Digital Divide-Digital Solutions

By: Michael J. Rice Ph.D, ARNP, BC

Michael has been employed by the Washington State College of Nursing, Spokane Washington since 1989. A full professor, he teaches in the Psychiatric Nurse Practitioner Program. He received his Master's Degree in Psychiatric Nursing from the College of Nursing at the University of Nebraska Medical Center, Omaha Nebraska in 1976. He received his PH.D in Clinical Nursing Research from the University of Arizona College of Nursing in 1988. He has been board certified by ANCC in Psychiatric Mental Health since 1995 and is licensed as a Psychiatric ARNP in Washington State. He also has a private practice at the Suncrest Wellness Center which is located in Steven's County Washington, a federally designated medically underserved rural community. He is a strong advocate for the use of technology to meet health care needs in rural communities and the recipient of the prestigious EDUCAUSE 2002 Award for Excellence in Technology Solutions amd the 2003 award for “The Best Corporate and Industrial Training Model” from the Education and Information Systems Technologies and Applications (EISTA) division of the International Institute of Informatics.

Enhancing Rural Health Education Using PDA's*

Mental health care in Washington State, an area of almost 100,000 square miles, has suffered even more because of the decline of the rural health care infrastructures. The Washington State Office of Rural Health reports that thirty six areas in thirty nine counties are federally designated as medically underserved or suffer from health professional shortages. This lack of access to care providers required that any provider seen in a rural area be prepared to deal with psychiatric and mental health issues.

However, there is a marked digital divide between the urban and rural health care communities. Even as distance education of health professionals has advanced, practitioners have identified that they do not have access to expert information and consultation as do providers in more urban areas, even through the internet because of the absence of adequate internet connections in rural areas. The absence of the current information often results in patients being transported to locations, facilities and services hundreds of miles from their homes. 

This study used a pretest post test design to examine the impact of  Personal Digital Assistants (PDA’s) as an educational tool in psychiatric nurse practitioner students rural and medically underserved educational experience. Twenty one psychiatric nurse practitioner students in the final clinical internship were given PDA’s which included a pharmacology program. The PDA’s with the included program provided students direct access to medical information otherwise not available in the rural clinical settings. Seldom were the clinical pharmacologists immediately available and often the nearest resource was close to 100 miles away.

The pharmacology program included on the PDA’s was Dr. Drugs published by FA Davis and provided over the internet by Skyscape. The benefit of this particular program was that it allowed students to do automatic updates when they placed the PDA in the charger. Thus the updates were automatic.     Dr. Drugs also provided the students with a wide range of essential information. The program provides information on 1. combination drugs, 2. Drug monographs, 3 natural drugs, pharmacological classifications and 4 therapeutic classifications.Within each classification was a wide range  of detailed information including, 1 Adverse effects, 2. Indications for use, 3. Drug Interactions, 4. Availability and cost, 5.Dosing, 6. Pharmacokinetics and 7 Patient and family teaching. The last feature was particularily helpful as many clients were given samples to start treatment and ordered their medications through mail order pharmacies. Thus, the patient and family education was often the first pieces of information available about the patients medications. While not an the information may not have been an equivalent supplement to a  one on one with a pharmacist, for many rural patients, this was more information that they had previously had available.

 The data collected during the semester was analyzed using frequencies and paired t tests. The data analysis indicated that the students used the PDA’s on a daily basis. The largest problem with the PDA use continued to be based on Human error and was related to the students forgetting to recharge the PDA’s.   However, once the batteries were charged, the students used the PDA’s and many rural clinics began to demand that the students bring the PDA with them to their clinical practicums. Students often reported that the senior clinicians began to rely on and look over their shoulders at the information that could be drawn on at a moments notice.  

Analysis of the data using the t tests indicated that that the use of the PDA’s resulted in statistically significant differences (p=.05) in all 8 dimensions measure by the scale (Table 1); 1.  Ease of ability to access to electronic information , 2 Decreased time spent waiting to obtain electronic information, 3. Ease of receipt of detailed information relevant to care, 4. Speed of receipt of information, 5 Decreased need to use the Internet search for clinical databases, 6. Decreased need to ask Faculty for clarification of information on care, 7. An increased understanding of the professional role and responsibilities and 8.  Recognition of the similarity of using PDA’s to real world practice. The data clearly indicated that the PDA’s greatly facilitated the students learning and should be integrated as a standard tool in the rural clinical experiences.  

Table 1: Paired Samples Test



Std. Deviation

95% Confidence Interval










Ease of access information







Decreased time to obtain information







Ease of receipt of information







Speed of receipt of information







Decreased need to use Internet for clinical databases







Decreased need to ask Faculty for information







Increased understanding of role and responsibilities







Recognition of real world practice







Beyond the quantitative data, the value of the PDA’s in rural settings became priceless as indicated by two anecdotal pieces of evidence. First, within the first week of the students use of the PDA’s, the data on the PDA’s prevented two preceptors from ordering medications that would have been lethal when combined with the patients’ medications for other co morbid conditions. 

In the second case, a student had loaded a medical decision tree onto the PDA. The use of the PDA’s and the decision making software allowed the student and her preceptor to work on the labs of a difficult to treat client. The diagnostic decision making resulted in the identification of an auto recessive genetic defect in a 20 year old college student which is usually not identified for until age 30 or 40. The disorder, Wilson’s disease, is a metabolism disorder associated with copper that occurs in less than one in every 30,000 people.  However, because of the databases in the PDA, the condition was diagnosed and treatment initiated before permanent organ damage occurred. The results, indicate that providing graduate Psychiatric Nurse Practitioner students with  PDA’s changes both their educational experience and lives in areas where students obtain real world experiences.

*Supported by a grant from Suffolk Community College & Symbol Technologies


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