Review: evaluating information systems in nursing

Examining nurses' awareness level and compliance between defined and required access levels to core functionalities of hospital information system : an observational and survey study

BACKGROUND

Nurses constitute the largest number of hospital information system (HIS) users. Therefore, their awareness level and access to HIS functions based on their needs are particularly important. The present study aims to determine nurses' access levels to HIS functions and examine the compliance between defined and required access levels to core functionalities of a comprehensive HIS.

METHODS

This observational and survey study was conducted on nurses using the census method (n = 110) in two phases. In the first phase, nurses' current access levels to core functionalities of the hospitalization management subsystem were identified in HIS. In the second phase, nurses' awareness of defined access levels to HIS functions and compliance with their needs were investigated using a valid and reliable questionnaire (α = 0.90). The data were analyzed by descriptive and analytical statistics (t-test and one-way ANOVA).

RESULTS

The hospitalization management subsystem had 57 functions in 6 task groups. The information technology (IT) department enabled nurses to access 35 functions but did not allow them to access 22. 58.0% of the nurses were aware of those 35 functions they had access to, and 35.9% were aware of those 22 functions they needed access to. There was a significant correlation between nurses' awareness of current and defined access levels (p < 0.0001), so the mean defined access levels were 23.42, greater than the mean level of nurses' awareness of their current access to core functionalities.

CONCLUSION

Users' lack of awareness and access to HIS functions more or less than required could reduce user satisfaction, acceptance, and efficiency of optimal use of these systems. Therefore, hospital administrators and policymakers should determine users' access levels based on their needs in accordance with the actual workflow and periodic evaluations. The method used in our study could help policymakers, managers, and staff at the hospital IT department accurately identify users' needs for HIS functions.

Identifying the value of a clinical information system during the COVID-19 pandemic

The COVID-19 pandemic has significantly augmented the urgency for service providers to identify and develop clinically urgent system alterations into healthcare systems to facilitate antibody testing and treatment interventions. However, it has been difficult to determine how users assess the value of an information system in terms of its functionality and features. Conversely, the system development process to address urgent user requirements, for example, developing new functionality for COVID antibody testing, has been beset by a myriad of difficulties as research to understand the value of specific aspects of clinical information systems has been elusive. This study addresses this knowledge gap by identifying specific aspects of a national clinical information system in Wales, UK. Through a series of semi-structured interviews, a quantitative study of 559 clinical users and a focus group, the study deconstructs system-related value into 14 unique attributes that have been found to vary according to different types of user roles and geographic location.

Attribution theory is identified in this study as a novel and effective way to study this multifaceted concept of system value. The identification of component attributes of the value of a clinical information system provides insights for service users, system developers, and organization managers to prioritize and focus their system development activity by using an importance ranking identified through this study.

Use of standardized terminologies in clinical practice: A scoping review

AIM

To explore the use and impact of standardized terminologies (STs) within nursing and midwifery practice.

INTRODUCTION

The standardization of clinical documentation creates a potential to optimize patient care and safety. Nurses and midwives, who represent the largest proportion of the healthcare workforce worldwide, have been using nursing-specific and multidisciplinary STs within electronic health records (EHRs) for decades. However, little is known regarding ST use and impact within clinical practice.

METHODS

A scoping review of the literature was conducted (2019) across PubMed, CINAHL, Embase and CENTRAL in collaboration with the Five Country Nursing and Midwifery Digital Leadership Group (DLG). Identified studies (n = 3547) were reviewed against a number of agreed criterion, and data were extracted from included studies. Studies were categorized and findings were reviewed by the DLG.

RESULTS

One hundred and eighty three studies met the inclusion criteria. These were conducted across 25 different countries and in various healthcare settings, utilising mainly nursing-specific (most commonly NANDA-I, NIC, NOC and the Omaha System) and less frequently local, multidisciplinary or medical STs (e.g., ICD). Within the studies, STs were evaluated in terms of Measurement properties, Usability, Documentation quality, Patient care, Knowledge generation, and Education (pre and post registration). As well as the ST content, the impact of the ST on practice depended on the healthcare setting, patient cohort, nursing experience, provision of education and support in using the ST, and usability of EHRs.

CONCLUSION

Employment of STs in clinical practice has the capability to improve communication, quality of care and interoperability, as well as facilitate value-based healthcare and knowledge generation. However, employment of several different STs and study heterogeneity renders it difficult to aggregate and generalize findings.

Quality of patient information in emergency department

PURPOSE

Data comprise one of the key resources currently used in organizations. High-quality data are those that are appropriate for use by the customer. The quality of data is a key factor in determining the level of healthcare in hospitals, and its improvement leads to an improved quality of health and treatment and ultimately increases patient satisfaction. The purpose of this paper is to assess the quality of emergency patients' information in a hospital information system.

DESIGN/METHODOLOGY/APPROACH

This cross-sectional study was conducted on 385 randomly selected records of patients admitted to the emergency department of Shahid Beheshti Hospital in Kashan, Iran, in 2016. Data on five dimensions of quality, including accuracy, accessibility, timeliness, completeness and definition, were collected using a researcher-made checklist and were then analyzed in SPSS. The results are presented using descriptive statistics, such as frequency distribution and percentage.

FINDINGS

The overall quality of emergency patients' information in the hospital information system was 86 percent, and the dimensions of quality scored 87.7 percent for accuracy, 86.8 percent for completeness, 83.9 percent for timeliness, 79 percent for definition and 62.1 percent for accessibility.

ORIGINALITY/VALUE

Increasing the quality of patient information at emergency departments can lead to improvements in the timely diagnosis and management of diseases and patient and personnel satisfaction, and reduce hospital costs.

Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review

AIM

To review the evidence on the effects/impact of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings.

BACKGROUND

Electronic documentation has been recommended to improve quality care and patient safety. With the gradual move from paper-based to electronic nursing documentation internationally, there is a need to identify interventions that can effectively improve quality care and patient safety.

EVALUATION

We conducted a systematic review on the effectiveness of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings.

KEY ISSUES

Six articles reporting on six individual studies met all eligibility criteria. They were uncontrolled pre/post intervention studies reporting positive impacts on at least one or more outcomes. Most outcomes related to documentation practice and documentation of content.

CONCLUSION

Some evidence from our review indicates that implementing electronic nursing documentation in acute hospital settings is time saving, reduces rates of documentation errors, falls and infections.

IMPLICATIONS FOR NURSING MANAGEMENT

A planned approach from management over time to allow nurses adapt to new electronic systems of documentation would seem a good investment in terms of efficiency of work time, possibly resulting in more time for clinical care.

WITHDRAWN: Nursing record systems: effects on nursing practice and healthcare outcomes

BACKGROUND

A nursing record system is the record of care that was planned or given to individual patients and clients by qualified nurses or other caregivers under the direction of a qualified nurse. Nursing record systems may be an effective way of influencing nurse practice.

OBJECTIVES

To assess the effects of nursing record systems on nursing practice and patient outcomes.

SEARCH METHODS

For the original version of this review in 2000, and updates in 2003 and 2008, we searched: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; MEDLINE, EMBASE, CINAHL, BNI, ISI Web of Knowledge, and ASLIB Index of Theses. We also handsearched: Computers, Informatics, Nursing (Computers in Nursing); Information Technology in Nursing; and the Journal of Nursing Administration. For this update, searches can be considered complete until the end of 2007. We checked reference lists of retrieved articles and other related reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled before and after studies, and interrupted time series comparing one kind of nursing record system with another in hospital, community or primary care settings. The participants were qualified nurses, students or healthcare assistants working under the direction of a qualified nurse, and patients receiving care recorded or planned using nursing record systems.

DATA COLLECTION AND ANALYSIS

Two review authors (in two pairs) independently assessed trial quality and extracted data.

MAIN RESULTS

We included nine trials (eight RCTs, one controlled before and after study) involving 1846 people. The studies that evaluated nursing record systems focusing on relatively discrete and focused problems, for example effective pain management in children, empowering pregnant women and parents, reducing loss of notes, reducing time spent on data entry of test results, reducing transcription errors, and reducing the number of pieces of paper in a record, all demonstrated some degree of success in achieving the desired results. Studies of nursing care planning systems and total nurse records demonstrated uncertain or equivocal results.

AUTHORS' CONCLUSIONS

We found some limited evidence of effects on practice attributable to changes in record systems. It is clear from the literature that it is possible to set up the randomised trials or other quasi-experimental designs needed to produce evidence for practice. Qualitative nursing research to explore the relationship between practice and information use could be used as a precursor to the design and testing of nursing information systems.

Exploring nurses’ reactions to electronic nursing documentation at the point of care

Purpose

The purpose of this paper is to investigate nurses’ attitudes, perceptions, and reactions to a new point-of-care information system for documenting nursing care.

Design/methodology/approach

A design science research methodology (DSRM) was used to examine the feasibility and usability of a novel nursing informatics solution in the context of acute hospital care. Data were collected using focus groups and non-participant observations. Analyses were guided by the theoretical lens of actor-network theory (ANT).

Findings

The findings unpack an understanding of the potential value of a new technology, rather than a binary understanding of positive or negative value. Using the ANT lens, the study reveals the dynamics of the nurse-technology relationships and consequent disruptions throughout the translation process. The findings highlight the central role of negotiation in the socio-technical construction of the hybrid actor-network during the implementation of new technology in acute hospital contexts.

Research limitations/implications

Further studies are needed to investigate the dynamics and complexity of the translation process that occurs during technology adoption, reactions of the involved actors to the emerging network and impacts on their role and work process.

Practical implications

Engaging nurses early during development and testing; aligning the new system’s functionality and interface with nurses’ interests and work practices; and supporting changes to clinical work process to enable an effective heterogeneous actor-network to emerge and become stable.

Originality/value

This study presents a novel use of ANT in a DSRM to understand an enterprise-wide system involving nurses and real clinical settings. The emerged actor-network provides insights into the translation process when nurses adapt to using new technology in their work.

Information Processing in Nursing Information Systems: An Evaluation Study from a Developing Country

BACKGROUND

In recent years, information technology has been introduced in the nursing departments of many hospitals to support their daily tasks. Nurses are the largest end user group in Hospital Information Systems (HISs). This study was designed to evaluate data processing in the Nursing Information Systems (NISs) utilized in many university hospitals in Iran.

METHODS AND MATERIALS

This was a cross-sectional study. The population comprised all nurse managers and NIS users of the five training hospitals in Khorramabad city (N = 71). The nursing subset of HIS-Monitor questionnaire was used to collect the data. Data were analyzed by the descriptive-analytical method and the inductive content analysis.

RESULTS

The results indicated that the nurses participating in the study did not take a desirable advantage of paper (2.02) and computerized (2.34) information processing tools to perform nursing tasks. Moreover, the less work experience nurses have, the further they utilize computer tools for processing patient discharge information. The "readability of patient information" and "repetitive and time-consuming documentation" were stated as the most important expectations and problems regarding the HIS by the participating nurses, respectively.

CONCLUSIONS

The nurses participating in the present study used to utilize paper and computerized information processing tools together to perform nursing practices. Therefore, it is recommended that the nursing process redesign coincides with NIS implementation in the health care centers.

