Computers and School Nurses in a Financially Stressed School System

Computer Technology and the Professional Lives of School Nurses: The Case of St. Louis

In December 1999, the Deaconess Foundation (a local, St. Louis philanthropic foundation), announced the establishment of an innovative educational partnership with the St. Louis Public Schools Foundation (SLPSF). The Deaconess Foundation established the partnership by agreeing to fund a 2-year project proposed by the SLPSF. The project costs exceeded US$500,000 and involved a plan to improve the health care of students enrolled in the city’s public schools through computer technology.

According to the press release, (Pierce, 1999),

“The Deaconess Foundation has given $500,000 to the St. Louis Public Schools to buy computers for school nurses and help pay for a computer network that will allow the nurses to exchange health information on students,”(p. 37).

The grant was the largest received by the SLPSF and the largest given by the Deaconess Foundation.

The program has been operational for more than a decade. This case study and evaluation analysis reports the results drawn from the first several years of operation. Numerous technical and managerial problems are encountered when computer technology is initially introduced into the professional lives of school nurses (Smith et al., 1998). Not only are the professional responsibilities of school nurses affected but also the numerous other aspects of the school system are altered and transformed. This article provides an overview of the multiple technical and managerial issues when computers and data processing technology are added to the professional responsibilities of school nurses. These new responsibilities not only changed the delivery of health services to students but also created numerous challenges to existing administrative protocols within the school system itself.

An ambitious agenda was established as a result of the grant to the St. Louis school system. According to the terms of the grant, all school nurses would undergo computer training and be online at the end of Year 1. The grant provided new computers for more than 100 school nurses; training was required of all nurses to build computer technology into their professional responsibilities. In addition, the new computer technology and professional software had to interface with the hardware and procedures maintained by the Division of Technology Services (DTS), St. Louis Public School System. This series of plans actually took several years to implement and involved a timeline much longer than initially envisioned.

A sophisticated software system was ultimately selected, the Schools Administrative Student Information (SASI) student information system (NCS Pearson, 2009), to implement the new technology. During the first 3 years of operation (2000-2003), it was envisioned that (a) training activities would be initiated and continued on a regular basis, (b) all existing health databases would be converted to the new SASI system, (c) new health databases would be maintained and updated, (d) utilization of the new health information system for management and planning purposes would be initiated and ultimately increased, (e) utilization of the new database for evaluation purposes would be increased, and (f) the SASI system would become maintained and serviced by the Division of Technology Services. Obviously, this constituted an ambitious training and administrative agenda. Not surprisingly, implementation of the new system created new administrative challenges.

Due to a variety of technical and training problems, program implementation during Year 2 did not proceed as swiftly or as efficiently as initially envisioned. The technical skill level of school nurses was much lower than anticipated. As a result, the amount of training required to move the target population toward computer proficiency was greater than originally assumed. During interviews with trainers, it was also established that computer skills tended to lag during the summer months. As a result, it was necessary to update skills at the beginning of each school year to reach the level of proficiency achieved at the end of the previous school year. This was accomplished through intensive training offered during the beginning of the 2001 and each subsequent school year. Clearly, the ambitious agenda initially envisioned in the grant application and implemented at the outset was challenging.

Because there were more than 100 schools and nurses requiring training and technical assistance, the volume of requests for help received by the two trainers often exceeded their capacity to meet the needs of the nurses. As a result, wide variations in computer proficiency continued to accompany implementation of the program during Years 2 and 3. These wide variations in technical proficiency not only tended to slow implementation of the program but also complicated the relationship between the SASI trainers and the Division of Technology Services. While some schools and nurses adapted to the new SASI information system quickly, and with a high degree of proficiency, others were much less proficient and used it in a much more limited and infrequent manner. Some nurses resented the added technological responsibilities and stalled implementation of the new system. Despite these setbacks, the data revealed that much higher levels of usage and proficiency were achieved in Year 2 and thereafter.

Once these logistical issues were addressed and solved, a series of technical problems with the new version of SASI required significant attention during much of the first 3 years of operations. The trainers initially estimated that by November 2003, the school nurses and the technical operations of the SASI program were again comparable to May 2001 proficiency levels. Between November 2001 and May 2002, the initial years of implementation, selected components of the SASI system were largely operational. All immunization data, with the exception of a small number of noncompliant schools, were stored and accessible. Many other elements of the health database, however, were not initially incorporated into the SASI protocols. Trainers estimated that it would likely take 2 to 3 additional years before all aspects of the initially envisioned databases would become part of the SASI network. Their prognosis was largely correct as it was not until the 2006 school year before most elements of the SASI program were fully operational.

One factor explaining the slow progress made in creating the large information system was the absence of trained personnel to transfer information from the existing records to the SASI system. In some schools, secretaries were charged with this responsibility. In other schools, however, the nurses themselves transferred data to the SASI system. In addition, it was not possible to enter information about the health status of an individual student until that student actually appeared in the database. In some schools, it was not clear who was responsible for actually entering the required information. Two databases (health information and general student data) must be interfaced to operate the SASI system. In addition, individual satellite schools were required to interface with the centralized DTS system for SASI to operate at maximum capacity. While significant progress was initially made to address these issues and to create the larger database, it does not appear that the full potential of the SASI health module was always utilized. The required interface between the new health system and the ongoing operations of the Division of Technology Services was not always smooth and it took several years before everyone’s responsibilities were clearly understood.

