Computer in nursing in the United States: technology induced changes and the response of the nursing profession, December 5, 1991

Moderator: University of Iowa, History of Medicine Society, December 5, 1991. This evening's speaker is Mr. Joseph Merchant, third year medical student, and recipient of the first prize in the 1991 John Martin Essay Award. Mr. Merchant's talk this evening is entitled, Computers in Nursing in the United States, Technology Induced Changes and the Response of the Nursing Profession. Joseph Merchant: Okay. Are you all hearing me okay anyway? Okay. Also I'd like to thank Colleen Prophet, one of the nurses who works with computer information systems at the university here for helping me with some slides and some information. That being said, my topic for tonight is ... What's wrong? Oh. As has already been announced, Computers in Nursing in the United States, Technology Induced Changes and the Response of the Nursing Profession. When friends of mine heard about this, my award, and saw the signs for the talk tonight the usual response has been, why did you write on this topic? You're a medical student and you don't know much about computers, so why did you get interested in this particular topic? And I admit in retrospect it seems like it's kind of out of place for a non-nurse and a non-computer expert to undertake this task, so by way of introduction I'd like to just describe how I got interested in this topic. As Susan said my undergraduate degree was in philosophy, and several books I read as an undergraduate got me interested, especially in the interaction between technology on the one hand and society on the other. For example, a French philosopher Jacques Ellul worried in his book, The Technological System, that technology has become the most important determining factor in current history. He wrote in that book that, "It used to be nature that imposed it's evolutionary rhythm upon us. Now it is technology. It use to be nature that determined certain social structures, now it is technology. It used to be nature that muted out the raw materials, not the crux is the technological processing. Technology infringes directly upon man's life, exacting adaptations like those once demanded by the natural environment." Ellul then the question of what technology actually does for us and to us is crucially important. Economist E. F. Schumacher in his book Small is Beautiful agrees with Ellul's concern. In this book he wrote, technology has a had dehumanizing effect in industrial societies, "Depriving man of the kind of work he enjoys most, creative, useful work with hands and brains, and given him plenty of work of a fragmented kind, most of which he does not enjoy at all." He goes on to write, "We need a different kind of technology, a technology with a human face, which instead of making human hands and brains redundant, helps them to become far more productive than they have ever been before." This brings me back to the subject of my paper. With the critiques of people like Ellul and Schumacher in mind, I wanted to study the effects that computer technology has had on healthcare institutions or medicine in general. And that's how I started out. I wanted to find out if in fact computer technology was dehumanizing medical work, making the hands and brains of medical professionals redundant. Or if it was instead as Schumacher would've wanted, a technology with a human face. An AP report in this past Mondays Des Moines Register gives an idea of the potential impact computers could have in healthcare. This is right next to an article about the suit about hospital malpractice in the death of Andy Warhol. The title kind of says it all. The title is Computer System is Best in Heart Attack Diagnoses. And it goes ... Computer network diagnose heart attacks in emergency rooms with patients more accurately than physicians. But researchers said the system should be used as an aid rather than a replacement. So this kind of gives an idea of the potential and the way people think about computers coming into healthcare these days. It's no doubt that computers are ubiquitous in hospitals today. This of course hasn't always been the case. Only 25 years ago, computers were rare in hospitals with some of the pioneers of hospital information systems beginning in the 1960's. It's been in the last 15 years, and especially in the last 10 years that with the advent of micro computers, that computers have really proliferated in hospitals. In fact, computers are so common in hospitals today, to find a hospital with no computers at all, I had to go all the way to eastern Africa in Kenya where I was fortunate enough to spend a summer after my first year of medical school at the Ortum Mission Hospital, which was a pretty small hospital with no computers and electricity only during the day. And I just want to briefly show some slides of this to give an idea for contrast of what we have here and how far we've come with computers before I go on with main subject of the talk. And I'm sorry for my bad photography, but this is just a picture on the wards of the hospital with the nurses handing out medications to the patients lined up. You can see the old ward atmosphere of the hospital. Here nurses are providing patient education to pregnant women out in the bush, out in the village in an isolated area. And here are some nurses doing some health screening in a classroom for just kids for vision. I like to challenge you to think, how would this picture be different if there was a computer in the picture? How would the work of these nurses in the hospital, the nature