International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571

Original Research Article

Confident or Confused: Nurses’ Perception and Acceptability of Electronic Documentation

Sulakshana Chand1, Jyoti Sarin2

1Northside Hospital, Atlanta, GA 30071 2Dean Principal, MM College of Nursing, Mullana, Ambala. Haryana

Corresponding Author: Sulakshana Chand

ABSTRACT

Nurses for the longest time have maintained paper-based records pertaining to the rendered patient care. The past few decades, however, have witnessed the transition of nursing from a simple care to much more complex profession thus entailing accurate, complete, comprehensive and quality nursing records. To counter the potential risks of illegible, inaccurate, incomplete paper-based nursing documentation (to mention a few), electronic documentation is rapidly finding roots in the healthcare setting. Computerization is taking over as paper-based documentation is phasing out. Successful implementation of technology primarily depends on user perception and acceptance. It is thus critical to understand nurses‟ perception, readiness and willingness to adapt electronic documentation. The present study explores nurses‟ perception, acceptability and utility of electronic nursing documentation program using a quasi-experimental approach with pretest posttest design. Perception assessment scale and acceptability and utility opinionnaire was utilized to collect data from 44 nurses working in ICU, surgical ICU and emergency units in a rural teaching tertiary care hospital. Nurses‟ perception was assessed pre and post-implementation of electronic nursing documentation program, whereas nurses‟ acceptability and utility of was assessed on day 100 of implementation of program. Findings revealed a significant overall and unit wise enhancement in the perception of nurses‟ post- implementation of electronic nursing documentation program. A weak positive relationship was established between perception and acceptability of utility of nurses exposed to electronic nursing documentation program.

Keywords: Electronic nursing documentation (END), Nursing documentation, Perception, Patient records.

INTRODUCTION facilitates coordination advancement, The significance of nursing records continuity and consistent quality was realized long ago when Florence improvement. In addition to providing Nightingale, the nursing pioneer realized the evidence of care, documentation is also a criticality of formal nursing documentation critical professional and medico legal to facilitate clear and thorough nursing requirement of nursing practice. [2] communication among care providers. [1] Thorough nursing documentation is Appropriate legible documentation provides considered a precondition for quality patient an accurate reflection of nursing care, efficient communication and assessments, alteration in conditions, care cooperation among the members of rendered and pertinent patient information healthcare team and should reflect nursing to support the multidisciplinary team to observation, assessments, decisions and deliver great care. Complete documentation interventions. [3] Deficiencies in nursing

International Journal of Health Sciences & Research (www.ijhsr.org) 197 Vol.9; Issue: 10; October 2019 Sulakshana Chand et.al. Confident or Confused: Nurses’ Perception and Acceptability of Electronic Nursing Documentation documentation include but are not limited concern and a goal. Nurses as end users may to; incomplete record, inaccurate patient take the challenge and transition smoothly representation, time consuming nature of without much chaos or they may perceive recording. Failure to proficiently exchange the change as a disruption in the routine and transfer information impacts the performance thus causing fear, anxiety, continuity and quality of rendered care, anger, resentment, confusion, exhaustion, hence the motivation to enhance nursing and irritability and resistance to change. In documentation has come forth from several order to implement new information sources including hospital management, technology, it is critical to understand the nurses and nursing researchers. Compliance readiness and willingness of hospital staff to with legal requirements, paperwork efficiently integrate it into their practice. [7] reduction drives, and meeting professional Takhti HK et al [8] reported that standards are also some of the common majority of the nurses (87.9%) expressed reasons for changing record keeping positive perceptions with regards to health regimes. [4] information system implementation in their The use of to daily practice. A study by Kossman SP et al document patient data is at the forefront of [9] showed that nurses believed computer use healthcare discussions and has been touted enabled them to provide safer care. Nurses as a way to promote free exchange of health also perceived that EHR use enhanced information while protecting patients‟ nursing work due to; better information privacy and improving the safety, efficacy access; improved organization and and quality of care. [5] Opportunities to efficiency; alert screens, and hindered streamline communication and nursing work through; increased documentation, decrease the amount of documentation time due to slow response of duplicative data entry, add to evidence base the system; numerous screens; reduced of practice, influence policy making, and interdisciplinary communication and improve the standard of care are inherent in impaired critical thinking. Kahouei M et al the electronic documentation. This system [10] however reported that in general, nurses will meet and indeed improve the had negative attitudes towards the impact of completeness of documentation of basic the nursing computer program on patient care, clarification of orders, quality and care. safety elements and Because user attitude towards the charting requirements adequately. [6] Hence, whole phenomenon impacts their the use of computers in healthcare is willingness to use and move towards becoming a necessity for healthcare paperless system, it is therefore vital to providers and organizations. establish the existing perception and attitude This move however, presents of nurses to determine how computerization multiple foreseen and unforeseen challenges will be achieved. [11] Successful to healthcare providers and their employing implementation of clinical information institutions. The transition from narrative to technology system primarily depends on electronic documentation demands a major user acceptance. Patient safety and quality change in mind set, knowledge, can only be achieved when nurses are performance and skills. There is no doubt willing to use the clinical information that such change will impact nurses as they technology. Aldosari B et al [12] reported a function at the core of patient care strong positive correlation between coordination. Because change is often perceived usefulness and perceived ease of challenging, time consuming and a costly use resulting in a positive effect on nurses' affair with potential unanticipated acceptance.Irrespective of how excellent the consequences, hence, positive attitude and electronic systems are, it is crucial to acceptance of end user is an important examine nurses‟ perception, usability and