Computer and School Nurses: An Evaluation of How Nurses Respond to New Responsibilities

To establish baseline data pertinent to the changing computer proficiencies of the school nurses, an evaluation team from Saint Louis University administered a short survey to the school nurses in July 2000. The timing of the baseline survey corresponded with the initiation of the SASI training scheduled in the beginning of the 2000 school year. The research instruments were mailed to the approximately 100 school nurses in the St. Louis school district. The surveys accompanied the announcements of the SASI training sessions scheduled before the opening of school. The survey was designed to measure computer literacy and ascertain additional information about future training needs of the school nurses. Another evaluation survey was administered in May 2002, approximately 2 full years after implementation of the initial computer program funded by the Deaconess Foundation. These two surveys reveal both the strengths and weaknesses of the St. Louis school nurses as they adapted to the new set of professional responsibilities.

In addition to the items appearing in the original instrument, the follow-up survey asked nurses to reveal their candid appraisal of the computer project, the SASI program, and the quality of training they received. They were also asked to offer any policy suggestions that might be directed toward the school system, the Division of Technology Services, and those who have been providing training in the SASI system. In the original survey, 66 surveys were returned with complete information. This represented an approximate 66% rate of return. In the follow-up survey, 71 instruments were returned with complete information; this represents more than a 70% rate of return, both are relatively high figures for a mailed survey. The comments of the school nurses are pertinent to all large, urban school systems that are coping with implementing new professional responsibilities in the school nursing population.

The results of the two surveys depict a relatively older workforce with a limited amount of prior exposure to computer and information technology. Based on the two surveys, about 42% of the population fell into the 51 to 60 age bracket, and more than 53% fell into the above 51 age category. About 44% of nurses indicated they had held their current position less than 5 years. These findings suggest considerable movement between schools within the district and the recruitment of new but relatively older nurses into the workforce. The age of the school nurses was probably associated with higher levels of resistance to the new set of technical responsibilities.

To measure the change in computer usage and proficiency before and after implementation of the new program, we separated the survey findings into two time periods: (a) July 2000 (preimplementation) and (b) May 2002 (postimplementation). These two periods represent the times at which the initial surveys were administered. We reasoned that any administrative and professional changes in behaviors or attitudes can be attributed to participation in and exposure to the new computer project. The initial report (Cummings, 2001) described the nursing population as having very low levels of computer literacy and technical competency. Initially, survey data indicate that the proportion of school nurses who had prior experience with computers before and after introduction of the computer program was fairly low. While 75.8% of nurses indicated they had used computers prior to the program, by May 2002, virtually 100% of nurses reported they were using computers frequently. This represents an approximate 25% increase in computer usage.

Table 1 shows that among those with computer experience in July 2000, 64% owned a home computer, 40% used a computer at work, and 48% had been exposed to formal computer training. By May 2002, 66.2% of all nurses surveyed owned a computer, 97.2% used a computer at work, and 70.4% had taken a formal computer class. These findings are very significant. The survey data established that the computer project was likely responsible for an approximate 159% increase in computer usage in the workplace and an approximate 37% increase in exposure to computer and technology training. It is highly likely that without the Deaconess intervention, a large portion of the city’s nursing population would have remained outside the technological mainstream.

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Table 1.

Access to Computers Among School Nurses

	July 2000	May 2002	% change
Do you own a home computer?
Yes	64.0	66.2	0.01
No	36.0	33.8
Do you use a computer at work?
Yes	40.0	97.2	158.9
No	60.0	2.8
Have you ever take a computer course?
Yes	48.0	70.4	37.3
No	52.0	29.6
	n = 50	n = 71

This observation is reinforced by the information appearing in Table 2. The initial survey established that among those with prior computer experience most nurses were either self taught (52%) or learned to use computers from peers (54%). About 38% indicated they participated in a program offering formal instruction in computer usage, and 26% indicated they learned to use computers through other methods. By May 2002, those nurses indicating peers had taught them computer usage were reduced to 29.6%; those who reported receiving computer knowledge through formal training had increased to 54.3%. The data indicate that reliance on informal networks and peers had been reduced by 45.2% and exposure to formal training had increased by 34%. Most significant in the survey data was information showing rapid increases in types of computer usage among the school nurses.

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Table 2.

