- Read the selected articles and include the following in your paper:
- Create a title page and a reference page in APA format. Use additional sources to justify your decisions about these articles.
- Begin with an opening paragraph and end with a closing paragraph
- Identify which article is quantitative
- List the major heading of the paper and provide a brief description of each;
- Provide at least 2 reasons why this is a quantitative design
- Identify which article is qualitative
- List the major headings of the paper and provide a brief description of each
- Provide at least 2 reasons why this is a qualitative design
- Three professional references required.
- Two will be the articles
- One will be related to quantitative versus qualitative designs
- This paper should be at least 3-4 pages long.
Please review the rubric to ensure that your assignment meets criteria.
- Critical Care Nursing Quarterly
Issue: Volume 41(2), April/June 2018, p 215-223
[Original Articles]
Copyright: Copyright (C) 2018 Wolters Kluwer Health, Inc. All rights
reserved
Publication Type: [Original Articles] DOI: 10.1097/CNQ.0000000000000201
ISSN: 0887-9303
Accession: 00002727-201804000-00013
Keywords: clinical simulation, eye tracking, human factors, interruption
management, medication administration, patient safety, Stay S.A.F.E. strategyThe Stay S.A.F.E. Strategy for Managing Interruptions Reduces Distraction Time
in the Simulated Clinical SettingHenneman, Elizabeth A. PhD, RN; Marquard, Jenna L. PhD; Nicholas, Cheryl PhD;
Martinez, Vanessa BSE; DeSotto, Kristine BS; Scott, Susan S. MSN; Soares,
William E. MD; Henneman, Philip L. MDAuthor Information
College of Nursing (Dr E. Henneman and Ms Scott), and Department of Mechanical
and Industrial Engineering, College of Engineering (Drs Marquard and Nicholas
and Mss Martinez and DeSotto), University of Massachusetts Amherst; Department
of Nursing, Westfield State University, Westfield, Massachusetts (Ms Scott); and
Department of Emergency Medicine, Baystate Medical Center, Springfield,
Massachusetts (Drs Soares and P. Henneman).Correspondence: Elizabeth A. Henneman, PhD, RN, College of Nursing, University
of Massachusetts Amherst, 226 Skinner Hall, 651 North Pleasant St, Amherst, MA
01003 (Henneman@nursing.umass.edu).This work was supported by a grant from the National Science Foundation CMMI
1234070.The authors have disclosed that they have no significant relationships with,
or financial interest in, any commercial companies pertaining to this article.———————————————-
Outline
Abstract
METHODS
Participants and setting
Simulation scenario
Instruments
Eye tracker
The intervention
The interruption
Data analysis
RESULTS
Pre- and postintervention nurse behaviors
Preintervention
Postintervention
NASA TLX scores
Participant response to open-ended questions
DISCUSSION
Future research
REFERENCES
Abstract
Interruptions occurring during the delivery of health care are frequent and
create a serious threat to patient safety. It is important to test strategies
directed at decreasing the negative effects of interruptions. The purpose of
this pilot study was to test the Stay S.A.F.E. strategy for managing interruptions.
A pretest, posttest quasi-experimental design was used to test the primary
hypothesis that the Stay S.A.F.E. interruption management strategy would
significantly (P P = .0004. The results of this study suggest that the Stay
S.A.F.E. interruption management strategy was effective in reducing the length
of time participants were distracted from the primary task in a simulated
clinical setting. In addition, nurses confirmed the reports of others that
interruptions are frequent, dangerous, and result in errors.———————————————-
INTERRUPTIONS occurring during the delivery of health care are frequent and
create a serious threat to patient safety.1-6 Interruptions disrupt the
performance of a task putting the primary task and interruption task at risk. It
is well described that interruptions result in an increase in medical errors.6-9
Errors associated with interruptions include patient identification and
medication errors,6,10 failure to complete tasks,8 and omission of critical
safety processes such as pretransfusion blood checks.7 Researchers have reported
that some interrupted tasks are never resumed 3,11 and others are resumed only
after completing up to 8 other tasks.3 In a recent observational study,
emergency physicians were interrupted 12 times per hour and three-quarters
stopped their primary task and engaged in the interruption task. Few used
interruption management strategies to handle the frequent interruptions.1Research to date has focused on evaluating interventions aimed at reducing the
frequency of interruptions during the medication administration process. Visual
alerts (eg, red vests, signage, no interruption zones), checklists, and
combinations of interventions have been shown to be effective in reducing the
frequency of interruptions 12-15 but have not always been well received by
patients or nurses leading some researchers to question their sustainability.15
In addition, few studies have been conducted in critical care units where
interruptions can have especially significant patient safety consequences. In a
pilot study by Anthony and colleagues,14 implementation of a no interruption
zone was shown to significantly reduce interruptions in intensive care units.
