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NURSING IN THE NEW MILLENIUM:

TOUCHING PATIENTS LIVES THROUGH COMPUTERS

Shirley M. Moore Constance Visovsky

Case Western Reserve University

Cleveland, Ohio

Common nursing functions, previously done in face-to-face interactions, are beginning to be done

using computer interactions, thus changing the work environment of nurses. This paper reports

experiences from a series of projects +bout the potential impact of electronic care delivery

systems on nurses work systems. Nurses attitudes towards technology, values central to nursing

practice and nursing functional roles are important factors to consider when designing

computerized nursing care delivery systems.

BACKGROUND

Although computers often are associated with

the business functions o f health care delivery (B rend,

1994) and decision support for professionals (Papemy,

Aono, Lehman, Hamar, Risser, 1990), their use to

deliver patient care has progressed slowly. More

recently, however, common nursing functions,

previously accomplished in face-to-face interactions,

are beginning to be done using computer

communications. Integrating the high touch values

commonly associated with nursing care into the design

of computerized nursing care deliveT systems is

essential if the widespread use of technology-mediated

care

is to be realized. This paper describes

characteristics of nurses and the work of nurses that are

important to consider when designing computerized

nursing care delivery systems. These characteristics are

nurses attitudes towards technology, values central to

nursmg practice and nursing functional roles.

Experiences from several projects in wh ich electronic

nursing care delivery systems were developed and

evaluated are described.

Nurses Attitudes toward Technology

Over the past 50 years nurses have increasingly

used technology to support the care they provide.

Widespread use of technology by nurses began

following the development of monitors, ventilators and

other machines for use in intensive care units by critical

care nurses. The use of technology in healthcare has

progressed to the point where machines, such as

ventilators are frequently used by home care nurses in

peoples homes. It has been proposed that modem

nursing is deeply connected to technology development

(Barnard, 1999). However, nurses attitudes toward

computers tend to indicate that they are undecided

about computer technology. In a survey of hospital

nurses, McConnell and colleagues (1989) found that

although nurses thought that the use of computers

improved the quality of patient care, they also believed

that their use dehumanized the care. It should be noted

that one half of the nurses surveyed had no experience

with computers. Another view dominant in the nursing

literature is that nurses are the patients bridge from the

impersonal, technologic world to the humanistic world

(McConnell, 1998). This technologic-humanistic

dualism philosophica l view has fostered nurses fears

about the increase of technical quality at the expense of

humanness. Thus, as a group, nurses have been reticent

to embrace computer-mediated care. Understanding

nurses professional values and their functional roles

may enhance he transition from traditional nursing care

delivery modes to a model that integrates widespread use

of computer-assistednursing care.

Nursing Values

Nurses are socialized to a set of values in their

professional education and practice. Nurse values of (1)

individualizing care, (2) fostering self-care, (3)

vigilance, (4) maintaining caring interpersonal

relationships, (5) supporting patient autonomy and (6)

providing collaborative care are factors that must be

considered in the design and implementation of

electronic tools to support nursing care. Although the

successful delivery of health care presumes a certain

degree of standardization of treatments

and

interventions, nursing values reinforce mod ifying care

away from the one size fits all model. Nursing care

focuses on tailoring care to the unique needs of patients

and their families. Fostering self-care refers to nurses

support and education of patients to engage n activities

that are health-promoting. Another value central to

nursing is vigilance. V igilance refers to the careful


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watchfulness of nurses in assessing, screening, and

monitoring patient clinical status and patient responses

to the application of interventions.

Basic to nursing values is the helping

relationships in which nurses engage with their patients

(Morse, 1990). This relationship progresses over time

as the nurse interacts with patients to m anage health

problems by building trust through genuine caring and

encouraging patients to share thoughts and feelings.

Through intimate interpersonal relationships, nurses

conduct activities aimed at restoring physical,

emotional, spiritual and social well being. Additionally,

nurses historically have fostered patient autonomy by

suppor ting patients rights to make decisions about their

health. Nurses also value collaboration with other

healthcare professionals to plan care.

Nursing Functional Roles

Common roles and functions of nurses are

caregiver, client advocate, case manager, rehab ilitator,

comforter, communicator, and teacher.