How School Nurses Learned to Use Computers

	July 2000	May 2002	% change
Taught by peers
Yes	54.0	29.6	−45.19
No	46.0	70.4
Self-taught
Yes	52.0	46.5	−10.58
No	48.0	53.3
Formal training
Yes	38.0	54.3	42.89
No	62.0	45.7
Other
Yes	26.0	21.1	−18.85
No	68.0	78.9
	n = 50	n = 71

Table 3 shows the actual types of usage reported by those with prior computer experience in July 2000 as compared to usage in May 2002. Every category of usage improved during the course of the computer project. While 40% of users indicated they conducted research with the computer in 2000, nearly 60% reported such usage by May 2002. E-mail communication rose from 38% in July 2000 to 71.8% in May 2002; word processing moved from 34% in 2000 to 45.1% in 2002, and educational usage increased from 32% in 2000 to 71.8% in 2002. Overall, research usage increased by 48% and e-mail usage increased by 89%. Educational usage increased by 124% as did computer usage for data manipulation. Most notably, collaboration among nurses for various health-related projects increased by 487%. We also asked in the initial survey if nurses were familiar with various Windows platforms that might be compatible with the SASI protocols. The comparative information between the two surveys appears in Table 4. Initially, about 40% were familiar with Windows 98 and 38% were familiar with Windows 95. Familiarity with other operating systems was reported at much lower rates.

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Table 3.

Primary Uses of Computer Technology Among School Nurses

	July 2000	May 2002	% change
Research
Yes	40.0	59.2	48.0
No	60.0	40.8
Communication and Email
Yes	38.0	71.8	88.9
No	62.0	28.2
Word processing
Yes	34.0	45.1	32.6
No	66.0	54.9
Education
Yes	32.0	71.8	124.4
No	68.0	28.2
Personal productivity
Yes	32.0	35.2	10.0
No	68.0	64.8
Databases
Yes	22.0	49.3	124.1
No	78.0	50.7
Spreadsheets
Yes	6.0	8.5	41.7
No	94.0	91.5
Collaboration in projects
Yes	6.0	35.2	486.7
No	94.0	64.8
Other
Yes	14.0	26.8	91.4
No	86.0	73.2
	n = 50	n = 71

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Table 4.

Primary Computer Platforms Currently Used by School Nurses

	July 2000	May 2002	% change
Windows 98
Yes	40.0	33.8	−15.5
No	60.0	66.2
Windows 95
Yes	38.0	9.9	−73.9
No	62.0	90.1
MS-DOS
Yes	14.0	4.2	−70.0
No	86.0	98.6
Windows 3.1
Yes	8.0	5.6	−30.0
No	92.0	94.4
Windows NT
Yes	6.0	54.9	815.0
No	94.0	45.1
Other
Yes	16.0	18.3	14.4
No	84.0	81.7
	n = 50	n = 71

By May 2002, the two systems with which nurses were most familiar were Windows 98 and Windows NT. Of greatest significance is the fact that school nurses increased familiarity with Windows NT operating system. Usage of older platforms like Windows 95 and MSDOS dropped by more than 70% and usage of Windows NT increased by 815%. Table 5 summarizes a comprehensive list of computer applications with which users in the school nurse population were familiar in July 2000 and in May 2002. The comprehensive list of applications is presented in a rank order according to the July 2000 data. The table also shows the percentage increase or decease between the two survey administrations. The greatest increases in computer usage among school nurses was found in reading and deleting e-mail messages (64.3%), Internet usage (55%), sending, replying to, and forwarding e-mail messages (71.5%), use of web site addresses (102.5%), finding files (58.5%) using search engines (65.6%), sending group mailings (171.4%), and posting messages (87.1%). The smallest improvements in computer usage between the two survey administrations were found in adjusting printer settings, saving and retrieving files from a cassette, CD, or floppy disk, and using spell and grammar check protocols on word processing programs. Overall, however, marked improvements in computer utilization were evident in nearly all categories.

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Table 5.

Computer Proficiency Among School Nurses

	July 2000	May 2002	% change
Start-up, reboot, and shut down a computer
Yes	80	97.2	21.5
No	20	2.8
Print a word processing document
Yes	66	74.6	13.0
No	34	25.4
Open and close menus in Windows
Yes	62	90.1	45.3
No	38	9.9
Log on to the Internet
Yes	60	93	55.0
No	40	7
Read and delete e-mail messages
Yes	54	88.7	64.3
No	46	11.3
Use spell and grammar check capabilities
Yes	54	52.1	−3.5
No	46	47.9
Create document using word processing program
Yes	50	62	24.0
No	50	38
Can find files
Yes	48	76.1	58.5
No	52	23.9
Can save and retrieve a file to and from a floppy
Yes	46	47.9	4.1
No	54	52.1
Load, launch, and quit a program from the hard drive
Yes	46	50.7	10.2
No	54	49.3
Create, send, forward, and reply to e-mail messages
Yes	46	78.9	71.5
No	54	21.1
Can resize windows on my desktop
Yes	44	70.4	60.0
No	56	29.6
Can delete files
Yes	42	59.2	41.0
No	58	40.8
Can adjust the settings on my printer
Yes	42	38	−9.5
No	58	62
Can save and retrieve a file to and from the hard drive
Yes	38	50.7	33.4
No	62	49.3
Can load, launch, and quit a program from a CD-Rom
Yes	36	38	5.6
No	64	62
Can access information using a www search engine
Yes	34	56.3	65.6
No	66	43.7
Can recognize the difference between an e-mail and a web site address
Yes	32	64.8	102.5
No	68	35.2
Can use more than one program at a time
Yes	28	43.7	56.1
No	72	56.3
Can rename files
Yes	26	40.8	56.9
No	74	59.2
Can create directories and folders
Yes	24	33.8	40.8
No	76	66.2
Can highlight, cut, copy, and paste text
Yes	24	26.8	11.7
No	76	73.2
Can subscribe to and unsubscribe from a mailing list
Yes	20	29.6	48.0
No	80	70.4
Can send group mailings
Yes	14	38	171.4
No	86	62
Can post messages on mailing lists
Yes	12	22.5	87.5
No	88	77.5
	n = 50	n = 71