International Journal of Health Sciences & Research (www.ijhsr.org) 198 Vol.9; Issue: 10; October 2019 Sulakshana Chand et.al. Confident or Confused: Nurses’ Perception and Acceptability of Electronic Nursing Documentation acceptability of electronic nursing extent; to no extent and a score of 3, 2, 1 documentation as end users. was assigned respectively. The The purpose of this study was to maximum and minimum possible scores explore the perception and ascertain the of the opinionnaire were 84 and 28 acceptability and utility of nurses regarding respectively. electronic nursing documentation (END) program. The specific research question The established reliability using test retest addressed was as follows: technique was found to be 0.89 and 0.86 How does computerized documentation respectively. change the nurses‟ perception and Setting acceptability of END program? The setting was an 830 bedded teaching tertiary care hospital in rural area. METHODOLOGY Permission was granted to conduct study in A quasi-experimental approach with the ICU (23 bedded), surgical ICU (12 pretest posttest design was adopted for this bedded) and emergency unit (38 bedded) study. Nurses‟ perception was assessed on only. day 1 before the implementation of Sample electronic nursing documentation program. Data was collected from November Nurses‟ perception, acceptability and utility 2013 to February 2014.The sample were assessed on day 100 post comprised of forty-four nurses working implementation of electronic nursing ICU, surgical ICU and emergency unit documentation program. selected by convenient sampling. Tools Ethical Consideration 1. Perception Assessment Scale: It Ethical approval for the study was comprised of declarative items obtained from institutional ethical pertaining to nurses‟ personal profile committee of the Maharishi Markandeshwar and 27 randomly scattered items (14 University. Permission was obtained from positive and 13 negative) pertaining to the Medical Superintendent of Hospital to electronic nursing documentation. The conduct the research study. As part of the responses varied from; strongly agree; approval process, the rights and agree; undecided; disagree to strongly confidentiality of the nurses were disagree. Each positive item was guaranteed. To protect the identity of the assigned a score of five for strongly nurses, the research data was maintained agree and a score of one for strongly through the use of pseudonyms for all the disagree and were scored as 5, 4, 3, 2, 1. participating nurses. Each negative item was assigned a score Data Collection of five for strongly disagree and a score Perception of nurses was assessed on of one for strongly agree and were day 1 and day 100 pre and post scored as 1, 2, 3, 4, 5. The maximum implementation of electronic nursing and minimum possible scores of the documentation program respectively. perception assessment scale were 135 Nurses‟ acceptability and utility of and 27 respectively. electronic nursing documentation was 2. Acceptability and utility opinionnaire: assessed on day 100 of implementation of It comprised of 28 positively stated electronic nursing documentation. responses pertaining to; training; operation; flexibility and learnability; RESULTS outcome of electronic nursing Perception of nurses regarding electronic documentation. The responses were nursing documentation program captured via a three point Likert scale Findings revealed that the overall ranging from; to great extent; to some mean and standard deviation of pre and post

International Journal of Health Sciences & Research (www.ijhsr.org) 199 Vol.9; Issue: 10; October 2019 Sulakshana Chand et.al. Confident or Confused: Nurses’ Perception and Acceptability of Electronic Nursing Documentation implementation perception scores of nurses that the electronic nursing documentation were 84.30±10.44 and 93.95±7.33 program was effective in enhancing the respectively. The computed „t‟ value of 5.00 perception of nurses regarding electronic was found to be statistically significant at nursing documentation program.(Table 1). 0.05 level of significance thus suggesting

Table 1 Comparison of perception scores of nurses regarding electronic nursing documentation program N=44 Perception Mean± SD MD SEMD „t‟ value df p value Before implementation 84.30±10.44 After implementation 93.95±7.33 9.65 1.93 5.00* 43 0.00

