Background
Methods
Aim
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How does staff describe their experiences with the benefits observed with respect to the computer-based records and their daily work?
Design
Search strategy and sample
Authors | Aims and objectives | Methods design | Interview | Focus group | Observation | Results |
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Data analysis | ||||||
Sample | ||||||
Date of publication | ||||||
Country | ||||||
Title | ||||||
Alexander et al. (2007) U.S.A. Clinical information systems in nursing homes: an evaluation of initial implementation strategies [38] | To explore implementation strategies, employee experiences, and factors influencing employee satisfaction | Explorative 4 nursing homes, 6 months after implementation | 23 | 22 | --- | Five themes emerged: (1) perception and cognition, (2) change, (3) workable system, (4) competence and (5) connectedness. |
Focus groups (22 à 60 Min.) | ||||||
Implementation strategies associated with lower satisfaction were availability of equipment, training resources, and the presence of professional information technology. The experiences differ [according] to the role. | ||||||
Unstructured observations (< 5 min., made when using the technology, (n=?) semi-structured interviews (unknown type) (n=23) axial coding | ||||||
Cherry et al. (2008) U.S.A. Factors affecting electronic health record adoption in long-term care facilities [39] | To gain information about Long Term Care leaders’ general understanding about Electronic Health Records (EHR) and identify factors that hinder and facilitate EHR in Long Term Care | Explorative | --- | 34 | --- | Primary barriers identified were costs, the need for training and the culture of change. Primary facilitators were training programs, well-defined implementation plans, evidence that the electronic systems will improve care outcomes. |
Focus groups (34) via telephone conference call with directors of nursing, Administrators and corporate executives divided into users and non-users | ||||||
Cherry et al. U.S.A. (2011) Experiences with electronic health records: early adopters in long-term care facilities [40] | Providing a description of the early users’ experiences, challenges and benefits with Electronic Health Records in Long Term Care | Explorative | 70 | --- | 10 | The RACF employees who work with EHR systems on a daily basis were positive about their experiences. In particular, operational improvements were achieved through increased access to resident information, cost avoidance, increased documentation accuracy and implementation of evidence-based practices. |
Semi-structured interviews of unknown type, group-observation | ||||||
10 "freestanding" Sites, one-site visit for 6-8 hours per visit with the following schedule for the face-to-face interviews: (a) 60 min for facility tour, (b) 45 min with the administrator, (c) 45 min with the DON, (d) 45 min with a group of assistant DONs and charge nurses, (e) 45 min with a group of direct care staff, (f) 45 min with residents and family members, (g) 60 min for observation on the unit during shift change | ||||||
Munyisia et al. (2012) Australia The impact of an electronic nursing documentation system on efficiency of documentation by caregivers in a residential aged care facility [26] | To examine the effect of the introduction of an Electronic Health Records system on the efficiency in a Long Term Care facility | NOT INCLUDED IN THIS REVIEW: | 8 | --- | --- | Qualitative interviews to gain a better understanding 1. Personal Carers were happy in general because of quicker access and release from referring to written doctors notes |
Longitudinal cohort study | ||||||
INCLUDED IN THIS REVIEW: | ||||||
2. Certain information items were double charted (Paper and EHR) due to organizational reasons | ||||||
Explorative semi-structured Interviews (n=8) unknown type 6 and 12 months after introduction | ||||||
3. It took longer to complete some documentation tasks using a computer (too many clicks to enter data) | ||||||
Qualitative content analysis | 4. Continuous training is needed for some caregivers to effectively use the EHR | |||||
Rantz et al. (2011) U.S.A. The use of a bedside electronic medical record to improve quality of care in nursing facilities: a qualitative analysis [41] | To examine the effect of the introduction of a bedside electronic medical record on the improvement of care in nursing facilities | (Part of the study of Alexander et al.) | 120 | 22 | ? | Communication and information was improved which led to a general improvement of patient care |
Explorative qualitative interviews (n=120), observations (?), focus groups (22) content analysisin all 4 homes 6,12, 18 months after implementation, additional interviews took place (n=?) 24 months after implementation in 2 homes | ||||||
Experience of limited time due to EHR (Direct Carer) vs. saved time (Management) | ||||||
Too much time for operating and managing the system | ||||||
Yu et al. (2008) Australia Caregivers' acceptance of electronic documentation in nursing homes [35] | The aim of the study was to investigate nursing home caregivers' acceptance of electronic documentation | NOT INCLUDED IN THIS REVIEW | 12 | --- | --- | Some staff (4) with low experience wished for more time in the beginning and more instructions |
Some staff (4) often used computers at home felt the software was easy to use | ||||||