of the hospital be different? So I had this slide made with a computer there. To kind of make you think about that. I think the different that the computer in this picture makes is kind of profound. The hospital could now have a lot of things it didn't have before. It could have computerized patient information, lab data, physician and nursing care plans, computerized billing and much more. And they could use the computer for inventory, for pharmacy, for radiology, writing grants to aid agencies, which they need to do all the time. A computer would I think transform the hospital making it more efficient and more accountable. And as well as probably improving patient care. Now it's with these same hopes that computers have been introduced widely in American hospitals today. Computers are expected to provide increased accountability and increase efficiency plus improve patient care. In pursuit of these benefits however, computers have inevitably and irreversibly changed the work of individuals in health-related jobs. Computerization has been and will continue to be a force for change in healthcare work, forcing the healthcare professions to completely rethink their roles, relationships, activities and attitudes. Comprising 50 to 75% of the employees of a typical hospital, and representing the largest information processing group, nurses have been uniquely positioned on the frontline as computers have been introduced in the healthcare workplace. [inaudible 00:08:54] is the continuing collision of nursing and computer technology has resulted in change in the four main domains of the nursing profession, research, education, practice and administration. So in this paper I tried to outline the computer-related change in nursing in the United States, with an aim to producing an understanding of the forces that have shaped the interaction between nursing profession and this technology. Before telling you what I found, it might be helpful to gain brief historical perspective on the nursing profession. Although some credit, Florence Nightingale with creating the nursing profession in the 19th century, the later half of the 19th century, nursing traditions extend well before that time. Between the 16th and 19th century for example, groups of religious women like the Sisters of Charity founded by St. Vincent DePaul in 1646 and the deaconess movement started by Lutheran minister Theodore Fliedner in 1822 played charitable roles in providing care for the poor, sick, dying or mentally ill. The work of these women consisted of such tasks as taking food to the sick, doing laundry and gardening, making patients comfortable, and watching over the sick and dying. Florence Nightingale did make many contributions to the nursing profession, including the intensive education system she introduced and administered at her Nightingale school and her many contributions to hospital and midwifery reform. Significantly breaking from the traditions of the Sisters of Mercy and deaconesses, Nightingale did not believe in nurses doing non-nursing tasks, saying, "To scour is a waste of power." Although many offer definitions of what it means to be a nurse, one of the most popular such definitions has been offered by Virginia Henderson of the Yale University School of Nursing. And I quote, "This function is to help persons sick or well from birth to death with those activities of daily living that they would perform unaided if they had the strength, the will and the knowledge. At the same time and throughout this relationship, nurses help people gain or regain their independence. When independence is impossible to cope with handicaps and irreversible disease, and finally to help others die with dignity where death in inevitable." This description emphasizes the human care aspects of nursing. But others now emphasize that nursing is also an information intensive field. Both in the proportion of data generated by nurses is within any healthcare system is substantial and that nurses must often act as gatekeepers of the information flow in the hospital or in the healthcare setting. It has been estimated some of the articles I read that nurses spend 30 to 40% of their time in information processing activities. So just to get started, go through the effects that computers have had in nursing administration. A survey of 34 hospital nursing executives in the greater Milwaukee area performed in 1987, attempted to assess the use and specific type of computers used in hospital nursing in that area. Over half of the applications reported were in the area of nursing administration. Indeed, as the first applications of computer technology to nursing were administrative aids, it's not surprising that today this type of application is still the most widely used. One of the most popular such administrative applications has been the computerization of unit staffing and the scheduling. The St. Joseph Mercy Hospital in Ann Arbor, Michigan was one of the pioneers in this type of application. There at the end of 1972, a patient classification system was devised with differing amounts of patient of nursing care allotted to patients with differing severity of illness. By September of 1974, this system was fully implemented in four of the hospital's nursing units and in the first year that it was used, the hospital realized the substantial savings of money, $160,000 in the first year it was used, solely on the basis of savings in nursing staff. More efficient use of nurses. Many other hospitals have since come to use similar forms of acuity-based staffing and in 1980 the joint commission for accreditation of