Similar to the increase in computer utilization, the data also indicate a drop in computer training needs between the two survey administrations (Table 6). The most frequently requested training needs in July 2002 included e-mail usage (68.2%), database management (66.7%), Internet usage (66.7%), operating systems (65.2%), presentation software (59.1%), and word processing (57.6%). By May 2002, every category of training needs had been reduced with the exception of spreadsheets. The greatest decrease in expressed training needs among nurses were Internet usage (–53.5%), e-mail usage (–42.2%), network connections (–38.2%), and database management (–30.3%). High needs for additional training, however, were still registered in the following categories: presentation software, spreadsheets, desktop publishing, and word processing.

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Table 6.

Computer Training Needs and Recommendations Among School Nurses

	July 2000	May 2002	% change
E-mail
Yes	68.2	39.4	−42.2
No	31.8	60.6
Database management
Yes	66.7	46.5	−30.3
No	33.3	53.5
Internet
Yes	66.7	31	−53.5
No	33.3	69
Operating systems
Yes	65.2	49.3	−24.4
No	34.8	50.7
Presentation software
Yes	59.1	54.9	−7.1
No	40.9	45.1
Word processing
Yes	57.6	50.7	−12.0
No	42.4	49.3
Network connections
Yes	54.5	33.8	−38.0
No	45.5	66.2
Spreadsheets
Yes	53.0	56.3	6.2
No	47.0	43.7
Desktop publishing
Yes	51.5	46.5	−9.7
No	48.5	53.5
Distance learning
Yes	40.9	32.4	−20.8
No	59.1	67.6
	n = 50	n = 71

The Introduction of Computer Technology Among School Nurses: Resistance and Accommodation

While the survey data clearly establish that nurses increased their general technical and computer proficiency over a 2-year period, it is also important to ascertain their overall reaction to the introduction of new professional and administrative responsibilities. SASI and SASIxp (NCS Pearson, 2009) are comprehensive software programs that manage extensive student information systems at both the school and district level. The program, which can use Windows or Macintosh, displays information in a graphical environment that organizes screens that look like index cards. In addition to health and immunization data, the program offers capabilities that include a variety of additional information such as student demographics, attendance, discipline, grades, schedules, emergency, and family circumstances. The software includes a variety of navigational methods, and individual users have the flexibility to view information organized in numerous windows and modules. Every authorized staff member is assigned a unique password and ID number that determines what data they can access and ensures the security of the entire system. As part of an impact evaluation, we asked the school nurses to respond to a variety of questions about their utilization of the SASI system. Nurses were also asked to evaluate the quality of the training they had received to operate the SASI protocols. Figure 1 shows the frequency with which nurses use the SASI program.

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Figure 1.

Frequency of SASI Usage by School Nurses (n = 71)

More than 84% of respondents indicated they use the SASI program daily. Only 3% of those surveyed in May 2002 stated they used the program less than once a month or not at all. Many of these individuals were substitute nurses or temporaries. Figure 2 shows the evaluations of the quality of training received by nurses to operate the SASI system. Approximately 89% indicated their training was good (45%) to excellent (44%).

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Figure 2.

Evaluation of the Quality of SASI Training (n-71)

Overall, it appears that the nurses were satisfied with the quality of training provided by the Division of Technology Services in the St Louis school system. At the same time, it is clear that the need for additional training increased and this indicates nurses would require additional services from the Division of Technology Service.

As previously explained, the nursing component of the SASI system is complex and has numerous component parts and applications. Table 7 shows a comprehensive list of SASI health applications. Nurses were asked to indicate their level of proficiency with the numerous applications. The many protocols and applications are presented in a rank order ranging from those procedures with which the nurses are most familiar to those with which they are least familiar. Very high levels of proficiency were reported for the following applications: inputting new immunization records, looking up existing information, accessing student atoms, printing immunization records, filling out health cards, accessing the health page, looking up student phone and address records, and recording health screening information.

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Table 7.

