Nursing is professional caring. Nursing care seeks mutual resolution of health care deficits in individuals, groups, and communities. Nurses have the knowledge and skills needed to provide quality care for those who have either a temporary or permanent loss of their self-care capabilities. Caring of this sort may involve anything from psycho-physiologic problems to deficits in personal or family health knowledge. This caring always includes genuine warmth, kindness, and empathy.
Nursing, as a profession, has undergone a considerable struggle in the effort to extract itself from the trappings of obedience, subdominance, unswerving loyalty, and limitless self-sacrifice. These characteristics of the nurse's "role" and image resulted from the fact that nursing has been primarily women's work subordinate to the male dominated medical profession@Cite(RitchieJ88a ", p. 30"). Although caring and selflessness are virtuous, nurses as persons and as professionals were want to clarify their roles, status, image, and responsibilities.
Professionalization for nurses involves the building of a strong foundation in nursing knowledge which is established, maintained, and constantly renewed through an ongoing program of research. With this knowledge the nursing profession can develop a theoretical basis for standards of practice which help clarify nursing roles and responsibilities. This clarification and definition of nursing practice leads to greater autonomy for the profession. Nursing education benefits as well, as a curriculum reflecting the knowledge, theory, and practice of nursing can be developed and substantiated in research. The knowledge base of nursing and its theoretical foundations help support another requirement of professionalization: the establishment of a code of ethics and appropriate mechanisms for discipline and control within the profession@Cite(MacPhailJ88a, KerrJR88a, BaumgartAJ88a).
In terms of practice, professionalism is realized through effective use of the nursing process. "The nursing process has been identified as nursing's scientific methodology for the delivery of nursing care"@Cite(TownsendMC88a ", p. 7"). The nursing process consists of five phases of nursing action in health care settings: assessment, diagnosis, planning, implementation, and evaluation@Cite(IyerPW86a ", p. 12").
Of these, nursing diagnosis is most closely associated with professionalism. Nurses use nursing diagnoses to state clearly the actual or potential health problems affecting their client's physical, psycho-social, and spiritual well being. This holistic approach to each client, regardless of their medical diagnosis, helps distinguish nursing roles from those of medicine and the other health professions. The nursing diagnoses direct attention to those aspects of a client's condition that can be helped by nursing interventions, and "which nurses, by virtue of their education and experience, are capable and licensed to treat"@Cite( GordonM82a ", p. 2").
In the present study, the nursing diagnosis task was particularly well suited to resolution through cooperative discussion. As part of the curriculum in nursing theory, students learn the principles and criteria used to establish a nursing diagnosis. However, in their first and second year they are not required to use exact, or officially accepted wording. Instead, they are encouraged to use their own words while following a set of guidelines. This flexibility opens the door to deliberations concerning both the content and the form of nursing diagnosis. The content was based on significant data provided in the case study and identification of factors which are within the realm of nursing practice. The form or format refers to the specification of components of the nursing diagnosis statement, and the proper sequencing of those components. The basic model (PES) is as follows:
"(P)roblem" related to "(E)tiology"
as manifested by "(S)igns and symptoms"
(Iyer et al., 1986, p. 83)
For example, one of the nursing diagnoses for a patient with a medical
diagnosis of "stroke" might be:
"impaired mobility" related to "left-sided weakness"
as manifested by "patient limps and reports
a feeling of numbness in the left hand"
Further discussion of the nursing diagnosis task and the evaluation criteria are presented in section @Ref(ssdaprepcode).
"The use of computers in health care is no longer a question for discussion and debate. Their application in nursing is a reality in many centers ..."@Cite(HannahKJ88a ", p. 263"). With this opening statement, Hannah presents a concise overview of the use of computers in nursing practice. The primary applications are in the support of nursing documentation, patient care planning, and patient monitoring.
Nurses must spend a considerable amount of time documenting the care they are giving to their patients. In non-computerized environments, this involves writing the nursing notes in longhand. These notes report on the treatments, medications, procedures, diagnostic tests, and other components of the patient's health and activity over a certain period of time. In computerized environments, the documentation process can be automated through the use of standard reporting forms and checklists that allow the nurse to use various computer interface modalities to quickly enter the information concerning the patient. Menus, windows, pointing devices, or cursor keys can be used to select standard items from lists, while specific data (such as numeric values) can be entered via a keyboard. This automated documentation process not only saves time, but it also increases the accuracy of patient information and makes it more readily accessible for diagnostic or statistical analysis.
Computerized patient care planning can be implemented in a manner similar to the documentation process noted previously. Since standard lists of nursing diagnoses and interventions for particular patient problems have been prepared for almost all areas of nursing, it is not too great a leap to present these items via computer so that they can be selected and associated with particular patients. Figure @Ref(fncpdemo) shows a sample screen presenting possible etiologies that can be selected in the development of the complete nursing diagnostic statement.