Questionnaire survey | Other staff (4) felt they needed more practice than theoretical lessons | |||||
INCLUDED IN THIS REVIEW | ||||||
Semi-structured interviews unknown type after 11 weeks computer-based (n = 12) | ||||||
Paper-based n =? | ||||||
One Home that implemented an Electronic Health Records; one home remained paper-based. | ||||||
Zhang (2012) Australia The benefit of introducing electronic health records in residential aged care facilities: A multiple case study [42] | The aim of this study was to identify the benefits of Electronic Health Record in Long Term Care and to examine how the benefit have been achieved | Explorative semi-structured Interviews (n=110) content analysis, theoretical sampling | 110 | --- | --- | BENEFITS TO THE STAFF |
Convenience and efficiency in data entry, distribution, storage and retrieval | ||||||
Ease of access more information to better understand the residents, the service and peer-learning | ||||||
Empowering care staff | ||||||
BENEFITS TO THE RESIDENTS | ||||||
Improving Quality of Care | ||||||
BENEFITS TO THE RACFs | ||||||
better information management | ||||||
Improving the communication system | ||||||
Improving access to funding facilitating care quality control better work environment educational benefits | ||||||
Data Foundation (at least) // 23 Interviews and 22 focus groups removed due to doubling
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320
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56
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10
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Analysis & synthesis
1. Phase | Getting started |
2. Phase | Deciding what is relevant to the initial interest |
3. Phase | Reading the studies |
4. Phase | Determining how the studies are related |
5. Phase | Translating the studies into one another |
6. Phase | Synthesizing translations |
7. Phase | Expressing the synthesis |
Phase 1: Getting started
Phase 2: Deciding what is relevant to the initial interest
Phase 3: Reading the studies
Phase 4: Determining how the studies are related
Phase 5–7: Translating the studies into one another, synthesizing translations and expressing the synthesis
Different information processing | Quality of documentation and resident care needs | Additional or lost time | |
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Alexander et al. [38] | Administrators were optimistic that this technology could improve management oversight and quality management | Administrators were optimistic that this technology could improve documentation of resident care | Administrator: |
nursing homes that implement [technology] need to be warned about the increased need for manpower during the initial months.
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Frustration set in when expectations were not met. This increased staff suspicion and decreased desire to work with the system. | Frustration set in when expectations were not met, problems not solved in a timely manner | ||
Licensed nurses liked being able to view many things about resident care at once | |||
liked being able to know what was done for their residents in real time identified increased documentation in comparison to the paper record | |||
When the documentation system wasn’t working properly, staff stated they didn’t chart. Others indicated that backup systems for documentation were created. Concerns surfaced about increased potential for errors resulting from service duplication. | |||
Cherry et al. [39] | The user group suggested that supervisors were able to more easily monitor documentation of resident care activities, regulatory compliance issues, or staff education needs | They agreed that improvements in the quality and accuracy of documentation would be realized. | They agreed that improvements in the efficiency would be realized. |
Staff would spent less time in documentation tasks | |||
The user group suggested that supervisors were able to more (…) quickly identify resident care needs and address quality of care issues (…) | |||
Specific aspects of care discussed included easier access to charts and medical information | |||
Staff would spend more time in resident care | |||
Better quality of care | |||
Ability to provide automatic alerts (plausibility check) | |||
Cherry et al. [40] | Administrators: | Administrators: | DONs & Charge Nurses: |
Staff were able to provide better information because of immediate access | Better care to residents because of immediate access to computerized records | Nurse supervisors generally believed that the system allowed direct care staff to spent more time with residents and less time in documentation | |
Immediate access to medical records allowed staff to access resident records without wasting time | Improved consistency, accuracy, and quality of documentation |
Gave the nurses more time on the floor since the paperwork went faster
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Fewer holes in documentation from a caregiver’s standpoint
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Direct Care Nurses: | DONs and Charge Nurses: | Direct Care Staff | |