healthcare organizations mandated that nursing services, "Define, implement and maintain a system by which the quantity and quality of available staff is based on identified patient needs." After the introduction of prospective payment through diagnosis related groups in October of 1983, the pressure for nurse administrators to contain costs and assure quality patient care also increased. At Vanderbilt University Hospital, nurses began to use computers to monitor quality of care in the early 1980's. This hospital uses the Rush Medicus quality of monitoring tool to perform quarterly studies of each nursing unit. Quality scores are generated for each unit on each objective and on each quality assurance objective and sub-objective and these are assembled into summary reports, which are available to each unit coordinator. Just to give you an idea, these summary reports contain a summary of statistics including quality scores, unit statistics, personnel statistics on recommended and actual hours by staff category and totals, and productivity indices, scores for the six quality objectives against time, acuity by day of the month, recommended staffing versus actual staffing, actual total hours per unit of workload per day, and percent distribution of total staff by shift by average patient acuity. Sounds pretty complicated. The unit managers then are expected to review these reports and set goals for improvement. Another example of using computers in nursing quality assurance is that the Cedars-Sinai Medical Center in Los Angeles where SICU nurses, and the SICU administrators use a hospital information database to generate a daily acuity score for each patient, which is extracted from 14 physiologic variables and 31 quantitative nursing interventions. They then use this score to find important relationships between patient acuity here on the bottom axis, and total nursing hours worked between acuity and patient mortality and between acuity and the service, which utilizes the intensive care unit, the SICU. So clearly, performing these kinds of tasks, which involve regular and extensive gathering of information from hospital, from a wide variety of hospital database sources, would take a long time to do manually. And having a computer, it enables nurse administrators to do these tasks with relative ease on a daily basis. Okay. Beyond using computers as administrative tools in staffing and quality assurance applications, nurse administrators have also been the ones to play the role of introducing a new technology into the hospital system, or playing the role of introducing the computers to other nurses. Although this role of bearer of new developments may not be a new one for the nurse administrator, the introduction of computers has required nurse administrators to establish new organizational structures and job positions. For example, some hospitals have created positions for nursing information system specialists, who function to act as an intermediary between nursing and the hospital information system. And so these nursing information specialists is an entirely new position in the nurse administration in many hospitals. Nurse administrators have also been forced to cultivate a new relationship with computer programmers. This relationship importantly has given nurse administrators a role in shaping the future of nursing applications of computers. Computer vendors have realized the key role of nurse administrators and have attempted to recruit them to be computer vendors themselves. And some of the papers I read indicated that nurse administrators are shifting out of the hospital to begin working for the computer vendors more and more. One of the writers I read wrote that because of this role of being the introducer of the technology into the hospital setting and because of their new interaction with computer vendors, nurse administrators, "Realistically may be in the forefront of nursing information system design. And may have a great impact in the future of nursing information system design." Gone to practice, nursing practice. The effects of computers, technology on nursing practice were felt first in specialty areas including cardiovascular and intensive care unit nursing. In these areas, computers have been part of physiologic monitoring systems since the early 1970's. One of the first of such applications was in Cincinnati, where a computer system called Alcyon, was introduced in 1971 for maintaining a neutral thermal environment for newborns and also indicating or alerting newborn nursery personnel when something was going wrong with the infant. The system controlled the climate and monitored the infant's heart and respiratory rates. The nurse's function with the Alcyon system was besides turning, feeding and changing the diapers of the infants, was to make sure the system was set up properly and to intelligently examine information collected by the computer. So in areas like this, computers have come between the nurse and the patient, sacrificing some of the direct patient monitoring duties of nurses for technological advance in healthcare practice. Although nurses in specialty areas have been working with computers since the early 1970's, it wasn't until the late 1970's and the 1980's that computer applications have had a substantial impact on general nursing practice. The impact on general nursing practice was felt first in larger hospitals. One of the first hospitals to pursue an integrated hospital information service with applications for nursing was the El Camino Hospital in Mountain View, California. Here the Technicon Medical Information System