Factors that influence the implementation of e-health: a systematic review of systematic reviews (an update)

Background

There is a significant potential for e-health to deliver cost-effective, quality health care, and spending on e-health systems by governments and healthcare systems is increasing worldwide. However, there remains a tension between the use of e-health in this way and implementation. Furthermore, the large body of reviews in the e-health implementation field, often based on one particular technology, setting or health condition make it difficult to access a comprehensive and comprehensible summary of available evidence to help plan and undertake implementation. This review provides an update and re-analysis of a systematic review of the e-health implementation literature culminating in a set of accessible and usable recommendations for anyone involved or interested in the implementation of e-health.

Methods

MEDLINE, EMBASE, CINAHL, PsycINFO and The Cochrane Library were searched for studies published between 2009 and 2014. Studies were included if they were systematic reviews of the implementation of e-health. Data from included studies were synthesised using the principles of meta-ethnography, and categorisation of the data was informed by the Consolidated Framework for Implementation Research (CFIR).

Results

Forty-four reviews mainly from North America and Europe were included. A range of e-health technologies including electronic medical records and clinical decision support systems were represented. Healthcare settings included primary care, secondary care and home care. Factors important for implementation were identified at the levels of the following: the individual e-health technology, the outer setting, the inner setting and the individual health professionals as well as the process of implementation.

Conclusion

This systematic review of reviews provides a synthesis of the literature that both acknowledges the multi-level complexity of e-health implementation and provides an accessible and useful guide for those planning implementation. New interpretations of a large amount of data across e-health systems and healthcare settings have been generated and synthesised into a set of useable recommendations for practice. This review provides a further empirical test of the CFIR and identifies areas where additional research is necessary.

Trial registration

PROSPERO, CRD42015017661

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0510-7) contains supplementary material, which is available to authorized users.

Implementation Processes of Hospital Information Management Systems: A Field Study in Turkey

Our aim is to reflect our experience of developing and implementing of an integrated Hospital Information Management System (HIMS), its financing contributions, technical and managerial challenges and key designing and planning factors. Following the strategic planning stage, HIMS was implemented into the hospital. Key issues were observed, total training hours and satisfaction levels of staff were followed year by year. Number of patients, surgeries and total income of the hospital were analysed. Cessation of printing radiology films, paper and manpower earnings were calculated. After the implementation of HIMS, total income of the hospital increased 37% in the first year. Total financial savings (paper printing, radiology films and manpower) as a result of HIMS implementation were approximately US$ 1.34[Formula: see text]million. HIMS prevents losses and leakages of medical materials, medicines and unnecessary processes in healthcare institutions. For an appropriate implementation of HIMS, healthcare managers should lend priority to seven critical design and implementation issues: (1) effective accessibility, (2) interoperability and integration, (3) ease of use (4) improvement of the quality of processes (5) centralised administration, (6) privacy and digital security, (7) precautions against resistance to IT.

An importance-performance analysis of hospital information system attributes: A nurses' perspective

PURPOSE

Health workers have numerous concerns about hospital IS (HIS) usage. Addressing these concerns requires understanding the system attributes most important to their satisfaction and productivity. Following a recent HIS implementation, our objective was to identify priorities for managerial intervention based on user evaluations of the performance of the HIS attributes as well as the relative importance of these attributes to user satisfaction and productivity outcomes.

PROCEDURES

We collected data along a set of attributes representing system quality, data quality, information quality, and service quality from 154 nurse users. Their quantitative responses were analysed using the partial least squares approach followed by an importance-performance analysis. Qualitative responses were analysed using thematic analysis to triangulate and supplement the quantitative findings.

MAIN FINDINGS

Two system quality attributes (responsiveness and ease of learning), one information quality attribute (detail), one service quality attribute (sufficient support), and three data quality attributes (records complete, accurate and never missing) were identified as high priorities for intervention.

CONCLUSIONS

Our application of importance-performance analysis is unique in HIS evaluation and we have illustrated its utility for identifying those system attributes for which underperformance is not acceptable to users and therefore should be high priorities for intervention.

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Background

Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.

Objectives

This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.

Design

We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.

Setting

Welsh Government and NHS Wales.

Participants

Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.

Main outcome measures

Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.

Results

An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.

Conclusions

Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The impact of using electronic patient records on practices of reading and writing

The aim of this study was to investigate the use of electronic patient records in daily practice. In four wards of a large hospital district in Finland, N = 43 patients' care and activities were observed and analysed in terms of the Grounded Theory method. The findings revealed that using electronic patient records created a particular process of writing and reading. Wireless technology enabled simultaneous patient involvement and point-of-care documentation, additionally supporting real-time reading. Remote and retrospective documentation was distant in terms of both space and time. The remoteness caused double documentation, reduced accuracy and less-efficient use of time. 'Non-reading' practices were witnessed in retrospective reading, causing delays in patient care and increase in workload. Similarly, if documentation was insufficient or non-existent, the consequences were found to be detrimental to the patients. The use of an electronic patient record system has a significant impact on patient care. Therefore, it is crucial to develop wireless technology and interdisciplinary collaboration in order to improve and support high-quality patient care.

Using principal components analysis to explore competence and confidence in student nurses as users of information and communication technologies

Aim

To report on the relationship between competence and confidence in nursing students as users of information and communication technologies, using principal components analysis.

Design

In nurse education, learning about and learning using information and communication technologies is well established. Nursing students are one of the undergraduate populations in higher education required to use these resources for academic work and practice learning. Previous studies showing mixed experiences influenced the choice of an exploratory study to find out about information and communication technologies competence and confidence. A 48‐item survey questionnaire was administered to a volunteer sample of first‐ and second‐year nursing students between July 2008–April 2009. The cohort (N = 375) represented 18·75% of first‐ and second‐year undergraduates. A comparison between this work and subsequent studies reveal some similar ongoing issues and ways to address them.