Grundgeiger et al 11 described factors that influence intensive care unit
nurses’ ability to resume tasks following an interruption and reported on
behaviors nurses used when responding to an interruption. These behaviors
included finishing the primary task before attending to the interrupting task
and holding onto artifacts related to the primary task while attending to the
interrupting task.Interruptions are not always preventable and are often necessary to provide safe
patient care. As a result, it is important to test strategies directed at
decreasing the negative effects of interruptions when they do occur. The purpose
of this pilot study was to test an investigator-developed strategy for managing
interruptions, termed Stay S.A.F.E. This innovative interruption management
strategy is based on Altmann and Trafton’s 16 empirically supported “Memory for
Goals” model. The model provides an explanation for how environmental and mental
cues can be used to create a “place mark” that aids in effectively and
efficiently resuming a task. A number of investigators in other domains have
demonstrated support for the memory for goals model.17,18This pilot study was conducted to inform a future, large study. Study objectives
were to (1) describe nurse participants’ experiences with interruptions in the
workplace, (2) evaluate the impact of the Stay S.A.F.E. interruption management
strategy on the length of time participants were distracted away from the
primary task following an interruption, (3) measure participants’ perceived
workload during the simulation scenarios, and (4) describe participants’
perceptions of the usefulness and applicability of the Stay S.A.F.E. interruption
management strategy.METHODS
A pretest, posttest quasi-experimental design was used to test the primary
hypothesis that the Stay S.A.F.E. interruption management strategy would
significantly (PParticipants and setting
Registered nurses with 1 or more years of experience were invited to participate
in the study. The study was conducted in a clinical simulation laboratory.
Participants signed a written consent form and were compensated with a $75.00
cash stipend. The institutional review board of the affiliated university
approved the study.Simulation scenario
Participants were instructed to provide care as they normally would in the
practice setting and were assigned tasks that needed to be completed. The tasks
included medication administration, medication reconciliation, and manual
calculation of 12-hour intake and output totals. The participants were told that
they could perform the tasks in whatever order they determined appropriate.Instruments
Eye tracker
Participants wore an eye-tracking device (SensoMotoric Instruments, Teltow,
Germany) during the simulation, which allowed the investigators to observe the
participants’ eye movements as they carried out assigned tasks. The eye-tracker
is a lightweight, tetherless system that allows participants to move freely
through the simulation environment. The device records a video of the area in
front of the wearer and uses pupil-corneal reflection to measure the position of
the eye in relationship to the environment. The eye-tracker software program
overlays crosshairs on a video, showing the exact locations in a scene where the
individual is directing his or her gaze throughout the simulated scenario.After completing the simulation, participants completed 3 written instruments:
(1) a demographic data form (2) the NASA Task Load Index (TLX) instrument, and
(3) an open-ended survey. The demographic data form asked participants for their
clinical specialty area, years of experience, and prior experience with clinical
simulation. The NASA TLX measures the perceived workload of a task, assessing
performance demands across 6 dimensions: mental, physical, temporal, effort,
performance, and frustration as well as overall weighted workload.19,20 In this
study, the NASA TLX instrument was used to measure participants’ perceived
workload associated with the simulation experience. The open-ended investigator-developed
survey was designed to capture the participants’ experience with interruptions
and their perception of the usefulness and applicability of the Stay S.A.F.E.
strategy in the clinical setting. We also asked for suggestions for improving
the Stay S.A.F.E. intervention and increasing the fidelity (realism) of the
clinical simulation.The intervention
The Stay S.A.F.E. interruption management strategy was developed on the basis of
the memory for goals model,16 evidence from disciplines that successfully manage
distractions using attention-based training in high-risk, error-prone environments,21
and previously described techniques used by nurses to stay on task following an
interruption.11,22 We developed the acronym Stay S.A.F.E. to make the interruption
management strategy easy to remember and implement, not adding measurably to the
cognitive burden imposed by the interruption.23 The Stay S.A.F.E. interruption
management strategy was taught to participants via a PowerPoint slide presentation
that included a short video showing an actor demonstrating the strategy. See
Table 1 for details of the Stay S.A.F.E. interruption management strategy and
example statements given during the presentation.The interruption
The interruption used in the simulation scenario was designed to maximize the
impact of the interruption but it did not require an immediate change in the
primary task. For the purpose of the study, an interruption was defined as a
distraction away from the primary task, which could result in a complete
cognitive break. The interrupting trigger (also called an alert or prompt) was a
knock on the door by the interrupter, an actor posing as a health care
professional. The interruption was a verbal patient report given to the
participant (see Figure 1).Data analysis
Eye-tracking videos were reviewed to measure the amount of time participants
gazed at predetermined areas of interest (AOI) in the simulated environment. The
eye movement metric was the gaze time on each AOI. Eye movement data were
divided into 2 categories, informational and transitional. Informational data
included eye gaze on the 5 AOI, the interrupter, medications, medication
administration record, medical record (medication reconciliation and intake and
output forms), and patient. Transitional data included scanning eye movements
between the 5 AOIs. Two researchers (C.N., K.D.) independently reviewed an
initial set of eye-tracking videos to ensure that coding methods were consistent
and then coded the remaining videos separately. Eye-tracking videos were coded
using the predefined informational (AOI) and transitional categories. Analyses
of the eye movement data extended from 2 seconds prior to the interrupter
knocking on the door to 5 seconds after the participant returned to the primary
task.A paired t test was used to compare the duration of participants’ eye gaze on
the interrupter in the pre- and posttest periods. Descriptive statistics were
used for eye movement and demographic data. Task load scores were calculated for
each dimension of the NASA TLX and for the overall mean for the sample as
described by Hart and Staveland 19 using the paper and pencil version.20
Open-ended participant statements related to experience with interruptions and
usefulness and feasibility of the Stay S.A.F.E. strategy were reviewed and
summarized by 2 study investigators (E.H., S.S.).RESULTS
Twenty nurses with a median of 12 years of experience (range: 1-45 years)
participated in the study. Participants had experience in a variety of clinical
specialties including critical care, acute care, and emergency nursing. All
participants had some prior experience with clinical simulation. Eye-tracking