was utilized by 1975 to support applications directly affecting the nursing service, including entry and communication of physician orders into the computer, some nursing care plans, charting against physician orders, and some charting of vital signs and other patient parameters. Although representing only one of the hospitals instituting information systems in the 1970's, the experience of nurses at the El Camino hospital is illustrative of the kinds of changes in daily work that came with the advent of generic hospital information systems. The systems hep nurses in these hospitals by organizing and keeping track of physician orders by automatically routing orders to the correct destination and tracking the status of ordered tests through to completion. And by assuming the part of clerical burden of processing discharges and transfers. Generic computer systems relieve the nurse of the responsibility for coordinating the distribution of non-nursing patient data to other departments. And some studies, some empirical studies have suggested that by doing all of these things, computer information system have saved nurses a substantial amount of time by cutting down on clerical and communication tasks. Although, the above effects on nursing practice were significant, by the early 1980's some nurses were beginning to be dissatisfied by the forced fit of these generic hospital information systems onto the nursing service. For example, Cameron Rider, the director of research at the Naval School of Health Sciences, noted in 1982, "Nurses today have remained naïve concerning the definition and design of information systems for day to day functioning. Because they assume that any automative hospital system would automatically satisfy nursing requirements. Yet a recent analysis of healthcare computer technology available for major companies indicated just the opposite. Nursing was the least defined area in terms of computer application." In an effort to correct this naivety, Cam Rider set up a committee, a tri-service nursing committee to define functions in nursing that would benefit from automated support. And the result of this committee's efforts was according to Rider, the creation of a nursing information system that delineates automative requirements for patient care, unit management and nursing administration in the in-patient, out-patient and operating room areas. So we see a general shift from generic hospital information systems towards nursing information system more specifically in the 1980's. So this happened in the early 1980's and the number of software packages specifically for nursing increased also in the 1980's from one 26 in 1982 up to 245 in 1989. Kind of nearing this movement towards specific nursing information systems. So that was the number of software packages ... There was a 900% increase in the number of software packages specifically for nursing information systems. Okay, just to give you a description of what a nursing information system is, I give a brief description of one that was instituted at the Northeast Georgia Medical Center in 1983. This nursing information system was based on standardized nursing diagnoses accepted by the North American Nursing Diagnosis Association. After admission, assessment and analysis of clinical variables, nurses at this hospital must make a nursing diagnosis for each patient. A computer then supplies for them a list of the possible etiologies for this diagnosis and a list of the most common desired outcomes for this patient. The nurse then selects a desired outcome, which is specific and measurable and appropriate for the patient. And the computer will respond then by displaying a list of nursing interventions normally used to achieve this outcome. The nurse will then select the interventions appropriate for the patient including patient teaching and discharge plans. And then can add individualized parts onto this plan as the nurse prefers. And at the end of this process, the screen will display the entire nursing care plan for that patient. So this is how, this is one way in which a nursing information system has been used with nursing diagnoses and nursing interventions to allow nurses to formulate complete and comprehensive care plans for the patients they're caring for. So administrators at this hospital, after instituting this plan, noticed significant savings again in nursing time, and money, as well as improved nurse and patient satisfaction after implementing this system. Also they noticed improvements in documentation and in clarity of nursing communication with this system in place. Finally, to close off the section on nursing practice, and one other section of nursing practice that is patient education, computers have been increasingly used in the 1980's to help nurses provide comprehensive systematic education to patients on their diseases. Or how they can best take care of themselves when they're out of the hospital. In response to JCAHO regulations issued in 1983, which required that instructional objections and desired learner outcomes that they be identified and a documentation be provided of teaching and outcomes, many hospitals have turned to computer assisted instruction as a means to provide effective patient education. So computer technology for this reason has been ... Both the computer technology has been used more and more to teach patients in the 1980's. So although the effect on computer practice and nursing practice began in the early 1970's in specialty areas, since the 1970's you've seen more and more specific applications of information systems and computer technology