Nurses' knowledge of and attitude to nursing information systems

Nursing in healthcare institutions in India, as in many others countries around the world, includes the independent and collaborative care of sick, disabled and injured individuals, not only to promote their health and wellbeing but also to prevent ill health and cure disease. Nursing roles also include education and research, promoting a safe healthcare environment, participating in shaping health policy and advocacy (International Council of Nurses, 2002). Nursing can be seen as both an art and a science—using both the heart and the mind. Nurses work around the clock with the patient and play a vital role in healthcare. Nursing's fundamental values are evident in patient assessment. They do not just look up test results, but instead, through the application of logical principles in the nursing process, they judge and integrate the objective data with the subjective experience of a patient's biological, physical, and behavioural needs to ensure every patient has the best possible care irrespective of who they are or where they may be. The roles and responsibilities of nurses can differ from decision making in critical care to providing inoculations in schools. Due to the wide range of specialisations in the nursing profession, each will have its own particular strengths, skills and proficiencies (World Health Organization (WHO), 2019).

To provide the best care to the patient, the nursing process follows a scientific method of five simple steps: assessment, diagnosis, planning, implementation and evaluation (WHO, 2019). Within these steps nurses will also plan, organise, collaborate with other health professionals in the multidisciplinary team and document their actions and findings. Nurses also perform some additional tasks such as ordering, scheduling, dispensing and monitoring medication, and communicating with health professionals in other teams such as pharmacy and physiotherapy (Kahouei et al, 2014). These activities related to patient care generate a huge amount of data and it becomes challenging for nurses and hospitals to capture, store, analyse and disseminate these data to various stakeholders locally, nationally and globally. An automated nursing information system (NIS) is designed to assist nurses in overcoming the challenges in managing patient data (Kahouei et al, 2014).

Nurses counterbalance the dehumanising effects of a computerised NIS with the humanising nature of nursing. However, using new technology can be challenging in terms of acceptance among nurses. The use of an NIS has been found to be useful in improving nursing practice, providing instantaneous access to patient information, enhancing overall productivity, and reducing potential errors (Yoder, 1998). NISs have replaced pencil-and-paper charting and avoid the duplication of charts and records, which ultimately has reduced the time spent and errors in documentation and allowed nurses to spend more time in hands-on patient care (Samuël, 1984; Toromanovic et al, 2010).

In recent years, there have been advances in NISs, with the inclusion of new methods not only of supporting nurses to collect, store and recover patient data but also of supporting them in making decisions in patient care. The NIS can be a single standalone system or a part of a larger hospital information system or electronic medical/health records system (Kahouei et al, 2014).

Despite their useful features, nurses in India and other countries have found accepting and using an NIS challenging. The challenge in adoption is mainly due to the current nursing education system in India in which most of the nursing graduates are taught the conventional way of documenting patient data using pencil and paper. Lack of exposure to IT systems and not knowing how to use an NIS makes it difficult for nurses to adapt to using an NIS for documenting patient data when they start practising in a hospital (Kahouei et al, 2014).

This study focused on assessing the knowledge of, attitudes to and practice of using an NIS among nurses in one hospital in India. It was hoped that the results would allow the hospital administrators to formulate strategies to make the NIS more acceptable and adoptable to nurses and enhance nursing care and services.

Method

This study was carried out in a tertiary care hospital in southern India. A total of 230 nurses participated in the study. A validated questionnaire was used for data collection. The questionnaire consisted of three sections with 40 questions, along with the demographic details of the participants. The first section consisted of nine questions related to knowledge about information technology and its application in healthcare, based on a 5-point Likert scale from ‘excellent’ to ‘below average’ on a scale of 5 to 1. The second section included 15 questions related to the attitude of nurses towards the NIS, based on a 3-point Likert scale from ‘agree’ to ‘disagree’ on a scale from 3 to 1 (Johnson’ and Morgan, 2016). Fifteen questions included in the third section related to the practice of using the NIS, based on a 3-point Likert scale from ‘agree’ to ‘disagree’ on a scale from 3 to 1. One practice question related to the frequency of the use of the NIS and was based on 4-point Likert scale from ‘always’ to ‘never’ on a scale from 4 to 1.

The purpose of the study was explained to the participants and their consent was obtained. Participants were assured that the collected data would not be disclosed without their consent and would only be used for academic purposes. The anonymity of the participants would be maintained. The collected data was analysed using SPSS version 20.0, and presented in terms of frequency and percentage. The Chi-square test was performed to understand the correlation between response and demographic data of the respondents, with significance at P<0.05.

Results

The results of the assessment of knowledge, attitude, and practice of NIS conducted among 230 nurses were as follows.