Degree of SASI Proficiency Among School Nurses

School nurse can use SASI to	% responding affirmatively
Input new immunization records	98.6
Look up existing information	94.4
Access the Student Atom	94.4
Print an immunization and health report	93.0
Fill out health cards	91.5
Access the health page	91.5
Look up student phone and address information	90.1
Record health screenings	90.1
Update compliance fields for my students	84.5
Record incidences and visits	78.9
Delete messages	78.9
Save messages	74.6
Use outlook e-mail	71.8
Retrieve mail messages over the network	71.8
Reply to mail messages	71.8
Print immunization notices for parents	63.4
Obtain historical data on new students	60.6
Record frequency of visits to my office	59.2
Create new toolbar and add/remove atoms off toolbar	54.9
Run update reports such as noncompliance	54.9
Use the Send Mail Atom to send mail messages to others	53.5
Access help from SASIxp Help files on desktop	53.5
Use the print command to print a query report	33.8
Create and use folders to store different types of atoms	31.0
Print generic reports (system ready)	30.0
Print customized reports	28.2
Use the query atom to print query data from a matrix	22.5
Create a query drag-and-drop atom	22.5
Save a query statement in a query atom	21.1
Retrieve and open atoms sent over the network	21.1
Print labels	18.3
Use the query atom to create and display a matrix	16.9
Use the query atom to display a total	15.5
Use the recurring print job option	12.7
Create and display a matrix	12.7
Sort records in a matrix	12.7
Perform multilevel sort	12.7
Create a data atom for a list of records	12.7
Activate and inactivate a filter atom	7.0
Use the query atom to create and save a filter atom	5.6
Use the send atom to send atoms to other users	5.6
Create a filter	4.2
Graph a matrix to display data in graph form	2.8
Export matrix data into a file	2.8
n	71

Note. SASI = Schools Administrative Student Information.

More than 60% of school nurses reported they were proficient with numerous other SASI protocols. Those SASI operations with which very few nurses were familiar included the analytical and data manipulation applications such as creating and displaying a matrix, sorting records in a matrix, performing multilevel sorts, creating a data atom, activating a filter atom, creating a filter, displaying data in a graph, and exporting a data matrix into a file. Despite the lack of sophistication with some of the more complex applications of the SASI program, it is clear that the school nurses made remarkable progress since their initial encounter with their new responsibilities over a 2-year period.

The initial evaluation described a nursing population that was very unfamiliar with computer technology and data processing. Many nurses expressed serious doubts about the new program and were very concerned about how their regular responsibilities would be affected. The later survey describes a population that is becoming increasingly sophisticated in the application of computer technology for health care delivery and service to the student population. Over the initial 2-year period, the majority of nurses clearly moved into the electronic mainstream of their profession. To understand more clearly the impact of the SASI experience on their job performance and professional responsibilities, we asked the nurses to respond to a series of questions about how the computer project had affected their work lives. Table 8 shows the results of this inquiry.

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Table 8.

Evaluation of SASI Impact on School Nursing Responsibilities

	%
SASI makes it difficult to complete my regular duties
Agree	18.5
Disagree	81.5
n	65
SASI makes my job more interesting
Agree	93.9
Disagree	6.1
n	65
It was a good idea to have school nurses use the new SASI program
Agree	97.2
Disagree	2.8
n	71
I will require more training to become proficient with SASI
Agree	84.1
Disagree	15.9
n	63
I use computers more frequently as a result of SASI
Agree	81.2
Disagree	18.8
n	69
Most school nurses are positive about SASI
Agree	96.8
Disagree	3.2
n	63
SASI will positively impact the health care of St. Louis children
Agree	98.5
Disagree	1.5
n	67
Because of SASI I use the Internet to research health issues
Agree	83.8
Disagree	16.2
n	68
Because of SASI I attend more professional meetings about nursing
Agree	53.9
Disagree	46.2
n	65
Because of SASI I communicate more frequently with nurses in other cities
Agree	25.4
Disagree	74.6
n	63
Because of SASI I communicate more frequently with other nurses in St. Louis
Agree	74.6
Disagree	25.4
n	67

Note. SASI = Schools Administrative Student Information.

Despite initial fears, most nurses were remarkably positive about the SASI experience. Very few nurses thought that the extra responsibilities associated with SASI made it more difficult for them to complete their regular duties (18.5%). A wide majority thought that SASI made their job more interesting (93.9%) and that SASI was a good idea (97.2%); nearly all reported that nurses have a positive opinion about SASI (96.8%). Many nurses also reported that they used computers more frequently because of SASI (81.2%) and predicted that SASI would ultimately improve the health care of school children (98.5%). Many nurses indicated that because of the SASI experience they now used the Internet to research health issues (83.8%), attended more professional meetings (53.9%), and communicated with other nurses in the district more frequently (74.6%). Overall, the data showed a remarkably positive professional impact among nurses as a result of participation in the computer technology project. Increased computer proficiency, however, was also accompanied by increasing demands on the Division of Technology Services and the school system itself.

To solicit policy recommendations from the nurses, we provided them opportunities to make direct suggestions about how training could be more effective. We also asked nurses to share their candid opinions about the SASI program, the trainers hired through the Deaconess grant, and any other commentary they thought might be useful for District administrators and officials. Table 9 shows interview commentary from nurses in response to queries about how the Division of Technology Services could provide better training to them. Interview commentary is presented in four general categories: (a) more frequent training, (b) more administrative support and more flexible scheduling, (c) provide training based on ability groupings, and (d) expand the number of trainers. Several nurses thought the number of training sessions could be expanded and requested that sessions be offered more regularly. Others thought that principals and other administrators should be more flexible and supportive of the nurses’ needs to become more proficient with computer technology and that training sessions should be held at more convenient times.