Methods

A principal components analysis (PCA) was carried out to determine the strength of the correlation between information and communication technologies competence and confidence. The aim was to show the presence of any underlying dimensions in the transformed data that would explain any variations in information and communication technologies competence and confidence. Cronbach's alpha values showed fair to good internal consistency.

Results

The five component structure gave medium to high results and explained 44·7% of the variance in the original data. Confidence had a high representation. The findings emphasized the shift towards social learning approaches for information and communication technologies. Informal social collaboration found favour with nursing students. Learning through talking, watching and listening all play a crucial role in the development of computing skills.

Innovations in inpatient flow and bed management

Purpose

– The purpose of this paper is to address a gap in operations management empirical research through the use of diffusion of innovation (DOI) theory to develop further insight into patient flow and bed management, a problem that has been taxing healthcare organizations across the world.

Design/methodology/approach

– The study used an action research (AR) approach and was conducted over an 18-month period within an acute hospital in the north east of England. Data were generated through enacting AR cycles, interviews, participant observation, document analysis, diaries, meetings, questionnaires and statistical analysis.

Findings

– The research conducted within this study has not only led to practical outcomes for the hospital in terms of the successful adoption of a new patient flow system but has also led to new knowledge about the determinants of diffusion for technological and process innovations in healthcare organizations which are complex and highly political.

Research limitations/implications

– AR is not suited to all organizations and is most appropriate within those that are culturally attuned to participative and democratic ways of working. The results from this study are not generalizable but some similar organizations may see merits in this approach.

Social implications

– The AR approach has supported the hospital in adopting the new system, PFMS. This system is helping to improve the quality of patient care, providing facilities to support the work of clinicians, aiding timely discharge of well patients back into the community and saving the hospital money in terms of not needing to open emergency “winter” wards.

Originality/value

– From an operations management perspective this work has demonstrated the potential to bring theory, in this case DOI theory, and practice closer together as well as show how academic research can impact organizations. Local-H intends to continue developing its AR approach and take it into other systems projects.

Effectiveness of nursing management information systems: a systematic review

Objectives

The purpose of this study was to review evaluation studies of nursing management information systems (NMISs) and their outcome measures to examine system effectiveness.

Methods

For the systematic review, a literature search of the PubMed, CINAHL, Embase, and Cochrane Library databases was conducted to retrieve original articles published between 1970 and 2014. Medical Subject Headings (MeSH) terms included informatics, medical informatics, nursing informatics, medical informatics application, and management information systems for information systems and evaluation studies and nursing evaluation research for evaluation research. Additionally, manag^* and admin^*, and nurs^* were combined. Title, abstract, and full-text reviews were completed by two reviewers. And then, year, author, type of management system, study purpose, study design, data source, system users, study subjects, and outcomes were extracted from the selected articles. The quality and risk of bias of the studies that were finally selected were assessed with the Risk of Bias Assessment Tool for Non-randomized Studies (RoBANS) criteria.

Results

Out of the 2,257 retrieved articles, a total of six articles were selected. These included two scheduling programs, two nursing cost-related programs, and two patient care management programs. For the outcome measurements, usefulness, time saving, satisfaction, cost, attitude, usability, data quality/completeness/accuracy, and personnel work patterns were included. User satisfaction, time saving, and usefulness mostly showed positive findings.

Conclusions

The study results suggest that NMISs were effective in time saving and useful in nursing care. Because there was a lack of quality in the reviewed studies, well-designed research, such as randomized controlled trials, should be conducted to more objectively evaluate the effectiveness of NMISs.

Can information and communication technologies support patient engagement? A review of opportunities and challenges in health social work

Despite becoming a prerequisite for participation in an information-based society, the use of information communication technologies (ICT) within social work and health care remains in its infancy. Currently, there is a push to adopt newer technologies to enhance practice. This article aims to highlight some of the innovative ways in which ICT have been adopted and adapted to augment social work practice. The need for social workers to become proficient in the use of newer technologies, opportunities for implementing ICT within a health care setting, and potential challenges at the professional, ethical, and systemic level are explored. Using the available literature as a guide, recommendations and strategies to strengthen implementation of ICTs into health social work are provided.

Educator informed practice within a triadic preceptorship model

Preceptorships have long been a subject of scholarship with proven effectiveness in preparing nursing students to transition into beginning graduate nurses. Nursing research has predominantly focused on the dyadic preceptor-student relationship. The triadic pedagogical relationship between educator-student-preceptor has garnered less attention and inquiry. Nurse educators' experience in preceptorships is under reported. Through a process of scholarly inquiry, nurse educators from one western Canada School of Nursing documented their experiences and professional judgment in facilitating preceptorships over one semester. In the context of the anticipated exodus of nursing experts in the midst of rapidly changing healthcare delivery, this paper recommends a reemphasis on preceptorships as a triadic pedagogical relationship. Educator informed practices that foster triadic relationships in preceptorships include attending to distant relationships, being mindful of the influence of continuity, recognizing a preceptor's proficiency, responding to rapidly changing and complex environments, facilitating common understanding through communication, and integrating practice and education performance expectations.

Description and comparison of documentation of nursing assessment between paper-based and electronic systems in Australian aged care homes

PURPOSE

To describe nursing assessment documentation practices in aged care organizations and to evaluate the quality of electronic versus paper-based documentation of nursing assessment.

