Nurse Education Today (2007) 27, 60â€“67
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Supporting pre-registration students in practice: A review of current ICT use Rod Ward *, Pam Moule Faculty of Health and Social Care, University of the West of England, Glenside Campus, Blackberry Hill, Bristol BS16 1DD, United Kingdom Accepted 23 February 2006
Summary It is unclear how current healthcare students based in the United Kingdom (UK) use information and communication technology (ICT) to support their learning and care delivery in practice environments. This position reflects the dearth of current empirical evidence that needs development in this rapidly changing field. Using focus group interviews involving 16 students from nursing and the allied health professions, to reflect the interprofessional nature of healthcare education, this research explored how students employ technology in placement settings. The students drew on networked resources for personal learning and gave examples of use to meet patient and user needs. Technology also provided a vehicle for communication with the University, though use was complicated by a number of issues. Access to computers and the Internet whilst in placement environments proved problematic for some, with the culture not seeming to support ICT use. Lack of time, attitudes towards computers and ICT skills also affected student engagement. These findings provide information to guide the development of ICT use in placement settings. c 2006 Elsevier Ltd. All rights reserved.
Practice support; Information and communication technology; Focus groups; Healthcare students
Healthcare students based in the United Kingdom (UK) are required to spend considerable periods of time developing practice skills in a variety of * Corresponding author. Tel.: +44 117 328 8422; fax: +44 117 328 8811. E-mail addresses: Rod.Ward@uwe.ac.uk (R. Ward), Pam. Moule@uwe.ac.uk (P. Moule).
placement settings, often located some distance from their higher education base. Whilst information and communication technology (ICT) is employed in the academic setting, it is unclear how such technology is used in placements to support student learning and care delivery. This reflects the current lack of empirical evidence in what is a rapidly evolving field. Additionally, there is uncertainty about how ICT use might be developed to facilitate students, though some 10 years ago it
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.02.008
Supporting pre-registration students in practice: A review of current ICT use was suggested that its use might be vital to supporting students whilst in distant practice environments (Hassett, 1995). Current National Health Service (NHS) initiatives promise expansion in the use of ICT for all health care professionals as part of the National Programme for Information Technology (IT) (NHS Connecting for Health, 2006). This suggests ICT will have greater impact in a variety of health care settings. Given these challenges, research was completed with students from nursing and the allied health professions, reflecting the interprofessional composition of a Faculty of Health and Social Care. It explored student’s experience of current ICT use in practice settings and those factors that affected its employment. This paper outlines and discusses the findings, drawing recommendations to facilitate the further development of ICT to support healthcare students in placement settings.
Literature review A limited number of empirical studies have considered how ICT is employed in practice settings. Morris-Docker et al. (2004) evaluated the impact of networked computers in four wards at a teaching hospital in the UK, concluding the employment of computers was unrefined, though information retrieval was the major function. Gosling et al. (2004) examined the use of online evidence and found usage was associated with nursing role, managerial and organizational support. More than 10 years ago Hassett (1995) considered the use of various technologies to communicate with nursing students who were widely dispersed, suggesting communication technology is vital to supporting students in placements. Various modes of communication were suggested, such as the Internet and voice mail. Current research suggests mobile devices are the domain of the young and will be increasingly used and developed (Anderson and Blackwell, 2004). Employing mobile enabled devices such as iPods, personal digital assistants (PDAs) and the use of different modes of communication such as SMS messaging may require staff development. Those employing technology to support teaching and learning in healthcare practice internationally report a number of issues. Atack (2003) reviewed nurses’ experiences of completing a web-based programme in the workplace and at home in Canada. Technical issues dominated the focus group discussions held during the research period, though these diminished over time. The
approach supported the development of ICT skills and facilitated a flexible approach to learning. The convenience of learning with computer-based materials is apparent, with flexibility of access and freedom from many of the constraints of face-to-face learning being identified (Ryan et al., 1999; Moule, 2002; Sit et al., 2005). However, not all students have convenient access to technology for study purposes, nor are they at the same level in terms of using technology (Andrusyszyn et al., 1999; Geibert, 2000; Honey, 2004). Users can find the experience of learning with computer technology anxiety provoking and more time consuming (Billings et al., 2001; Conole et al., 2002; Atack and Rankin, 2002; Atack, 2003).
Aim Given the paucity of research considering student’s use of technology in practice and the differing interpretations of the benefits of ICT use within healthcare education, this study aimed to: 1. Ascertain the current use of ICT by UK based healthcare students in practice to support learning and care delivery. 2. Explore issues related to current use of ICT in practice. 3. Use the findings to make recommendations related to the possible development and implementation of technology to enhance student practice support.