towards the nursing process and you've seen nurses become more involved in the implementation of nursing information systems in hospitals. To move on to education, computers have been used in nursing education since 1966 when the University of Illinois initiated a project in one of the nursing classes teaching maternity nursing, which used a computer to help the students learn on their own. This computer was called Plato. And what it did, was it would present students with simulated patients and commonly encountered questions or problems. And the nursing students could then have an interactive relationship with this computer. Many nursing educators have looked upon computer assisted instruction like Plato, this Plato program as a means to individualize instruction and allow nursing students to place themselves. By 1986, 20 years after this first program was introduced in Illinois, one study estimated that computer assisted instruction was used as a teaching method in approximately one half of the baccalaureate nursing programs in the United States. So while uses of computers to facilitate teaching on non-computer information did begin way back in 1966, it was not until 1977 that nursing schools began teaching computer literacy type courses to their students. And the first school of nursing which did this was the State University of New York in Buffalo in 1977. That year they offered a course which addressed learning about computer terminology, history, applications, and social and ethical issues. So just this side is just sort of my idea of the kinds of things they talked about. Learning about what computers, learning some of the terminology with computers and what computers were about. The following year another similar course was offered at the University of Akron College of Nursing. These courses have ... These were pioneering courses and they've stuck around since. They're still around today. And other classes like them have been introduced at other nursing schools across the country. One of the most recent developments in the relationship between computers and nursing education has been the implementation of the first graduate program in nursing informatics. And that was at the University of Maryland at Baltimore School of Nursing in 1988. So this was a program which would provide a masters in computer nursing information system, or information science, or nursing informatics. So that the role of computers in nursing education has evolved from being used just as a tool to help nursing students learn non-computer subjects, to the point where now many nursing schools have classes just on computers themselves. And there's even a graduate course just on nursing informatics in at least one nursing college. So finally, just to briefly just go over the effects of computers in nursing research, primarily these have been in statistical data analysis with computerized statistics programs allowing nurse researchers to analyze their data more easily and more quickly on the computer using these software programs. Also computers have helped nurses just as in many areas by providing quick literature searches like on Medline or other databases like the International Nursing Index, which has been around since 1966. While we've had these two uses of computer technology in nursing research, some people have noted a lack of nursing research into computer applications in nursing as a subject to be studied. One writer, after reviewing the literature in 1989 wrote, "Despite the number of articles written about computer applications in nursing and the perceived benefits, empirical studies about changes in work activity and the service benefits of using computers in nursing are rare." So a gap seems to have developed between the needs of nursing for expert information on computer applications in the nursing field. And on the one hand in the output of academic institutions, nursing colleges on that subject area. One write, Barbara Thomas in surveying the use of computers in nursing education since 1983 uncovered probably one of the reasons for this gap. She found that only 28% of responding deans and directors of nursing programs reported having any faculty at all with expert computing skills. In these programs, the mean percentage of faculty with expert skills was 5.5%. So the people who are in the academic positions, there are just not enough of them with these expert computer skills to help provide cutting edge information for nurses. So this leaves again computer vendors and nurse administrators, which have been recruited to work with computer vendors at the forefront of nursing administration system design. In general, this is not the case at Iowa, as I found out. Here the nursing information system is home grown, developed by nurses here. And in conjunction with the hospital information system people here. But that's another story. I found that out since writing my paper. So in conclusion, with this part of the paper it's clear for me that the introduction of computer technology into nursing has resulted in substantial change in the four main domains of the nursing profession, research, education, practice and administration. Many factors have directed the rapid proliferation of computer applications in healthcare in general and for that matter in nursing in particular. This is a list of some of the ones I came up with. And one of the most important of these factors, which have pushed computers into the healthcare institutions in general on nursing in particular have been government regulations. Like the 1965 Medicare and Medicaid laws, which put pressure on