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Table 9.

Recommendations About How the Division of Technology Services Can Provide Better Training to School Nurses

More frequent training

Online updates and suggestions on a weekly basis

I would like classes more often

Regular training; once a week and refresher sessions

Frequent availability for questions

Open door sessions are always welcome

Continue to provide services to nurses by sending direct information about computer classes

Please come to my school and help me!! We need on-site training

More frequent classes or longer time periods for the classes. It helps if I repeat some courses for more advanced computer work

Need more time

More administrative support and more flexible scheduling

Maybe a week of training before school year begins would be helpful

Talk with principals so they can allow more time for training (should be mandatory)

Offer training sessions during morning or early afternoon

Have classes during regular working hours

No more cancellations of classes

Provide training based on level of ability

Small groups; set up small groups for 1 hr training 1 or 2 days a week until proficient in its usage especially for beginners and or until nurse feels comfortable with the computer skills

Need one-on-one training

Please continue the training until we are more proficient

When we do have training, the nurses need to be kept on track

More in services on advanced skills

Group nurses according to knowledge base and interest in classes or according to grade levels (elementary, middle, high school). Each level requires different informational immunization requirements

More than one class on a particular area

Teach one aspect of using the computer one at a time so as not to overwhelm with too much information

Separate the beginners from the advanced students

Expand number of trainers and improve training material

Need more trainers

Continue to provide a trainer for nurses only. Provide a nurse trainer who can continue to research the effectiveness of the computers in schools

Provide more coordinators who can respond to the nurses needs readily

Since SASI is system wide, training should be mandated for all nurses (full-time & substitutes)

Collaborate with the teachers to that every school has someone to help the nurse with Windows NT and SASI

Put all procedures in a step-by-step book

Trainers available for all schools

Note. SASI = Schools Administrative Student Information.

A number of nurses complained about the way in which training sessions were held. Some nurses apparently wanted to move faster and felt held back by colleagues who were not as proficient. Likewise, those who are less proficient suggested that they might benefit more from training sessions if they were grouped with others who are at similar levels of competency. Last, many nurses apparently believed that two trainers were not sufficient to meet the needs for technical and data processing assistance. Many recommended that more trainers are needed for the SASI program to become fully operational.

Nurses were also asked to identify the three most positive aspects of the SASI program. Table 10 shows their responses to this query. Overall, the nurses were extremely positive about the quality of training provided by the District. Numerous nurses offered commentary along the following lines: “Please continue monthly workshops for nurses with [the two trainers]; they are excellent with patience extraordinaire.” “Training has been excellent.” “Just keep doing the great job that you do.” It is clear from the interviews that nurses were very happy with the quality of training received. At the same time, they would like to see more training provided and at more flexible times.

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Table 10.

Most Positive Elements of SASI Training

Quality of training and instruction

All training was helpful

The classes/workshops

The teachers

Friendliness of staff

Professionalism of staff

Written material is easy to understand

Continuing education/training

Patience of instructors

Follow up by instructors. Appreciate how quickly J & D get back to you

Availability of instructors when needed

Introduced training and created the desire to learn

Thorough/comprehensive

Informative

Times were good.(2-hr interval)

D & J never made me feel stupid or low-tech

D & J were helpful no matter what the problem was. The instructors took the time to answer one-on-one questions and come to your site to help you

Tricks to make assessing different fields easier (location of different arrows)

Class size was good

I know more about a computer. Reduced the fears of using a computer

Personal attention at our own pace

Quick response from the technical team when problems arise

Help is only a phone call away

We had basic instruction to assist those of us who had no or little computer experience

Time was taken individually (if needed)

Training books were helpful

J & D will give you help in person or on the phone

Classes were offered more than once

Had more than one person to contact

Classes were geared to help people without prior computer training

Sometimes I had a particular question on how to do something and it has always been answered

The instructor used audiovisual aids

They provide lots of instruction manuals and accessibility via telephone if we have problems

Usable information provided by the SASI program

Finding historical information on each student

Obtain health/immunization data (printing for parent or other)

Teaching query, printing addresses on envelopes

Being able to post health data

Locating student files

It saves me time

Easy access

Introduced the Internet

Update health records

Ability to create documents with graphics

Information written to recheck info

Retrieving medical data and information on my students and recording new data in their files.