data were available for 16 of 20 participants. Complete task analysis scores
were available for 17 of 20 participants. Missing eye-tracking data resulted
from difficulty calibrating the eye tracker because of thick eyelashes in 2
participants and placement of the eye-tracking glasses that resulted in 1
participant’s line of vision to be blocked. In one case, no eye-tracking data,
including video data, ever appeared on the computer screen. Three of the 20
participants did not complete the entire NASA TLX instrument.Pre- and postintervention nurse behaviors
There was a significant decrease in the amount of time that participants were
distracted away from the primary task between the pretest (134.47 seconds, SD =
6.87) and posttest (6.08 seconds, SD = 1.27) periods (P = .0004). A visual
timeline of data demonstrating gaze times on the various AOIs in the pre- and
postintervention periods is shown in Figure 2.Preintervention
In the preintervention period, 4 of the 16 participants (25%) who were
interrupted immediately stopped their task, turned toward the door, and took
report from the interrupter. Nine of the 16 nurses (56%) turned toward the door,
looking away from their task, but did not take report and told the interrupter
that they would be with them shortly. The remainder of the nurses (19%) did not
turn toward the interrupter and kept their finger on the data they were
attending to, although their visual scanning patterns showed disengagement with
the task (Figure 3).Postintervention
The majority of participants (14/16) used the entire Stay S.A.F.E. strategy when
responding to the interruption. An example of the eye-tracking data of a nurse
who used the complete Stay S.A.F.E. strategy is displayed in Figure 4. The
remainder of the nurses (2/16) used parts of the Stay S.A.F.E. strategy but
looked briefly at the interrupter before completing the entire strategy.NASA TLX scores
The highest NASA TLX scores were related to temporal (56.9) and mental (51.0)
demand and the lowest to physical demand (13.2). The overall average task load
index was 45.8. (See Table 2 for scores in all dimensions.)Participant response to open-ended questions
Participants described interruptions as common, frustrating, and likely to
result in errors. Common sources of interruptions reported by participants were
other staff, physicians, patients, and family members. Themes related to the
impact of interruptions included increased time to complete tasks, delay in
resuming a task, forgetting to complete tasks, and the potential for medication
and documentation errors.Several nurses reported that they were often interrupted while engaged in tasks
requiring a high level of cognitive attention, such as when documenting on the
computer. They described comments from colleagues such as “can you help me now
while you’re not busy?” Also noteworthy was a novice nurse’s comments on the
impact of the interruption on her ability to continue the primary task. She
related that as soon as she was told that she would be getting a new admission,
she was unable to concentrate and instead of focusing on the primary task, her
thoughts turned to the new patient, including trying to remember whether or not
she had cared for any patients with the same diagnosis.All participants commented that the Stay S.A.F.E. strategy would be feasible and
useful in the workplace setting for staying on task. The majority of nurses
(17/20) commented that the Stay S.A.F.E. acronym was easy to remember. Several
nurses (4/20) commented that the strategy would be beneficial to other
clinicians including student nurses, medical students and resident physicians.
Of note were that 3 nurses reported feeling uncomfortable with the Stay S.A.F.E.
strategy initially because they were not immediately attending to the person
doing the interrupting, believing that they were being disrespectful but later
were able to appreciate that providing safe care was more important than trying
to be polite.Participants’ suggestions for improving the fidelity of the simulation included
increasing the number of interruptions, having an interruption by the patient,
moving the medication area away from the patient, having more background noise
such as family member conversations and alarms, and increasing the time demand
of the simulation.DISCUSSION
The results of this study suggest that the Stay S.A.F.E. interruption management
strategy was effective in reducing the length of time participants were
distracted from the primary task in a simulated clinical setting. In addition,
nurses confirmed the reports of others that interruptions are frequent,
dangerous, and result in errors.1-9 Participants also reported that the Stay
S.A.F.E. strategy was easy to remember, useful, and feasible to implement in the
clinical setting.Comments by some participants that the failure to immediately attend to the
interrupter could be interpreted as being impolite speak to the variety of
system and human factors other than cognitive processes that impact how
interruptions are managed. System factors such as workplace norms that support
hierarchical reporting structures can have a profound influence on how
interruptions are managed including when and how to address an interrupting
event. This decision is based, in part, on prior knowledge and experience with
the task being performed and the cognitive load imposed by the interruption.24
Other factors that influence how an interruption is managed include the urgency
imparted by the interrupter and the level of trust the person being interrupted
has in the interrupter’s evaluation of the level of urgency.23The cognitive load imposed by the interruption in this study is supported by the
high mental NASA TLX scores of study participants, which were similar to those
reported by physicians in a naturalistic setting.25 Of note is that the mental
workload scores in our study increased significantly (28.3-60.3, P = .01) after
making minor changes (interrupter wearing white coat and increasing the time
pressure) to the simulation intended to increase the fidelity of the simulation.
These increases in workload may have been related to the changes in the
relationship between interrupter and the participant and sense of urgency that
resulted from these modifications to the simulation. Experimental manipulations
have previously been shown to be associated with significant changes in workload
ratings.19The potential negative impact of an interruption was described by a novice nurse
participant who related being so distracted by the thought of getting a new
admission that she could not concentrate on the task at hand. This finding
suggests that the impact of an interruption is influenced not only by the
individuals’ knowledge and experience with carrying out the primary task but
their knowledge and experience with the new task imposed by the interruption.24Limitations of the study include a small sample size and having the posttest
evaluation immediately following the intervention. It is not clear that the
results would be similar with a larger group or if the postevaluation occurred
at a later time. Noteworthy, participants in the study were from a number of
different hospitals and health care settings, and the subjective comments of the
nurses regarding concerns with interruptions and ways to improve the simulation
were similar.Future research
Research is needed to investigate the effectiveness and acceptance of the Stay
S.A.F.E. interruption management strategy in the clinical setting. In particular,
it will be important to evaluate whether the strategy is accepted and used over
time. It is likely that real sustainability of any interruption management
strategy including Stay S.A.F.E. will require an organizational commitment to an
interruption management program that is framed within a culture of safety.
