Abstract
A comparative study was conducted in two Australian nursing homes operated by the same organization. One home had implemented an electronic documentation system and the other remained paper-based. Survey questionnaires were answered by 14 of the 17 caregivers at the electronic documentation site (82%) and 10 of the 23 caregivers at the paper documentation site (43%). They provided opinions about satisfaction with their home's documentation system, and the training and support provided. Information was also obtained on the caregivers' attitudes towards using electronic documentation. The caregivers at the electronic documentation site quickly adapted to the use of the new technology after receiving effective training and support. Caregivers at both homes were satisfied with their homes' documentation system, and had positive attitudes towards using electronic documentation systems. As an important communication tool, electronic nursing documentation may lead to improved efficacy of telemedicine in nursing home settings.
Introduction
For elderly people living in nursing homes in Australia, nursing documentation includes functional assessment, care planning and daily progress reporting. Such documentation is essential for providing care that reflects the needs of the elderly. 1,2 Many old people living in nursing homes suffer from chronic progressive illnesses, so medical care is an essential component of their care. This requires a multidisciplinary team of caregivers in a nursing home and collaborating health-care professionals outside, such as doctors, physiotherapists and dentists. A severe shortage of health-care workers in Australia, coupled with a high demand for medical care by the elderly in nursing homes, leads to an unavoidable, intermittent use of remote diagnosis and prescription by doctors managing people suffering from chronic illness.
Telemedicine approaches have provided a means of improving the access of nursing home residents to services from health professionals who are located off-site. 3 The quality of such remote diagnosis and prescription relies on the accurate assessment and recording of changes in the residents' conditions, and timely reporting of these changes by nurses to the relevant medical staff off-site. Therefore, nursing documentation is essential not only for the provision of good nursing care, but also for accurate diagnosis and treatment of nursing home residents by other medical care providers. It is also critical for meeting government accreditation requirements. Consequently, the process of documentation forms part of the overall organizational process. 2
Paper-based nursing documentation practice is time-consuming and records are often illegible. Missing data may lead to medical errors. Data must frequently be entered several times and may not be easy to retrieve or update. Such difficulties have been identified as a major cause of stress and dissatisfaction among nurses in aged care, and an important factor in the attrition of aged-care nurses, who are a scarce resource. 1,4 Despite the recognition that information technology (IT) may provide solutions to problems with paper-based documentation practice, the uptake of IT in nursing homes in Australia remains low. 5,6 This problem is not unique to Australia. The adoption of IT in nursing homes is far behind that in hospitals and physicians' offices in the USA. 7 Although the technology lag is often attributed to the attitudes of care workers, no detailed study of the acceptance of nursing information systems has been conducted in nursing homes.
The aim of the present study was to investigate nursing home caregivers' acceptance of electronic documentation.
Methods
Attitudes of staff in two nursing homes were compared. The first site was the Tantula Rise Retirement Community (TRRC), a nursing home on the Sunshine Coast in Australia operated by RSL Care, a not-for-profit provider. At the time of the study, the TRRC had recently implemented an electronic nursing documentation system. The system included modules for each resident's baseline health assessment, care plan, admission notes and progress notes. Training time on the use of the system was 2.5 days for Registered Nurses (RNs) and Endorsed Enrolled Nurses (EENs), 1.5 days for Personal Care Workers (PCWs) and Assistants in Nursing (AINs), and one day for the support staff at the TRRC.
The comparator site was another RSL Care nursing home, the Centaur Memorial Retirement Community (CMRC), also located in the Sunshine Coast region. The CMRC had a documentation system that remained paper-based. Training was provided on a needs basis. Any care worker could request and obtain training on a specific issue of care. The organizational structure and staff ratio in the two study sites were similar, with 28 nursing care beds in CMRC, and 30 beds at TRRC at the time of the survey.
Ethics approval was granted by the appropriate committee. The study population consisted of the available caregivers in both homes, including RNs, EENs, PCWs and AINs. A convenience sampling method was used to recruit the participants. Staff were surveyed using questionnaires, developed from previously validated instruments. 8 Variables measured using the questionnaires included satisfaction with training and support, satisfaction with the documentation practice (either electronic or paper-based) and attitude towards electronic nursing documentation. 9,10 The environmental (including manager's and co-worker's) influence on each caregiver's attitude towards using their home's documentation system (subjective norm) 11 and organizational culture of the two nursing homes 12 were also compared. All items were measured using a 6-point scale (strongly agree, agree, slightly agree, slightly disagree, disagree and strongly disagree) except for culture, which was measured on a 7-point scale following the same order of the other items.
