T h e In f l u e n c e o f

Tec h n o l o g y i n N u r s i n g
Education
Stephen D. Krau, PhD, RN, CNE

KEYWORDS
 Text mining  Data mining  Technology  Meaningful use  Telehealth  HIT
 Nursing education

KEY POINTS
 The complexity of the relationship between nursing and technology becomes greater with
the advent of new technology and technological devices.
 Faculty who are in the clinical area on a limited basis, and for nurses who are not involved
in decisions related to the adoption of technology, terms and concepts related to technol-
ogy can be misconstrued or misunderstood.
 Some major terms used in reference to technology and technological approaches such as
meaningful use, as well as data mining (DM), along with concepts related to telehealth can
only enhance the intricate relationship between nursing and technology.
 Keeping current with new technologies and concepts that affect optimal patient outcomes
is a mandate for all nurses as they work with the technology and guide patient education
related to technology.

INTRODUCTION

There is much progress in the development of new technology and technologic modal-
ities for either directly or indirectly improving patient care, as new innovations are
created every day. There has been a great deal of discussion regarding how new
technology has been seen as a hindrance to patient care by decreasing the time nurses
spend in patient care, as well as regarding expenses that have emerged in purchasing
programs and providing education and the rapid evolvement that literally makes yester-
day’s invention, obsolete today. Nurses have identified that technology also has the
potential for depersonalization and objectification of patients. The potential for technol-
ogy to affect patient individuality and subjectivity and create an alienation between the

Disclosure: None.
School of Nursing, Vanderbilt University Medical Center, 461 21st Avenue South, Nashville, TN
37240, USA
E-mail address: steve.krau@vanderbilt.edu

Nurs Clin N Am 50 (2015) 379–387

http://dx.doi.org/10.1016/j.cnur.2015.02.002 nursing.theclinics.com
0029-6465/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
380 Krau

patient and health care providers with their caring purpose is clear. The complexity of
the relationship between technology and nursing care is not new.1
This complexity is further intensified by the new terms and concepts that continue to
inch into the vocabulary and discussions; this is evident not only in nursing practice
but also in the society as a whole. For example, who could have guessed a decade
ago that there would be talks about “sexting,” much less all of the legal and ethical
issues that have ensued.2 Understanding the various terms to describe technology
in health care and conceptual terms related to health care is an ongoing task. For
nurses who are not involved in technological decisions, and for faculty who have stu-
dents in a clinical setting on a limited basis, the exposure to these concepts and terms
can be restricted. Terms and concepts are heard in discussions, and in a nonsystem-
atic context, can be misinterpreted or misunderstood. As part of an ongoing process,
there are some basic terms and important concepts used in the arena of technology
that should be understood by all nurses. There are many technology formats for edu-
cation and learning, as well as simulation; the focus in this article is on technology seen
in the clinical arena and research and often discussed by nurses. Students may over-
hear these words and come to the instructor for clarification. Nurses at the bedside
may be unclear about what some of these concepts and terms actually entail. Under-
standing these terms and concepts is integral to the use and discussion of some of the
many technological innovations.
When discussing technology, the focus could be on any one of a thousand concepts;
the concepts explained in this article include terms related to health information tech-
nology (HIT) and meaningful use. Slipping from other technological areas are those
terms that center on data management and data use such as text mining and DM. Moni-
toring devices and telehealth systems continue to carry some mystique for the novice
nurse and nursing students. In addition, the recent importance of early warning systems
(EWS) has emerged, because these systems provide a valuable tool for the early detec-
tion of deterioration in patient status, prompting quick intervention. Even when the
names and concepts make sense in general, the meaning that these terms hold for
nurses and nursing students can easily be misinterpreted or misunderstood.