Outcomes to the implementation of any interruption management strategy include
time to return to task, noncompletion of tasks, postcompletion errors, and
stakeholder satisfaction.REFERENCES
1. Ratwani RM, Fong A, Puthumana JS, Hettinger AZ. Emergency physician use of
cognitive strategies to manage interruptions. Ann Emerg Med. 2017;70:683-687.2. Walter SR, Raban MZ, Dunsmuir WTM, Douglas HE. Emergency doctors’ strategies
to manage competing workload demands in an interruptive environment: an
observational workflow time study. Appl Ergon. 2017;58:454-460.3. Brixey JJ, Tang Z, Robinson DJ, et al Interruptions in a level one trauma
center: a case study. Int J Med Inform. 2008;77:235-241.4. Chisholm CD, Dornfeld AM, Nelson DR, Cordell WH. Work interrupted: a
comparison of workplace interruptions in emergency departments and primary care
offices. Ann Emerg Med. 2001;38:146-151.5. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department
workplace interruptions: are emergency physicians “interrupt-driven” and
“multitasking”? Acad Emerg Med. 2000;7:1239-1243.6. Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of
interruptions with an increased risk and severity of medication administration
errors. Arch Intern Med. 2010;170:683-690.7. Liu D, Grundgeiger T, Sanderson PM, Jenkins SA, Leane TA. Interruptions and
blood transfusion checks: lessons from the simulated operating room. Anesth
Analg. 2009;108:219-222.8. Collins S, Currie L, Patel V, Bakken S, Cimino JJ. Multitasking by clinicians
in the context of CPOE and CIS use. In: Kuhn KA, Warren JR, Leong T-Y, eds.
Medinfo 2007: Proceedings of the 12th World Congress on Health (Medical)
Informatics; Building Sustainable Health Systems. Amsterdam: IOS Press;
2007:958-962.9. Marquard JL, Henneman PL, He Z, Jo J, Fisher DL, Henneman EA. Nurses’
behaviors and visual scanning patterns may reduce patient identification errors.
J Exp Psychol Appl. 2011;17:247-256.10. Henneman PL, Fisher DL, Henneman EA, Pham TA, Campbell MM, Nathanson BH.
Patient identification errors are common in a simulated setting. Ann Emerg Med.
2010;55:503-509.11. Grundgeiger T, Sanderson P, MacDougall HG, Venkatesh B. Interruption
management in the intensive care unit: predicting resumption times and assessing
distributed support. J Exp Psychol Appl. 2010;16:317-334.12. Pape T, Guerra D, Murquiz M, et al Innovative approaches to reducing nurses’
distractions during medication administration. J Contin Educ Nurs. 2005;36:108-116.13. Relihan E, O’Brien V, O’Hara S, Silke B. The impact of a set of interventions
to reduce interruptions and distractions to nurses during medication administration.
Qual Saf Health Care. 2010;19:1-6.14. Anthony K, Wiencek C, Bauer C, Daly B, Anthony MK. No interruptions please:
impact of a no interruption zone on medication safety in intensive care units.
Crit Care Nurse. 2010;30:21-29.15. Westbrook JI, Li L, Hooper TD, Raban MZ, Middleton S, Lehnbom EC. Effectiveness
of a “do not interrupt” bundled intervention to reduce interruptions during
medication administration: a cluster randomised controlled feasibility study.
BMJ Qual Saf. 2017;26:734-742.16. Altmann EA, Trafton JG. Memory for goals: an activation-based model.
Cognitive Sci. 2002;26:39-83.17. Hodgetts HM, Jones DM. Interruption of the tower of London task: support for
a goal activation approach. J Exp Psychol Gen. 2006;135:103-115.18. Sasangohar F, Donmez B, Easty AC, Trbovich PL. Effects of nested interruptions
on task resumption: a laboratory study with intensive care nurses. Hum Factors.
2017;59:628-639.19. Hart SG, Staveland LE. Development of NASA-TLX (Task Load Index): results of
empirical and theoretical research. Adv Psychol.1988;52:139-183.20. NASA. Task Load Index Paper and Pencil Version. Moffett Field, CA: NASA Ames
Research Center; 2017. http://humansystems.arc.nasa.gov/groups/TLX/download/TLXScale.pdf.
Accessed January 20, 2018.21. Pradhan AK, Divekar G, Masserang K, et al The effects of focused attention
training (FOCAL) on the duration of novice drivers’ glances inside the vehicle.
Ergonomics. 2011;54:917-931.22. Colligan L, Bass EJ. Interruption handling strategies during paediatric
medication administration. BMJ Qual Saf. 2012;21:912-917.23. Boehm-Davis DA, Remington R. Reducing the disruptive effects of interruption:
a cognitive framework for analyzing the costs and benefits of interruption
strategies. Accid Anal Prev. 2009;41:1124-1129.24. Cades DM, Boehm-Davis DA, Trafton JG, Monk CA. Mitigating the disruptive
effects of interruptions through training: what needs to be practiced? J Exp
Psychol Appl. 2011;17:97-109.25. France DJ, Levin S, Hemphill R, et al. Emergency physicians’ behaviors and
workload in the presence of the electronic whiteboard. Int J Med Inform.