While

caregiving will always require some face-to-face

interaction (i.e. bathing patients, physical

examinations), many nursing caregiver functions are

amenable to computer mediation, such as symptom

monitoring, the provision of information, assistance

with decision-making,

and providing emotional

support. As patient advocates, nurses support and

uphold patients values and assist them to navigate the

health care system to get their needs addressed.Nurses

also act to protect the human and legal rights of those in

their care. As case managers, nurses assess,coordinate

and organize the healthcare resources needed by

patients throughout their illnesses. As rehabilitators,

nurses direct and engage n activities aimed at restoring

physical and psychological functioning. As comforters,

nurses direct care of the whole person, giving the

physical and emotional support needed for coping with

illness or preparing for death.

The role of

communicator is central to nurses in their interactions

with patients, families and other healthcare

professiona ls. As teachers, nurses offer explanations

about the patients condition, necessary treatments, and

demonstrate procedures to facilitate the persons self-

care abilities.

Nurses work in several types of environments.

Hospitals, a major work environment of nurses, are

complex orgamzatmns in which nurses have

traditionally had a large responsibility for system

maintenance. Nurses also provide ca re in clinics,

homes, schools, industrial companies, and health

advocacy agencies. But, common to all of these work

environments of nurses, is the nurse-patient relationship

as the most basic of environments. Computer-mediated

nursing care delivery systems represent a new

environment for therapeutic nurse-patient relationships.

Therefore, as electronic healthcare delivery systems are

developed, we must be mindful of professional nursing

values and essential nursing functional roles.

EXPERHXNCES WITH ELECTRONIC

NURSING CARE DELIVERY SYSTEMS

ComputerLink

Electronic care delivery systems are creating

new work environments for nurses. The use of electronic

systems to deliver nursing care has been refined by the

authors in a series of projects and is described below. In

the first project, Brennan, Moore and Smyth (1995)

provided home care support to caregivers of persons

with Alzheimers disease using a computer network,

ComputerLink. Computer terminals placed in clients

homes allowed 24-hour access to a variety of features,

including a communications module, an information

module and a decision assistance module. The

communications module included a public bulletin

board, where clients and a nurse moderator publicly

posted and read messages; a Question and Answer

section in which clients anonymously posted questions

to a registered nurse; and a private mail system. The

information system provided several hundred indexed

screens of information about the disease course,

diagnosis, and treatment, symptom management, care

issues and community services. The decision support

module guided clients through decisions using an

analysis process that incorporated their own words and

preferences, thus assisting them to make choices

consistent with their own values. The nurse moderator

employed both individual and group interventions of

support, information-giving, encouraging expression of

feelings and ideas, acceptance, eassurance,clarification,

and interpretation. In the ComputerLink project, we

learned that clients with little or no compu ter skills

easily learned to use computers and accessed

information and support electronically.

Clinical interventions using ComputerLink

required the nurse to have an understandirig of how

computer technology affected client participation,

communication, relationship development, and group

norms, both social and computer behavior (Moore,

1997). Several

challenges of the computer

communications that affected the nursing system of care


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included: (1) the lack of physical presence of clients,

(2) diffuse time referents, (3) asynchronous

communication, and (4) the necessity to teach clients to

use the technology. The absence of face-to-face visual

cues required the nurse to rely on a new set of cues,

many of which differ from those of clinical encounters

involving face-to-face or voice communication.

Developing and maintaining relationships is a goal in

any therapeutic clinical encoun ter. Rapport and trust

were developed between the nurse and clients though

the use of standard protocols for comptiter

introductions

among

participating

parties,

encouragement of the use of a conversational tone in

messagesposted on the system, and nurse modeling of

emotional expressions n messages.

Changing Cardiac Risk Factors

In another project, interd isciplinary teams of

health professions students (medical, nursing, nutrition,

and epidemiology) worked w ith an electronic

community of individuals to change cardiac risk

factors, such as increasing physical activity and

following a low fat, reduced calorie diet (Moore, in

press). Using on-line methods without face-to-face

interactions, the students: (1) deve loped a therapeutic

relationship w ith clients over a computer network (2)

assessedclients current health patterns regarding diet

and exercise compliance with heart-healthy lifestyle

guidelines, (3) employed a series of behavior change

strategies while electronically coaching clients to

make these lifestyle behavior changes, and (4) tracked

trend da ta related to diet and exercise behavior over the

project period. The interdisciplinary teams held virtual

team meetings for case discussion of their client load.