Demographic characteristics of the respondents

In the age category, the respondents consisted of:

• 80 (34.8%) aged 21-25 years
• 68 (29.6%) aged 26-30 years
• 53 (23%) aged 31-35 years
• 29 (12.6%) aged 35 years and above.

The distribution of respondents based on their years of work experience indicated that:

• 123 (53.5%) had been working for 0-5 years
• 72 (31.3%) had been working for 6-10 years
• 29 (12.6%) had been working for 11-15 years
• 5 (2.2%) had been working for 16-20 years
• 1 (0.4%) had been working for 20 years or more.

Knowledge about information technology and its application in healthcare

The results of the study indicated that the majority of respondents had a good knowledge of computers, such as laptops, desktops and tablets. More than 70% of the respondents claimed to have very good to good knowledge about computer vocabulary, MS Word, and MS Excel. Nurses are expected to be familiar with the hospital information system (HIS), electronic medical record (EMR) and health management information system (HMIS), as these assist them in documenting patient data. When asked about these applications, around 52% of respondents said they had very good to good knowledge, whereas 33.5% indicated average knowledge (Table 1).

About 54% of the respondents claimed good to very good knowledge about solving problems associated with hardware and software during their day-to-day activities, whereas 43% reported average knowledge. More than 60% of the respondents knew how to use a computer for presentations and had good knowledge about apps and how to browse the internet (Table 1). When the authors compared the scores of those respondents who were older and had more experience with those of their less experienced colleagues, their scores were higher and statistically significant (P<0.05).

Attitudes of nurses towards the NIS

It is essential that nurses have a positive attitude towards the NIS used in patient care, documentation, and other legal or regulatory aspects. Nurses' knowledge about the NIS will influence their attitude and ultimately their approach to the system. A positive attitude will lead to better acceptance and ultimately improve their productivity with respect to documenting patient data (McGonigle and Mastrian, 2021).

Attitude of nurses towards the NIS in patient care

In this study, more than 50% of the respondents agreed that the NIS has the potential to improve nursing care, improve communication among healthcare providers, and save time in retrieving patient data. Around 70.8% of the respondents felt that the NIS has improved the documentation of patient care and made the process of documentation much easier and more feasible when compared to paper-based records (Table 2).

However, when the respondents were asked about the role of NIS in depersonalising nursing care, 41.7% agreed and stated that the NIS would increase their interaction time with the system rather than the patient (Table 2). When the authors compared the scores of those respondents who were older and had more experience with those of their less experienced colleagues in relation to the role of NIS in improving medical documentation, the scores of those who were more experienced were higher and statistically significant (P<0.05).

Attitude of nurses towards the NIS in medical documentation

The health information system, if implemented with the right approach, has proved to not only to enhance the medical documentation by reducing the time, errors, cost and workload but also to assist in maintaining the privacy and confidentiality of patient data (Rahimi et al, 2009). In this study, 67.8% of the respondents agreed that the NIS assists them in maintaining the privacy of patient information. Around 71.8% agreed that NIS reduces paperwork and duplicate entries and assists them in improving the medical documentation process. Only 35.7% agreed that the NIS assisted in statistical analysis and reporting of patient data in different formats, whereas 68.7% agreed that the NIS reduces overall healthcare costs (Table 3).

More than 70% of the respondents felt the need for formal education about information systems and technology, especially during their undergraduate studies to enhance their IT skills and their application in patient care. The responses of those who were older and with more experience related to the support of the NIS in protecting the privacy of patient data, reducing paperwork and the requirement of technical skills in handling the NIS were statistically significant (P<0.05).

Practice of using the NIS among nurses

A nurse's attitude can influence their behaviour positively or negatively and ultimately impact on their practice (Boundless Management, 2020). In this study, when asked about practice with their institution's NIS, more than 50% of respondents agreed that the NIS they used assisted them in developing and implementing care plans and pathways and generating lists of patients with specific conditions (Table 4). Some 97.8% agreed that it assisted them in retrieving information on time. The responses of those who were older and had more experience related to the support of the NIS in generating lists of patients with specific conditions reached statistical significance (P<0.05). Around 73% of the nurses agreed that the NIS assisted them in charting patients' vital signs (Table 4).

When the respondents were asked whether the NIS supported the documentation of patient records, more than 90% agreed that the NIS supported them in maintaining an active medication allergy list, viewing and analysing patients' pathological lab reports for a better treatment plan and exchanging patient information with other care providers (Table 5). However, only 40% of the respondents agreed that the present NIS assisted them in performing drug formulary checks, collecting and disseminating the required information, recording nursing assessments, and care plans. They wanted more specific features in the present NIS to perform these activities (Table 5). Once again, the responses of those who were older and had more experience on the role of the NIS in performing drug formulary checks, reporting hospital clinical quality measures to the clinical management system and in recording nursing assessments and care plans were found to reach statistical significance (P<0.05).

