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Shirley M. Moore ConstanceVisovsky
Case Western Reserve University
Cleveland, Ohio
Common nursing functions, previously done in face-to-face interactions, are beginning to be done
using computer interactions, thus changing the work environment of nurses. This paper reports
experiences from a series of projects +bout the potential impact of electronic care delivery
systems on nurses work systems. Nurses attitudes towards technology, values central to nursing
practice and nursing functional roles are important factors to consider when designing
computerized nursing care delivery systems.

Although computers often are associated with
the business functions of health care delivery (B&rend,
1994) and decision support for professionals (Papemy,
Aono, Lehman, Hamar, & Risser, 1990), their use to
deliver patient care has progressed slowly. More
recently, however, common nursing functions,
previously accomplished in face-to-face interactions,
are beginning to be done using computer
communications. Integrating the high touch values
commonly associated with nursing care into the design
of computerized nursing care deliveT systems is
essential if the widespread use of technology-mediated
care is to be realized. This paper describes
characteristics of nurses and the work of nurses that are
important to consider when designing computerized
nursing care delivery systems. These characteristics are
nurses attitudes towards technology, values central to
nursmg practice and nursing functional roles.
Experiences from several projects in which electronic
nursing care delivery systems were developed and
evaluated are described.
Nurses Attitudes toward Technology
Over the past 50 years nurses have increasingly
used technology to support the care they provide.
Widespread use of technology by nurses began
following the development of monitors, ventilators and
other machines for use in intensive care units by critical
care nurses. The use of technology in healthcare has
progressed to the point where machines, such as
ventilators are frequently used by home care nurses in
peoples homes. It has been proposed that modem
nursing is deeply connected to technology development
(Barnard, 1999). However, nurses attitudes toward
computers tend to indicate that they are undecided

about computer technology. In a survey of hospital

nurses, McConnell and colleagues (1989) found that
although nurses thought that the use of computers
improved the quality of patient care, they also believed
that their use dehumanized the care. It should be noted
that one half of the nurses surveyed had no experience
with computers. Another view dominant in the nursing
literature is that nurses are the patients bridge from the
impersonal, technologic world to the humanistic world
1998). This technologic-humanistic
dualism philosophical view has fostered nurses fears
about the increase of technical quality at the expense of
humanness. Thus, as a group, nurses have been reticent
to embrace computer-mediated care. Understanding
nurses professional values and their functional roles
may enhance the transition from traditional nursing care
delivery modes to a model that integrates widespread use
of computer-assistednursing care.
Nursing Values
Nurses are socialized to a set of values in their
professional education and practice. Nurse values of (1)
individualizing care, (2) fostering self-care, (3)
vigilance, (4) maintaining caring interpersonal
relationships, (5) supporting patient autonomy and (6)
providing collaborative care are factors that must be
considered in the design and implementation of
electronic tools to support nursing care. Although the
successful delivery of health care presumes a certain
degree of standardization of treatments and
interventions, nursing values reinforce modifying care
away from the one size fits all model. Nursing care
focuses on tailoring care to the unique needs of patients
and their families. Fostering self-care refers to nurses
support and education of patients to engage in activities
that are health-promoting. Another value central to
nursing is vigilance. Vigilance refers to the careful