2005;74(10):827-837.clinical simulation; eye tracking; human factors; interruption management;
medication administration; patient safety; Stay S.A.F.E. strategy———————————————-
2nd Article
CIN: Computers, Informatics, Nursing
Issue: Volume 35(11), November 2017, p 599-605
Copyright: Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights
reserved.
Publication Type: [FEATURES]
DOI: 10.1097/CIN.0000000000000358
ISSN: 1538-2931
Accession: 00024665-201711000-00008
Keywords: Electronic health record, Electronic medical records, Hospital
information system, Nursing process, Nursing records
Nurses’ Perception of Challenges in the Use of an Electronic Nursing
Documentation System
Heidarizadeh, Khadijeh MSc; Rassouli, Maryam PhD, RN; Manoochehri, Houman PhD;
Zagheri Tafreshi, Mansoureh PhD; Kashef Ghorbanpour, Reza MA
Author Information
Author Affiliations: School of Nursing & Midwifery, Shahid Beheshti University
of Medical Sciences (Ms Heidarizadeh and Drs Rassouli, Manoochehri, and Zagheri
Tafreshi); and Iranian Social Security Organization, Tehran, Iran (Mr Kashef
Ghorbanpour).
The present study is part of a nursing PhD thesis and a research project
approved by the Research Council of Shahid Beheshti University of Medical
Sciences.
The authors have disclosed that they have no significant relationships with,
or financial interest in, any commercial companies pertaining to this article.
Corresponding author: Maryam Rassouli, PhD, RN, Pediatric Nursing Department,
School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences,
Vali-e Asr St, Cross Niyayesh Highway, Tehran, Iran (Rassouli.m@gmail.com).
———————————————-
Outline
Abstract
MATERIALS AND METHODS
Data Collection
RESULTS
Perceived Usefulness
Subjective Norms
Experienced Benefits
Perceived Difficulty
Rationalization
Challenges in Accepting Change
DISCUSSION
CONCLUSION
Acknowledgments
References
Abstract
This qualitative study was based on the Technology Acceptance Model and
conducted through directed content analysis to explore perceptions of nurses in
Iran of the challenges of using an electronic documentation system. Participants
were selected through purposive sampling via interview from a teaching hospital
in western Iran. Data were analyzed using MAXQDA 10. Data consistency was
ensured through validation methods and by the researcher’s prolonged engagement
in the subject. Twelve codes, four subcategories, and two main categories
(“perceived usefulness” and “perceived difficulty”) emerged from the analysis of
the data based on the Technology Acceptance Model. “Perceived usefulness”
consisted of the subcategories “subjective norms” and “experienced benefits”;
and “perceived difficulty” contained the subcategories “rationalization” as well
as “challenges in accepting change.” According to the Technology Acceptance
Model, to promote acceptance of this system, the benefits of usage should be
highlighted. The biggest hurdle to acceptance is familiarity and comfort with
previous methods.
———————————————-
As a quality assurance tool, nursing reports are important,1 and proper
documentation is vital; however, foreign and domestic studies reveal substandard
clinical care reports and the absence of frameworks for the presentation and
documentation of nursing care.2,3
Nursing procedures can be documented through different methods, including
electronic report writing, which is the best method for logging nursing
reports.4,5 It also provides a proper means of documenting patient information
without wasting time, enables the design and implementation of joint care
programs for nurses, determines the anticipated outcomes of care, and reduces
medical errors 6,7 as well as nurses’ workload.8,9
The global transition from paper to electronic documentation has been slow.
Since 2004, medical teams have come to favor electronic documentation in matters
of patient care and studies demonstrate the emerging positive attitudes toward
the use of electronic documentation systems.10 Nevertheless, despite the
advances in health information technology, the documentation of nursing care is
still performed using the traditional paper method in Iran.11
In addition, the shortage of nurses is one of the biggest challenges in Iran’s
health system.12,13 Authorities are looking for ways to reduce nurses’ workload,
and since nursing reports are documented manually,14 the use of an electronic
documentation system could save nurses’ time.8,9 To accomplish this end,
strategies are required to change nurses’ attitudes toward the acceptance of
electronic nursing documentation.
Davis’s Technology Acceptance Model (TAM) is a reliable model for predicting the
acceptance of technology.15-17 The use of technology often depends on the user’s
desire to accept and to use the available systems. The TAM explains the link
between inherent psychological variables and the actual use of a system.
According to Davis, “perceived usefulness” and “perceived ease of use” are the
main factors affecting the attitude toward the use of a system and, depending on
their presence, may lead to actual system use.18 These two elements are
influenced by external factors, comprising experience and the voluntary or
involuntary nature of the decision to use the technology in question.16 The TAM
considers cultural as well as social inclination as a major factor; also, it
focuses on what affects the users’ accepting technology.19,20
Venkatesh and Davis 21 introduced an updated version of the model (TAM2) that
explains the effects as well as functional features resulting from both social
effects and cognitive instrumental processes. The TAM2 incorporates additional
theoretical constructs spanning social influence processes (subjective norm,
voluntariness, and image) and cognitive instrumental processes (job relevance,
output quality, result demonstrability, and perceived ease of use).21
Despite the widespread use of computers for logging nursing procedures as a
means of compensating for the shortage of nurses in Iran, implementation of
documentation systems is still a challenge. The present study was therefore
conducted to explore nurses’ perceptions of the challenges involved in the use
of the electronic nursing documentation system based on the TAM2.