hospitals to have much better ways to efficiently process patient records by requiring certain patient information before a reimbursement would be provided. Also as I said earlier, the introduction in 1983 of prospective payment put more pressure on hospitals to contain costs and become more efficient and hospitals have viewed computers as a way to become more efficient and contain costs and have better quality assurance. Also the Tax Equity and Fiscal Responsibility Act, which I had never heard of before writing this paper, but which I guess provided incentives for HMO's, or provided incentives for people to enroll in HMO's. This also provided legislative pressure towards increased efficiency and cost containment in all hospitals. Again, also JCAHO has been responsible for putting pressure on hospitals to become more efficient and also has with some specific mandates made computers use in nursing necessary for accreditation. 1980, they mandated using acuity levels to base nursing staffing levels on. And in '83 they mandated that patient education should be comprehensive and documented. In 1980 also based accreditation more on quality assurance parameters, which all of these have encouraged hospitals to use computers and in particular have encouraged new applications of computers in nursing. Under three of the litigates environment in which all healthcare workers work, has also played a role in encouraging hospitals to pursue information systems that will provide accurate, complete and comprehensive documentation of care provided. This is one of the most frequently noted benefits of adopting a nursing information system, is the improved legibility and accuracy of documentation. On patient demographics, the patient population served in hospitals is becoming older and the problems, the acuity level of the patients is becoming higher as there are more older patients with chronic illnesses and disabilities. Paralleling this change in patient demographics has been a shortage in the number of nurses around. For example, nursing vacancy rates more than doubled between 1983 and 1987 from about 4.4% to 11.3% in that time span. Also, 76% of all hospitals in 1987 reported some degree of nursing shortage and 19% reported severe shortages. As a result, this increase in patient acuity and shortage of nurses has forced nurses who are practicing today to deliver quality care in less time with fewer resources and in a more complicated environment. So these two things have also put pressure towards computers as a solution to the squeeze on nurses. Now under nursing attitudes, this has also had a role in shaping the interaction between nursing and computers because in some of the articles I read indicated that the nursing profession carried with it some preconceptions in its introduction of first relationship with computers. One survey in 1967 showed that nursing students had more negative attitudes towards computers than any other occupational group in the healthcare setting. Another setting in 1872 of attitudes of about 400 healthcare workers towards computers showed that the 40 registered nurses were the least willing to use data processing systems of any of the healthcare workers. Reason for the computer anxiety of nurses included fear of job loss, fear that the computer will eliminate quality interaction with coworkers and patients, and moral concerns for confidentiality of patient data in computers. A study performed in 1989 indicated that this anxiety might be getting a little bit less, or actually substantially less. This score is a score on a computer anxiety scale by somebody and between 80 and 105 indicates the "comfort zone" on this scale. And 106 to 120 indicates mild anxiety or an anxiety. So you can see the graduate students I guess are in the comfort zone on this study, while these other groups of nurses are in sort of mild anxiety about computers. But anyway, this writer said that this indicates a trend towards less anxiety about computers. And as for the response of the nursing profession to this introduction of computers, it's come in many ways including the establishment of new professional bodies, the birth of at least one new journal and a growing body of literature, which is devoted to the subject of nursing informatics. And one of the first reactions was of the American Nursing Establishment was in 1975 when the ANA, American Nurses Association council on continuing education started a computer special interest group, which discussed issues related to computers in nursing education. In 1984, the ANA set up a council specifically for computer applications in nursing. And they stated a purpose of this new council to be to increase nursing's contribution of the advancement of computer technology. Computers in Nursing, which is the journal I was speaking about, started in 1982 as Dot Matrix Newsletter from the University of Texas at Austin, and since its founding it has developed from a pretty skimpy newsletter to a regular journal format. That's just a picture of the journal itself. Also many several nurses have written books about computers and nursing informatics. This is one example of an anthology. Another example of another general textbook of computers in nursing. In addition there are many conferences or there are several conferences at least are held each year to facilitate the sharing of information in the field of nursing informatics. These conferences include an annual computer technology and nursing conference at the NIH, held since 1981. And an annual symposium on computer applications in medical care held each fall here in Baltimore and