The questionnaires were distributed to the available caregivers during site visits to the nursing homes five weeks after implementation of the electronic documentation system at the TRRC. Responses to the questionnaire were analysed using SPSS 15.0 for Windows. For the measures composed of multiple items, the scores of each item were summed and then divided by the number of items to produce a mean score (answers to the negative statements were reverse coded). As the data were not normally distributed, a non-parametric Mann-Whitney test was used to detect any significant differences in caregivers' responses between the two nursing homes.
Semi-structured interviews were also conducted to acquire information from caregivers about their roles and responsibilities in the facility, their documentation practice in a paper or electronic environment, their experience with the documentation system, and their perceptions of the strengths, weaknesses, opportunities and threats of electronic or paper-based documentation. Interviews were held during site visits to the homes at five and 11 weeks after implementation of the new system at the TRRC. The interviews were recorded and transcribed. Concepts presented in the discussion were extracted for each transcript using NVIVO software.
Results
Survey questionnaires were answered by 14 of the 17 caregivers at the TRRC (82%) and 10 of the 23 caregivers at the CMRC (43%). There was no significant difference between sites in the respondents' ages, job roles or aged-care work experience. Eight of the 24 caregivers were in their 50s, seven were in their 40s and seven were under 40. Only four of the 24 respondents (17%) had previous experience with an electronic documentation system.
Culture and subjective norms
The organizational culture in the two facilities was perceived by the respondents as open, slightly tough, team-oriented, personal, centralized, participative, quality-oriented, innovation-promoting and proactive. Only two out of the 12 test items measuring culture were significantly different between sites. The climate at the electronic site was perceived to be more competitive and formal than that of the paper-documentation site.
The subjective norms in regard to using the nursing documentation system were equally positive in both nursing homes. (A subjective norm is a ‘person's perception that most people who are important to him think he should or should not perform the behaviour in question’. 13 )
Satisfaction with training and support
A high level of satisfaction with the training and support they had received for using their home's documentation system was expressed by the two cohorts of respondents (Table 1). All the respondents agreed or strongly agreed with the statements ‘I am supported and encouraged by my manager to use the current documentation system’, ‘Management has provided the necessary help and resources to achieve rapid familiarity with the current documentation system’, ‘When I have difficulty with the current documentation system, the support is available’ and ‘The support personnel available to me are competent’.
Median scores for items on caregivers' satisfaction with training and support for use of their documentation system
The scores ranged from 1 = strongly agree to 6 = strongly disagree
The interquartile ranges are given in parentheses
Satisfaction with documentation systems
The caregivers at both homes reported high levels of satisfaction with the documentation system that they used (Table 2). They were happy or very happy with ease of use, efficiency and usefulness of their system. Overall satisfaction with the documentation system was slightly higher at the electronic site than at the paper site.
Median scores for items on caregivers' satisfaction with their home's documentation system
The scores ranged from 1 = high to 6 = low. The interquartile ranges are given in parentheses
All 12 staff members interviewed at the electronic documentation site were happy with the design of the system, but complained about its running speed when logging on and off and about the time needed for the synchronization of data with other computers. Ten of the 12 staff members interviewed at the paper documentation site were satisfied with their system.
Five weeks after using the electronic documentation system, the caregivers were significantly happier with the documentation speed, legibility and accessibility of the electronic records than their peers using paper-based documentation. In contrast, eight staff members at the paper documentation site complained about the problems with paper-based documentation practice, such as double data entry and illegible handwriting, and difficulty in retrieving information one month back.
Attitudes to the electronic documentation system
The overall attitude towards using an electronic documentation system was positive at both homes (Table 3), although the answers to three of the 12 test items were significantly more positive from caregivers at the electronic documentation site. Those at the electronic site had more self-confidence working with computers. They disagreed more strongly that computers create more problems than they solve and that the use of electronic documentation dehumanises residential aged care.
Median scores for items on caregivers' attitudes toward using an electronic documentation system
The scores ranged from 1 = strongly agree to 6 = strongly disagree
The interquartile ranges are given in parentheses
a P < 0.05, electronic documentation site vs. paper documentation site
Thirteen of the 14 respondents at the electronic site supported their organization's decision to continue with the electronic documentation practice (the other person slightly disagreed). Even though some of the caregivers at the paper documentation site were not yet confident computer users, seven of 10 respondents supported their organization's decision to introduce electronic information systems. They saw it as an inevitable work practice change that would happen sooner or later, and thus supported such a change.
