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The application of computer technology to teaching and assessing nurses, doctors and patients

Mike Lowry
Leeds Metropolitan University, Leeds, England
The world of health care is developing rapidly, carrying in its wake an obligation to provide the highest standards of education in support of changing therapies. It is recognised that health care is no longer the responsibility of the doctor or nurse in isolation, but that it is a cooperative venture. Patients enjoy enhanced quality of life and recover more effectively when they are knowledgeable about their care protocols. It is through patients as well as their carer's needs to learn, that computer technology can play such a vital role on the threshold of this new and exciting era.

There is growing evidence that an understanding of their conditions and treatments, has benefits for patients in term of their recovery and quality of life. Nurses and doctors may use multimedia and computer technology both for their own and for their patients' teaching and learning needs. This paper argues the benefits for developing and using such resources in health care delivery, and also in education. It is proposed that such technology has benefits in terms of costs and of time saved, thereby ultimately contributing towards a more efficient and safe delivery of care.

Before addressing the focal issues of this paper, it may be useful to identify the characters involved and their relative positions.

Nursing has a traditional image in the eyes of the lay public, that of being substantially concerned with the comfort and well being of patients in hospital, and with the carrying out of sometimes menial and unpleasant tasks associated with care (Lowry, 1993). Whilst this image of nursing has some basis in fact, what may be less apparent are the advances associated with professional nursing over recent years, and how these advances move towards improving patients' quality of life and carer's job satisfaction. In the United Kingdom there have since the 1970s, been graduate programs in nursing, designed to further the academic base of the profession and to encourage development through research.

Whilst nursing in Europe has until relatively recently retained a high level of tradition and some would argue mediocrity, other countries notably the United States of America, have in some respects been far ahead in terms of advances in nursing theory and nursing practice. There is evidence of these developments in for example nursing models, in which education and patient teaching often forms a significant part. It is widely recognised how valuable patient teaching is, in creating patient empowerment and subsequently informed collaboration in care. It has been demonstrated by authors such as Anderson (1987) as to how this collaboration and insight has tangible benefits in terms of patients' recovery and quality of life issues. The education and practice of doctors may not have always been so advanced as the medical profession might prefer to believe. One needs only to listen in on doctor-patient interaction to recognise the often unilateral slant of the information which may be exchanged. More often than not, the pattern evolves through taking note of the patient's history, making an assessment of the medical 'condition' and prescribing (hopefully appropriate) intervention in the form of drugs or other therapy.

The patient might not be prepared to ask questions in every case, and indeed might not know what questions to ask. It could be some time after the initial consultation that an idea emerges which the patient seeks an understanding of, but by then it could be perceived as being too late, out of context or, worse, that the practitioner is 'too busy to be answering seemingly insignificant questions' (Benner, 1984). The emergence of innovations through Nursing Development Units (NDUs) and multi-disciplinary Practice Development Units (PDUs) (Williams, Lee & Lowry, 1993), together with the creation of posts for advanced practitioners and clinical nurse specialists, has led to openings for a deeper understanding of care needs and consequently a call for broader education within the key objectives of nursing and other health care provision. In other words a more creative approach to providing care through such moves as primary nursing, and the expertise with which to maximise quality of life through better health needs awareness. This is arguably what makes nursing's contribution unique.

Such innovations do not always come cheap. There are costs, both in personnel resources for setting up developments, as well as implications for managers in being able to justify funding for projects. It is likely that information technology could indeed drastically reduce the costs of implementing practice development schemes. This could be brought about by, for example, the provision of data bases containing guidelines for interpretation of policies and also by meeting requests for information regarding setting up new ventures ie, information sharing across disciplines and care centres. Such a facility, perhaps in the form of interactive software would help to reduce teething problems such as time spent in identifying key factors necessary for operationalising, and similar pitfalls. As the frontiers of medicine advance, so do those of nursing and allied health care professions. The USA has led the field in terms of technical nursing advances, though there remains much left to develop in terms of the educational and academic provision. This is an area which when it is developed to fullest potential, will ultimately equip the professional nurse and doctor to carry out his or her work more efficiently and more effectively. This must be for the benefit of patients as individuals and also for society in its broader sense.