Nurses’ notes and notes by other caregivers are much easier to read | More consistent and legible documentation | About half the nurses reported that they had more time to spend with residents because of less time charting, and because of less time looking for “missing” charts, and about half reported no change or an increase in time required for charting and that they had less time with residents because of the amount of time spent in documentation activities Reports regarding the time required to admit a new resident was mixed, with some nurses reporting that new admissions were much easier and quicker and others reporting that it took much longer. | |
Important issue discussed was the need for more information about the residents they care for | More thorough assessments with assessment templates that guide nurses through body systems for documentation and to help nurses improve observations skills | ||
Ease of access to patient information was a definite benefit identified by the nursing staff | Direct Care Nurse: | ||
Several noted how information on residents, including diagnosis and demographics, is now more readily available | Half reported Care Plans were easier to originate and maintain, half reported that it was more difficult | ||
Missing charts didn’t matter because the information was in the computer | Improved documentation were definite benefits identified by the nursing staff | ||
Information is more readily accessible | Quality of care was neutral (no change) to improve after the implementation | ||
DON and Charge Nurse: |
Guided templates improve observation skills, which in turn provides for better care for the residents
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Ability to track and trend quality indicators |
We are able to more proactive address residents’ problems
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Increased ability to monitor staff and complete chart audits in very timely manner | Additional information increases a nurses’ awareness of the patient condition and allows for better care | ||
Immediate access to records for any authorized staff member | More legible and accurate information | ||
Munyisia et al. [26] | The PCs were happy with the electronic documentation system because the access to the residents’ notes had been improved. | The paper-based record helped them make real-time care decisions |
I get a resident’s note on a computer at a finger click. Unlike using the manual system that required me to go over there (points a filing cabinet), search for a folder, come back, find the right page, and when the page was missing, go and get a photocopy. Therefore, access to one resident’s notes would probably take me 20 minutes before I sit down and start writing
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I get a resident’s note on a computer at a finger click.
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When there was a clinic here (at the facility), the doctor wrote everything on the computer. Therefore I did not have to write progress notes because the doctor has already done it
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The only real problem I have is with the continence charts, it takes so long to enter everyone’s information in the system. It can take up to one hour to enter data and when using the paper system, it is just a 5 Min. job
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It does get slow to enter data into the computer that you eventually give up
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Rantz et al. [41] | Communication about resident care was reported as improved | Improvement with documentation was noted | All expressed concern that there was limited time to spent with residents and that the required documentation and time spent in managing the technology limited the amount of time actually spent with residents |
Easier access of information improved communication | Licensed and certified staff believed that the care was safer through the use of the system. | ||
All stakeholders concluded that information was more easily accessible | Some licensed staff commented that the assessments caused them to think about what to assess and that it helped them identify problems that they might not have otherwise found. | ||
The system required time to operate and manage. | |||
Documentation is too time consuming and a burden | |||
Documentation is perceived as too time consuming | |||
Frustration set in when the system don’t work (that causes more time) | |||
Yu et al. [35] | --- | --- | --- |
Zhang et al. [42] | The most common viewed benefits for individual staff members are (…) more information to better understand the residents | Better understand the residents due to more information | The most common viewed benefits for individual staff members are (…) time efficiency |
More information to better understand the residents and the care services, to support peer learning and to facilitate performance appraisal for managers | Broader and more holistic view of the residents | Most of the staff saw reduction of paper work and time saving | |
Easily check what care had been delivered |
For instance if I am unsure of how to do the palliative care, I can just easily click a button and find out it has been done for a similar patient at another facility
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I think the computer is quicker because you can get to delete stuff and you can fix it
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Able to see if something has been identified, has somebody done something about It, if there is a gap and ensure that is corrected.