METHODS

This was a retrospective nursing documentation audit study. Study samples were 2299 paper-based and 6997 electronic resident assessment forms contained in 159 paper-based and 249 electronic resident nursing records, respectively, from three aged care organizations. The practice of nursing assessment documentation in participating aged care homes was described. Three attributes of quality of nursing assessment documentation were evaluated: format and structure, process, and content by seven measures: quantity, completeness, timeliness comprehensiveness, frequencies of documentation specific to care domains and data items, and whether assessment forms were signed and dated.

RESULTS

Varying practice in documentation of nursing assessment was found among different aged care organizations and homes. Electronic resident records contained higher numbers and more comprehensive resident assessment forms than paper-based records. The frequency of documentation was higher in electronic than in paper-based records in relation to most care domains. There was no difference between the two types of documentation systems on other aspects of nursing assessment documentation (overall completeness and timeliness, variation of frequencies among different care domains, and item completion in personal hygiene assessment forms).

CONCLUSIONS

Electronic nursing documentation systems could improve the quality of documentation structure and format, process and content in the aspects of quantity, comprehensiveness and signing and dating of assessment forms. Further studies are needed to understand the factors leading to the variations of practice and the limitations of nursing assessment documentation and to evaluate documentation quality from a clinical perspective.

Unintended adverse consequences of introducing electronic health records in residential aged care homes

PURPOSE

The aim of this study was to investigate the unintended adverse consequences of introducing electronic health records (EHR) in residential aged care homes (RACHs) and to examine the causes of these unintended adverse consequences.

METHOD

A qualitative interview study was conducted in nine RACHs belonging to three organisations in the Australian Capital Territory (ACT), New South Wales (NSW) and Queensland, Australia. A longitudinal investigation after the implementation of the aged care EHR systems was conducted at two data points: January 2009 to December 2009 and December 2010 to February 2011. Semi-structured interviews were conducted with 110 care staff members identified through convenience sampling, representing all levels of care staff who worked in these facilities. Data analysis was guided by DeLone and McLean Information Systems Success Model, in reference with the previous studies of unintended consequences for the introduction of computerised provider order entry systems in hospitals.

RESULTS

Eight categories of unintended adverse consequences emerged from 266 data items mentioned by the interviewees. In descending order of the number and percentage of staff mentioning them, they are: inability/difficulty in data entry and information retrieval, end user resistance to using the system, increased complexity of information management, end user concerns about access, increased documentation burden, the reduction of communication, lack of space to place enough computers in the work place and increasing difficulties in delivering care services. The unintended consequences were caused by the initial conditions, the nature of the EHR system and the way the system was implemented and used by nursing staff members.

CONCLUSIONS

Although the benefits of the EHR systems were obvious, as found by our previous study, introducing EHR systems in RACH can also cause adverse consequences of EHR avoidance, difficulty in access, increased complexity in information management, increased documentation burden, reduction of communication and the risks of lacking care follow-up, which may cause negative effects on aged care services. Further research can focus on investigating how the unintended adverse consequences can be mitigated or eliminated by understanding more about nursing staff's work as well as the information flow in RACH. This will help to improve the design, introduction and management of EHR systems in this setting.

Factors of accepting pain management decision support systems by nurse anesthetists

BACKGROUND

Pain management is a critical but complex issue for the relief of acute pain, particularly for postoperative pain and severe pain in cancer patients. It also plays important roles in promoting quality of care. The introduction of pain management decision support systems (PM-DSS) is considered a potential solution for addressing the complex problems encountered in pain management. This study aims to investigate factors affecting acceptance of PM-DSS from a nurse anesthetist perspective.

METHODS

A questionnaire survey was conducted to collect data from nurse anesthetists in a case hospital. A total of 113 questionnaires were distributed, and 101 complete copies were returned, indicating a valid response rate of 89.3%. Collected data were analyzed by structure equation modeling using the partial least square tool.

RESULTS

The results show that perceived information quality (γ=.451, p<.001), computer self-efficacy (γ=.315, p<.01), and organizational structure (γ=.210, p<.05), both significantly impact nurse anesthetists' perceived usefulness of PM-DSS. Information quality (γ=.267, p<.05) significantly impacts nurse anesthetists' perceptions of PM-DSS ease of use. Furthermore, both perceived ease of use (β=.436, p<.001, R(2)=.487) and perceived usefulness (β=.443, p<.001, R(2)=.646) significantly affected nurse anesthetists' PM-DSS acceptance (R2=.640). Thus, the critical role of information quality in the development of clinical decision support system is demonstrated.

CONCLUSIONS

The findings of this study enable hospital managers to understand the important considerations for nurse anesthetists in accepting PM-DSS, particularly for the issues related to the improvement of information quality, perceived usefulness and perceived ease of use of the system. In addition, the results also provide useful suggestions for designers and implementers of PM-DSS in improving system development.

Description and comparison of quality of electronic versus paper-based resident admission forms in Australian aged care facilities

PURPOSE

To describe the paper-based and electronic formats of resident admission forms used in several aged care facilities in Australia and to compare the extent to which resident admission information was documented in paper-based and the electronic health records.

METHODS

Retrospective auditing and comparison of the documentation quality of paper-based and electronic resident admission forms were conducted. A checklist of admission data was qualitatively derived from different formats of the admission forms collected. Three measures were used to assess the quality of documentation of the admission forms, including completeness rate, comprehensiveness rate and frequency of documented data element. The associations between the number of items and their completeness and comprehensiveness rates were estimated at a general level and at each information category level.

RESULTS

Various paper-based and electronic formats of admission forms were collected, reflecting varying practice among the participant facilities. The overall completeness and comprehensiveness rates of the admission forms were poor, but were higher in the electronic health records than in the paper-based records (60% versus 56% and 40% versus 29% respectively, p<0.01). There were differences in the overall completeness and comprehensiveness rates between the different formats of admission forms (p<0.01). At each information category level, varying degrees of difference in the completeness and comprehensiveness rates were found between different form formats and between the paper-based and the electronic records. A negative association between the completeness rate and the number of items in a form was found at each information category level (p<0.01), i.e., more data items designed in a form, the less likely that the items would be completely filled. However, the associations between the comprehensiveness rates and the number of items were highly positive at both overall and individual information category levels (p<0.01), suggesting more items designed in a form, more information would be captured.