Figure 2-6: Etiology selection screen for a particular diagnosis
In terms of more advanced applications for nursing practice, Hannah (1988) mentions decision support systems in reference to possible applications of artificial intelligence. She suggests that data collected by nurses in the process of assessing or monitoring the patient could be entered at bedside computer terminals and quickly processed by expert decision support systems to provide a more individualized set of possibilities for inclusion in the nursing care plan (p. 271). This consultative role for for the computer in supporting clinical decisions in nursing is discussed further by Ryan (1989). She @CiteMark(RyanSA89a) reports on an expert system for nursing practice implemented at Creighton University. It, "involves the structure of the domain of nursing, a rich and detailed semantic network based on conceptual relationships of more than 20,000 terms; the ability to search heuristically, based on `If _____, then _____,' rules, explores the relationships" (p. 271).
It is surprising that a review of the literature concerning the use computers in nursing education does not reveal the potential of expert, knowledge-based systems such as the one mentioned in the previous section (Ryan, 1989). Obviously, such a rich source of information provided in a semantically contextualized manner would prove useful in the education of nurses as well as in their practice.
Text-book coverage of computers for nursing education reflects a lag time of about ten years in the sophistication of educational applications for this field. They are either constrained by an out-dated view of computer literacy that suggests, for example, the teaching of programming skills to nurses as a part of their core curriculum@Cite( RonaldJ87a ", pp. 33-43"), or they are stuck in the mould of archaic computer-assisted instruction applications that do not offer much more than a drill-and-practice mode for computer based learning@Cite(MikulekyMP87a). There are, however, some examples of more advanced applications such as the use of simulations@Cite(CoxH87a ", p. 115"), and at least one paper reports on the use of educational computer games as an effective and appropriate teaching strategy in nursing education@Cite(ReynoldsA89a).
When "networking" is mentioned, it most often refers to the non-electronic form where, for example, instructors of computers in nursing are advised to make contact with their colleagues in the field to exchange ideas, data, and software. Human-to-human interaction via electronic networks for the purposes of education has not been overlooked, but often these reports reflect, quite distinctly, an "outsider's" view of the technology: "Computer messaging services are being expanded into computer conference systems. These provide participants with an on-line and continually growing forum for exchanging information on specific topics"@Cite(vanReenenJ90a ", p. 25").
Certainly, there is evidence of computer conferencing being used in nursing education. Hayes (1988) reports on the use of Confer II at the University of Alberta to assist in the compilation and dissemination of continuing nursing education (CNE) information for those who generate and market CNE programs and for their potential customers. Since the system is asynchronous, available 24 hours/day, and cumulative with respect to the information that is entered, it serves well as a clearing house for CNE information. Apparently, however, the relatively low number of users reduced the interactive potential of the system@Cite(HayesP88a ", p. 126"). It is likely that an absence of moderating roles and group communication structures also affected the possibilities for group interaction.
Sleightholm Cairns (1991) describes the use of computer conferencing @CiteMark(SleightBJ91a) in the delivery of distance education to post-RN students who are seeking their baccalaureate degree in nursing. She outlines her efforts in trying to overcome some of the common problems of distance learning. The students' feelings of isolation, for example, were addressed at the beginning of their online interaction by requiring various activities for introductions and "getting to know you" scenarios (p. 210). In general, however, Sleightholm Cairns indicates that the application of asynchronous computer conferencing for the delivery of nursing instruction requires a great deal of effort to work around the limitations of the medium. She states that the effectiveness, "may be greatly dependent on the skill and knowledge of the instructor in designing a course to suit the medium" (p. 211). Unfortunately, this suggestion is counter to the more generally accepted view that computer applications should be designed to suit the needs of the community of users they serve, not vice versa.
Sleightholm Cairns and O'Kelly (1989) have reported on the use of synchronous text-based computer-mediated communication as well. For a demonstration field study, nursing students in a "clinical group" were given the opportunity to use real-time conferencing software on a local area network for their group discussions. They were given the task of establishing a collective care plan based on patient data in a case study. This is similar to the present study, except that it involved group interaction as opposed to dyad interaction. Further, it did not explore the content of the communications, nor did it seek to discover anything about the actual learning that was taking place. Rather, it surveyed the impressions and opinions of the nursing student participants after their online experience. The findings were very positive. Most students reported that the task was fun and that they enjoyed the experience. More importantly, however, "They cited [sic] that the interaction and exchange of ideas and constructive criticism were of benefit to their group"@Cite(SleightBJ89a ", p. 298").