MATERIALS AND METHODS
This study was conducted using qualitative directed content analysis. The
participants were selected through purposive sampling from among nurses who were
willing to express their experiences, had enough knowledge about the existing
status of report writing and its challenges, and had first-hand experience with
the documentation and evaluation of nursing reports. The study was set at a
teaching hospital in western Iran. Table 1 presents participants’ demographic
details.
Data Collection
The data required for the study were collected through in-depth semistructured
interviews and analyzed simultaneously. Examples of the interview questions are
as follows: “What do you include in your records?” “To what extent do the
records match the standard nursing records?” “What cases have challenged the
recording process?” and some other leading questions such as “Will you please
explain more about that?” Data collection continued until data saturation
occurred.
To analyze the data, directed content analysis based on TAM2 was utilized. The
systematic classification of the data yielded the codes and themes, and the
meaningful units as well as initial codes were thus extracted. The codes were
then categorized into two final categories pertaining to the main concepts of
the TAM2.22
Each of the interviews lasted from 15 to 30 minutes and was recorded. The data
obtained were analyzed by MAXQDA 10 (VERBI GmbH, Berlin, Germany). The
interviews were recorded and later were transcribed on paper. Then, a file was
created in MAXQDA and the interview was added in a document system. Based on the
participant quotes, codes were selected and transformed to the code system. At
last, the codes were classified into groups and subgroups based on their
similarities. At the end of interview 15, no new data were obtained and the
quotations were repetitive. To ensure saturation, three more interviews were
conducted; thus, after 18 interviews, the process ended.
Consistency and accuracy of the data were ensured through four validation
methods by Lincoln and Guba 23; the results were reviewed by participants and
checked externally by supervisors to verify validity and credibility. Additional
supervisors and professors were asked to take an in-depth look at the interviews
as well as the way the information was extracted to allow assessment of the
results. Keeping related documents as well as other sources of study ensured the
confirmability of the study results. Being in touch with the participants,
attempting to elicit their ideas, and paying attention to each individual’s
opinion are among other factors to enhance the confirmability of this study.23
Ethical considerations were observed throughout the study by obtaining written
informed consent from the participants and by assuring the confidentiality of
data.
RESULTS
Twelve codes, four subcategories, and two main categories (“perceived usefulness”
and “perceived difficulty”) emerged from the TAM2-based analysis of the data.
Table 2 presents main categories, subcategories, and codes.
Perceived Usefulness
The participants defined the category of “perceived usefulness” as the benefit
expected to be derived from using an electronic nursing documentation system and
ascribed the subcategories of “subjective norms” and “experienced benefits” to
it.
Subjective Norms
Subjective norms refer to the individual’s perception of the perspectives that
the influential members of the group have of his/her behaviors and behavioral
rules.24 The codes in this subcategory include “accuracy and time-saving
capacity,” “reliability and legitimacy,” and “the transferability of all the
patient details in brief” using electronic reporting.
Due to the nature of their job, nurses need to use accurate methods of
documentation with a time-saving capacity so that they can dedicate more time to
direct patient care. One of the nurses stated that hospital directors believe
that the use of an electronic documentation system both reduces the time being
spent on transcribing nursing reports and allows them to dedicate more time to
patient care. Commenting on the increased accuracy achieved with such systems,
one participant commented, “Electronic reporting allows for a greater accuracy,
inpatient admission, discharge and it can save us time since it is faster.”
Given their experience with legal proceedings, the interviewed officials
believed that the only legal document that can be used to defend a nurse is the
nursing report. The new nursing documentation system can be accepted and used by
nurses only if it is reliable and has a legitimate status in legal cases. One of
the nurses said, “These reports allow for the nurses in the next shift a
reliable follow-up on everything; for example, been checked up on, or receiving
the necessary training. It’s almost a standard and reliable method. A good
electronic report is one that can be used as evidence and come to your defense
whenever there is a legal problem.”
Regarding the transferability of all the patient details, in brief, one
participant argued, ‘An electronic report is one that conveys everything that
has been done for the patient and also contains the patient’s entire details. It
is brief and contains all the essentials without unnecessary explanations.”
Another subcategory that emerged in this category was “interest in use due to
the novelty of the new technology.” One participant commented on this subcategory,
“It’s a good addition that is very useful. It’s a new technology that can be of
great help and we like to use it because it’s all new to us.”
Experienced Benefits
This subcategory consists of categories such as “full systematic documentation”
and “flexibility.” The full systematic electronic documentation implies a report
that contains all the procedures performed on the patient and follow-up actions.
One nurse stated, “An electronic report should discuss whether the doctor has
been notified of the patient’s critical state. For instance, it should report
the actions that have been taken for the patient and the feedback. And you
should be able to enter all the data, diagnoses, procedures, care measures, and
follow-ups that are required for the patient. This helps the next shift nurses
to be informed of what has been done and what should or shouldn’t be done.”
A standard electronic report applies to numerous patients in various conditions
and in different hospital departments; in other words, such report machine is
flexible. One participant discussed the flexibility of these reports, “An
electronic report should be a little flexible and should apply to different
wards, especially the ICU and the emergency ones.”