E-mail system

Improved communication and professional networking

Ability to connect with other RNs

Ability to contact care providers

Communication (being alerted to concerns not addressed by parents)

Table 10 also shows that many nurses were impressed with access to the important health information made possible by the SASI program. Many commented that they like having quick and easy access to student health records and related information. This access helps them improve their job performance and deliver critical information to parents quickly and efficiently. Other nurses commented that the SASI experience improved their ability to communicate with other nurses, health care professionals, and parents. When asked to identify the three most negative aspects of the SASI experience (Table 11), nurses’ commentary fell into five general areas: (a) not enough training, (b) not enough time to become proficient, (c) technical problems, (d) absence of administrative support, and (e) inconvenient training times and locations. Interview information made it clear that while many nurses were generally very positive about the SASI program and the new professional obligations and responsibilities accompanying it, they would like more training and more time to become proficient. They would also like to see more administrative support to attend special training sessions and have these sessions offered at more convenient times. Many nurses were also concerned about the technical problems that have accompanied the SASI program. Some nurses indicated that the “downtime” was extensive and that few provisions had been made to ensure that new data are input in an efficient and timely manner.

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Table 11.

Most Negative Elements of SASI Training

Not enough training

Need more individual training

I need more training

Sessions sporadic

Sessions not ongoing/overlapping

Nonconsistent training

No make up training for employees out on leave of absence who missed out due to illness, etc

Classes not frequent enough

Not enough time to become proficient

Not enough time

Time factor. Limited time to use the computer

Too much material presented in short span of time

Not enough time to apply what is presented in training class

Trainer went too fast for information to be understood

Because of the increase volume of students/hands on activities daily, I don’t have adequate time to explore the things I’ve been taught by John and Diedre from the in-services

Absence of administrative support and resources

Sometimes have to wait too long to have a question answered because the staff was in the field

Unavailability of trainer

Not enough trainers to assist on site. (took too long to get)

Lack of interest toward nurse staff of school to support the necessity of how to learn to use the computer

Instructors are not available at critical times

Inconvenient training times and locations

Courses offered at too many different sites

Courses offered at inconvenient times

Classes are too large

After school scheduling was not helpful (tired after work)

Locations of training were inconvenient and parking

Classes held during work hours. Hard to leave the school

Technical problems

Lots of procedures I do not use due to time, uncertainty

Sometimes information won’t input in computer

Too long down time

My school hasn’t been updated to Outlook; I attended the e-mail training session but my computer at school has not been updated yet

Allow communication from school to school

Ability to access only the records of students at your school

Computers are down quite frequently

Have SASI up and running for use

I’ve had to wait months and months with students in my schools records because they were city students and records were not in my computer yet. It is difficult to go through a whole freshman class (160 or more) and then need to go over them all a second time when they finally do put in the information and the student is noncompliant

Information not readily available due to secretary—old information remains

Waiting at beginning of year and at start of new semester for records to be put into my computer for my whole class causes my job to be MUCH more difficult

For new students a more reasonable period of time to be input

My computer has been down most of the year. Many things are deleted from last year

Some school nurses expressed frustration with the DTS for not solving technical problems in a timelier manner. They also thought the ability to access information between schools could be improved as well as the ability to interface with the larger health care data set. Some of these concerns appear significant and were reinforced by interviews with trainers and other District personnel. Some of these technical problems were described earlier and represent important challenges facing the longer term sustainability of the SASI initiative. Clearly the DTS faced administrative challenges when the school nurse population was added as a new consumer of the school system’s computer services. It is toward some of these larger challenges that our attention will now turn.

Policy Recommendations: The Dilemmas of Implementation

In response to changes in computer technology, information processing, and electronic communication, the school nursing profession has undergone significant transformations over the past two decades. According to numerous researchers (Turansky, 2000; Vuori, l977), computer technology is becoming an integral and necessary component of school nursing education. As the health care field becomes more reliant on computer technology, nurses will not only be expected, but also required, to become more and more proficient with electronic data processing and management systems. Several scholars document the importance of incorporating computer technology and electronic communication as a standard part of nursing education (Smith et al., 1998). Some of the research literature addresses the specific problems encountered by school nurses when computer technology is introduced as part of their professional responsibilities without adequate prior training (Bergren, 2005a, 2005b; Bergren & Mehl, 1993a, 1993b, 1995).

An extensive list of research reports, Internet sites, and published articles that discuss these problems and issues is included in the reference list of this article. These documents address how the cybernetic revolution has affected the nursing profession generally and school nurses specifically. The various articles and published reports identify and describe the numerous ways in which computerized data processing and electronic communication have significantly changed the school nursing profession. Some of the more important changes include (a) medical record keeping, (b) the availability of web sites containing innovations and changes in health care policy, (c) enhanced electronic communication among and between nurses, (d) access to health care research sites on the Internet, and (e) access to online certification information and procedures (Bergren, 1999a, 1999b; Henry, 1997; Hodge, Gostin, & Jacobson, 1999; Lybecker, 1997; Murphy, 1995; Nicholl & Oullette, 1996; Pealer & Dorman, 1997a, 1997b, 1997c; Pharow & Blobel, 2004).

