b j e c t s would t h i n k about t h e u t i l i t y o f computers f o r documentation p u r p o s e s . One s u r p r i s i n g f i n d i n g was t h a t v e r y few s u b j e c t s i n e i t h e r f i r s t (36%) or t h i r d (38%) y e a r , and none i n second y e a r , d i s c u s s e d t h e use o f computers as t e a c h i n g t o o l s . T e a c h i n g and l e a r n i n g p r i n c i p l e s a re t a u g h t i n t h e f i r s t y e a r 174 o f t h e n u r s i n g program, and s t u d e n t s are e v a l u a t e d a f t e r each c l i n i c a l r o t a t i o n , on t h e i r a b i l i t y t o i n c o r p o r a t e p a t i e n t t e a c h i n g i n t o t h e i r d e l i v e r y o f p a t i e n t c a r e . However, s t u d e n t s a r e not i n t r o d u c e d t o , or e x p e c t e d t o use computer a s s i s t e d i n s t r u c t i o n (C.A.I.) packages at any p o i n t i n t h e C a r i b o o C o l l e g e n u r s i n g program, and c o n s e q u e n t l y appear t o have d i f f i c u l t y e n v i s i o n i n g t h e use o f computer a s s i s t e d p a t i e n t t e a c h i n g packages i n h o s p i t a l n u r s i n g . Use o f C.A.I, l e a r n i n g packages by n u r s i n g s t u d e n t s t o f a c i l i t a t e t h e i r l e a r n i n g i n t h e e d u c a t i o n a l environment might i n c r e a s e t h e i r a b i l i t y t o u n d e r s t a n d how computers may be used as a t e a c h i n g t o o l by b o t h s t a f f , and p a t i e n t s i n t h e h o s p i t a l environment. W h i l e t h e m a j o r i t y o f f i r s t (100%), and t h i r d (77%) y e a r s u b j e c t s d i s c u s s e d t h e use o f computers as a r e f e r e n c e s o u r c e , o n l y 36% o f t h e second-year s u b j e c t s n o t e d t h i s a p p l i c a t i o n . Most s u b j e c t s , i n a l l y e a r s , who d i s c u s s e d t h i s use f o r computers d i d so i n r e l a t i o n t o i t s use as a s o u r c e o f d r ug i n f o r m a t i o n . F i r s t - y e a r s u b j e c t s , a t t h e t i m e o f t h e s t u d y (March and A p r i l , 1988), were j u s t c o m p l e t i n g t h e i r f i r s t Pharmacology c o u r s e i n which t h e y were exposed t o a tremendous amount o f drug i n f o r m a t i o n i n a r e l a t i v e l y s h o r t t i m e span. G i v e n t h e volume o f i n f o r m a t i o n f i r s t - y e a r s t u d e n t s a r e r e q u i r e d t o become f a m i l i a r w i t h , i t i s not s u r p r i s i n g t h e n , t h a t a l l f i r s t - y e a r s u b j e c t s n o t e d t h e use o f computers as a r e f e r e n c e s o u r c e , f o r drug i n f o r m a t i o n . I t i s s u r p r i s i n g though t h a t o n l y 36% o f t h e second-year 175 s u b j e c t s n o t e d t h e use o f computers as a r e f e r e n c e s o u r c e . Second-year s t u d e n t s a d m i n i s t e r a l a r g e number o f r e g u l a r l y p r e s c r i b e d m e d i c a t i o n s t o a group o f p a t i e n t s i n t h e h o s p i t a l f o r t h e f i r s t t i m e , and are r e q u i r e d t o r e s e a r c h and be f a m i l i a r w i t h t h e s e drugs p r i o r t o a d m i n i s t e r i n g them. Most second-year s t u d e n t s p r e s e n t l y : (a) purchase c o m m e r c i a l l y p r e p a r e d drug i n f o r m a t i o n c a r d s which t h e y c a r r y i n t h e i r u n i f o r m p o c k e t s f o r easy r e f e r e n c e w h i l e i n t h e c l i n i c a l a r e a , (b) r e f e r t o drug t e x t s on t h e n u r s i n g u n i t / and (c) c a l l t h e h o s p i t a l pharmacy f o r drug i n f o r m a t i o n i f t h e y a r e u n a b l e t o o b t a i n i t e l s e w h e r e . The absence o f computer f a c i l i t i e s i n t h e h o s p i t a l a t t h e t i m e of t h e s t u d y , and t h e p e r c e i v e d r e l a t i v e ease of o b t a i n i n g drug i n f o r m a t i o n might e x p l a i n why second-year s u b j e c t s d i d not appear t o d i s c u s s use o f t h e computer as a r e f e r e n c e s o u r c e . A t t h e t i m e of t h e s t u d y , t h i r d - y e a r s u b j e c t s were w o r k i n g s i d e - b y - s i d e w i t h p r e c e p t o r s i n t h e h o s p i t a l i n o r d e r t o l e a r n t h e r o l e and e x p e c t a t i o n s o f a h o s p i t a l employed n u r s e . A t t h a t p o i n t i n t h e program, t h e y are r e s p o n s i b l e f o r a d m i n i s t e r i n g l a r g e numbers of a l l t y p e s o f drugs, by a l l d r u g r o u t e s , i n c l u d i n g t h e d i r e c t i n t r a v e n o u s r o u t e . They r e c e i v e l i t t l e o r no s u p e r v i s i o n from t h e i n s t r u c t o r , and a r e r e s p o n s i b l e f o r knowing about t h e drugs t h e y a d m i n i s t e r . H i s t o r i c a l l y , a t t h i s p o i n t , when s t u d e n t s are e x p e c t e d t o f u n c t i o n i n d e p e n d e n t l y , t h e y become a c u t e l y aware o f t h e tremendous r e s p o n s i b i l i t y p l a c e d on them f o r s a f e drug 176 a d m i n i s t r a t i o n . The m a j o r i t y o f t h i r d - y e a r s u b j e c t s appeared t o see t h e u t i l i t y o f a computer as a t o o l f o r o b t a i n i n g drug i n f o r m a t i o n , which would e n a b l e them t o p e r f o r m t h e i r r o l e s a f e l y , and e f f i c i e n t l y . V e r y few s u b j e c t s d i s c u s s e d use o f t h e computer by h o s p i t a l employed n u r s e s f o r communication p u r p o s e s . The e x c e p t i o n was t h e t h i r d - y e a r s u b j e c t s . S i x t y - n i n e p e r c e n t o f them commented on i t s use as a means o f communication between h o s p i t a l departments. T h i s i s not s u r p r i s i n g as t h i r d - y e a r s u b j e c t s , a t t h e t i m e o f t h e s t u d y , were d o i n g t h e i r c l i n i c a l p r e c e p t o r s h i p where t h e y a r e e x p e c t e d t o b e g i n t o make t h e t r a n s i t i o n from t h e r o l e o f a s t u d e n t t o t h a t o f a g r a d u a t e n u r s e . T h e i r p r e c e p t o r s h i p i n c l u d e s more team l e a d i n g f u n c t i o n s which e n t a i l s i n c r e a s e d r e s p o n s i b i l i t y f o r communicating w i t h o t h e r h o s p i t a l departments. A d m i n i s t r a t i v e n u r s i n g a p p l i c a t i o n s are not s t r e s s e d i n a community c o l l e g e n u r s i n g program, and t h i s was r e f l e c t e d i n t h e low numbers o f s u b j e c t s who c i t e d use o f a computer t o f a c i l i t a t e t h e s e f u n c t i o n s . D e s p i t e t h e i r apparent l a c k o f computer awareness and knowledge, s u b j e c t s e n r o l l e d i n each o f t h e t h r e e y e a r s c o n c e p t u a l i z e d t h e impact o f computers on h o s p i t a l employed n u r s e s i n f o u r c a t e g o r i e s : (a) n u r s i n g image, (b) p a t i e n t c a r e , (c) w o r k l o a d , and (d) p r o f e s s i o n a l i s m . I t i s i n t e r e s t i n g t o note t h a t a l l o f t h e s e c a t e g o r i e s r e l a t e t o t o p i c s which h i s t o r i c a l l y are d i s c u s s e d i n t h e N u r s i n g 177 P r e s p e c t i v e s c o u r s e t h r o u g h o u t t h e t h r e e y e a r s o f t h e C a r i b o o C o l l e g e n u r s i n g program. There are two r e a s o n s why i t i s not s u r p r i s i n g t h a t t h e m a j o r i t y o f s u b j e c t s , i n a l l y e a r s , commented on t h e c a t e g o r y o f w o r k l o a d . F i r s t l y , as n u r s i n g s t u d e n t s t h e y a r e e x p e c t e d t o not o n l y c a r r y an academic w o r k l o a d , i n terms o f c o n t a c t h o u r s , which i s c o n s i d e r e d t o be heavy by c o l l e g e s t a n d a r d s but s e c o n d l y , t h e y a r e a l s o e x p e c t e d t o c a r r y an i n c r e a s i n g l y l a r g e r , and more complex p a t i e n t - c a r e l o a d i n t h e i r c l i n i c a l e x p e r i e n c e , i n each s u c c e e d i n g semester o f t h e program. W i t h r e c e n t media coverage, and i n c r e a s e d a