The availability of computer technology has opened up a whole new field of possibilities for educational provision and developments in nursing and other health care disciplines. This is, as has previously been suggested, significant in facilitating improved quality outcomes for patients and their carets. Such a point is highlighted by Benner (1984), when addressing the issues of readiness to learn and of the provision of gaff (nurses and doctors) time to assist with educating patients.

It is to the areas of education, teaching and learning which this paper will be addressed.

The main intention here is to consider the benefits and costs of introducing computer programs as part of the teaching provision for nurses, doctors and other health care providers both at beginner and also at advanced level. In parallel to this is the transferability of such technology to patient teaching.

I have an interest through my emergent doctoral studies, in reflection and creativity in nursing. In keeping with this, is facilitating creativity through the development and application of computer based learning for nurses, initially with the specific topics of 'physical assessment' and 'emergency triage' in mind. 1 will focus onto 'snapshot' examples of such a facility in relation to physical assessment and to triage (sorting and assessing) by nurses, of patients who visit hospital emergency departments.

The packages in question, whilst initially aimed at the education of nurses, may be equally transferable to the teaching of other health care professionals, notably medical students and novice/ beginner medical practitioners.

The resources necessary for the intended programs would include a standard personal computer which has universal compatibility, and the software which has a universal language facility. Thus such a program once developed may be applied any whom in the world at relatively little cost to the user or provider. Work in the area of language and finance is already being implemented successfully (Waywell, Dacre & Wisniewski, 1992), and these are potential benefits of this approach to health care teaching.

As an application for the teaching of, for example, physical assessment, the student would be able to access a monitor which has a two dimensional high quality image depicting a part of the human body. It would be possible to rotate the image about an axis and to simulate the application of a diagnostic device such as a stethoscope or auroscope with attendant images and audible sounds where appropriate. Amongst the problems facing nurses, doctors and others in their learning, are the ethical questions arising as a result of involving patients (or animals). This issue is easily addressed through the use of technology, and will afford wider scope for teaching. such as multi-centre linking for lectures as opposed to confining a few individuals around the bed of an anxious patient. There is established work of a similar nature in progress, related to teaching anatomy using graphic simulations of dissected rats (Quentin-Baxter & Dewhurst, 1992). The same principle would be appropriate in the case of emergency triage, wherein the image may contain pathological changes such as fractures to bones breaks in skin surface, or bleeding, together with attendant clinical features which the practitioner may assess and prioritise. This moves onto ultimately suggesting an appropriate course of treatment and to students obtaining feedback on their performance.

A strength of such a resource is the facility for students to be able to self assess their performance at various levels, thereby reducing the emergence of fear of failure which is known to impede learning, as highlighted by Claxton (1984) and Holt (1982). Added to this is the facility to prepare a hard copy for reference and reflection. The value of reflection in learning is widely recognised, and much work in dais field has already been carried out by Boud (1985) in education, Elliot (1981) in action research, and many others.

If we consider a widely used taxonomy such as that of Bloom (1956), then we can quickly see how anyone may traverse the various levels from recall of information through to the higher synthetic and analytical stages. The latter require greater levels of expertise, together with input from a suitably qualified facilitator. Thus by the use of such a package in an introductory sense, there will be cost effectiveness in terms of lecturer/ facilitator time and energy, allowing the learner to build on 'knowns' and leaving the higher level cognitive domains for exploration later. This must have the potential benefits of facilitating increasing understanding and development of the topic from the perspectives of both the student about their level of development, and the academic about the students learning needs and progress. The cost benefits in human as well as material terms are to be self evident as a result of this.

The installation process of computer based materials for teaching and assessing, as mentioned earlier ought to be cost effective if not relatively inexpensive. Once the initial system is purchased and installed, the updating of materials and data is quick, easy and efficient. Those involved in the development of such packages would include computer literate research assistants, ideally though not necessarily with a health care background. These would be under the guidance of an experienced educator.

Self assessment will have measurable benefits in terms of time saved for academic staff in marking and feeding back to students on their work. For the student there are the added benefits of rapid feedback, and the reduced need for having to access their lecturers after each stage of a piece of work being completed.