Familiarity with documentation practice
The caregivers at both homes had a similar level of familiarity with the documentation system that they used. Their responses to the statement ‘I could complete the documentation if there was no one around to tell me what to do’ were between the scores for ‘slightly agree’ and ‘agree’ (median = 2, IQR = 2), the same as their responses given to the statement that ‘I could call someone for help if I got stuck’ (median = 2, IQR = 1.5). They ‘slightly’ agreed that ‘I could complete documentation if I had a lot of time to complete the job for which it was provided’ (median = 2, IQR = 1.9).
Eleven weeks after the system implementation, four of the 12 care staff interviewed at the electronic documentation site, who did not have much previous experience with computers, felt that they needed ‘a bit more time in the beginning to use it and a bit more instruction’. Four of the staff who often used computers at home felt that the software was very easy to use. The four other care staff felt what they needed was more practice instead of lessons.
At the paper-documentation site, the caregivers reported that they were very familiar with the system and knew how to enter data and retrieve the needed information from it. Some of them considered that their paper documentation system was kept in a systematic, convenient manner. However, some interviewees, including both RNs and PCWs, felt that they were still not certain about what should be documented and how to express their observations appropriately.
Discussion
Human factors play an important role for the success of information systems. Moody et al. suggested that input from nursing staff is useful for defining nurses' preferences for documentation, barriers they encounter in using an electronic health record (EHR) and the extent of problems with EHR implementation. 14 To our knowledge, no such study has been conducted in a nursing home setting. Nor has there been research on the attitudes of PCWs or AINs, who account for 58% of caregivers in the residential aged care sector in Australia, 4 towards computerized nursing documentation. Our study provides preliminary information in this field.
After five weeks' experience of using the electronic system for daily nursing documentation, the caregivers at the electronic site had a similar high level of satisfaction with their home's documentation system to that of their counterparts who used paper-based documentation. They had very positive attitudes towards the electronic documentation practice. This suggests that these caregivers can adopt a useful IT solution quickly, providing the system is easy to learn and that good training and support are provided.
Three of the 10 respondents at the paper documentation site were sceptical about the new electronic documentation practice. This suggests that the previously mentioned worries about the negative attitude of long-term care workers towards electronic documentation were realistic. Experience at the electronic documentation site, responses to questionnaires and information from interviews indicated that caregivers at the paper documentation site were willing to adapt to electronic documentation.
The majority of caregivers who participated in the study were comfortable with electronic documentation and felt that they worked in a user friendly, supportive environment. This finding is consistent with that of Moody et al. 14 Our study also indicates that the experience of working with a real electronic documentation system alleviated caregivers' fears about this new practice and increased their confidence in using computers. The majority of caregivers would accept electronic nursing documentation if sufficient training and support were given.
The training provided to the caregivers for using the electronic documentation system was concentrated over 2–3 days, in a classroom environment. For a few of these people, this was insufficient with further training seen as necessary after using the system for 11 weeks. Difficulties with training for some staff may have been associated with the competing demands of establishing routine work processes for the new documentation system. The caregivers' positive feedback about the on-site support arrangement suggests that this support arrangement for a care team of about 20 was adequate.
The present study found that caregivers were able to use the electronic nursing documentation system in a short time-frame. This agrees with some previous findings about nurses' attitudes towards nursing information systems in hospital settings. 15–17 While the findings from the study are encouraging, they should be interpreted cautiously as they are based on self-reporting by survey participants and the sample size was small.
The obvious benefits of electronic documentation are improved documentation efficiency, legibility and accessibility of nursing records. An important consequence of these improvements is a better understanding of an elderly person's needs for personal and medical care by direct caregivers, including RNs. With an RN's communication of an elderly person's medical needs with a doctor off-site, better remote diagnosis and prescription will be achieved. Therefore, as an important communication tool, electronic nursing documentation may lead to improved efficacy of telemedicine in nursing home settings.
Footnotes
Acknowledgements
The study was sponsored by RSL Care. We are grateful to Ross Smith, Deborah Oxlade, Cheryl Richardson, Matthew Maw, Steve Powell, Susan DeVries and Susan Lane. We also thank Leanne Miller, Sue Beasley and Madeleine Strong Cincotta.