t t e n t i o n i n t h e N u r s i n g P e r s p e c t i v e s c o u r s e on t h e i s s u e o f n u r s i n g s h o r t a g e s , and n u r s e s l e a v i n g t h e p r o f e s s i o n due t o burn out brought on by heavy w o r k l o a d s , i t i s s m a l l wonder t h a t t h i s c a t e g o r y r e c e i v e d t h e most a t t e n t i o n . P a t i e n t c a r e , t h e c a t e g o r y r e c e i v i n g t h e second l a r g e s t amount o f a t t e n t i o n by s u b j e c t s , i s t h e f o c u s o f t h e c l i n i c a l component i n a l l y e a r s o f t h e program, a l t h o u g h more desk r e l a t e d t y p e s o f d u t i e s , such as team l e a d i n g , are i n t r o d u c e d i n second and t h i r d - y e a r . I t i s i n t e r e s t i n g t h a t 100% o f t h e f i r s t - y e a r s u b j e c t s commented on p a t i e n t c a r e , which i s t h e main f o c u s o f a t t e n t i o n i n t h e c l i n i c a l component of f i r s t y e a r . A s l i g h t l y s m a l l e r number of t h e second (91%), and t h i r d (91%) y e a r s u b j e c t s commented on p a t i e n t c a r e . T h i s p o s s i b l y r e f l e c t s a s h i f t i n a t t e n t i o n t oward more team-l e a d i n g t y p e s of a c t i v i t i e s as s t u d e n t s p r o g r e s s t h r o u g h t h e 178 program. A l t h o u g h t h e m a j o r i t y o f f i r s t (55%) second (91 % ) , and t h i r d (77%) y e a r s u b j e c t s commented on t h e c a t e g o r y of n u r s i n g image, t h e p e r c e n t a g e s o f f i r s t - y e a r s u b j e c t s commenting was n o t i c e a b l y l e s s . T h i s might p o s s i b l y be r e l a t e d t o f i r s t - y e a r s u b j e c t s ' l a c k o f : (a) u n d e r s t a n d i n g o f t h e r o l e o f h o s p i t a l employed n u r s e s , (b) awareness o f how n u r s e s a r e o f t e n p o r t r a y e d : i n . t h e media, and (c) knowledge o f t h e a t t e n t i o n t h e i s s u e o f n u r s i n g image i s r e c e i v i n g from t h e p r o f e s s i o n a l a s s o c i a t i o n . A s m a l l m a j o r i t y o f s u b j e c t s i n each y e a r (64% f i r s t , 64% second, 62% t h i r d - y e a r ) d i s c u s s e d t h e c a t e g o r y o f p r o f e s s i o n a l i s m . T h i s f i n d i n g s u p p o r t s t h e b e l i e f , h e l d by many, t h a t even though t h e s o c i a l i z a t i o n p r o c e s s o f a d o p t i n g t h e c h a r a c t e r i s t i c s o f a p r o f e s s i o n a l n u rse b e g i n s i n t h e e d u c a t i o n a l s e t t i n g , i t i s o f t e n not u n t i l a s t u d e n t g r a d u a t e s t h a t he\she s t a r t s t o i d e n t i f y h i m s e l f \ h e r s e l f as b e i n g a p r o f e s s i o n a l who i s bound by a p r o f e s s i o n a l code o f e t h i c s . S u b j e c t s ' c h o i c e t o d i s c u s s how each of t h e f o u r c a t e g o r i e s (image, p a t i e n t c a r e , w o r k l o a d , and p r o f e s s i o n a l i s m ) c o u l d be: (a) enhanced, (b) d e t r a c t e d from or (c) b o t h enhanced and d e t r a c t e d from, was a n a l y z e d i n a s u p e r f i c i a l way i n t h i s s t u d y . The f r e q u e n c y of s u b j e c t s , i n each y e a r , commenting on each of t h e t h r e e s u b - c a t e g o r i e s was t a b u l a t e d . A l t h o u g h t h i s u n s o p h i s t i c a t e d q u a n t i t a t i v e 179 measure a l l o w e d f o r some comparisons t o be made between y e a r s , i t might have proven more i n t e r e s t i n g , and i n f o r m a t i v e had some c o r r e l a t i o n s been done between i n d i v i d u a l s u b j e c t s ' a t t i t u d e s t oward computers, and whether t h e y f o c u s e d t h e i r d i s c u s s i o n on how computer use: (a) enhanced, (b) d e t r a c t e d from, o r (2) b o t h enhanced and d e t r a c t e d from, each c a t e g o r y of c o n c e p t i o n d i s c u s s e d . Research Q u e s t i o n s (a) and (b) There appears t o be a d i f f e r e n c e i n c o m p l e x i t y between f i r s t , second, and t h i r d - y e a r s u b j e c t s ' c o n c e p t i o n s o f t h e impact o f computers on h o s p i t a l employed n u r s e s . T h i s d i f f e r e n c e appears t o be d i r e c t l y p r o p o r t i o n a l t o t h e y e a r i n which s u b j e c t s are e n r o l l e d i n t h e program. Because t h e number o f c l i n i c a l hours i n c r e a s e s s i g n i f i c a n t l y w i t h each a d d i t i o n a l y e a r of t h e program (see Chapter 1, T a b l e 2 ) , s p e c i f i c r e s e a r c h q u e s t i o n s (a) and (b) w i l l be d i s c u s s e d t o g e t h e r . L e a r n i n g t h e r o l e and e x p e c t a t i o n s o f t h e n u r s e , o c c u r s t h r o u g h a g r a d u a l s o c i a l i z a t i o n p r o c e s s over t i m e . T h e r e f o r e , i n t u i t i v e l y , one would expect t h a t as s t u d e n t s p r o g r e s s t h r o u g h t h e n u r s i n g program, t h e i r c o n c e p t i o n s would become more s o p h i s t i c a t e d inJ terms, o f knowing: (a) what t h e i r r o l e as a h o s p i t a l employed nurse might be, and (b) how t h e i r r o l e might be impacted on by a v a r i e t y o f v a r i a b l e s . T h i s 180 s t u d y v e r i f i e d t h e s e e x p e c t a t i o n s . S u b j e c t s i n each s u c c e e d i n g y e a r o f t h e program were a b l e t o c o n c e p t u a l i z e t h e impact computers may have on h o s p i t a l employed n u r s e s a t a h i g h e r l e v e l . Thus t h e f i n d i n g i s c o n s i s t e n t w i t h t h e c u r r i c u l u m d e s i g n o f t h e C a r i b o o C o l l e g e n u r s i n g program which sequences n u r s i n g c o n t e n t t o be t a u g h t s t a r t i n g from t h e s i m p l e and t h e n moving t o t h e complex. Even though t h e r e i s a t t e n t i o n drawn t o t h e computer l e a r n i n g needs o f n u r s e s i n t h e l i t e r a t u r e , (Anderson e t a l . , 1974; Walker, 1981; Ronald, 1983; Hannah, 1983; H e l l e r e t a l . , 1985; Merrow, 1985; & P a r k s e t a l . , 1986) t h e r e does not appear t o be e i t h e r : (a) a consensus o f r e q u i r e d competencies f o r n u r s e s w i t h r e g a r d t o computer knowledge and use, o r (b) a w i d e l y a c c e p t e d approach f o r t e a c h i n g n u r s e s t o use computers. P r e s e n t l y , t h e r e are no s t a t e d p r o v i n c i a l o r n a t i o n a l norms o f what i s e x p e c t e d i n terms o f t h e l e v e l o f computer knowledge o r use f o r n u r s e s . T h i s l a c k o f a more g l o b a l d i r e c t i o n has s e r v e d t o f o c u s t h e i d e n t i f i c a t i o n o f computer l e a r n i n g needs a t t h e l o c a l l e v e l . The i s s u e o f l a c k o f p r o v i n c i a l , and n a t i o n a l norms i s a concern t o e d u c a t o r s who f e e l t h a t s t u d e n t s , upon g r a d u a t i o n , s h o u l d be p r e p a r e d t o work not o n l y i n l o c a l h o s p i t a l f a c i l i t i e s but a l s o i n o t h e r h o s p i t a l s a c r o s s t h e country;. The M i n i s t r y Of Advanced E d u c a t i o n And Job T r a i n i n g i n B r i t i s h Columbia, i s moving a l i t t l e c l o s e r t o some 181 s t a n d a r d i z a t i o n o f programming by s u p p o r t i n g t h e Computers In  N u r s i n g P r o j e c t / and by making t h r e e l e a r n i n g modules a v a i l a b l e f r e e o f charge t o a l l n u r s i n g programs i n B r i t i s h C olumbia. T h i s a g a i n , i s a "what t o " and a "how t o " approach s i m i l a r t o t h o s e d e s c r i b e d i n t h e l i t e r a t u r e by a number of a u t h o r s (Edmunds/ 1982; S k i b a , 1983; Ronald, 1983; Hannah, 1983; & R o n a l d & S k i b a , 1987). These modules, w i t h t h e i r s t a t e d o b j e c t i v e s , a r e e x p e c t e d t o be i n c o r p o r a t e d i n t o e x i s t i n g n u r s i n g programs i n t h e p r o v i n c e by September, 1988. Even though t h e i n t e n t o f t h e modules i s