Nursing is an holistic discipline. This means that amongst elements for consideration are the dimensions of self other than the physical, those are intellectual; emotional; spiritual and social (Beck, Rawlins & Williams, 1984). Addressing these may be easily included in the package, and are likely to represent the higher level discursive and analytical domains.

Factors such as health screening and genogram related questions may, through a lifestyle assessment, indicate areas for development of health education or further investigation. This may be related to the example given earlier of triage within a hospital emergency department.

There are known to be measurable benefits and improved outcomes where patients have an understanding of their condition and of the related treatments (Redman 1981; 1988; Papenfuss, 1985). A study by Anderson in 1987 confirmed measurable differences between the control groups progress with that of the group subjected to planned preparation for their treatments. The author reported significantly less anxiety in the experimental group, increased belief in control over recovery and lower incidence of hypertension than the control group. The use of computer technology as an aid to patient teaching would include offering packages for use by nurses, doctors and patients which outline specific elements of the patients condition and recommended treatments. Evaluation of similar work has already been carried out in this area (Firby et al, 1991). The patient may be offered a hard copy of the information which could include graphics as well as text. There exists in such a case the further opportunity of deeper inquiry by the patient or significant others at their leisure and to maintain awareness of developments in terms of their condition.

This provision of information would do much to relieve the anxiety associated with lack of information about a situation or condition. People generally do want to know about their treatment and condition, although the 'right time' might not always be the most convenient time for their carers. For the nursing and medical staff, there would he maintained a record of exactly what information may have been given to the patient and others thereby reducing the likelihood of conflicting or unnecessarily duplicated information. This facility will also lend itself to the transfer of information through the various professional groups and will ensure a more accurate record of such things as medications and other treatments which may have been used, together with a record of their effectiveness or otherwise. Confidentiality needs appropriate attention, and this may be ensured by the use of enumerative or other coding systems before access may be gained to records.

There is an additional bonus associated with the use of computers in the teaching of patients, this being the audio facility for example on CD-ROM for those with visual impairment. The audio facility way easily be developed to offer multiple language formats and translation facilities, where for example a patient does not speak the same language as their carers and vice versa. This would be especially important in, for example, an accident department where a patients history needs eliciting before a diagnosis may be made and treatment offered. The facility would therefore be interactive in the sense that a key word or phrase may be input to the monitor and a comparable word or phrase in the patients language appear either audibly or visually.

A likely criticism of the use of such technology, is that it reduces the human interaction which is such an important and necessary part of caring. Verbal and non verbal communication including the therapeutic use of touch by carers is an invaluable adjunct to other systems of care delivery and must not be minimised in favour of an essentially automated and technology centred approach to care. The human element of caring cannot nor should be reduced in terms of its known importance in enhancing patients well being. In reply to this is the increasing accuracy of communication and record keeping which rather than reducing the human interactive elements of health care will enhance them though making more effective use of carers available contact time with their patients, thereby potentially increasing human contact time.

In conclusion, it is clearly evident that the use of computers in health care and health care related teaching has wide reaching benefits for all users. The facility is cost effective and requires minimal maintenance. In the case of peripatetic health care workers, a portable computer or 'electronic note pad' would offer similar facilities. The way is clear for the development of such systems, and with the widening base of technological expertise available coupled with caring 'know how', the bounds are limitless.


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Claxton, G. (1984). Live and learn: An introduction to the psychology of growth and change in everyday life. Open University.

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Firby, P. A. Luker, K. A. & Caress, A. (1991). Nurses opinions of the introduction of computer assisted learning for use in patient education. Journal of Advanced Nursing, 16(8), 987-995.

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Author: Mr Mike Lowry, Senior Lecturer in Nursing, Leeds Metropolitan University, Calverley Street, Leeds LSI 3HE, England. Tel: 0532 832 600 Ext. 3875 Fax: 0532 833 124

Please cite as: Lowry, M. (1994). The application of computer technology to teaching and assessing nurses, doctors and patients. In C. McBeath and R. Atkinson (Eds), Proceedings of the Second International Interactive Multimedia Symposium, 317-320. Perth, Western Australia, 23-28 January. Promaco Conventions. http://www.aset.org.au/confs/iims/1994/km/lowry.html

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