Health Information Technology

The report from the Institute of Medicine on the future of nursing makes a recommen-
dation that nurses be involved in the development of new approaches to technology
such as HIT, to advance as well as to improve health care.3 HIT systems are those
that are based on technology and are used to access, exchange, automate, and
enhance decision making; provide support to health care professionals as well as
patients; and promote behaviors that enhance health and wellness.4 As such, HIT
has the potential to affect health and health care in a myriad of ways. For example,
this impact can be focused on improving the quality and the cost of health care; it
can also expand the range of health care. There is recent evidence that it can play a
significant role in the management of disease processes.5,6 HIT specifically refers to
those technologies that permit health care professionals to improve outcomes by
sharing and using information, gather information from electronic health records
(EHRs), collaborate through sharing information via secure information networks,
allow electronic prescribing, as well as engage patients and their families in care via
technological methods.4

Meaningful Use
Although the term meaningful use carries a strong semblance to the suggestion of the
term’s connotation, the term has been operationalized to have specific
 Technology in Nursing Education 381

considerations. This term is not a generic one as could be construed, but actually
incorporates very specific parameters for what constitutes meaningful use. Passage
of governmental reform and legislation including Health Information Technology for
Economic and Clinical Health (HITECH), a component of the American Recovery
and Reinvestment Act of 2009, Public Law11–5, and the Affordable Care Act has
had a tremendous impact on the health care system in the United States.7 HITECH
created a program that provides financial incentives for eligible health care institutions
to use electronic health care records (EHRs) in a fixed way. The law includes US $19.5
billion for incentives to health care agencies and health care professionals who use
technology in a meaningful way, which is based on the development and use of EHRs.
As such, meaningful use does not imply that better health care results from adopting
technology itself, but rather through the exchange and use of information to best affect
the clinical decisions that occur at the point of care.8 The Alliance for Nursing Infor-
matics, which is composed of 25 organizations, issued a document stating that
“Meaningful use of EHR systems should strive for nothing less than an integrated
healthcare community that is patient centered and promotes usable, efficient, and
seamless information flow.”9
The meaningful use program is designed in 3 stages. The first stage, which took
place from 2011 to 2012, was to focus on capturing data and sharing information.
The second stage within a 2014 time frame was to focus on the use of technology
to advance clinical processes. The third stage, which is going to occur in 2016, is
focused on the use of meaningful use directed at improving outcomes.10 In order to
qualify for the governmental incentives, health care organizations and health care pro-
viders must demonstrate that they have met clear criteria for meaningful use.
The meaningful use criteria identifies standards to advance the use of HIT in health
care. A summary of meaningful use standards specific to Medicare and Medicaid
standards are identified in Box 1.
One of the issues identified with meaningful use and the use of electronic health care
records (EHR) in general is that it might not be pervasive enough to assist patients and
families in the participation, and ultimately, the success of its use. The meaningful use
criteria does not emphasize patient involvement or patient perception enough for
some health care providers who maintain that the success of use of EHRs is contin-
gent on engaging patients and their families.11 As nurses advocate for patients and
their families, this omission can be perceived as a flaw in the operationalization of
“meaningful use.” While technologies considered in meaningful use, such as EHRs,

Box 1
Meaningful use standards operationalized by Medicare and Medicaid

1. Use certified electronic health care records to track, record, and exchange information.
a. Use computerized physician order entries
b. Record demographics and vital signs
c. Maintain problem lists that are up to date
d. Evaluate insurance eligibility and submit claims
e. Exchange key clinical data
f. Maintain privacy and security
2. Capture and submit specific clinical quality measures
3. Provide patients an electronic copy of their health information
382 Krau

directly involve patients and their families, they could also represent a platform for
improving access to care, improving quality of care, empowering patients, and
providing support between office visits. Some advocates think that meaningful use
should include an assessment of the patient’s experience as they engage with health
care providers and institutions.11