According to Brown (1998), staying up-to-date in any profession is vital. In the medical fields, staying abreast of the research literature can assist the delivery of critical health services. The technological world offers opportunities for better patient care and more efficient delivery of health services. For school nurses, the Internet provides one of the best ways to keep up with critical knowledge regarding students’ health needs (Bergren, 1996a, 1996b). This technology will reduce secretarial duties of filing and transferring files and improve the storage of critical health information (Bergren & Harrigan, 1998; Bergren & Mehl, 1994). These new computerized information systems will make the storage of health data more cost effective and efficient (Felton & Keil, 1998). Numerous published articles and research reports emphasize the need for school nurses to become more familiar with computer technology, Internet usage, and electronic communication (Billings & Phillips, 1991). For school nurses, the requirements and admonitions by national professional organizations and established researchers to become computer proficient is viewed as a necessary step in meeting the health needs of school children. Health care educators and researchers increasingly see the importance of becoming more technologically proficient as part of the minimal competency standards and requirements for today’s school nurses (Zielstorff, Hudgings, & Grubb, 1993).

Based on an extensive review of contemporary health policy research and educational literature, it is clear that the initial, private foundation grant to the St. Louis School system made a major contribution to the continuing professional development of the city’s school nurses. The technology and hardware provided through the grant, the educational services made possible by the hiring of the two trainers, and the financial assistance enabling the purchase of the SASI software helped move the school nurses into the technological mainstream of their profession. Without the Deaconess grant, it is highly likely that movement of this population into the technological mainstream of their profession might have been delayed by several years.

The introduction of computer technology and a new data management system, however, was not accomplished without affecting other parts of the school system. These impacts were both administrative and financial; these changes had as much influence on the school system as the nursing population. There were significant financial influences on the school system itself. Most of the original computers have been upgraded; the cost of the new computers was borne by the school system and not the granting agency. While the initial grant saved the school district significant expenditures, maintenance of the system is extremely expensive. While the SASI program has become the model for other parts of the school system, like special education, additional technological, training, and administrative costs have also been incurred throughout the organization. A new web-based program has been implemented throughout the school system; the nurses are currently connected to the new system and doing their reporting in this manner. This change also involved additional costs and administrative reorganization; current costs are more significant than those initially incurred. Nonetheless, the new administrative structure has become the model for other parts of the school system, like special education. The school system has also installed new printers and supplies; these changes have also affected the budgets for the years subsequent to the initial grant. A regular, ongoing, training program on all new systems is essential and also entails significant new expenditures. A new director of school nursing was also installed after the original head of nursing retired and is now in charge of an expanded set of responsibilities that includes “health professionals” for the St. Louis school system. While the new administrator was not officially appointed due to the added technical responsibilities, it is widely assumed by many that the new director of school nursing must be “computer savvy,” whereas previous administrators were not.

The initial survey and interview data clearly show that over the introductory period, the nursing population moved from very low levels of computer proficiency to moderately high levels of competency. In some instances, the increase in skill and ability levels improved dramatically over the implementation period. In addition, the interview data revealed that the introduction of computer responsibilities had a positive impact on changing nurses’ attitudes about their professional responsibilities related to electronic data processing and information management. Many nurses ultimately expressed gratitude and enthusiasm about the new responsibilities and identified numerous ways in which the introduction of computers opened new windows of opportunity for communication, research, and collaboration with other nurses.

Regardless of the many positive contributions made to the professional development of the school nurses, there are important additional concerns that need to be addressed to ensure the sustainability of the original initiative. These additional responsibilities reside more in the school system itself rather than with the school nurses. It is important to complete full implementation of the database and maintain a high level of computer proficiency. Not all components of the health information system were easily converted to the SASI system and have posed ongoing challenges to the DTS and the city’s administrators. While many components of the larger information system were initially operational through the SASI protocols, including immunizations, other important parts of the student health records were slower to be rendered fully operational. These include information about vision, hearing, scoliosis, and daily visit logs. These components of the database, while slow to become fully operational, have gradually been incorporated into the health management system. The increasing level of sophistication, however, places additional strains on the DTS managerial operation. To establish a consistent level of performance among all schools, additional training is required and will entail additional resources. While the two trainers employed as part of the original grant have been moved to the Division of Technology Services, the nurses still require assistance, technical support, and administrative services. These needs will require additional support provided by the school system itself but have proven difficult to sustain financially. By the 2005-2006 school years, the nurses were not able to access the same level of technical support with which they were accustomed. Due to budget cuts and reductions in administrative support, the St. Louis School system has found it difficult to sustain levels of technical support for the computer needs of school nurses at levels comparable to earlier efforts. Nonetheless, the effort has been sustained and the nurses continue to function at high levels of computer proficiency.

Overall, it is clear that the St. Louis case clearly establishes the importance of moving school nurses into the technological mainstream. This movement entails considerable financial investments and administrative reorganization. While the costs are substantial, the benefits produced are significant and permanent. As observed by one individual closely linked to the St. Louis initiative, “I think this project is an example of culture change. When moving from paper to a computer system, if implemented properly with training, they never go back. In fact, I think most people will limp along with worn out computers before returning to paper.” As the case indicates, it is critical that positive changes be sustained over time. Getting school nurses online, and keeping them online, involves the entire school system and the individuals and organizations responsible for administering it.