Perceived Difficulty
The category of perceived difficulty refers to the problems and barriers with
which nurses are faced in their use of the electronic documentation system and
includes the subcategories of “rationalization” and “challenges in accepting
change.”
Rationalization
Participants had different reasons for refraining from the use of the electronic
documentation system. This subcategory contains categories including “need for
training,” “insufficient number of computers,” and “challenges associated with
the system’s security.”
The need for training means that nurses need to be instructed on how to use the
electronic documentation system. “Since the program has been designed using the
Clinical Classification System and the nurses were not familiar with it, they
should be taught how to use such new technology and how to work with this new
system.”
Another participant described her experience of the insufficient number of
computers, “There are very few computers available here for personnel’s use, and
this scarcity causes problems because you have to wait in line to get to write
your report and the waiting takes up a big portion of time.”
The inability to sign and stamp nursing reports is a major legal challenge of
writing electronic nursing reports, because, in legal cases, the writer of every
report should be easily identifiable. This impossibility provides a challenge
that threatens the system’s security.
One participant noted, “It is vital for any report to have the personnel’s
signature and stamp, and we have requested for a software to be designed that
can input signatures, but so far to no avail. The issues are that, when the
computer is on, no one bothers to log out first and log back in under their own
name; they just open their patient’s file and write their report under the
previous colleague’s username.”
Challenges in Accepting Change
Changing routine work processes leads to a number of problems and obstacles.
Nurses are accustomed to traditional or nonstandard computer methods and forcing
them to readjust themselves to new methods is challenging for them. This
subcategory includes “changes in current practices,” “difficulty starting new
tasks,” and “resistance.”
Changes in current practices imply the replacement of old methods with new ones
or changes in how an action is performed. One participant explained, “It takes
time for everyone to get used to a new software or to the changes implemented in
a software, because when changes take place and new technologies arrive, they no
longer know how to use them, especially if the new software is much different
from the previous one.”
Emphasizing the effect of having accustomed to an old system, another participant
said, “Everyone is used to the old method and the new one is challenging for us.
In the past, when the old company was replaced with a new one, it was difficult
for the personnel to readjust. It was much easier for the new nurses to adjust
because they didn’t know the old method. But it was excruciatingly difficult for
the more experienced nurses because they had used to the old ways.”
On the difficulty of starting new tasks, one participant remarked, “Any task is
difficult at first. If they don’t like it, they come up with a million excuses,
like ‘we don’t have time.’ And here is another trouble we could do without.”
Resistance is another theme that was discussed in the interviews, “They won’t
easily accept it. The wards are busy, and if they have time, they write their
reports properly; otherwise, when they don’t have enough time to write a
detailed report, they botch it and write something just to get it over with;
they don’t care whether it’s accurate and comprehensive or not.”
One of the reasons for this resistance is the unfamiliarity with the new
software, “They aren’t familiar with the new software and don’t know how it
works. That’s why they find it hard to accept such a change because they are not
familiar with the software or the new writing method they should adopt.”
DISCUSSION
One of the main duties of nurses along with their nursing activities is to
register reports about patients. Previous studies have demonstrated the
unfavorable quality of nurses’ report registration in Iran as well as across the
world.3 In the majority of hospitals in Iran, nursing reports are documented
manually. Even though the hospital in this study had an electronic documentation
system, and nursing reports were registered on a computer, the nurses were
unfamiliar with standard electronic report registration. In addition, despite
their efforts to provide high-quality patient care, their documentation was
insufficient to support them in a court of law, and due to improper registrations
in many cases, the judge’s ruling would not be in their favor. The present study
was therefore conducted to explore nurses’ perceptions of the challenges in the
establishment of an electronic nursing report registration system.
The obtained results based on TAM2 showed two main categories, including
‘perceived usefulness,” and ‘perceived ease of use.”
Perceived usefulness is the degree to which an individual believes that using a
particular system will improve his performance; perceived ease of use is the
amount of effort that the user expects to be relieved of by choosing to use the
system.16,25
Based on TAM2, subjective norms comprise an important factor involved in the
acceptance of a new technology. Subjective norms refer to the individual’s
perception of the perspectives that the influential members of the group have of
his/her behaviors and behavioral rules. Having been encouraged to use the new
technology, it is first necessary to identify the group’s most influential
members and thus use their influence so that the other members accept the
change. A study showed that identifying influential members of a group allowed
the rest of the group to better adapt to innovations and to accept new phenomena
more easily.26 Studies showed that in the medical profession, people with
greater knowledge, better manners, and good social relations are considered
influential 27; however, in the nursing profession, skills and experience play a
part too.28
Understanding nurses’ own perspectives can also help identify and resolve the
obstacles faced in the use of a new system. Based on TAM2 21 and Lewin’s theory
of change,29 devising plans can help improve the acceptance and use of new
methods.
With respect to codes such as increased accuracy and time-saving capacity,
reliability and legitimacy, and the transferability of all the patient details,
a study showed that systematic nursing documentation can reduce nurses’
workload, save them time, improve the quality of their documentation and,
thereby, the quality and continuity of patient care, increase the reliability of
the documents, and facilitate the writing of patient admission reports.9 These
are all part of the perceived usefulness of an electronic reporting system,
which is also one of the two main concepts in TAM2.18,21
Previous studies have not discussed the importance of the brevity of nursing
reports.9 The reports written in the study hospital tended to include unnecessary
details, such as whether the patient had been visited, had the prescription been
ordered, were the vital signs checked; however, electronic registrations were
believed to effectively reduce the length of nursing reports. The concept of
perceived usefulness in TAM2 confirms this theme.