CONCLUSION

Better quality of documentation in resident admission forms was identified in the electronic documentation systems than in previous paper-based systems, but still needs to be further improved in practice. The quality of documentation of resident admission data should be further analysed in relation to its specific content.

Contribuições dos registros eletrônicos para a segurança do paciente em terapia intensiva: uma revisão integrativa

Revisão integrativa que analisou nas publicações as contribuições dos registros eletrônicos em saúde para a segurança do paciente em unidades de terapia intensiva. A pesquisa foi realizada nas bases de dados CINAHL, MEDLINE e SciELO, utilizando os descritores: registros eletrônicos de saúde, sistemas de informação, informática em enfermagem, informática médica, unidades de terapia intensiva, segurança do paciente e gerenciamento de segurança. Foram incluídos 64 artigos, sendo analisados em três categorias: "sistemas de informação e informática em saúde: o registro eletrônico para a continuidade do cuidado de Enfermagem", "sistemas de apoio à decisão: contribuições para a segurança do paciente" e "indicadores de qualidade do cuidado e de segurança do paciente partir dos registros eletrônicos". Os estudos apontaram como contribuições a continuidade do cuidado, a tomada de decisão baseada nos sistemas de apoio à decisão e a criação de indicadores de qualidade e segurança do paciente a partir dos registros eletrônicos.

Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review

OBJECTIVE

To systematically review the literature on the implementation of e-health to identify: (i) barriers and facilitators to e-health implementation, and (ii) outstanding gaps in research on the subject.

METHODS

MEDLINE, EMBASE, CINAHL, PSYCINFO and the Cochrane Library were searched for reviews published between 1 January 1995 and 17 March 2009. Studies had to be systematic reviews, narrative reviews, qualitative metasyntheses or meta-ethnographies of e-health implementation. Abstracts and papers were double screened and data were extracted on country of origin; e-health domain; publication date; aims and methods; databases searched; inclusion and exclusion criteria and number of papers included. Data were analysed qualitatively using normalization process theory as an explanatory coding framework.

FINDINGS

Inclusion criteria were met by 37 papers; 20 had been published between 1995 and 2007 and 17 between 2008 and 2009. Methodological quality was poor: 19 papers did not specify the inclusion and exclusion criteria and 13 did not indicate the precise number of articles screened. The use of normalization process theory as a conceptual framework revealed that relatively little attention was paid to: (i) work directed at making sense of e-health systems, specifying their purposes and benefits, establishing their value to users and planning their implementation; (ii) factors promoting or inhibiting engagement and participation; (iii) effects on roles and responsibilities; (iv) risk management, and (v) ways in which implementation processes might be reconfigured by user-produced knowledge.

CONCLUSION

The published literature focused on organizational issues, neglecting the wider social framework that must be considered when introducing new technologies.

Factors determining nurse acceptance of hospital information systems

This study proposed an evaluation model, derived from the Technology Acceptance Model and Information System Success Model, to explore factors influencing the acceptance of hospital information systems by nurses. Although many healthcare institutions have applied hospital information systems, relatively few studies have investigated the perceptions of nurses regarding the usefulness, ease of use, or acceptance of these systems. This study recruited the nursing staff of a regional hospital in Taiwan. A total of 297 questionnaires were sent, and 277 were returned, for a response rate of 93.3%. The results indicated that system quality, information quality, and service quality were positively correlated with the perceived ease of use (R=0.69) and perceived usefulness (R=0.72). Information quality has the greatest influence on perceived usefulness (γ3=0.57, P<.001) and ease of use (γ4=0.61, P<.001). Perceived usefulness and ease of use have a significant influence on system acceptance (R=0.75). Perceived usefulness (β1=0.61, P<.001) has a significant influence on system acceptance. These findings indicated that nursing care requires high-quality healthcare information to support the daily activities of nursing professionals. The results of this study also provide a valuable reference for hospital administrators in developing hospital information systems.

Health information technology in the workplace: findings from a 2010 national survey of registered nurses

The objective of this study was to examine RNs' experiences with health information technology (HIT) and their perceptions of the effect of this technology on quality of care and daily work. The adoption and use of HIT are expected to increase substantially over the next 5 years because of policy efforts at the federal and state levels. Given the size of the RN workforce and their critical role in healthcare delivery, their experiences with HIT could help adoption efforts. The method used was a nationally representative survey of 1500 nurses with a 56% response rate. Findings suggest wide variation in the availability of HIT functionality, with functions more likely available to hospital RNs. Overall, RNs perceived the effect of these technologies on quality of care and their daily work as positive. Ensuring that HIT systems are relevant to and usable for RNs will be a critical component in achieving the meaningful use of these systems.

A study of factors affecting acceptance of hospital information systems: a nursing perspective

BACKGROUND

Hospital information systems (HISs) are widely used in Taiwan, and HIS performance must be carefully evaluated. Nursing personnel are the largest group of staff in a hospital and are the center of care delivery; thus, they play an important role in the adoption and evaluation of HISs.

PURPOSE

The primary objective of this study was to explore the critical factors affecting the acceptance of HISs in Taiwan from a nursing perspective. On the basis of the technology acceptance model, we used six exogenous variables (system quality, information quality, user self-efficacy, compatibility, top management support, and project team competency) as investigation factors.