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It does improve what you want to do because you get the whole picture, not just what’s happened on your shift. It does impact on how I deal with a resident
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Care plans on paper are very time consuming, and the computer make it faster, since when it’s written once, you don’t need to write it again
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It helps me identify what is needed by the staff
| Improvement in the quality of residents’ records led to improvement in the quality of care |
Care plans on paper are very time consuming, and the computer make it faster, since when it’s written once, you don’t need to write it again
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Opportunities to, like I said, all the information that we need or help out with the students today. Like they wanted to know a little bit about all the resident’s conditions and stuff, so I just set them up on my system and they sat on there for a couple of hours and they really enjoyed it. Say a thing, they were able to find out everything they wanted to know about all the residents as well.
| Quick response to resident’s care needs |
It’s easier for the care staff members to entry data even if they are only typing with two fingers
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Quicker and easier care decisions, the system has an impact on clinical judgment and decision making | |||
Better care follow up | |||
The most common viewed benefits for individual staff members are ease of access | |||
Some reported it was easier and quicker | |||
Some noted quick data distribution | |||
I just need to enter it into the computer and then that information is there for the staff to see. So it saves a log of time.
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Quick data retrieval was a well-recognized benefit. They found it was quicker and easier to find data | |||
Being able to scroll through and the way the notes are broken up into different categories where you can select whatever it is you are looking for and be done fairly quickly
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Ease of use and ability to use it | Equipment availability and technical functionality | Attitude | |
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Alexander et al. [38] | Terminology was not understandable or did not match with the hard copy record | Equipment availability strongly affected staff perception (Number of workplaces and breakages) | Frustration set in when expectations were not met, problems not solved in a timely manner. This increased staff suspicion and decreased desire to work with the system. |
Did not match what they intended to chart | The lack of equipment failures, and PC availability were viewed as contributing to overtime work and led to distrust in the system | All levels of staff indicated it was difficult to maintain a positive attitude about the system and move forward when the implementation wasn’t going smoothly | |
Staff appeared less comfortable without guidance | The lack of IT support, and PC availability were viewed as contributing to overtime work | When issues hindered job performance that led to dislike of the system and uncertainty about how to use the system correctly | |
Initial and ongoing training was a prominent theme | |||
Cherry et al. [39] | Complex systems are difficult to navigate | Improved staff retention because of a sense of pride and empowerment associated with using computers in the work setting. | |
Barriers frequently mentioned were the quality of staff training | |||
Fear of computers were identified as a barrier | |||
Concerns about training | |||
Strong initial and follow-up training | |||
Cherry et al. [40] | Learning to use the computer is a negative aspect | The primarily disadvantage consistently reported by all were related to technology problems and maintenance | Administrators reported that the system contributed employee satisfaction and staff retention (“the facility is viewed as more modern and more attractive to potential new staff.”)
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Nurses in supervisory positions were overwhelming positive about the system and would be very opposed to going back to the “precomputer” days. | |||
Direct Care Staff: | |||
Managers had a greater respect because they cared enough to give them computers for their work | |||
Munyisia et al. [26] | Data in computerized records was located in various sections of the electronic system and, thus, difficult for the PCs and even the doctors to track the trend | Computerized documentation was not feasible at the bedside | |
We want a chronological view of this data to make care decisions
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I am able to go from one resident to the next using the electronic system, but when I have 35 residents, that is a lot of clicking and switching screens
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PCs charted certain information items on both paper and on a computer | |||
We report blood pressure data on paper because we get very frustrated looking for a resident’s data from various sections of the electronic system.
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Caregivers practice of double charting was partly caused by the way nursing data was organized in the system, making the data inconvenient to review | |||
Rantz et al. [41] | Entered data could not be located later | The primarily disadvantage related to technology problems and maintenance | Some view documentation as a “waste of time” and documentation takes time away from the residents |
Ongoing and refresher training of staff is important | |||
Licensed and certified staff expressed concern that they could be watched by the monitoring of their documentation. On the other side, others saw the monitoring as a positive addition, since when reviewing the documentation they would know that the staff completed their assigned work Frustration set in when the system don’t work (that causes more time) | |||
Technology could be frustrating when it did not work | |||
Using paper created a double documentation system. This creates more problems since information is inconsistently transferred | |||
Yu et al. [35] | Some felt the software was very easy to use | ||
Some wished for more practice instead of lessons | |||
Zhang et al. [42] |
We are still learning I feel, we are learning something new every day
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