When the respondents were asked how frequently they use the NIS, the majority (59.1%) stated that they use it often in patient documentation, report generation, and dissemination of patient data to other care providers (Table 6).

Discussion

This study was intended to assess nurses' knowledge of and attitude towards the NIS and how they used it in practice. Nurses play a key role in patient care and create a vital link between doctors and patients. They provide round-the-clock services to ensure that the patient receives the treatment and care they require. To provide quality and continuous care, nurses need patient data in real time, irrespective of geographical boundaries. Conventional paper-based documentation of patient data is not suitable because patients expects high-quality care at the point of contact based on up-to-date information. It can be argued that paper-based documentation takes more time to be completed and thus allows less time for patient care (Lee, 2007). An automated NIS can be seen as a key component in avoiding such challenges in capturing and sharing patient data (Topkaya and Kaya, 2015).

To adopt and use the NIS effectively, nurses should have good computer skills and knowledge about all aspects of information and communication technology (ICT). As health professionals, nurses' computer skills cannot be compared with those of IT professionals, but they are expected to use computers and an NIS for documenting and reporting patient data (Ahmadian et al, 2017). These skills can be developed if they study ICT and its application in nursing care during their nurse education. This approach would allow them to easily adapt to any information system one they begin nursing practice in hospital. Respondents in this study also reported the need for training. Similar findings were noted in the study by Shami (2013) on knowledge of, attitudes towards and use of computers by bachelor-level nursing students. The result indicated that around 30% of nursing students had average knowledge of MS Office applications. The students suggested that IT concepts should be covered in nurse education.

The present study reported a positive attitude among nurses towards the NIS in terms of saving time in retrieving patient information, improving nursing care, reducing paperwork and improving communication between healthcare providers. A similar finding was observed in the study by Galani (2015) on factors affecting nurses' use of the NIS in a residential care home, where 70% of the nurses reported that data retrieval from the NIS was much easier than when a paper-based system was used. A study by Ajibade (2013) on knowledge of and attitudes towards the introduction of informatics to nursing training, reported that more than 95% of the participants thought that NISs help them in improving nursing care and reducing paperwork. A study by Kipturgo et al (2014) on the attitude of nursing staff towards computerisation found that the nurses had favourable attitudes because computerisation had reduced their workload and enhanced the process of medical documentation.

A study by Suppiah Dall (2014) on factors influencing nurses' attitudes towards IT in nursing practice in Western Australia, reported that 76.9% of the participants had the opinion that IT improves communication in healthcare and 88.8% identified that it saves time in seeking information such as medical records and pathology results. However, 59.7% of the nurses reported that the use of IT depersonalises nursing care, and 43.3% of the participants claimed that the use of information technology increases nurses' workload. About 81.3% of the participants stated that IT is required to improve nursing care, while 91% of them reported that technology skills are a requirement for lifelong learning.

The present study resulted in similar findings to the existing literature. The majority of nurses had a positive attitude towards the NIS in patient care and documentation. Evidence from the present study and the existing literature also suggests the need for a good training programme on the health information systems used in hospitals, with an emphasis on the NIS. Some 70.7% of respondents in the present study reported that formal education in IT is necessary within nursing (Table 3).

Conclusion

Heath information systems have become essential in modern healthcare to support health professionals in achieving high-quality patient care. The NIS is one of the important components of the health information system and supports nurses not only in creating a connection between patient and carers, but also assisting them in improving documentation, reducing error, and accessing real-time information. This study found that the respondents understood the concept of NISs and they are looking forward to such technology implementation in all hospitals in India to achieve better sharing of patient data. However, nurses need training to better understand the NIS's features and its application in patient care. Since nurses play a vital role in patient care, providing more training will improve their knowledge and will help them develop a positive attitude and thus enhance the use of NISs.

KEY POINTS

• Nurses generate a large amount of data during patient care
• Nurses expect patient data to be available in real-time while providing continuous care
• Nursing information systems (NISs) play a key role in supporting nurses in managing patient data
• Good computer skills and knowledge about the NIS, influence the behaviour, and promote a positive attitude towards the NIS, resulting in better acceptance and sustainability of the system
• Nurses in this study agreed that more education and training in the use of NISs was required

CPD reflective questions

• Does the nursing information system used in your area of work improve your practice?
• Consider whether nursing information systems lead to more depersonalised care and interactions. If so, how can this problem be overcome?
• Consider a hospital with paperless nursing information system. The system then goes down for several days. What action would you take to access healthcare data for patient care?