Method Focus group interviews were employed. These have many advantages when attempting to establish the feelings, needs and development of a certain group of individuals. Kitzinger (1995) suggests that focus groups are useful to explore people’s experiences. They are also seen as an effective way to carry out evaluation and development of a programme of activities (Race et al., 1994). The focus groups involved 16 students in total. Conducted in September and October 2004, they explored how students supported their learning whilst in practice and suggestions they might have to improve electronic support whilst on placement. Staff from different professional disciplines to the students facilitated the focus groups. This limited any effects on the discussions from potential coercion or power relationships.
R. Ward, P. Moule
The research aimed to sample students from undergraduate programmes in one Faculty, from all sites reflecting the interprofessional and dispersed nature of the student learning experience. Students from years two and three of the programmes were selected, having previous practice placement experience. A form of quota sampling was employed (Hek et al., 2002), to ensure all students were given the opportunity to be involved. The final sample composition is shown in Table 1. The focus group discussion was recorded and later transcribed. Ethical approval was obtained from the relevant University and Faculty Ethics Committee. Participants were given written and verbal information about the purpose of the study and how it would be conducted. All signed consent forms before participating and could withdraw from the study at any time. The identities of all participants were kept confidential.
Data analysis The focus group leader and another researcher, reviewed each transcript independently, to enhance the rigour and provide some degree of inter-rater reliability. The analysis was largely based on Pattern Coding and Pre-structured Case Analysis (Miles and Huberman, 1994). Each transcript was treated in a systematic way as suggested by Webb and Kevern (2001), to identify emergent concepts and themes while still recognising the importance of the group processes and dynamics captured during the focus groups. The emergent issues were coded and then merged into themes as appropriate and presented as two key themes with illustrative data.
Findings The focus group findings are presented using respondent identifiers (see Table 2) to demonstrate
The recruited sample
Professional group Physiotherapy Radiography Mental health nursing Adult nursing Learning disability nursing Childrenâ€™s nursing Total
Number recruited 5 3 3 3 1 1 16
Mental health nursing Adult nursing Learning disabilities nursing Childrenâ€™s nursing Allied health professions
MH A LD C AHP
the origins of the student views. The two themes that were seen to emerge included: Use of ICT in practice Barriers to ICT use.
Use of ICT in practice The students identified two main areas of use whilst in practice, including information retrieval and the employment of ICT to facilitate communication with the University. They also discussed the potential for ICT to support peer communication.
Information retrieval Students described various ways in which they used ICT and networked resources to find and retrieve information both for their own use and to help patients and users; â€˜â€˜. . . the last essays have been policy based, and when itâ€™s been quiet on the ward, Iâ€™ve sort of had a quiet word to the sister in charge, or the nurse in charge and they go yeah whatever and weâ€™ll give you a shout when its busy . . .â€™â€™ (A) â€˜â€˜Iâ€™ve made a document to myself with all the drug names and what theyâ€™re used for and I type those down to myself on the University webmail because I can access that online and I donâ€™t ever erase that message, I just leave that message with the attachment there.â€™â€™ (MH) â€˜â€˜I think theyâ€™re [discussion boards] good, Great Ormond Street on their Website have an international discussion room which is open to parents.â€™â€™ (C) They also describe ways in which staff use ICT for information management and communication in practice: â€˜â€˜Iâ€™ve seen them used for emails between the medical staff and nursing staff umm between the
Supporting pre-registration students in practice: A review of current ICT use nursing staff across different districts, different areas that sort of thing, umm off the Internet I’ve seen it used for developing care plans umm and diary . . . various aspects of people’s care and that sort of thing umm . . . Time sheets and there’s a lot of standard letters. Pro-formas aren’t there, and that sort of thing.’’ (MH) Students were trying to find information relating to both their university course and the organisation in which they were undertaking their placement, processes that were not always easy; ‘‘. . . there isn’t one standard place to look for one thing, so if you did have umm . . . I mean cos like the university site is really good, but to try and find umm the library clinical, you know skills sessions is a nightmare.’’ (A)
Facilitating communication Several of the students described the isolation they felt on placements from the University support mechanisms and their peer group. Those in the community or at sites some distance from the University felt this more acutely. It was suggested that a mechanism for communication was needed when there were ‘problems’ on the placement, and at these times the students wanted support quite rapidly; ‘‘. . . sometimes they felt a bit on their own and if the information they wanted was available or a scenario of where to go and how to do it they could tap in to it rather than go through the system because if you’re unlucky and it takes a couple of days, a couple of days can seem like an eternity if you’re having a really rough time.’’ (LD) A few students considered the ability to email their tutor a ‘lifeline’, ‘‘It’s a lifeline really when you’ve got a bad placement . . . we only come in once every two weeks and you can email your tutor or a lecturer and say I’ve been asked to do something, I’m not sure what to do . . . help!’’ (A) Several commented about the potential use of discussion boards as a method of sharing information and communicating with peers, particularly while on placement; ‘‘I never used it [discussion board] on placement, I used it in my first year IP module. I can imagine it might be useful for those people out on similar placements to keep in touch.’’ (AHP)
Barriers to ICT use There were a number of perceived barriers to the use of ICT in practice settings. These related to access difficulties, problems with finding the time for computer use in clinical settings and issues with computer skills and general attitude to computer use.