commendable, problems are i n h e r e n t i n t h i s approach f o r a number o f r e a s o n s . F i r s t l y , n u r s i n g programs, i n B r i t i s h Columbia, use a v a r i e t y o f c u r r i c u l a frameworks. U n l e s s an attempt i s made t o i n c o r p o r a t e t h e modules, i n t o t h e s e e x i s t i n g frameworks, and t o p r o v i d e f o l l o w - u p t o i n d i v i d u a l programs as t h e y attempt t o use them, t h e modules a r e doomed t o s i t on a s h e l f c o l l e c t i n g dust i n someone's o f f i c e . Secondly, even though t h e modules are d e s i g n e d t o be adapted by i n d i v i d u a l programs t o f i t t h e i r p a r t i c u l a r l o c a l needs, t h e r e i s a danger t h a t w i t h o u t f o l l o w - u p , t h e s e a d a p t a t i o n s w i l l not be made. T h i r d l y , t h i s packaged approach assumes t h a t t h e computer l e a r n i n g needs of a l l s t u d e n t s a r e t h e same. T h i s we know t o be a f a l l a c y , a l o n g w i t h t h e n o t i o n t h a t one approach w i l l work f o r a l l ( S k i b a , 1982). The d i m e n s i o n m i s s i n g i n t h i s t h r u s t , and i n o t h e r approaches c h r o n i c l e d i n n u r s i n g l i t e r a t u r e , i s how t o 182 e v a l u a t e l e a r n i n g which t a k e s p l a c e as a r e s u l t o f such e f f o r t s . W i t h no agreed upon c r i t e r i o n o f adequacy e x i s t i n g , i t i s d i f f i c u l t t o e v a l u a t e i f t h e e x p e c t e d l e v e l o f l e a r n i n g has o c c u r r e d . T h i s study demonstrates t h a t t h e q u a l i t y o f c o n c e p t i o n s d i f f e r s between s t u d e n t s e n r o l l e d i n d i f f e r e n t y e a r s o f a community c o l l e g e n u r s i n g program. By s u b s c r i b i n g t o t h e n o t i o n t h a t l e a r n i n g i s a change i n c o n c e p t i o n (Dahlgren, 1978), one must th e n ask two q u e s t i o n s : How can l e a r n i n g be measured?, and how can t h e q u a l i t y o f l e a r n i n g be changed? W i t h i n t h e c o n t e x t o f n u r s i n g programs i n B r i t i s h Columbia, not o n l y must a t t e n t i o n be p l a c e d on t h e c u r r i c u l a r c o n t e n t (modules) but a l s o on how c u r r i c u l a can be o p e r a t i o n a l i z e d t o a l l o w f o r t h e i n c l u s i o n o f t h e s e modules i n a way which w i l l enhance t h e q u a l i t y o f s t u d e n t l e a r n i n g . One approach t h a t can be used t o o p e r a t i o n a l i z e c u r r i c u l a r g o a l s i s t o use a taxonomy l i k e t h e SOLO Taxonomy o f B i g g s and C o l l i s (1982) . SOLO, o r a s i m i l a r taxonomy, may be used t o s p e c i f y a c c e p t a b l e o r u n a c c e p t a b l e l e v e l s o f performance w i t h r e g a r d t o n u r s e s ' knowledge o f , and use o f computers i n each semester, and ye a r o f community c o l l e g e n u r s i n g programs. When a t t e m p t i n g t o sequence computer c o n t e n t f o r n u r s e s i n t h e c u r r i c u l a o f n u r s i n g programs, i t would seem l o g i c a l t o b u i l d on e x i s t i n g knowledge by a t t e m p t i n g t o use a t e s t e d taxonomy, such as t h e SOLO taxonomy. A l t h o u g h t h i s s t u d y f o r m a l l y grouped s u b j e c t s ' c o n c e p t i o n s 183 i n t o two l e v e l s o f c o m p l e x i t y : h i g h , and low, i t was i n t u i t i v e l y o b v i o u s t h a t i n f a c t a range o f l e v e l s , from h i g h t o low e x i s t e d . The SOLO taxonomy i d e n t i f i e s f i v e l e v e l s o f l e a r n i n g outcomes which r e p r e s e n t a s h i f t i n c o m p l e x i t y o f c o n c e p t i o n from low t o h i g h . Because t h e s e q u e n c i n g o f c u r r i c u l a r c o n t e n t from t h e s i m p l e t o t h e complex appears t o be i n h e r e n t i n t h e c u r r i c u l a o f most n u r s i n g programs, use o f a taxonomy o f l e a r n i n g outcomes t o f a c i l i t a t e s e q u e n c i n g computer c o n t e n t seems t o be l o n g overdue. Hands-on e x p e r i e n c e t o i n c r e a s e s t u d e n t s ' comfort l e v e l s u s i n g a computer, as w e l l as t h e o r e t i c a l d i s c u s s i o n s about t h e impact o f computer use on n u r s e s can be sequenced t h r o u g h use o f a taxonomy, which i s aimed a t changing s t u d e n t s ' l e v e l o f c o n c e p t i o n . I t appears t h a t u n l e s s a s t u d e n t has e x p e r i e n c e i n a p a r t i c u l a r a r e a , h i g h l e v e l responses are not e x p e c t e d . T h i s i s s u p p o r t e d by Merrow's (1985) f i n d i n g t h a t i n d i v i d u a l s who were r a t e d as m i n i m a l l y knowledgeable about computer use i n n u r s i n g p r a c t i s e had never used a computer. T h i s two pronged approach s h o u l d s e r v e t o i n c r e a s e computer awareness and knowledge which s h o u l d s e r v e t o i n c r e a s e t h e c o m p l e x i t y o f s t u d e n t s ' c o n c e p t i o n s o f computer use by h o s p i t a l employed n u r s e s . Use o f a taxonomy of l e a r n i n g outcomes t h e n , would a l l o w f o r : (a) t h e o r g a n i z a t i o n o f l e a r n i n g components i n t o a h i e r a r c h y o f l e v e l s o f i n c r e a s e d a b s t r a c t i o n , (b) s y s t e m a t i c o r d e r i n g o f components i n t h e a p p r o p r i a t e o r d e r , and (c) t h e 184 e v a l u a t i o n o f t h e s u c c e s s o f t h e t o t a l i n s t r u c t i o n a l e p i s o d e . The i n c l u s i o n o f computer c o n t e n t i n n u r s i n g c u r r i c u l a i n community c o l l e g e programs i n B r i t i s h Columbia, and els e w h e r e , c o u l d t h e r e f o r e be a c h i e v e d i n a l o g i c a l f a s h i o n . U l t i m a t e l y , t h e c u r r i c u l u m framework o f i n d i v i d u a l programs would s e r v e as t h e b l u e p r i n t f o r i n c o r p o r a t i n g computer c o n t e n t which i s o r g a n i z e d a c c o r d i n g t o a taxonomy. The q u e s t i o n o f how t h e q u a l i t y o f s t u d e n t s ' l e a r n i n g can be changed a d d r e s s e s t h e n o t i o n o f moving s t u d e n t s from a c e r t a i n l e v e l o f l e a r n i n g t o one which i s q u a l i t a t i v e l y h i g h e r . S e v e r a l p o s s i b l e ways t o move s t u d e n t s from a low l e v e l o f c o n c e p t i o n t o a h i g h e r one a r e : (a) i n c r e a s e t h e i r awareness about t h e use o f computers b o t h w i t h i n , and o u t s i d e t h e i r immediate environment, (b) d i s c u s s t h e f o u r c a t e g o r i e s o f c o n c e p t i o n i n terms o f how each may be enhanced and d e t r a c t e d from, and (c) t e a c h about non-keyboard o p e r a t e d computer a p p l i c a t i o n s which a r e b e i n g used i n h o s p i t a l s . An e f f o r t must be made t o broaden t h e c o n t e x t o f computer use so t h a t s t u d e n t s do not become t o o s e t i n t h e i r own s m a l l n u r s i n g w o r l d , but r a t h e r a re a b l e t o r e l a t e happenings i n t h e i r f i e l d t o t h e w o r l d a t l a r g e . By d o i n g t h i s , e d u c a t o r s open t h e door f o r c r o s s - f e r t i l i z a t i o n o f i d e a s among d i s c i p l i n e s which i n i t s e l f enhances q u a l i t y o f c o n c e p t i o n . 