Comparison of unit wise perception of 85.54±11.4 and 97.31±7.42 (surgical ICU) nurses regarding electronic nursing and 83.69±7.96 and 91.69±5.07 (emergency documentation program unit) respectively. The computed „t‟ value The „t‟ value was computed unit of; 2.33 (ICU); 3.05 (surgical ICU) and 3.81 wise to determine the significance of (emergency unit) were found to be difference between perception scores of statistically significant at 0.05 level of nurses pre and post implementation of significance. It can be inferred that the electronic nursing documentation program electronic nursing documentation program in ICU, surgical ICU and emergency unit. was effective in enhancing the perception of Findings revealed that the mean and nurses exposed to electronic nursing standard deviation of pre and post documentation program in all the units. perception scores of nurses were; (Table 2) 83.87±12.37 and 93.47±8.50 (ICU);

Table 2 Unit wise comparison of perception scores of nurses regarding electronic nursing documentation program N=44 Perception Mean± SD MD SEMD „t‟ value df p value ICU Pre implementation 83.87±12.37 9.6 4.12 2.33 14 0.03 (n=15) Post implementation 93.47±8.50 Surgical ICU (n=13) Pre implementation 85.54±11.4 11.8 3.87 3.05 12 0.01 Post implementation 97.31±7.42 Emergency unit Pre implementation 83.69±7.96 8.0 2.09 3.81 15 0.01 (n=16) Post implementation 91.69±5.07

Nurses’ perception  A little less than half of the nurses (47.7%) The five strongly agreed upon positive strongly agreed that electronic nursing statement and five strongly disagreed upon documentation “is easier to maintain as negative statements by nurses before and compared to the paper records” whereas after implementation of electronic nursing 18.2% strongly agreed before documentation were also analyzed. implementation of electronic nursing  More than half of the nurses (59.1%) documentation program strongly agreed that electronic nursing More than half of the nurses (56.8%) documentation “improves the quality of strongly agreed that electronic nursing clinical documents by preventing documentation “prevents duplication of submission of incomplete information” as patient data entry” as compared to 27.4% compared to 6.9% before implementation of before implementation of electronic nursing electronic nursing documentation program documentation program  Fifty percent of the nurses strongly agreed  Nearly half of the nurses (45.6%) strongly that electronic nursing documentation agreed that electronic nursing “prevents changes in the already entered documentation “will take time to be adapted patient data” as compared to 9.1% before by nurses in the clinical setting” as implementation of electronic nursing compared to 18.2% before implementation documentation of electronic nursing documentation program

International Journal of Health Sciences & Research (www.ijhsr.org) 200 Vol.9; Issue: 10; October 2019 Sulakshana Chand et.al. Confident or Confused: Nurses’ Perception and Acceptability of Electronic Nursing Documentation

 More than one fourth of the nurses before implementation of electronic nursing (31.8%) strongly disagreed that electronic documentation program nursing documentation is “difficult to  Less than one fourth of the nurses (13.5%) operate” as compared to 2.3% before strongly disagreed that electronic nursing implementation of electronic nursing documentation “decreases communication documentation program between members of health care team and  Nearly one fourth of the nurses (21.4%) the various departments of the hospital” as strongly disagreed that electronic nursing compared to 2.2% before implementation of documentation “is time consuming” as electronic nursing documentation program compared to 2.3% before implementation of Nurses’ acceptability and utility of electronic nursing documentation program electronic nursing documentation  Nearly one fifth of the nurses (18.2%) program strongly disagreed that electronic nursing The mean and standard deviation of documentation “creates information acceptability and utility scores of nurses was overload by displaying all the information 75.43±6.67 with the obtained scores of about the patient” as compared to 4.5% nurses ranging from 58 and 84 thus before implementation of electronic nursing indicating that electronic nursing documentation program documentation program was highly  One fifth of the nurses (20.5%) strongly acceptable and useful among nurses. (see disagreed that electronic nursing table 3) documentation “does not allow tracing of all patient data entered” as compared to 9.1%

Table 3 Mean, standard deviation and range of acceptability and utility scores of nurses Variable n Minimum score Maximum score Mean±SD Range of obtained scores Acceptability and utility 44 28 84 75.43±6.67 58-84