watchfulness of nurses in assessing, screening, and
monitoring patient clinical status and patient responses
to the application of interventions.
Basic to nursing values is the helping
relationships in which nurses engagewith their patients
(Morse, 1990). This relationship progresses over time
as the nurse interacts with patients to manage health
problems by building trust through genuine caring and
encouraging patients to share thoughts and feelings.
Through intimate interpersonal relationships, nurses
conduct activities aimed at restoring physical,
emotional, spiritual and social well being. Additionally,
nurses historically have fostered patient autonomy by
supporting patients rights to make decisions about their
health. Nurses also value collaboration with other
healthcare professionals to plan care.
Nursing Functional Roles
Common roles and functions of nurses are
caregiver, client advocate, case manager, rehabilitator,
comforter, communicator, and teacher. While
caregiving will always require some face-to-face
examinations), many nursing caregiver functions are
amenable to computer mediation, such as symptom
monitoring, the provision of information, assistance
with decision-making, and providing emotional
support. As patient advocates, nurses support and
uphold patients values and assist them to navigate the
health care system to get their needs addressed.Nurses
also act to protect the human and legal rights of those in
their care. As case managers,nurses assess,coordinate
and organize the healthcare resources needed by
patients throughout their illnesses. As rehabilitators,
nurses direct and engagein activities aimed at restoring
physical and psychological functioning. As comforters,
nurses direct care of the whole person, giving the
physical and emotional support needed for coping with
illness or preparing for death.
The role of
communicator is central to nurses in their interactions
with patients, families and other healthcare
professionals. As teachers, nurses offer explanations
about the patients condition, necessary treatments, and
demonstrate procedures to facilitate the persons selfcare abilities.
Nurses work in several types of environments.
Hospitals, a major work environment of nurses, are
complex orgamzatmns in which nurses have
traditionally had a large responsibility for system
maintenance. Nurses also provide care in clinics,
homes, schools, industrial companies, and health

advocacy agencies. But, common to all of these work

environments of nurses, is the nurse-patient relationship
as the most basic of environments. Computer-mediated
nursing care delivery systems represent a new
environment for therapeutic nurse-patient relationships.
Therefore, as electronic healthcare delivery systems are
developed, we must be mindful of professional nursing
values and essential nursing functional roles.
Electronic care delivery systems are creating
new work environments for nurses. The use of electronic
systems to deliver nursing care has been refined by the
authors in a series of projects and is described below. In
the first project, Brennan, Moore and Smyth (1995)
provided home care support to caregivers of persons
with Alzheimers disease using a computer network,
ComputerLink. Computer terminals placed in clients
homes allowed 24-hour access to a variety of features,
including a communications module, an information
module and a decision assistance module. The
communications module included a public bulletin
board, where clients and a nurse moderator publicly
posted and read messages; a Question and Answer
section in which clients anonymously posted questions
to a registered nurse; and a private mail system. The
information system provided several hundred indexed
screens of information about the disease course,
diagnosis, and treatment, symptom management, care
issues and community services. The decision support
module guided clients through decisions using an
analysis process that incorporated their own words and
preferences, thus assisting them to make choices
consistent with their own values. The nurse moderator
employed both individual and group interventions of
support, information-giving, encouraging expression of
feelings and ideas, acceptance,reassurance,clarification,
and interpretation. In the ComputerLink project, we
learned that clients with little or no computer skills
easily learned to use computers and accessed
information and support electronically.
Clinical interventions using ComputerLink
required the nurse to have an understandirig of how
computer technology affected client participation,
communication, relationship development, and group
norms, both social and computer behavior (Moore,
Several challenges of the computer
communications that affected the nursing system of care

included: (1) the lack of physical presence of clients,
(2) diffuse time referents, (3) asynchronous
communication, and (4) the necessity to teach clients to
use the technology. The absence of face-to-face visual
cues required the nurse to rely on a new set of cues,
many of which differ from those of clinical encounters
involving face-to-face or voice communication.
Developing and maintaining relationships is a goal in
any therapeutic clinical encounter. Rapport and trust
were developed between the nurse and clients though
the use of standard protocols for comptiter
encouragement of the use of a conversational tone in
messagesposted on the system, and nurse modeling of
emotional expressionsin messages.
Changing Cardiac Risk Factors
In another project, interdisciplinary teams of
health professions students (medical, nursing, nutrition,
and epidemiology) worked with an electronic
community of individuals to change cardiac risk
factors, such as increasing physical activity and
following a low fat, reduced calorie diet (Moore, in
press). Using on-line methods without face-to-face
interactions, the students: (1) developed a therapeutic
relationship with clients over a computer network (2)
assessedclients current health patterns regarding diet
and exercise compliance with heart-healthy lifestyle
guidelines, (3) employed a series of behavior change
strategies while electronically coaching clients to
make these lifestyle behavior changes, and (4) tracked
trend data related to diet and exercise behavior over the
project period. The interdisciplinary teams held virtual
team meetings for case discussion of their client load.
This virtual approach to team care solved some of the
challenges normally associated with interdisciplinary
collaboration in the health professions, such as finding
convenient times to meet and creating efficient records
of team discussions and decisions.
In a recent project, HeartCare (Brennan, et al.,
1998), customized teaching and home management
support are provided by nurses to patients for six
months following cardiac surgery using home-based
WebTV. In this project, several hundred pages of
cardiac recovery information on the Internet were
evaluated for accuracy, appropriateness,reading level,
and gender focus. Additionally, nearly 200 pages of
cardiac information not available on the Internet were