Washington. So in conclusion, this paper in charting the relationship between nursing and computer technology, it was clear to me that computers have changed the way nurses do research, teach, practice nursing and administer. While nurses were largely passive in the early stages of computer introduction to healthcare organizations in the 1980's have seen a more activist approach. Nurses have established professional bodies and conferences, started journals and written books in the decade of the 80's. And it's through these kinds of professional response that nursing has gained more power over the practice of computerization in the healthcare workplace. So although computer technology has changed nursing in many ways, nurses have begun to bend computer technology to specific nursing tasks, imposing a more human face on this technology. That's all I have. Audience Member: Do you take questions? Joseph Merchant: Yeah, sorry I took so long. I thought it was going to take me less time. Are there any questions? Moderator: So if you have questions or comments, [inaudible 00:49:01]. Joseph Merchant: Are there some nurses here tonight? What did you think? Audience: [inaudible 00:49:12] Moderator: You need to be more familiar with [inaudible 00:49:18]. Moderator: Thank you Joe. I think you did a very nice job. I see why your paper was picked as a winner. As a historical paper you've given us chronology and data and documented that this has indeed happened. And all this change has gone on. You almost sounded like a computer salesman. Not quite, but what I'm getting at is that your presentation gave us the positivity, the good aspects of it. You didn't deal a whole lot with value but you had value statements in there about good things happening. I don't remember that you said a thing about the downside of it. Is there anything you can tell us about how it's buttered us up? How it's got us so messed up with information overload and I'm sure the other guys ... Joseph Merchant: Yeah, that's one of the weaknesses of ... In writing this paper I had to rely on the nursing literature about computer information systems. And nursing informatics, which is of course very positive about everything almost. It's all about new developments, and isn't this great kind of stuff. And so I think that's why, that's one of the reasons, a bias of the paper in that I think most of my sources were positive. As I said, I went into the paper trying to find out, has this been a good or a bad thing for nursing? And I found a lot of good things it seemed like that were happening. And in talking to some of the nurses I've talked with are also very enthusiastic. But again, they are nurses who are doing nursing information system stuff here at the university. So I'm sure and maybe if you were to interview nurses that in general you could find some negative, a lot of negative things. Or you might be able to find some negative things. And I don't know what a nurse as a practicing nurse would say would be some of the negative aspects. Audience Member: Well we're working in a mandatory care situation right now. So we're not part of that hospital [inaudible 00:51:51] nursing usage affecting [inaudible 00:51:58] but most of the nursing care plans and the things that are going on over there right now are for in-patient. But they are working on out-patient. And I think there's going to be a lot of these things for us coming out. Joseph Merchant: Here at Iowa it's kind of interesting, talking to Colleen Prophet who's in charge of nursing information systems here, they apparently got together and she had no previous experience in computer programming and et cetera. And with some other nurses in 1982 put together a nursing information system specifically for Iowa. So they didn't take a system like the Technicon system, which is used at a lot of other hospitals. Rather they through a period of it sounded like four to six years have developed their own system. And each different section of the hospital, the nurses can sort of customize this system as they like to provide the best, what they think is the best, easiest one. So for example, urology nurses may specialize their information system to urology. Or obstetrics gynecology may have a different set of care plans that they need and they write for themselves. So I think I went into it from some of the quotes I had at the beginning, technology is bad. It's take away, it's dehumanizing medical care. And I don't know, it seems like computers have done a lot of useful things for nurses. I don't know. Audience Member: I think that the biggest concern here is about patient confidentiality. I know just in hearing Colleen Prophet talk and asking people, asking [inaudible 00:53:57] to choose what would be useful for them, that that was one of the concerns about if they present lab data available on the nursing screens, then how many of the nurses should [inaudible 00:54:13]. Or should all the nurses, because then there's so many people available to those screens that you sort of start worrying about patient confidentiality that might be more damaging. Joseph Merchant: Another downside, and like the article I quoted from The Register, if the computers keep doing more and more, for example are physicians going to be required to use computers to diagnose everything? Is it degrading the profession of nursing or the profession of medicine, I don't know. Because there are programs out which allow people to just plug in patient data and the computer may generate a differential diagnosis on that patient. And is that a good thing? It doesn't seem like it is to me. Audience