For describing nurses‟ acceptability indicated a weak positive relationship and utility of electronic nursing between perception and acceptability of documentation program, frequency and utility of nurses exposed to electronic percentage of each item on the opinionnaire nursing documentation program. was computed. Finding revealed that the overall percentage of acceptability and DISCUSSION utility of electronic nursing documentation Nursing documentation is one of the program was; 71.98% (to great extent); critical elements among other nursing 25.49% (to some extent); 2.53% (to no activities. Perception of nurses regarding extent) as expressed by nurses exposed to electronic nursing documentation was electronic nursing documentation program. assessed before and after the Relationship between nurses’ perception implementation of electronic nursing and acceptability and utility of electronic documentation program. Data analysis of nursing documentation program the current study revealed an overall The mean perception score was enhancement in nurses‟ perception compared to the mean acceptability and regarding electronic nursing documentation utility score of nurses. The mean and program. The improvement was found in all standard deviation of perception and the three units viz. ICU, surgical ICU and acceptability and utility scores of nurses emergency unit. In support of the present exposed to electronic nursing findings, Alquraini H et al [13] reported that documentation program were 93.95±7.33 respondents generally had positive attitudes and 75.43±6.67 respectively. The computed toward computerized Health Information „r‟ value of 0.24 was not found to be System. A study conducted by Harmon CS significant at 0.05 level of significance. This [14] et al also revealed nurses‟ favorable

International Journal of Health Sciences & Research (www.ijhsr.org) 201 Vol.9; Issue: 10; October 2019 Sulakshana Chand et.al. Confident or Confused: Nurses’ Perception and Acceptability of Electronic Nursing Documentation attitude towards the use of Electronic Health strongly agreed the software to be user Record five years post implementation. friendly. In addition, nurses also felt that Raddaha AHA [15] reported that the change they were provided enough support during introduced in the system was important to the change process. Conflicting results were their work and the retrieved information was however reported in a study undertaken by updated to be more likely confident in using Viitanen J et al [19] which revealed that the the system. Fargaly WAT [16] et al reported ENR systems shared several usability that majority of the nurses had a positive problems in common. Nurses mainly attitude towards using Electronic expressed negative experiences with Information System. electronic nursing records as; Nurses’ acceptability and utility of documentation required a lot of resources, electronic nursing documentation patient information was hard to find, and program procedures does not meet the contextual Findings of the current study needs thus suggesting usability problems revealed that among nurses, the overall having significant effects on nurses‟ percentage of acceptability and utility of documentation practices and nursing work. electronic nursing documentation program Relationship between nurses’ perception was; 71.98% (to great extent); 25.49% (to and acceptability and utility of electronic some extent) and 2.53% (to no extent). This nursing documentation program suggested that majority of the nurses who Findings of the current study were exposed to END program expressed it indicated a weak positive relationship to be highly acceptable. Nurses in the between perception and acceptability of present study, agreed “to great extent” that utility of nurses exposed to electronic END program; “uses terms that I am nursing documentation program. On the familiar with” (84.1%); “after hands on contrary, Adosari B [12] et al reported a experience, I became confident regarding strong positive correlation between how to document electronically” (84.1%); perceived usefulness and perceived ease of “hands on experience provided me use resulting in a positive effect on nurses‟ opportunities to try out electronic acceptance. documentation and clarify doubts before the implementation” (81.82%); “is easy to CONCLUSION understand and use” (81.82%); “increases Electronic nursing documentation program accuracy of documentation of nursing was effective in enhancing the overall as activities”. Ifinedo P1 [17] et al reported the well as unit wise perception regarding RNs perceived usefulness, favorable electronic nursing documentation computer habits and behavioral intentions to use Heath Information System have positive Conflict of Interest: None effects on their acceptance of such Funding: None technology. These finding are supported in a study conducted by Myera JO [18] that REFERENCES 1. Turpin PG. Transitioning from paper to examined the beliefs nurses undergoing computerized documentation. change form paper based to computerized Gastroenterology Nursing. 2005;28(1):61-2 documentation. Results showed that nurses‟ 2. Royal children‟s hospital Melbourne. assessment of EMR as user friendly Available at : increased over time. Four months after http://www.rch.org.au/rchcpg/hospital_clini implementation of the EMR 39% nurses cal_guideline_index/Nursing_Documentatio agreed or strongly agreed the EMR to be use n/. Retrieved on 6.6.2015 friendly as compared to 67% by six months 3. Ammenwerth E, Ulrich M, Iller C, post implementation. At one-year post Eichstadtr R. Factors affecting and affected implementing, 56% of the nurses agreed or by user acceptance of computer-based

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How to cite this article: Chand S, Sarin J. Confident or confused: nurses‟ perception and acceptability of electronic nursing documentation. Int J Health Sci Res. 2019; 9(10):197-203.

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International Journal of Health Sciences & Research (www.ijhsr.org) 203 Vol.9; Issue: 10; October 2019