185 Res e a r c h Q u e s t i o n (c) The m a j o r i t y o f s u b j e c t s i n t h i s s t u d y had a p o s i t i v e a t t i t u d e t oward computer use i n h o s p i t a l n u r s i n g . T h i s i s congruent w i t h t h e t r e n d s i n d i c a t e d i n t h e n u r s i n g l i t e r a t u r e of n u r s e s becoming more p o s i t i v e (Ronald, 1983 & Merrow, 1985). T h i s s t u d y found t h a t s u b j e c t s r a t e d as h a v i n g n e g a t i v e a t t i t u d e s t oward computer use by h o s p i t a l employed n u r s e s were: (a) a l l female, and (b) e n r o l l e d i n f i r s t , and second-year. I t was not s u r p r i s i n g t h a t t h e s u b j e c t s w i t h n e g a t i v e a t t i t u d e s toward computer use by h o s p i t a l employed n u r s e s were female, g i v e n t h e a t t e n t i o n p a i d by some a u t h o r s i n t h e l i t e r a t u r e t o t h e n o t i o n o f women h a v i n g a n e g a t i v e "mind s e t " t o w a r d t e c h n o l o g y (Menzies, 1982). I t i s e s s e n t i a l t o p o i n t out though, t h a t t h e s m a l l sample s i z e o f male n u r s e s i n t h i s s t u d y may have skewed t h e f i n d i n g s . P r e v i o u s e x p e r i e n c e has been found by some (Houle, 1980 and Chang, 1984) t o a f f e c t a t t i t u d e . Comments, t a k e n from t h e t r a n s c r i p t s o f t h e s u b j e c t s i n t h i s s t u d y w i t h n e g a t i v e a t t i t u d e s (see Chapter 4 ) , l e n d s u p p o r t t o t h i s n o t i o n . However, i t was s u r p r i s i n g t h a t t h i r d - y e a r s u b j e c t s were more p o s i t i v e t h a n b o t h f i r s t and second-year s u b j e c t s . Based on a r e v i e w o f t h e l i t e r a t u r e , i t was f e l t , a t t h e o u t s e t , t h a t t h i r d - y e a r s u b j e c t s might have more n e g a t i v e a t t i t u d e s toward computer use. More a t t e n t i o n seems t o be 186 f o c u s e d on computers use now, i n t h e e d u c a t i o n a l environment, work s e t t i n g , and media, t h a n t h r e e y e a r s ago when t h a t group e n t e r e d t h e n u r s i n g program. The p o s i t i v e a t t i t u d e s o f t h i r d - y e a r s u b j e c t s might be e x p l a i n e d by t h e f a c t t h a t t h e y now have more o f an u n d e r s t a n d i n g o f what t h e i r r o l e as a n u r s e i s , are more c o m f o r t a b l e w i t h i t , and c o n s e q u e n t l y , appear t o be a b l e t o see t h e p o s i t i v e e f f e c t s t h a t computers may have on them as h o s p i t a l employed n u r s e s . One o f t h e most s i g n i f i c a n t r e s u l t s o f t h i s s t u d y i s t h e f i n d i n g t h a t t h e r e i s a r e l a t i o n s h i p between s u b j e c t s ' a t t i t u d e s toward computer use.by h o s p i t a l employed n u r s e s , and t h e c o m p l e x i t y o f t h e i r c o n c e p t i o n s . A l l s u b j e c t s who were a b l e t o t h i n k c o m p l e x l y about t h e impact o f computers on h o s p i t a l employed n u r s e s , had p o s i t i v e a t t i t u d e s . S u b j e c t s who c o n c e p t u a l i z e d about such t h i n g s a t a lower l e v e l were d i v i d e d i n terms o f b o t h p o s i t i v e o r n e g a t i v e a t t i t u d e s ; y e t , a l l s i x s u b j e c t s w i t h a n e g a t i v e a t t i t u d e had low l e v e l s o f c o n c e p t i o n . I n l o o k i n g a t t h e t r a n s c r i p t s o f t h e s i x n e g a t i v e s u b j e c t s w i t h low l e v e l c o n c e p t i o n s , i t was o b v i o u s t h a t t h e i r a t t i t u d e seemed t o " b l o c k " them from b e i n g a b l e t o d i s c u s s t h e i r c o n c e p t i o n s i n any depth. They kept coming back t o t h e f a c t t h a t t h e y " d i d not l i k e computers," and were unable t o move beyond t h a t p o i n t . On t h e o t h e r hand, s u b j e c t s who had p o s i t i v e a t t i t u d e and low l e v e l s o f c o n c e p t i o n , may not have been a b l e t o a r t i c u l a t e t h e i r i d e a s 187 o r may have been p r e o c c u p i e d as i n d i c a t e d by t h e examples o f two s u b j e c t s d i s c u s s e d i n Chapter 4. D i s c u s s i o n Of Secondary F i n d i n g s Secondary f i n d i n g s i n t h i s s t u d y were r e p o r t e d on demographics/ and computer usage. The more s i g n i f i c a n t f i n d i n g s , under each h e a d i n g , are s i n g l e d out and d i s c u s s e d i n t h e f o l l o w i n g p a r a g r a p h s . Demographics T h i s sample d i f f e r e d from t h a t o f o t h e r s t u d i e s r e p o r t e d i n t h e n u r s i n g l i t e r a t u r e . The s u b j e c t s i n t h i s s t u d y were e n r o l l e d i n a Canadian community c o l l e g e n u r s i n g program whereas o t h e r s t u d i e s , w i t h t h e e x c e p t i o n o f Hannah (1983), have been American and d e a l t w i t h s u b j e c t s e n r o l l e d i n u n i v e r s i t y programs (Walker, 1981; H e l l e r e t a l . , 1985; & P a r k s e t a l . , 1986). The m a j o r i t y o f s u b j e c t s who p a r t i c i p a t e d i n t h i s s t u d y were between t h e ages o f e i g h t e e n and t w e n t y - f o u r , f o l l o w e d by t h e group r a n g i n g between ages t w e n t y - f i v e and t wenty-n i n e . Inman (1983) n o t e d t h a t e x p e r t s have found t h a t i n d i v i d u a l s i n t h e i r m i d - t h i r t i e s , and younger, t e n d t o adapt q u i c k l y t o t h e computer w h i l e t h o s e f i f t y and o ver a r e more l i k e l y t o be i n t i m i d a t e d . Krampf and Robinson (1984) found 188 t h a t most o l d e r a d u l t s do not appear t o be t h r e a t e n e d by t h e computer. T h i s s t u d y found t h a t o f t h e s i x s u b j e c t s who d i s p l a y e d a n e g a t i v e a t t i t u d e t oward computers, f i v e were i n t h e age range of e i g h t e e n t o t w e n t y - f o u r , and one was between t w e n t y - f i v e and t w e n t y - n i n e . T h i s i s c o n t r a d i c t o r y t o Inman's (1983) r e p o r t i n g . A l l seven of t h e o l d e r s u b j e c t s (between ages t h i r t y and f i f t y - n i n e ) had p o s i t i v e a t t i t u d e s t o w a r d computers which s u p p o r t s t h e f i n d i n g s o f Krampf and Robinson (1984). The n u r s i n g f a c u l t y a t C a r i b o o C o l l e g e i n t u i t i v e l y f e e l t h a t t h e t r e n d appears t o be f o r s t u d e n t s t o t a k e some s o r t o f f o r m a l e d u c a t i o n p r i o r t o e n t e r i n g t h e n u r s i n g program. The f i n d i n g s i n t h i s s t u d y l e n d s u p p o r t t o t h i s b e l i e f . The assumption one o f t e n h e a r s i n c a s u a l c o n v e r s a t i o n i s t h a t s t u d e n t s coming out o f h i g h s c h o o l today are computer l i t e r a t e . T h i s s t u d y found t h a t w h i l e t h e m a j o r i t y o f s u b j e c t s had hands-on computer e x p e r i e n c e p r i o r t o e n t e r i n g t h e n u r s i n g program, 40% had no f o r m a l computing e x p e r i e n c e , and o n l y 34% had exposure i n t h e s c h o o l system. I f t h i s sample i s t y p i c a l , t h e common assumption t h e n t h a t s t u d e n t s coming out o f h i g h s c h o o l are computer l i t e r a t e , appears t o be q u e s t i o n a b l e . The n u r s i n g f a c u l t y must be aware t h a t s t u d e n t s have de v e l o p e d an a t t i t u d e toward computers i n g e n e r a l (based on t h e i r p r e v i o u s e x p e r i e n c e ) , p r i o r t o e n t e r i n g t h e n u r s i n g program, and t h i s must not be assumed t o be p o s i t i v e . 