Generating New Knowledge for Decision Making

With the expansion of EHRs and the overwhelming amount of information to which
health care professionals have access, there are new modalities of harnessing this in-
formation. Through using this information and creating algorithms, and models, this
information may yield additional information that is not known or not well understood.
In essence, old information can be clarified, and even new knowledge can be created
from these vast data systems. These processes can lead to knowledge that could be
instrumental in clinical decision making and assuring optimal patient care.
Two terms that have come to the forefront related to obtaining and using knowledge
from various data banks, including EHRs, are data mining and text mining.12 Both
involve accessing and extracting information from a large volume of documents. DM
is the process in which useful knowledge and information is obtained from data banks.
The goal of DM is to access information for further analysis and potential decision mak-
ing.12,13 Text mining is a more comprehensive process than DM in which there is mining
of unknown and obscure parts of information from structured and semistructured text.
Although very similar, there are elements of a priori algorithms and association rules
that form a basis for text mining. These techniques are used for the enhancement of
nursing diagnosis, improvement of consistency in the use of nursing terms, and reduc-
tion of time in the production of new ideas and concepts. DM is not just a single method
or single technique but rather a spectrum of different approaches that search for pat-
terns and relationships of data.12 The methodological basis of DM is the discernment
of patterns and relationships in large quantities of data that results in the construction
of models that can help the assignment of class labels through the use of statistical
methods, artificial intelligence to the management of databases.14
Both text mining and DM involve the use of a computer to access and organize data.
Text mining is essentially the discovery of new or unknown information from large
amounts of different unstructured textual resources. Extracted information is linked
together to create new facts or ideas to be explored by more empirical means of inves-
tigation. When considering DM, patterns are discerned from natural language text as
opposed to databases. Another aspect of text mining is related to web mining in which
the input is unstructured and free text, whereas the web sources themselves are struc-
tured. The goal is to generate genuinely new information. This mining is different from
simple information retrieval in which no genuinely new information is found. With infor-
mation retrieval or what is commonly called a web search the health care professional
is looking for something that has already been confirmed or validated.
The value of DM and text mining tools is in the application of these models in pro-
grams that analyze the vast amounts of information related to health care. When
considering the tremendous data generated by patient health care visits, information
in EHRs, medication errors, prescriptions, the filling of prescriptions, and specific
physician notes, there is information that might be extrapolated into patterns that
could improve patient outcomes and overall health care. There are many commercial
text mining programs and tools, and there is much discussion about the efficacy and
value of all these various programs. The importance of these processes becomes
stronger with more frequent use and through the comprehension of health care pro-
viders who can connect these processes to their clinical practice.
 Technology in Nursing Education 383

Evidence
Although there are many studies that demonstrate the use and value of DM, the one of
particular note is a study that applies it to improve the diagnosis of neonatal
jaundice.15 The investigators validated the usefulness of DM. In this study the re-
searchers concluded that “the main finding of this study showed that DM techniques
are important and valid approaches for prediction of neonatal hyperbilirubinemia.”15
The inference is that DM is useful to support medical decision making, and in this
case contributes to improved diagnostics.

Daily Activity Monitors

With so much communication and so many devices able to convey information, and
receive information, the implementation of daily activity monitors has modernized
health promotion and disease management.16,17 There are multiple devices available
for monitoring daily activities, and some of them will affect the efficacy in practice.
These devices vary in their usability, security, measurement parameters, support
system, and convenience.
When exploring these devices, some of the mystique disappears when one considers
pedometers that have been used for decades. The principle is similar, although current
devices do much more than measure steps. Activity monitors can be used to measure
multiple physiologic occurrences such as sleep cycle, calorie expenditure, heart rate,
skin temperature, blood glucose levels, and activity classification.17 These devices
can also measure to what degree a goal was obtained in activity for a specific period.
Daily activity monitoring devices have been the focus of many companies. Some
have been very successful, whereas others have fallen by the wayside. The evolution
of activity monitoring devices continues. Although they are used more commonly
today, and many associate their inaugural emergence with computers, activity moni-
toring devices in some form have been around since 1920.17 Although not considered
medical devices by the US Food and Drug Administration,18 the use of monitoring
devices and now apps has been flourishing since the mid-1960s (Fig. 1).
Daily activity monitoring devices are a mainstay in the health care system and allow
the patient more self-care with regard to decision making based on information. Many
devices have a variety of peripherals that can attach to phones, computers, tablets,
and exercise machines. Fig. 2 shows the Nike running watch, Basis watch, Jawbone
UP with peripherals, and Fitbit One with peripherals. Although intimidating at first,
many of these become as common as watches for many patients.
Nurse’s knowledge of these devices and issues related to safety, privacy, and effi-
cacy can only be obtained through thorough examination of the types of devices and
the specific patient need. Depending on the health state of the patient, and the
patient’s specific needs, nurses are postured to help patients make decisions and
to teach them about the different devices. It is now commonplace in some facilities
to see patients bring their devices with them on admission. A more thorough discus-
sion of the devices and types is warranted should frontline nurses or students be
engaged in the decision-making process.