METHODS

Survey research targeted nursing personnel in the selected case hospital as participants. A total of 545 questionnaires were sent out, and 501 were returned, indicating a valid response rate of 91.9%. Collected data were analyzed using multiple regression analysis.

RESULTS

: Results indicate that user self-efficacy, top management support, compatibility, and information quality have significant impacts on perceived ease of use. In addition, top management support, compatibility, and information quality were identified as having significant impacts on perceived usefulness. Furthermore, nurses' perceived ease of use and perceived usefulness on HISs was found to impact significantly on system acceptance, with 45.1% of the total explained variance.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Results can help managers understand key considerations affecting HIS development and use and may be applied as a reference for system development and improvement.

Nurses' experience of using electronic patient records in everyday practice in acute/inpatient ward settings: A literature review

Electronic patient record (EPR) systems have a huge impact on nursing documentation. Although the largest group of end-users of EPRs, nurses have had minimal input in their design. This study aimed to review current research on how nurses experience using the EPR for documentation. A literature search was conducted in Medline and Cinahl of original, peer-reviewed articles from 2000 to 2009, focusing on nurses in acute/ inpatient ward settings. After critical assessment, two quantitative and three qualitative articles were included in the study. Results showed that nurses experience widespread dissatisfaction with systems. Current systems are not designed to meet the needs of clinical practice as they are not user-friendly, resulting in a potentially negative impact on individualized care and patient safety. There is an urgent need for nurses to be directly involved in software design to ensure that the essence and complexity of nursing is not lost in the system.

ICU nurses' acceptance of electronic health records

OBJECTIVE

To assess intensive care unit (ICU) nurses' acceptance of electronic health records (EHR) technology and examine the relationship between EHR design, implementation factors, and nurse acceptance.

DESIGN

The authors analyzed data from two cross-sectional survey questionnaires distributed to nurses working in four ICUs at a northeastern US regional medical center, 3 months and 12 months after EHR implementation.

MEASUREMENTS

Survey items were drawn from established instruments used to measure EHR acceptance and usability, and the usefulness of three EHR functionalities, specifically computerized provider order entry (CPOE), the electronic medication administration record (eMAR), and a nursing documentation flowsheet.

RESULTS

On average, ICU nurses were more accepting of the EHR at 12 months as compared to 3&emsp14;months. They also perceived the EHR as being more usable and both CPOE and eMAR as being more useful. Multivariate hierarchical modeling indicated that EHR usability and CPOE usefulness predicted EHR acceptance at both 3 and 12 months. At 3 months postimplementation, eMAR usefulness predicted EHR acceptance, but its effect disappeared at 12 months. Nursing flowsheet usefulness predicted EHR acceptance but only at 12 months.

CONCLUSION

As the push toward implementation of EHR technology continues, more hospitals will face issues related to acceptance of EHR technology by staff caring for critically ill patients. This research suggests that factors related to technology design have strong effects on acceptance, even 1&emsp14;year following the EHR implementation.

Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review

AIMS

This paper reports a review that identified and synthesized nursing documentation audit studies, with a focus on exploring audit approaches, identifying audit instruments and describing the quality status of nursing documentation.

INTRODUCTION

Quality nursing documentation promotes effective communication between caregivers, which facilitates continuity and individuality of care. The quality of nursing documentation has been measured by using various audit instruments, which reflected variations in the perception of documentation quality among researchers across countries and settings.

DATA SOURCES

Searches were made of seven electronic databases. The keywords 'nursing documentation', 'audit', 'evaluation', 'quality', both singly and in combination, were used to identify articles published in English between 2000 and 2010.

REVIEW METHODS

A mixed-method systematic review of quantitative and qualitative studies concerning nursing documentation audit and reports of audit instrument development was undertaken. Relevant data were extracted and a narrative synthesis was conducted.

RESULTS

Seventy-seven publications were included. Audit approaches focused on three natural dimensions of nursing documentation: structure or format, process and content. Numerous audit instruments were identified and their psychometric properties were described. Flaws of nursing documentation were identified and the effects of study interventions on its quality.

CONCLUSION

Research should pay more attention to the accuracy of nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement.

Hospital information technology systems' impact on nurses and nursing care

OBJECTIVE

We conducted a review of the literature to determine the impact of health information technologies (HITs) on nurses and nursing care.

BACKGROUND

Nurses' effective use of HIT has the potential to produce a positive impact on nursing-sensitive patient outcomes, patient safety, and quality of care.

METHODS

A review of the literature produced 564 unique references of which 74 were selected for review.

RESULTS

Findings suggest that (1) HIT improves the quality of nursing documentation; (2) HIT reduces medication administration errors; (3) nurses are generally satisfied with HIT and have positive attitudes about it; and (4) nurse involvement in all stages of HIT design and implementation, and effective leadership throughout these processes, can improve HIT.

CONCLUSION

HIT has had positive influences on nurse satisfaction and patient care. Effective nursing leadership can positively influence the effective development, dissemination, and use of HIT.

The experience of home nurses with an electronic nursing health record

BACKGROUND

Electronic records are currently being introduced in both the hospital and the home care setting. However, there are few studies focusing on the evaluation of an electronic nursing record (ENR) from applicability to technicality and soft- and hardware, and from the perspective of home nurses.

AIM

The study aims to evaluate home nurses' experiences with an ENR.

METHODS

A qualitative, explorative study was used by means of 13 in-depth interviews with home nurses, head nurses and Administrators, and four focus groups with a total of 24 home nurses. All participants were employees of the Wit-Gele Kruis, an organization for home nursing in Flanders, Belgium.