Access Access to ICT was a major concern for the students. Experiences varied depending on the placement setting, however, ICT availability was often limited. Students described placements where there was little or no provision, with many finding it easier to use their own facilities at home; ‘‘. . . some hospitals haven’t got IT suites, haven’t got decent IT software. Accessing it while on placement in the day is difficult, but at home it’s not. (C) In placement areas which did provide ICT access the attitude of staff could provide a barrier to its use by students; ‘‘Our last placement the staff were very protective about the computer in the nurses’ office, even though it was meant to be a general computer for the use of everyone, it was Sister’s computer.’’ (A) Some placement areas did make ICT access available in a library or study centre which was seen as very useful, however accessing this during short breaks from the clinical area was difficult; ‘‘You wouldn’t have time in half an hour to go to the library and use the computer there or, you know if you’re on a shift and its late then your break would probably be the time the library was closed anyway.’’ (A) Not having necessary usernames and passwords to enable computer use proved problematic. Those students on placements geographically dispersed discussed problems of Internet access from their accommodation; ‘‘My placement, there was just one computer in the hospital and we didn’t have logins so we couldn’t use it and we didn’t have the Internet where we were staying but I think it would have been useful to use it but I wouldn’t really have known where to look for information or where to start.’’ (AHP)
Time In addition to the barriers created by lack of access to ICT, several students mentioned the time pressures while on placement that affected its use. ‘‘There’s a guilt thing about using the computer on your placement, because you’re meant to be fulfilling your competencies and not spending time in an office just staring at a computer screen . . . Umm but I tend not to do it that often in work, on placement, I tend to do it more from the one at home.’’ (MH)
Student’s computer skills Many students felt that they needed further development in this area; ‘‘ [I would like] more lectures on IT because it still takes me hours.’’ (LD) ‘‘I think as well as having access to the Internet and online learning, we should be taught to use it properly, for instance the discussion board, I don’t know what it is.’’ (AHP)
Attitudes to ICT Students demonstrated a range of attitudes towards ICT use. Generally these were positive although negative aspects were identified. Students weren’t sure of the University expectations of use and there was some suggestion that any effort to contribute to online discussions for example, should be credited in some way. ‘‘I think that . . . I mean the impression I’ve got is that even the people who use Blackboard and contribute to it don’t really know where they stand with it because like we said we’re asked to contribute to it, compulsorily, and then we’ll be asked to contribute to it voluntarily, and people will choose the voluntary . . . to voluntarily not contribute to it and that’s fine but those who do don’t seem to get any recognition for the fact that they contribute to this, not officially any way, umm and . . .’’ (MH)
Discussion The use of ICT in placement settings centred around meeting information retrieval needs, as seen in academic based nursing courses (Clarke,
R. Ward, P. Moule 1998). Students also employed ICT as a mechanism for communication with the University. It is interesting to note that the students provided a number of examples of Internet and ICT use to support patient and user care. They cited particular web-sites as being helpful and used the hospital Intranet to access local policy information. In addition, the University site was accessed to search for course related materials and to use online library facilities. This activity seems to mirror research findings suggesting nurses integrated the use of the Internet into their working lives, often undertaking work-related searching and accessing library data bases (Morris-Docker et al., 2004). The students described ‘feelings of isolation’ from the University and colleagues while they were undertaking their placements. This was compounded when sited at distant placements. In these circumstances the students employed a variety of communication strategies to contact their ‘home base’ and members of lecturing staff. This seems to support the early view of Hassett (1995), who suggested communication technology would provide vital support to students in distant placements. Often email was used, viewed as a convenient and quick messaging service, though replies were often delayed for more than a day. It should also be noted that a number of students were unable to communicate using email or to use ICT for information retrieval, as access to computers varied. Students in mental health, learning disabilities and community settings described inferior ICT provision than those placed in acute hospitals. These findings support those of a study conducted in a similar geographical area with qualified staff in National Health Service (NHS) settings. The results suggested ICT availability was variable, with higher levels of access afforded in hospital settings (AGW WDC, 2004). When computers were available, access was frequently denied as staff could be ‘protective’ of computer systems. In addition, necessary usernames and passwords were often not issued. An inability to gain connection to the NHS network impacts on the student’s ability to see the records of patients and users as well as preventing access to university based resources, literature and other supporting materials. These issues have been identified elsewhere in the country (Gilchrist and Ward, 2006) and are also experienced by other NHS staff and students, notably medical practitioners (E-Health Insider, 2005). It is apparent that a number of factors impact on access to computers for a number of students