189 S u b j e c t s ' v e r b a l i z a t i o n o f w a n t i n g i n c r e a s e d computer c o n t e n t i n t h e n u r s i n g program r e f l e c t s s o c i e t a l t r e n d s , and p o s s i b l y t h e i r p e r c e p t i o n t h a t t h e y w i l l need t h i s knowledge t o p e r f o r m t h e i r r o l e as h o s p i t a l employed n u r s e s i n t h e f u t u r e . F i n d i n g s t h a t s u b j e c t s p r e f e r a v a r i e t y o f l e a r n i n g approaches, i f f a c e d w i t h h a v i n g t o l e a r n t o use computers, a r e c o n s i s t e n t w i t h t h e c h a r a c t e r i s t i c s o f a d u l t l e a r n e r s and t h e p r i n c i p l e s o f t e a c h i n g and l e a r n i n g documented i n t h e a d u l t e d u c a t i o n l i t e r a t u r e . Computer A c c e s s And Usage Even though a l l s u b j e c t s have a c c e s s t o t h e C a r i b o o C o l l e g e computer system, few a r e u s i n g i t . T h i s d i s c o v e r y i s v i t a l f o r n u r s i n g f a c u l t y who are charged w i t h c u r r i c u l u m p l a n n i n g f o r t h e i n t e g r a t i o n o f t h e B.C.I.T. l e a r n i n g modules i n t o t h e C a r i b o o C o l l e g e n u r s i n g program i n September 1988. F a c u l t y ' s e x p e c t a t i o n s r e g a r d i n g s t u d e n t use o f computers, and t h e i r r e l a t i v e comfort w i t h computers i n e d u c a t i o n a l s e t t i n g s must be c a r e f u l l y examined. I f i t i s b e l i e v e d t h a t computers a r e t o become another t o o l , which n u r s e s must be c o m f o r t a b l e w i t h i n o r d e r t o p r a c t i s e n u r s i n g , f e l t b a r r i e r s i d e n t i f i e d by s u b j e c t s p r e v e n t i n g t h e i r use o f computers i n t h e e d u c a t i o n a l s e t t i n g s h o u l d be examined, not i g n o r e d . W i t h t h e i n c r e a s e d use o f computers by n u r s e s employed i n h o s p i t a l s e t t i n g s , becoming a r e a l i t y , i t i s up t o e d u c a t o r s 190 t o p r o v i d e s t u d e n t s w i t h o p p o r t u n i t i e s t o use computers i n t h e e d u c a t i o n a l s e t t i n g so t h a t t h e y w i l l be b e t t e r a b l e t o t r a n s f e r t h a t knowledge t o t h e h o s p i t a l s e t t i n g . G e n e r a l i z a b i l i t y Of F i n d i n g s I n c o n s i d e r i n g t h e g e n e r a l i z a b i l i t y o f t h e r e s u l t s o f t h i s r e s e a r c h , s e v e r a l p o i n t s must, be c o n s i d e r e d . The s u b j e c t s used i n t h i s r e s e a r c h were a l l e n r o l l e d i n a community c o l l e g e d i p l o m a n u r s i n g program, and as such were a s e l f - s e l e c t e d sample. Community c o l l e g e d i p l o m a n u r s i n g programs, i n B r i t i s h Columbia, d i f f e r not o n l y i n l e n g t h , c o n t e x t , and p r a c t i c u m e x p e r i e n c e but a l s o i n terms o f t h e emphasis on computer c o n t e n t i n t h e i r c u r r i c u l a . However, a l l o f t h e s e community c o l l e g e d i p l o m a n u r s i n g programs: (a) must meet t h e a p p r o v a l c r i t e r i a o f t h e Program A p p r o v a l s Committee o f t h e R e g i s t e r e d Nurses A s s o c i a t i o n o f B r i t i s h Columbia, and (b) are charged w i t h e d u c a t i n g b e g i n n i n g p r a c t i t i o n e r s who meet a minimum s t a n d a r d f o r s a f e p r a c t i c e . T h i s s t u d y f o c u s e d on one p a r t i c u l a r s e t t i n g w hich means th e f i n d i n g s a r e grounded i n t h a t s e t t i n g . T h i s r e s e a r c h e r i s i n t e r e s t e d i n t h e a c c u r a c y and comprehensiveness o f t h e d a t a c o l l e c t e d , and i s e s p e c i a l l y i n t e r e s t e d i n t h e " f i t " between what i s r e c o r d e d and what was a c t u a l l y o c c u r r i n g w i t h C a r i b o o C o l l e g e n u r s i n g s t u d e n t s a t t h e t i m e o f t h e s t u d y . However, i t i s t h e r e s e a r c h e r ' s b e l i e f t h a t community 191 c o l l e g e s i n B r i t i s h Columbia share more s i m i l a r i t i e s , t h a n d i f f e r e n c e s , i n t h a t a l l a r e p r e p a r i n g b e g i n n i n g p r a c t i t i o n e r s . T h e r e f o r e , g e n e r a l i z a b i l i t y o f t h e s e r e s u l t s may be p o s s i b l e . I t i s now up t o o t h e r r e s e a r c h e r s t o l o o k a t t h e s e f i n d i n g s i n l i g h t o f t h e p e c u l i a r i t i e s o f t h e i r own community c o l l e g e n u r s i n g programs. As a l r e a d y n o t e d , t h e p r i m a r y f i n d i n g s o f t h i s s t u d y have i m p l i c a t i o n s f o r a l l community c o l l e g e n u r s i n g programs. In a d d i t i o n , t h e p r i m a r y f i n d i n g s , c o u p l e d w i t h t h e secondary f i n d i n g s , ( s p e c i f i c t o t h e C a r i b o o C o l l e g e n u r s i n g program) may be a c t e d on l o c a l l y t o a f f e c t change which i s grounded i n r e s e a r c h based on t h e s t u d e n t s ' p e r s p e c t i v e . L i m i t a t i o n s Of The Study There are s e v e r a l l i m i t a t i o n s o f t h i s s t u d y t h a t have become e v i d e n t as t h e s t u d y u n f o l d e d . The major l i m i t a t i o n i s t h a t i t i s weak on c r o s s - c o m p a r i s o n s between i n s t i t u t i o n s . A l t h o u g h a t t e m p t s were made t o make comparisons w i t h i n and between y e a r s , t h e s t u d y f o c u s e d on one i n s t i t u t i o n o n l y ( S t r a u s s , 1987) . A second l i m i t a t i o n i s i n h e r e n t i n t h e i n t e r v i e w method of d a t a c o l l e c t i o n . A c o u p l e o f s u b j e c t s commented on t h e f a c t t h a t i t was d i f f i c u l t t o " t h i n k on t h e s p o t . " However, t h e p r e s e n c e o f a t a p e r e c o r d e r d i d not appear to_make any of t h e s u b j e c t s nervous, p r o b a b l y because s u b j e c t s were f a m i l i a r 192 with using both audio and video equipment throughout the nursing program. The timing of the interviews might have been detrimental to the quality of responses. Interviews were held i n March and A p r i l 1988, This time period was not ideal as subjects may have been preoccupied with f i n a l examinations which were scheduled early i n A p r i l . Two subjects i n p a r t i c u l a r , appeared to be pre-occupied during the interviews: one by recent news of her father's i l l n e s s , and the other with a job interview. A f i n a l l i m i t a t i o n was a personal one for the researcher in her f i r s t attempt to do q u a l i t a t i v e research. At times the volume of information obtained during the interviews, and generated by the formative and summative data analysis, was overwhelming. In p a r t i c u l a r , the volume of data generated by the forced-response questions on the respondent p r o f i l e section of the interview schedule (although of benefit i n understanding the sample) tended to challenge the researcher to remain focused on the research questions. 193 Recommendations G e n e r a l Recommendations A number o f recommendations a r e o f f e r e d f o r c o n s i d e r a t i o n by community c o l l e g e n u r s i n g programs: (1) E f f o r t s h o u l d be p l a c e d on p r o v i d i n g f a c t u a l i n f o r m a t i o n on c u r r e n t happenings w i t h r e g a r d t o computer use i n n u r s i n g , t o s t u d e n t s e n r o l l e d i n community c o l l e g e n u r s i n g programs. The i n t e n d e d purpose of t h i s recommendation i s t o h e i g h t e n s t u d e n t n u r s e s ' knowledge and awareness o f l o c a l , p r o v i n c i a l , and n a t i o n a l t r e n d s . (2) Comparative r e s e a r c h needs t o be done: a. I n h o s p i t a l s , b o t h b e f o r e and a f t e r computers are a c t u a l l y used by n u r s e s , t o determine t h e q u a l i t y o f n u r s e s ' c o n c e p t i o n s and t h e i r a t t i t u d e s about computer use. T h i s d a t a c o u l d t h e n be used t o d e v e l o p and e v a l u a t e computer l e a r n i n g e x p e r i e n c e s w i t h t h e i n t e n t o f f o s t e r i n g p o s i t i v e a t t i t u d e s and h i g h l e v e l s o f c o n c e p t i o n . b. To determine i f t h e c o n c e p t i o n s and a t t i t u d e s o f s t u d e n t s e n r o l l e d i n o t h e r community c o l l e g e n u r s i n g programs, b o t h w i t h i n , and o u t s i d e t h i s p r o v i n c e , are s i m i l a r t o t h o s e o f s t u d e n t s a t C a r i b o o C o l l e g e . c. To determine i f s t u d e n t n u r s e s ' c o n c e p t i o n s o f and a t t i t u d e s toward computer use by h o s p i t a l employed . 