This virtual approach to team care solved some of the

challenges normally associated with interdisciplinary

collaboration in the health professions, such as finding

convenient times to meet and creating efficient records

of team discussions and decisions.

He Care

In a recent project, HeartCare (Brennan, et al.,

1998), customized teaching and home management

support are provided by nurses to patients for six

months following cardiac surgery using home-based

WebTV. In this project, several hundred pages of

cardiac recovery information on the Internet were

evaluated for accuracy, appropriateness, reading level,

and gender focus. Additionally, nearly 200 pages of

cardiac information not available on the Internet were

created by the project team. These Web pages were

entered into a data-base and are dynamically pulled

according to a tailoring algorithm based on information

known to the nurse about patient health status, gender,

co-morb idities, risk factors and recovery time frame. For

example, the Web pages provided for a patient with a

smoking history and diabetes are different from those

given to a patient who needs weight managemen t and an

exercise program. The nurse also is able to add or delete

pages any time during the six-month recovery period for

individual patients based on changes in the their health

status or treatment plan. Thus, individualizing recover

information for each client is cenhal in the design of the

HeartCare system.

Patient self-care is fostered by the design of the

content on the Web pages. The content of the Web pages

was built following the guidelines of a nursing theory of

self-regulation (Johnson, 1999) that specifies the type of

information to provide to individuals to assist them to

self-manage stressful illness situations. In addition, a

search function using patient, rather than medical

language terms allows patients to seek healthcare

information on the HeartCare system.

Maintenance of the Heart -e system also is

conducted by the nurse moderator who provides vigilant

attention to server performance, Web page address and

content changes. Although an automated link checking

system is employed, supplemental manual checks are

done to insure link stability and the nurse checks weekly

for unexpected changes or alterations in W eb page

content to insure clinical applicability of the information.

The nurses role as educator has expanded with

the increased use of Web-based healthcare information

by patients. Nurses are learning to critically analyze Web

site content, source of content, quality o f content, and

intended audience. When patients present information

downloaded from the Internet, nurses must be prepared

to analyze the information for accuracy and applicability

and advise patients about proper use of Web-based

health care resources and current treatment interventions.

Teaching patients how to use search engines, bookmark

favorite Web sites, and access health-re lated support

groups are examples of patient education skills nurses

soon will be providing on a daily basis. Nurses are

beginning to develop Web pages containing health

information for clients. This is an important role for

nurses since they are knowledgeable about hdw to tailor

information to appropriate reading levels, cultural

aspects, and developmental needs of patients.

The HeartCare system also has an electronic

mailing communication feature though which the nurse

monitors patients progress, manages symptoms, and


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provides personal recovery advice. The nurse is able to

develop an interpersonal relationship with clients that

encompassed the roles of teacher, communicator,

comforter, rehabilitator, and caregiver. In its current

form, the He Care system does not support

collaboration among health care professionals, although

this function easily could be added.

SUMMARY

Over the past ten years, om experiences n the

design and testing of electronic nursing care delivery

systems has provided us with insights about the

potential impact of electronic care delivery systems on

nurses work systems. We are learning abou t the ideal

client load that can be reasonably managed

electronically by a nurse or healthcare team, how much

electronic client contact should be done individually or

in groups, the extent to which clients families can be

involved, and the correct balance between the amount

of work done with clients on-line and using other forms

of communication, i.e., telephone, written, or face-to-

face. We also are learning about design features that are

important to patients and nurses.

Technology is an important factor in the

evolution of nursing practice and the experience of

nursing (Barnard, 1996). It is suggested that adequate

conceptions of technology will emerge when nursing

defines technology as influential in the organization of

human labor and fundamental to its moral and political

goals. Our experience has shown us that a technologic-

humanistic dualism does not have to exist in

technology-mediated nursing care. Challenges to the

humanistic aspects of nursing (maintaining high

touch in a high tech system) can be sufficiently

managed f computerized nursing care deliveT systems

include design features mindful of professional nursing

values and functional roles.

REFERENCES

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anatomy of definition. Internationa l Journal of

Nursine Science. 33,433.441.

Barnard, A. (1999). Nursing and the primacy of

technological progress. International Journal of

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Behrend, S. W. (1994). Documentation in the

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Nursing. IO. 264-280.

Brennan, P. F., Caldwell, B., Moore, S. M., O Brien, R.,

Sreenath, S., Jones, J. (1998). Designing

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