Supporting pre-registration students in practice: A review of current ICT use in practice environments. This affects their ability to communicate with the University and access information about their course. One possible way forward could include the use of mobile devices such as mobile phones, as suggested by Anderson and Blackwell (2004). These might enable two-way communication between the student and University, and peer communication, also facilitating access to course information. It should be acknowledged however, that the introduction of such mobile enabled devices may require training for staff and students and would have cost implications. It was acknowledged that the provision of computers in hospitals was increasing, though students noted that such facilities were often placed in libraries or specific rooms away from the practice settings. This meant finding specific time for access, often not seen as feasible. There was a reluctance to seek permission to use computer resources either during ‘work’ or ‘break’ affording little opportunity to complete any online activities. The use of computers in the workplace for learning has been affected by a lack of time and access (Moule, 2003). A number of studies have confirmed that health care staff found it difficult to commit the time needed for computer use in e-based learning (Gillis et al., 2000; Atack and Rankin, 2002; Conole et al., 2002; Atack, 2003). Computer location and proximity have long been seen to influence workplace learning (Khiony, 1995), with local computer access and Internet connection being essential for use (Atack, 2003). Morris-Docker et al. (2004) suggested that Internet provision resulted in staff accessing computers in the clinical settings. It is interesting to note that use was greatest at the times when wards were most quite, often seen in the later evening and during the nightshift. This reported pattern of engagement suggests that online activity by staff and students will be enhanced if computers are based within the practice setting, as recommended by NPfIT, though use is likely to be linked to clinical demands. To try and overcome access problems in the placement settings, several students described using ICT from home to support learning and the placement experience. Home availability can increase confidence in ICT use and afford ease of access, though presents possible disadvantages for those unable to secure such access (Martyr, 1998; Dewhurst et al., 2000; Moule, 2003). Some students were thwarted in their efforts to use home based computers, especially those based in disparate locations, where accommodation failed to provide necessary computer and Internet access. One stu-
dent suggested that all accommodation used by Universities might be required to have such provision. Students commented on the need to develop ICT skills to support computer use. A number of studies have reported that nurses and nursing students involved in computer use or based study identified a need for increased computer skills (Andrusyszyn et al., 1999; Geibert, 2000; Gillis et al., 2000; Moule, 2002; Atack, 2003). It has been suggested that computer skills should be integrated within study programmes (Wharrad et al., 2002) as skills and confidence development are essential to enable student ICT use (Hara and Kling, 2000; Wharrad et al., 2005). A number of studies report improved ICT use as a result of engagement in computer use (Gillis et al., 2000; Atack and Rankin, 2002; Atack, 2003; Moule, 2006). All NHS staff are currently eligible to gain the European Computer Driving Licence qualification and it is suggested all healthcare students are supported in attaining this (Gilchrist and Ward, 2006), perhaps through integrating such a programme into pre-qualifying curriculum. Students attitudes to the use of ICT were generally positive, though varied. Previous research identified differences in attitudes towards and use of computers between nursing students and trainee teachers (Wishart and Ward, 2002). This could not be explained by age, gender or educational level, but indicated nursing students were less likely to use ICT and to have home computer access. It is also apparent that the University might need to be clearer about expectations of use.
Limitations In interpreting the results of this study it is important to acknowledge that the research was conducted in one University Faculty, involving a small number of healthcare students.
Conclusions Information and communication technology can provide support for students in UK practice settings, particularly when placements are some distance from the University campus. Students are able to use ICT to support their educational needs and enhance care delivery. They also draw on technology to enable communication with University staff. This said, there are a number of factors that thwart ICT use. Access to computers in practice settings can be problematic for a number of
66 reasons and whilst availability is often an issue, the placement culture can also inhibit use, those this may change as a result of NPfIT (NHS Connecting for Health, 2006). Lack of time, attitudes towards computers and ICT skills also affect student engagement. It is clear however, that technology is becoming increasingly important and that students where possible are employing ICT as part of their professional practice. Factors that might enhance this include the increasing provision of computers throughout the NHS and the possible use of mobile enabled devices to ensure some form of electronic communication for all students. In addition to increasing technological provision, students and staff supporting them will need to feel confident in their ability to engage in its use, requiring training and technical support.
Acknowledgements Funding for this project was obtained from the Academic Small grants programme Faculty of Health and Social Care, University of the West of England, Bristol. The authors thank fellow members of the research team for their assistance with the project. We are also grateful to those students who gave their time to be involved in the project.
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