FINDINGS

This study revealed three levels that feature the implementation and integration of an ENR in home nursing: the preparation, the technicality of the ENR and the 'user' as an individual. Despite technical difficulties, the home nurses are willing to give the ENR a chance, because they believe in its value. But, at the same time, they are trying to find a balance between this belief and their capacity to learn to work with an IT device. This involves the need to integrate the ENR in their daily work, to meet their responsibility towards the patient and their belief that his care comes first, the impact of technical difficulties on their workload and the integration of the ENR in their personal lives.

CONCLUSION

This study provided insights in the necessity for a multilevel approach when implementing an ENR in home nursing.

Nurses' perception of the use of computerised information systems in practice: questionnaire development

AIM

To develop and validate a questionnaire to explore the perceptions of nurses about the implementation of a computerised information system in clinical practice.

BACKGROUND

A growing interest in understanding nurses' experience of developing and implementing clinically relevant Information Technology systems and the lack of measurement tools in this area, justifies further research into the development of instruments to provide an insight into nurses' experience.

DESIGN

Survey and questionnaire development.

METHOD

An initial draft of the questionnaire was developed based on the literature and expert opinion. The questionnaire was piloted by ten nurses to check face validity, reliability and test-retest reliability. A revised version of the questionnaire was distributed to nurses working in the in-patient area of a university hospital in Spain (n = 227). Principal components analysis with oblique rotation was carried out to test theoretically developed underlying dimensions and to test construct validity. Cronbach's alpha coefficient was used to determine internal consistency.

RESULTS

Cronbach's alpha for all the items included in the different scales was 0.88 in the pilot questionnaire and test-retest reliability was adequate. Principal components analysis of items related to mechanisms produced a three-component structure ('IT support', 'usability' and 'information characteristics'). The three factors explained 48.6% of the total variance and Cronbach's alpha ranged from 0.66-0.79. Principal components analysis of items related to outcomes produced a three factor solution ('impact on patient care', 'impact on communication' and 'image profile'). The factors explained 65.9% of the total variance and Cronbach's alpha ranged from 0.64-0.85.

CONCLUSION

The study provides a detailed description and justification of an instrument development process. The instrument is valid and reliable for the setting where it has been used.

RELEVANCE TO CLINICAL PRACTICE

The instrument could provide insight into nurses' experience of IT implementation that will guide further development of systems to enhance clinical practice.

A quantitative analysis of the impact of a computerised information system on nurses' clinical practice using a realistic evaluation framework

OBJECTIVE

To explore nurses' perceptions of the impact on clinical practice of the use of a computerised hospital information system.

DESIGN

A realistic evaluation design based on Pawson and Tilley's work has been used across all the phases of the study. This is a theory-driven approach and focuses evaluation on the study of what works, for whom and in what circumstances. These relationships are constructed as context-mechanisms-outcomes (CMO) configurations.

MEASUREMENTS

A questionnaire was distributed to all nurses working in in-patient units of a university hospital in Spain (n=227). Quantitative data were analysed using SPSS 13.0. Descriptive statistics were used for an overall overview of nurses' perception. Inferential analysis, including both bivariate and multivariate methods (path analysis), was used for cross-tabulation of variables searching for CMO relationships.

RESULTS

Nurses (n=179) participated in the study (78.8% response rate). Overall satisfaction with the IT system was positive. Comparisons with context variables show how nursing units' context had greater influence on perceptions than users' characteristics. Path analysis illustrated that the influence of unit context variables are on outcomes and not on mechanisms.

CONCLUSION

Results from the study looking at subtle variations in users and units provide insight into how important professional culture and working practices could be in IT (information technology) implementation. The socio-technical approach on IT systems evaluation suggested in the recent literature appears to be an adequate theoretical underpinning for IT evaluation research. Realistic evaluation has proven to be an adequate method for IT evaluation.

Nursing record systems: effects on nursing practice and healthcare outcomes

BACKGROUND

A nursing record system is the record of care that was planned or given to individual patients and clients by qualified nurses or other caregivers under the direction of a qualified nurse. Nursing record systems may be an effective way of influencing nurse practice.

OBJECTIVES

To assess the effects of nursing record systems on nursing practice and patient outcomes.

SEARCH STRATEGY

For the original version of this review in 2000, and updates in 2003 and 2008, we searched: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; MEDLINE, EMBASE, CINAHL, BNI, ISI Web of Knowledge, and ASLIB Index of Theses. We also handsearched: Computers, Informatics, Nursing (Computers in Nursing); Information Technology in Nursing; and the Journal of Nursing Administration. For this update, searches can be considered complete until the end of 2007. We checked reference lists of retrieved articles and other related reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled before and after studies, and interrupted time series comparing one kind of nursing record system with another in hospital, community or primary care settings. The participants were qualified nurses, students or healthcare assistants working under the direction of a qualified nurse, and patients receiving care recorded or planned using nursing record systems.

DATA COLLECTION AND ANALYSIS

Two review authors (in two pairs) independently assessed trial quality and extracted data.

MAIN RESULTS

We included nine trials (eight RCTs, one controlled before and after study) involving 1846 people. The studies that evaluated nursing record systems focusing on relatively discrete and focused problems, for example effective pain management in children, empowering pregnant women and parents, reducing loss of notes, reducing time spent on data entry of test results, reducing transcription errors, and reducing the number of pieces of paper in a record, all demonstrated some degree of success in achieving the desired results. Studies of nursing care planning systems and total nurse records demonstrated uncertain or equivocal results.

AUTHORS' CONCLUSIONS

We found some limited evidence of effects on practice attributable to changes in record systems. It is clear from the literature that it is possible to set up the randomised trials or other quasi-experimental designs needed to produce evidence for practice. Qualitative nursing research to explore the relationship between practice and information use could be used as a precursor to the design and testing of nursing information systems.