194 n u r s e s d i f f e r from t h o s e o f n u r s e s a l r e a d y employed i n Canadian h o s p i t a l s . (3) F u r t h e r work needs t o be done t o e i t h e r d e v e l o p , o r adapt t h e use o f an e x i s t i n g taxonomy o f l e a r n i n g outcomes which may be used i n community c o l l e g e n u r s i n g programs t o f a c i l i t a t e t h e s e q u e n c i n g and e v a l u a t i o n o f t h e q u a l i t y o f s t u d e n t s ' l e a r n i n g about computers. (4) A t t e n t i o n needs t o be f o c u s e d p r o v i n c i a l l y , and n a t i o n a l l y on d e t e r m i n i n g d e s i r e d l e v e l s o f c o n c e p t i o n o f computer use f o r s t u d e n t s e n r o l l e d i n each y e a r o f n u r s i n g programs, and a l s o a t t e n t i o n needs t o be f o c u s e d on t h e l e v e l o f computer competency e x p e c t e d a t t h e c o m p l e t i o n o f community c o l l e g e n u r s i n g programs. (5) R e s e a r c h i s needed t o determine t e a c h i n g t e c h n i q u e s t o f a c i l i t a t e moving s t u d e n t s ' c o n c e p t i o n s o f computer use from one l e v e l t o a nother which i s q u a l i t a t i v e l y d i s t i n c t . L o c a l Recommendations A number o f recommendations a r e o f f e r e d f o r c o n s i d e r a t i o n by t h e C a r i b o o C o l l e g e n u r s i n g program: (1) F a c u l t y s h o u l d s t r i v e t o i n t e g r a t e more computer awareness c o n t e n t t h r o u g h o u t t h e n u r s i n g program i n an attempt t o decrease t h e mystique o f computers. 195 (2) The f a c u l t y needs t o b u i l d e x p e c t a t i o n s i n t o t h e n u r s i n g c u r r i c u l u m t h a t s t u d e n t s use a computer f o r such t h i n g s as p r o d u c i n g papers o r weekly a n e c d o t a l n o t e s i n o r d e r t o i n c r e a s e t h e i r comfort l e v e l w i t h u s i n g computers. (3) The n u r s i n g d e p a r t m e n t . s h o u l d l o b b y c o l l e g e a d m i n i s t r a t i o n more a s s e r t i v e l y f o r g r e a t e r a c c e s s a b i l i t y and a v a i l a b i l i t y o f computer t e r m i n a l s f o r use by n u r s i n g s t u d e n t s . (4) The c u r r i c u l u m committee s h o u l d c o - o r d i n a t e t h e i n c l u s i o n o f computer c o n t e n t t h r o u g h o u t t h e n u r s i n g program by u s i n g a taxonomy which would a l l o w f o r t h e q u a l i t y o f l e a r n i n g t o be e v a l u a t e d . (5) F a c u l t y s h o u l d s t r i v e t o i n c o r p o r a t e t h e use o f n u r s i n g C.A.I, l e a r n i n g packages as a method o f i n s t r u c t i o n (where a p p l i c a b l e ) i n o r d e r f o r s t u d e n t s t o e x p e r i e n c e t h i s computer a p p l i c a t i o n . One i n t e n t i n d o i n g t h i s i s t h a t s t u d e n t s who used computers t o f a c i l i t a t e t h e i r own l e a r n i n g might be more a b l e t o , i d e n t i f y w i t h t h e computer as a v a l u a b l e t e a c h i n g t o o l f o r use i n t h e h o s p i t a l . (6) An attempt s h o u l d be made t o a s c e r t a i n s t u d e n t s ' a t t i t u d e s toward computers by u s i n g a t o o l t o measure a t t i t u d e l i k e t h e one de v e l o p e d by Stronge and Br o d t (1985) . T h i s c o u l d be done on e n t r y i n t o t h e program so t h a t f a c u l t y c o u l d d e v e l o p s t r a t e g i e s t o h e l p n e g a t i v e s t u d e n t s become more p o s i t i v e . 196 S i g n i f i c a n c e Of Res e a r c h R e s u l t s o f t h i s s t u d y w i l l p r o v i d e guidance f o r n u r s i n g f a c u l t y i n community c o l l e g e s , l o c a l l y , p r o v i n c i a l l y and n a t i o n a l l y , who a r e r e s p o n s i b l e f o r impl e m e n t i n g computer c o n t e n t i n t o n u r s i n g c u r r i c u l a . The r e s u l t s w i l l a l s o be v a l u a b l e f o r h o s p i t a l i n - s e r v i c e c o - o r d i n a t o r s , who a r e r e s p o n s i b l e f o r p l a n n i n g computer e d u c a t i o n programs f o r nu r s e s who have g r a d u a t e d from community c o l l e g e n u r s i n g programs. They w i l l be o f immediate b e n e f i t t o n u r s i n g f a c u l t y i n B r i t i s h Columbia who a r e e x p e c t e d t o implement t h e t h r e e modules d e v e l o p e d as a r e s u l t o f t h e COMPUTERS IN  NURSING PROJECT i n t o t h e i r : c u r r i c u l a i n September, 1988. T h i s study was based on t h e premise t h a t l e a r n i n g i s a change i n c o n c e p t i o n , and t h a t t h e r e i s a q u a l i t a t i v e s h i f t from one c o n c e p t i o n t o an o t h e r when l e a r n i n g has o c c u r r e d (Dahlgren, 1978). S t u d e n t s e n t e r community c o l l e g e n u r s i n g programs w i t h e s t a b l i s h e d c o n c e p t i o n s o f computers and computer use by n u r s e s . I t appears l o g i c a l t h e n , t h a t upon e n t r a n c e t o a community c o l l e g e n u r s i n g program, attempts s h o u l d be made t o i d e n t i f y and a s s e s s s t u d e n t s ' c o n c e p t i o n s o f computer use so t h a t c u r r i c u l a d e c i s i o n s may be made. T h i s s t u d y found t h a t t h e c o m p l e x i t y o f s t u d e n t s c o n c e p t i o n s was d i r e c t l y p r o p o r t i o n a l t o t h e i r year i n t h e program, and t o t h e l e n g t h o f t h e i r c l i n i c a l e x p e r i e n c e . T h i s f i n d i n g p r o v i d e s e v i d e n c e t h a t computer c o n t e n t i n 197 community c o l l e g e n u r s i n g c u r r i c u l a s h o u l d be sequenced t o move from more s i m p l e c o n c e p t s e a r l y i n t h e program, when t h e c l i n i c a l hours a r e r e l a t i v e l y low, and s t u d e n t s a r e j u s t b e i n g i n t r o d u c e d t o t h e r o l e o f a n u r s e , t o more complex con c e p t s l a t e r i n t h e program, when t h e c l i n i c a l hours a r e g r e a t e r , and s t u d e n t s are more aware o f t h e i r r o l e as n u r s e s . T h i s s t u d y a l s o found t h a t t h e r e i s a r e l a t i o n s h i p between t h e q u a l i t y o f s t u d e n t s ' c o n c e p t i o n s o f t h e impact o f computers on h o s p i t a l employed n u r s e s and s t u d e n t s ' a t t i t u d e s t o w a r d computers. I t appears t h a t s t u d e n t s w i t h h i g h l e v e l s o f c o n c e p t i o n toward computer, use a l s o have p o s i t i v e a t t i t u d e s . Based on t h i s f i n d i n g , a t t e m p t s must be made t o f o s t e r p o s i t i v e a t t i t u d e s i n n u r s i n g s t u d e n t s , i f t h e i n t e n t o f n u r s i n g programs i s t o f a c i l i t a t e t h e development o f h i g h l e v e l c o n c e p t i o n s among i t s ' s t u d e n t s . The f i n d i n g s o f t h i s s t u d y are s p e c i f i c t o one s e t t i n g ( C a r i b o o C o l l e g e ) and t i m e (1988) . By u s i n g t h e n u r s i n g i n f o r m a t i c s (NI) r e s e a r c h p y r a m i d ( S c h w i r i a n , 1986), a t t h e o u t s e t , t o i d e n t i f y r e s e a r c h q u e s t i o n s , t h i s s t u d y has c o n t r i b u t e d t o our p r e s e n t knowledge about s t u d e n t n u r s e s c o n c e p t i o n s o f , and a t t i t u d e s toward computer use i n h o s p i t a l s . However, change i s i n e v i t a b l e and t h e r e f o r e t h e s e a r c h must c o n t i n u e f o r a deeper u n d e r s t a n d i n g o f s t u d e n t n u r s e s ' c o n c e p t i o n s o f t h e impact computers are p r e s e n t l y h a v i n g and w i l l c o n t i n u e t o have on them as h o s p i t a l employed n u r s e s . 