Evidence
At present, there is a lack of vigorous studies to support the value of the use of activity
device to the consumer. The various companies that make these devices market them
more based on the idea and the theoretically value that these devices may have for
their customers. Most certainly this is partly because of the lack of involvement by
the US Food and Drug Administration for approval. The next step in the evolution of
 384
Krau
Fig. 1. The evolution of activity monitoring devices. (From Mancuso PJ, Thompson M, Tietze M, et al. Can patient use of daily activity monitors change
nurse practitioner practice? J Nurse Pract 2014;10(10):789; with permission.)
 Technology in Nursing Education 385

Fig. 2. Some devices with their peripherals. (From Mancuso PJ, Thompson M, Tietze M, et al.
Can patient use of daily activity monitors change nurse practitioner practice? J Nurse Pract
2014;10(10):788; with permission.)

monitoring devices should include strong studies with large populations to determine
the overall value of these devices.

Early Warning Scores Using the Electronic Medical Record

Along with providing vast amounts of data for mining, the health care record can also
be used as a tool to assist the nurse in the detection of early patient status compro-
mise in order to promote safety and enhance optimal patient outcomes.19 There is
often a subtle decline in patients’ conditions 8 to 12 hours before an event, which
can allow time for the health care team to identify patients at risk.20

Evidence
The use of EWS in conjunction with the electronic medical record and nurse alerts has
been found to improve patient care and to enable early recognition of the need for emer-
gent care. The use of the EWS has also been shown to assist in the education of nurses
and in their personal development of autonomy and critical thinking skills.20 The EWS
can provide a guide for new nurses as they develop skills in determining a patient’s
overall condition, as well as recognizing even the most subtle changes in patient status.
The EWS can also help nurses determine trends that might otherwise go unnoticed.

Telehealth
The Health Resources and Services Administration explains that telehealth is “the
electronic information and telecommunications technologies to support long distance
clinical health care, patient and professional health-related education, public health,
and health administration.”21 Within the scope of nursing, one might hear this referred
to as “telehealth nursing” and “telenursing”.21 At present, telehealth is not a nursing
specialty area, but it is not hard to imagine that this technology will be needed in every
nurse’s skill set in the near future. Some of the devices and their uses are listed in
Table 1.
Telehealth is being delivered in many inpatient and outpatient settings. Telehealth
can provide such important services as telestroke, teledermatology, telepediatrics,
teleneonatology, telepsychiatry, and telecardiology to many underserved areas.22
The use of telehealth allows communication between patients and health care pro-
viders by improving access to care, regardless of the location (see Fig. 2).
386 Krau

Table 1
Some of the uses of telehealth technology

Remote monitoring These devices allow patients to connect with health care
devices professionals from their communities, or from their homes.
Systems can include real-time connection such as
videoconferencing. Some systems are asynchronous and allow
the patient to answer such questions as “how is your heart rate
this morning?” Replies are recorded and sent to the health care
provider whose early detection of a potential problem can
ameliorate exacerbation of the problem, and potentially a
hospital visit
Remote physical These are similar to daily activity monitors; however, these allow
assessment peripherals patients to submit data from their home to the health care
provider. These devices can include weight scales, pulse
oximeters, glucose monitors, medication tracking equipment,
and even “intelligent toilets.” Data can be sent as real time, or
can be stored and recorded to be sent later. These devices allow
the tracking and display trends in patient information. In
addition, some of these even allow for alerts should the heart
rate become too high or a there be an extraordinary weight loss
or gain
Mobile health These are wearable sensors that can track information in real time.
(mHealth) devices These devices can track and transmit information ranging from
glucose levels to movement and balance
Personal health These apps are for mobile devices; they can hold patient
record apps information such as medication reminders and health history as
well as collect environmental triggers for some respiratory
issues, such as amount of pollen in the air or smog

Adapted from Grady J. Telehealth: a case study in disruptive innovation. Am J Nurs 2014;114(4):40;
with permission.

SUMMARY

There are clearly implications for nursing education with advancement of this technol-
ogy. Some suggest that technology might even be disruptive to the traditional ways in
which nurses are taught, and that instead of passive learning, students should have
the opportunities to apply and synthesize.23 The newer generations of nursing
students come with knowledge and skills related to much technology that they will
use in nursing. It is instructors from previous generations who are the immigrants to
the digital generation of nursing students and new nurses. However, it is essential
that the terminology used in the description and understanding of new technologies
be clear and understood by all nurses.

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