Member: It's like [inaudible 00:55:08] question [inaudible 00:55:10] differential diagnosis [inaudible 00:55:13]. Joseph Merchant: Yeah, yeah. Audience Member: Joe, I want to thank you for your presentation. I'm a nursing [inaudible 00:55:21] here at Iowa at the College of Nursing and I think that I wanted to ask you if in your sense of covering the nursing literature, and indeed you have highlighted some of the premier projects for nursing programs of educational applications. But given the numbers of nurse practitioners, nurses in practice and given the number of nurse educators, did you have a sense of what might not be reflected given those numbers and then having a sense of the not really large numbers of projects that you saw in the literature, but was there a sense in you of whether it might not be represented? Joseph Merchant: Yeah, I was also thinking about that. This paper of course covers the information systems of other places, which have pushed their system out into the limelight. And so it's biased in that way. And for example, a place like Iowa, which I've since come to find out has kind of innovative things going on with regard to nursing information systems, but I didn't see anything published about Iowa's stuff. So this is supposedly the history of nurses and computers. But it's really the history of nurses and computers as published in everything I could find. That of course for me as an outside, that shows the weakness of that approach to a subject. Not knowing anything about it, a better way would've been to combined this literature review with interviews. And yeah I definitely think there are things not covered. Audience Member: I think one of the things that I've noticed in seeing nursing unfold in the records to compare us is that although there are premier projects, there has been in general a rather slow evolving when you consider the number of nurses and the number of applications that are possible. I think that's a positive [inaudible 00:57:49] of nursing in a sense of the cautiousness of the profession in relationship to [inaudible 00:57:55] privacy issues, which has really been ... And other issues like the machinery coming between the nurse and patient relationship. You also have to have a pretty good system set up because one of the things that we have found at Iowa in psych is that we've had these wonderful care plans. And then the computer system did not have quite the capacity. You have to fit this into 50 characters. So actually it's pretty restricting when you can only have so many nursing orders. And so [inaudible 00:58:31] some of the wonderful, all the ideas that some of our care plans had to be sort of drawn out or repressed and consolidated. So in some ways if you're not careful it can be very restricting too. I have a question that I guess might play to the dark side if there is one of nursing/computers. Some of the historians of nursing since World War ... Nursing practices in America since World War II of [inaudible 00:59:07] brings to mind that emphasized one of the salient facts of nursing professions since the 40's has been status and anxiety might not be the right word but strong status aspirations. So [inaudible 00:59:27] nurses at least spokesmen, or leaders of the profession. And in that, not unlike other occupations who's professional status is uncertain or insecure, schoolteachers, social work, my own occupation, librarians ... In fact librarians should [inaudible 00:59:55] has something to do with my question. Here you have this important fact of status aspirations and you have the other fact of acceptance of ... A rapid advent and acceptance of computers it's not on the part of the actual practitioners. And there's suggestion there a lot of time their enthusiasm on part of administrators working with vendors and so on. It's been suggested in librarianship that part of the enthusiasm for computers have in the 70's and 80's, not so much the 90's has led to less status aspirations. It helps the image of a profession if it can get next to a high status technology, which computers certainly were in the 70's and 80's. Computer technology certainly was in the 70's and 80's. Not so much the 90's, [inaudible 01:01:11]. Did you in your research find anything like this going on, any link of status aspirations on the one hand having something to do with [inaudible 01:01:28]? Joseph Merchant: Nothing springs to mind specifically about ... Specifically speaking to that point. But for example one of the quotes that I read tonight about one of the nurses attached to the Navy, Karen Rider, was very concerned that nurses are naïve with regard to the impacts the computers are having on nursing. And is there by assuming that there are going to be specific applications for nursing, if they continue to assume that and be passive as she put it in some of the articles that she wrote, that this was going to be a bad thing for nursing. That this would be bad for the nursing profession as a profession. And that for the nursing profession to ... That the right thing for the nursing profession to do, or the way to advance the nursing profession, or the way that they should react to this technology should be to have specific applications for nursing. So and I guess I could see that there's also an anxiety of the nursing profession on the part of some of the nursing profession, how should be properly react to this technology? We're not doing anything right now. We're just sort of sitting by and letting computer programmers put more and more computers onto the wards and tell us, "Now you enter your orders here." And now ...