198 Gi v e n t h e emphasis t o d a y f o r r e s e a r c h - b a s e d n u r s i n g p r a c t i c e and e d u c a t i o n , t h i s s t u d y w i l l p r o v i d e g u i d a n c e , from t h e s t u d e n t s ' p e r s p e c t i v e , as t o where t h e f o c u s of e d u c a t i o n a l programs must l i e and w i l l s t i m u l a t e e d u c a t o r s t o p r o v i d e b o t h s i d e s o f t h e i s s u e s t o e n a b l e s t u d e n t s t o de v e l o p more complex ways o f v i e w i n g computer use i n t h e i r work w o r l d . Because t h i s s t u d y i s t h e o n l y one o f i t s k i n d known t o t h e r e s e a r c h e r , t h e q u a l i t a t i v e d a t a g e n e r a t e d w i l l s e r v e as a f o u n d a t i o n f o r o t h e r s t u d i e s . C o n c l u s i o n As computer t e c h n o l o g y moves i n t o h o s p i t a l s , a c r o s s t h i s c o u n t r y , n u r s e e d u c a t o r s a r e e x p e c t e d t o p r e p a r e s t u d e n t s t o i n c o r p o r a t e i t s use i n t o t h e i r n u r s i n g p r a c t i c e . With t h e Canadian Nurses A s s o c i a t i o n (C.N.A.) s t a n d on e n t r y t o p r a c t i s e t h a t , by t h e y e a r 2000 b e g i n n i n g n u r s e s w i l l r e q u i r e a b a c c a l a u r e a t e degree t o e n t e r t h e n u r s i n g p r o f e s s i o n , i n c r e a s e d a t t e n t i o n i s b e i n g p l a c e d on p r e p a r i n g a nurse who can cope w i t h t h e s e and o t h e r t r e n d s i n n u r s i n g . The n a t u r e o f t h e s e p r o p o s e d changes i n n u r s i n g programs i s r e c e i v i n g c o n s i d e r a b l e a t t e n t i o n i n n u r s i n g c i r c l e s and attem p t s a re b e i n g made t o make recommendations based on s c i e n t i f i c knowledge and r e s e a r c h . T h i s s t u d y has p o i n t e d out t h a t as we d e v e l o p t h e s e programs, we must c o n s t a n t l y pay a t t e n t i o n t o how we 199 s o c i a l i z e n u r s e s t o assume t h e i r r o l e i n t h e p r o f e s s i o n . P r e s e n t l y , n u r s e s appear t o be concerned about a C a t c h 22 p o s i t i o n i n terms o f f e e l i n g t h e p u l l between t e c h n o l o g y and the p a t i e n t (see F i g u r e 3 ) . One t h i r d - y e a r s u b j e c t became v e r y e m o t i o n a l as she n o t e d , " I f e e l t h a t t h e p a t i e n t i s more i m p o r t a n t . W i t h computers, t h e f e a r i s g e t t i n g away from t h e p a t i e n t . " Patient < Nurse > Technology F i g u r e 3. Nurse And Technology The onus i s on e d u c a t o r s t o s o c i a l i z e s t u d e n t n u r s e s so t h a t t h e y can m a i n t a i n t h e i r e q u i l i b r i u m w i t h i n t h i s push-p u l l s i t u a t i o n . We must l i s t e n t o our s t u d e n t s and respond t o them as i n d i v i d u a l s , w i t h v a r i e d a t t i t u d e s toward, and c o n c e p t i o n s o f computer use. Above a l l , we must s t r i v e , t o enhance t h e q u a l i t y o f t h e i r c o n c e p t i o n s t h r o u g h t h e use o f a taxonomy i n programming computer c o n t e n t . 200 REFERENCES A l e x a n d e r , M., S i e g e l , C , Dl u g a c z , Y., & F i s c h e r , S. (1983). P o s t Implementation Changes i n P h y s i c i a n s A t t i t u d e s Toward an Automated Drug Review System. I n R.E. Dayhoff (Ed.) 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Computers And N u r s i n g : S t a t e o f The A r t The Canadian Nurse, June, 47-48. Whitehouse, C , P r e s t o n , T., T o b i n , G., M i l l e r , J . & B a i l e y J . (1975) . W e s t m i n i s t e r H o s p i t a l Computer System User A t t i t u d e s . ACTA A n e s t h e s i o l o g i c a B e l g i c a (23), 205-214. Wiersma, W. (1986). R e s e a r c h Methods I n E d u c a t i o n An  I n t r o d u c t i o n (4th e d . ) . B o s t o n : A l l y n and Bacon,Inc. 208 Appendix A COMPUTER SYSTEMS IN CANADIAN HOSPITALS PROVINCE AND HOSPITAL B r i t i s h Columbia Peace A r c h D i s t r i c t H o s p i t a l Grace H o s p i t a l L i o n s Gate H o s p i t a l Shaughnessy H o s p i t a l U.B.C. H e a l t h S c i e n c e s C e n t r e A l b e r t a F o r t McMurray R e g i o n a l H o s p i t a l C a l g a r y G e n e r a l H o s p i t a l C h a r l e s C a m s e l l G e n e r a l H o s p i t a l G l e n r o s e R e h a b i l i t a t i o n H o s p i t a l F o r e s t Grove U n i v e r s i t y Of A l b e r t a H o s p i t a l Red Deer H e a l t h Care C e n t r e O n t a r i o Kenora D i s t r i c t F o r The Aged S t . Joseph's H e a l t h C e n t r e Chedoke-McMaster H o s p i t a l s York C e n t r a l Sunnybrook M e d i c a l C e n t r e M i s s i s s a u g a H o s p i t a l The H o s p i t a l F o r S i c k C h i l d r e n U n i v e r s i t y H o s p i t a l , London New Brunswick R e s t i g o u c h e N u r s i n g Home S a i n t John R e g i o n a l H o s p i t a l U n i t e d Church Home F o r S e n i o r s Loch Lomond V i l l a C h a l e u r R e g i o n a l H o s p i t a l K. E. Spencer Memorial Home Nova S c o t i a V i c t o r i a G e n e r a l H o s p i t a l Newfoundland V a l l e y V i s t a N u r s i n g Home S t . C l a r e ' s Mercy H o s p i t a l G e n e r a l H o s p i t a l Corp. (HSC) HARDWARE IBM Data General IBM VT 220 Data General IBM UNISYS (Burroughs) Tandem Tandem CADO Tandem E l e c t r o n i c Data Systems CADO Beehive DEC IBM T e l e x Data G e n e r a l H e w l e t t P a c k a r d E s p r i t Systems CADO Techni c o n IBM PC AT IBM System 36 Burroughs CADO Sp e r r y Burroughs Data G e n e r a l Data G e n e r a l Note. Adapted From "Computers And N u r s i n g : S t a t e o f The A r t " by K. Webber, 1988, The Canadian Nurse, June, p. 48. 210 Because o f t h e t i m e c o n s t r a i n t s d i c t a t e d t o me by t h e u n i v e r s i t y , and my own commitment t o f i n i s h t h i s r e s e a r c h w h i l e w o r k i n g h a l f - t i m e t h i s semester, I would a p p r e c i a t e a r e p l y a t your e a r l i e s t c o n v e n i e n c e . P l e a s e f o r w a r d t o my a t t e n t i o n , a l e t t e r a u t h o r i z i n g p e r m i s s i o n f o r me t o i n t e r v i e w C a r i b o o C o l l e g e n u r s i n g s t u d e n t s . T h i s l e t t e r s h o u l d be a d d r e s s e d t o : Dr. S. Coren Chairman, B e h a v i o r a l S c i e n c e s S c r e e n i n g Committee The O f f i c e o f Res e a r c h S e r v i c e s Room 331, IRC B u i l d i n g , U.B.C. I w i l l t h e n send a l l t h e n e c e s s a r y documentation t o t h e committee as one s u b m i s s i o n , a f t e r c o n s u l t i n g w i t h my t h e s i s a d v i s o r s . Thank you i n advance f o r your h e l p i n t h i s m a t t e r . P l e a s e do not h e s i t a t e t o c o n t a c t me f o r f u r t h e r c l a r i f i c a t i o n . S i n c e r e l y , Karen A b b o t t N u r s i n g F a c u l t y 213 Appendix E CONSENT FORM Student Nurses And Computers In Hospitals As part of my Masters Program at the University of B r i t i s h Columbia, I am conducting a research study to learn more about how nursing students view the use of computers i n hospital settings. Several studies have been completed which deal with student nurses' perceptions about computers. These studies are predominantly American, and the students are enrolled i n either baccalaureate or masters degree programs. This leaves a void of information available on Canadian student nurses, most of whom are educated i n community colleges, and employed in hospitals. This study focuses on t h i s p a r t i c u l a r group. Your cooperation i s v i t a l to the study's outcome. You have been randomly selected to take part i n t h i s study. The interview w i l l take 30 minutes or le s s . It w i l l be taped and w i l l be scheduled at a mutually convenient time. Following the taped interview, a written t r a n s c r i p t w i l l be made of the interview and returned to you for your v e r i f i c a t i o n . With the exception of myself, and.my supervisory committee at the University of B r i t i s h Columbia, no one w i l l have access to the interview tapes or t r a n s c r i p t s . You may be assured of complete c o n f i d e n t i a l i t y . You w i l l be i d e n t i f i e d by a number on the trans c r i p t , and the data w i l l be available only for the use of the researcher. Data eventually may be made available to other research groups. However, a l l i d e n t i f i c a t i o n w i l l be deleted. You have the right to refuse to par t i c i p a t e or to withdraw from the study at any time. If you choose not to parti c i p a t e , you can be assured that t h i s w i l l i n no way ef f e c t your student status at Cariboo College. This research w i l l be written i n the form of a Masters thesis and, upon completion,. w i l l be available, i n the l i b r a r y system at the University of B r i t i s h Columbia. 