created by the project team. These Web pages were

entered into a data-base and are dynamically pulled
according to a tailoring algorithm based on information
known to the nurse about patient health status, gender,
co-morbidities, risk factors and recovery time frame. For
example, the Web pages provided for a patient with a
smoking history and diabetes are different from those
given to a patient who needs weight managementand an
exercise program. The nurse also is able to add or delete
pages any time during the six-month recovery period for
individual patients based on changes in the their health
status or treatment plan. Thus, individualizing recover
information for each client is cenhal in the design of the
HeartCare system.
Patient self-care is fostered by the design of the
content on the Web pages. The content of the Web pages
was built following the guidelines of a nursing theory of
self-regulation (Johnson, 1999) that specifies the type of
information to provide to individuals to assist them to
self-manage stressful illness situations. In addition, a
search function using patient, rather than medical
language terms allows patients to seek healthcare
information on the HeartCare system.
Maintenance of the Heart&-e system also is
conducted by the nurse moderator who provides vigilant
attention to server performance, Web page address and
content changes. Although an automated link checking
system is employed, supplemental manual checks are
done to insure link stability and the nurse checks weekly
for unexpected changes or alterations in Web page
content to insure clinical applicability of the information.
The nurses role as educator has expanded with
the increased use of Web-based healthcare information
by patients. Nurses are learning to critically analyze Web
site content, source of content, quality of content, and
intended audience. When patients present information
downloaded from the Internet, nurses must be prepared
to analyze the information for accuracy and applicability
and advise patients about proper use of Web-based
health care resources and current treatment interventions.
Teaching patients how to use search engines, bookmark
favorite Web sites, and access health-related support
groups are examples of patient education skills nurses
soon will be providing on a daily basis. Nurses are
beginning to develop Web pages containing health
information for clients. This is an important role for
nurses since they are knowledgeable about hdw to tailor
information to appropriate reading levels, cultural
aspects, and developmental needs of patients.
The HeartCare system also has an electronic
mailing communication feature though which the nurse
monitors patients progress, manages symptoms, and


provides personal recovery advice. The nurse is able to

develop an interpersonal relationship with clients that
encompassed the roles of teacher, communicator,
comforter, rehabilitator, and caregiver. In its current
form, the He&Care system does not support
collaboration among health care professionals, although
this function easily could be added.
Over the past ten years, om experiences in the
design and testing of electronic nursing care delivery
systems has provided us with insights about the
potential impact of electronic care delivery systems on
nurses work systems. We are learning about the ideal
client load that can be reasonably managed
electronically by a nurse or healthcare team, how much
electronic client contact should be done individually or
in groups, the extent to which clients families can be
involved, and the correct balance between the amount
of work done with clients on-line and using other forms
of communication, i.e., telephone, written, or face-toface. We also are learning about design features that are
important to patients and nurses.
Technology is an important factor in the
evolution of nursing practice and the experience of
nursing (Barnard, 1996). It is suggested that adequate
conceptions of technology will emerge when nursing
defines technology as influential in the organization of
human labor and fundamental to its moral and political
goals. Our experience has shown us that a technologichumanistic dualism does not have to exist in
technology-mediated nursing care. Challenges to the
humanistic aspects of nursing (maintaining high
touch in a high tech system) can be sufficiently
managed if computerized nursing care deliveT systems
include design features mindful of professional nursing
values and functional roles.
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