215 Appendix F INTERVIEW SCHEDULE: STUDENT NURSES AND COMPUTERS IN HOSPITALS INTRODUCTION Thank you f o r a g r e e i n g t o be i n t e r v i e w e d . I am w o r k i n g on a r e s e a r c h p r o j e c t t h a t l o o k s a t n u r s i n g s t u d e n t s ' t h o u g h t s about t h e r o l e o f computers i n h o s p i t a l n u r s i n g . I'm g o i n g t o ask you q u e s t i o n s about your own e x p e r i e n c e w i t h computers/ and about how you vi e w t h e i r use i n h o s p i t a l n u r s i n g . The whole i n t e r v i e w s h o u l d t a k e 20-30 minutes o r l e s s . I 'd a l s o l i k e t o tap e r e c o r d i t so t h a t I can l i s t e n t o you more c a r e f u l l y now, and l a t e r on I ' l l r e v i e w what you s a i d . I s t h a t a l l r i g h t w i t h you? QUESTION 1 F i r s t I ' d l i k e you t o t h i n k back t o t h e f i r s t t i m e you can r e c a l l u s i n g a computer. I t c o u l d be r e c e n t l y , o r i t c o u l d be some t i m e ago, maybe i n s c h o o l o r maybe o u t s i d e o f s c h o o l . Think back t o your f i r s t e x p e r i e n c e w i t h a computer. T e l l me about i t . a. I f not a b l e t o r e c a l l t h e f i r s t t i m e o f computer use, use t h e s e p r o b e s : - a u t o m a t i c bank t e l l e r ? - home computer? b. What happened as you s e t about u s i n g i t ? (1) What was d i f f i c u l t ? (2) What was t h e b e s t p a r t ? (3) How d i d you f e e l ? c. Now, t e l l me about a r e c e n t e x p e r i e n c e (as r e c e n t as p o s s i b l e ) when you used a computer. (1) What was i t l i k e ? (2) Was i t d i f f e r e n t from your i n i t i a l e x p e r i e n c e ? (3) I f d i f f e r e n t , do you r e c a l l a t u r n i n g p o i n t ? (4) T e l l me about d. Was l e a r n i n g t o use a computer a t y p i c a l l e a r n i n g e x p e r i e n c e f o r you? (1) What was t y p i c a l ? (2) What was un u s u a l ? (3) T e l l me more I'd l i k e t o move on t o t h e next q u e s t i o n 216 QUESTION 2 You a r e a n u r s i n g s t u d e n t a t C a r i b o o C o l l e g e , and your n u r s i n g program i s p r e p a r i n g you t o work i n a h o s p i t a l s e t t i n g . I 'd l i k e you t o t a k e some t i m e t o t h i n k about t h e h o s p i t a l s e t t i n g as you know i t t o be from your c l i n i c a l e x p e r i e n c e as a s t u d e n t n u r s e , and as you u n d e r s t a n d i t t o be from your r e a d i n g . Think o f y o u r s e l f as a nurse w o r k i n g i n a h o s p i t a l t o d a y . I 'd l i k e t o know..... a. What do you t h i n k computers a r e d o i n g f o r you, i n your j o b as a n u r s e , w o r k i n g i n a h o s p i t a l ? (1) What are t h e b e n e f i t s ? (2) What a r e t h e l i m i t a t i o n s ? (3) T e l l me more b. How do you t h i n k your r o l e as a n u r s e , w o r k i n g i n a h o s p i t a l , i s e f f e c t e d by computers? (1) I s i t p o s i t i v e ? (2) I s i t n e g a t i v e ? (3) D e s c r i b e more about I'd l i k e t o move on t o t h e l a s t q u e s t i o n QUESTION 3 Take as much t i m e as you need f o r t h i s l a s t q u e s t i o n . I 'd l i k e you t o p r o j e c t i n t o t h e f u t u r e . T h ink about y o u r s e l f , employed as a nurse i n a h o s p i t a l f i v e y e a r s a f t e r you g r a d u a t e . That would be (year 1 - 1995, y e a r 2 - 1994, y e a r 3 - 1993). a. What do you t h i n k computers w i l l be d o i n g f o r you t h e n , i n your j o b as a nurse i n a h o s p i t a l ? (1) How w i l l i t d i f f e r from t h e p r e s e n t ? (2) What do you t h i n k t h e b e n e f i t s w i l l be? (3) What do you t h i n k t h e l i m i t a t i o n s w i l l be? (4) T e l l me more about b. How do you t h i n k your r o l e as a nu r s e w o r k i n g i n a h o s p i t a l w i l l be a f f e c t e d by computers i n t h e y e a r ? (1) How w i l l i t d i f f e r from t h e p r e s e n t ? (2) W i l l i t be p o s i t i v e ? (3) W i l l i t be n e g a t i v e ? (4) D e s c r i b e more about I'd l i k e t o c o n c l u d e t h i s i n t e r v i e w w i t h a few g e n e r a l q u e s t i o n s . I s t h a t a l l r i g h t w i t h you? 217 RESPONDENT PROFILE DEMOGRAPHICS 1. Sex: Male Female 2. Age: 18-24 25-29 30-39 40-49 _50-59 65+ 3. What was your educational experience p r i o r to entering the nursing program? High School Degree Other(specify) 4. Have you had education s p e c i f i c to computing? Yes No Please describe COMPUTER USAGE 5. Do you currently have ready access to a computer? (a) at home? Yes No If yes, what type? (b) i n the community? Yes No If yes, what type? 218 6. I f you c u r r e n t l y use a computer system, how d i d you l e a r n t o use i t ? s e l f t a u g h t computer company r e p on t h e job t r a i n i n g o t h e r ( s p e c i f y ) 7. Does your s p o u s e / s i g n i f i c a n t o t h e r use a computer? Yes No 8. I f yes, how o f t e n ? e v e r y day once a week once a month l e s s o f t e n 9. Do you have c h i l d r e n ? Yes No I f so, how many? Are any o f them computer u s e r s ( e x c l u d i n g arcade games)? Yes No I f y e s , where? _ s c h o o l home o t h e r 10. F e e l f r e e t o make any a d d i t i o n a l comments. THANK YOU! 220 APPENDIX H: THEMES Themes from Interviews 1 - 35 CAREGIVING ROLE DIVISION OF LABOUR TIME MANAGEMENT ACCURACY AVAILABILITYYACCESSIBILITY SOPHISTICATION OF SOFTWARE COMPETENCE OF NURSE COST EFFICIENCY SPACE TYPING ABILITY TEACHING COMMUNICATION SPECIALIZATION LEGALITIES CONFIDENTIALITY RESPONSIBILITY RESISTANCE TO CHANGE FEELINGS ABOUT JOB DECISION MAKERS AGENDA STEREOTYPING PATIENTS MACHINE ORIENTED ARTICULATE NEEDS HUMAN ERROR WORKLOAD INFORMATION TAMPERING LEARNING TO USE STAFFING DOWNTIME PATIENT FEELINGS CURRENT INFORMATION COMPUTER DEPENDENCY NATURE OF WORK DEPERSONALIZATION QUALITY OF PATIENT CARE MODERNIZATION PROMPTING NURSE ACCOUNTABILITY ETHICAL DILEMMAS TECHNICIAN NURSE'S PRIORITIES CLERICAL INDIVIDUALIZED CARE IMAGE - Caregiver - Div i s i o n Of Labour - Sp e c i a l i z a t i o n - Machine oriented - Nature Of Work - Depersonalization - Modernization - Technician - Nurse's P r i o r i t i e s - C l e r i c a l 221 APPENDIX I: CATEGORIES GROUPED PATIENT CARE WORKLOAD - Time Management - A v a i l a b i l i t y \ A c c e s s i b i l i t y - Sophistication Of Software - Cost - E f f i c i e n c y - Space - Typing A b i l i t y - Decision makers Agenda - Learning To Use - Sta f f i n g - Downtime - Accuracy - Competence Of Nurse - Teaching - Communication - Resistance To Change - Feelings About Job - Stereotyping Patients - Patient Feelings - Current Information - Computer Dependency - Prompting Nurse - Individualized Care - Quality Of Patient Care PROFESSIONALISM - Responsibility - A r t i c u l a t e needs - Human Error - Information Tampering - Accountability - E t h i c a l Dilemmas - L e g a l i t i e s - C o n f i d e n t i a l i t y 222 • APPENDIX J COMPUTER USE BY NURSES NURSING B. COMMUNICATION teaching t o o l - patients - s t a f f physiological monitoring documentation - charting - patient care notes - flow sheets nursing care plans - assessment - problem statement reference source - drug information - calculations - compatabilities - p o l i c i e s and procedures - past h i s t o r i e s - old charts - lab results - admissions nurses - d a i l y assignments - s h i f t report - Kardex doctors - orders hospital departments - order drugs - order supplies - schedule tests - dietary other hospitals C. ADMINISTRATION scheduling - staffing\P.C.U's - rotations - O.R. bookings - O.P.D. bookings finance - p a y r o l l - b i l l i n g - inventory control s t a t i s t i c s - bed a v a i l a b i l i t y 

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