Regarding the reliability and legitimacy of reports, the results obtained were
consistent with those found in other studies, and the reliability of the system
was found to affect its usefulness and subsequent acceptance.30,31 According to
the interviewed nurses, the system’s ability to legally defend nurses also
affects their acceptance of it. Due to the discussed features, electronic
nursing report can be of help in the legal defense of nurses; this ability helps
increase the acceptance of the system.
Other studies also noted nurses’ interest in the use of new technologies as a
factor affecting technology acceptance,15,32-35 and since the examined hospital
took advantage of hospital information system, the nurses favored the use of new
technologies and wished to avoid traditional manual methods.
Full systematic registration was another theme that was discussed in several
other studies.9,16,18,26,30,31,36,37 Given the importance of nursing report
registration, full systematic report registration was another concept of the
perceived usefulness of the system also confirmed in TAM2 and believed to affect
the nurses’ acceptance of the new system.
The results obtained in this study on the flexibility of the system were
consistent with those obtained in some other studies.38 Given the shortage of
nurses, their heavy workload, and the registration of nursing reports taking
place at the end of every shift, only a system that resolves these problems and
matches their work conditions can be easily accepted and used by nurses. If the
electronic nursing report registration system acts poorly to solve the nurses’
problems, the nurses will not accept it or will show great resistance.
After being trained on how to use the new technology, they showed apparent
results that were consistent with those obtained by other studies.39 Another
study confirmed the challenges concerning the security of system.38 Holding
training courses and assigning usernames and passwords to each nurse can
increase the system’s acceptability. Venkatesh and Davis 21 believe that
resolving all the problems and facilitating use can improve the acceptance of a
new system.
The insufficient number of computers is a problem that was not discussed in
other studies; however, the need for proper facilities and resources for the use
of electronic systems and computers was emphasized in other studies.40,41
The results of this study were consistent with those obtained in other studies
with regard to computer knowledge 42,43 or the nurses having become accustomed
to old methods.44,45
Since the interviewed nurses already used a computer report registration system,
introducing an electronic report registration system to them was met with less
resistance and had better acceptance. If the old system and the new one are
similar, the new system is more easily accepted.
A study showed that habits were the biggest obstacle against the acceptance of
technology because people tend to get used to their old technologies over
time.46 The results of a study demonstrated that the electronic registration
system is useful because it is standard; yet, its acceptance takes about a
year.47 The findings of several other studies also confirmed the need for at
least 1 year to pass until a new system is considered accepted.40,48
The results obtained in the current study on the difficulty of starting new
tasks and resistance were in line with the outcomes found in some other
studies.40,49 According to Lewin’s theory of change,29 starting new tasks and
implementing changes faced with resistance reduce the likelihood of the
acceptance and use of the new methods. As stated by other studies, resistance to
change is an actual phenomenon, and according to the theory of change, the best
way to promote the acceptance and use of electronic report registration is to
communicate with those involved in the system and to foster the feeling of a
need for change. The nurses’ awareness of the benefits of electronic reporting
and the feeling of a need for change help to persuade them to use the new
system. By introducing the new system and establishing changes in report
writing, nurses gradually incorporate use of the electronic system in practice.
These stages coincide with one of the main concepts in TAM2, namely, “perceived
usefulness.” The nurses’ resistance, due to familiarity and comfort with the old
system, is also manifested in the second concept elaborated in TAM2, namely,
“perceived difficulty.” When the nurses compare the new and old electronic
report systems and perceive the benefits of the new method, they gradually
become more willing to use it. Thus, they replace the old method with the new
one.29,50
The main limitations of the present study are small number of participants and
participants’ unwillingness to express their actual views, one that is common
among all qualitative studies. Future studies are recommended to examine the
difficulties in the acceptance of change and the excuses made to evade change
with the collaboration of hospital authorities and nurse representatives, so
that the potential limitations, such as few samples, reluctance in expressing
views in using a standard electronic nursing report registration system can be
identified and resolved through appropriate strategies.
CONCLUSION
Promoting nurses’ use of computers, particularly in the registration of their
reports, may appear a routine task that is far from advanced; however, it helps
prepare them for the acceptance of new technology and facilitates the adoption
and implementation of standard electronic nursing report registration systems.
The results obtained in this study indicated that, due to its perceived
benefits, nurses are willing to use the electronic reporting system but that
certain problems in the implementation and use of the software should first be
resolved to make the system more easily acceptable. It thus appears that
improving the acceptance of electronic nursing report registration by Iranian
nurses requires a greater emphasis on the benefits of the system, since having
become accustomed to the previous system and dealing with change appear to be
the main obstacles against the acceptance of the new method.
Acknowledgments
The authors would like to express their gratitude to Dr. Virginia Saba and all
the participants and those who helped conduct the study.
References
1. Johnson KH, Bergren MD. Meaningful use of school health data. The Journal of
School Nursing. 2011;27(2): 102-110.
2. Varzeshnezhad M, Rassouli M, Tafreshi MZ, Ghorbanpour RK, Moss J. Transcultural
mapping and usability testing of the clinical care classification system for an
Iranian neonatal ICU population. Computers, Informatics, Nursing : CIN.
2014;32(4): 182-188.
3. Hannah KJ, White PA, Nagle LM, Pringle DM. Standardizing nursing information
in Canada for inclusion in electronic health records: C-HOBIC. Journal of the
American Medical Informatics Association. 2009;16(4): 524-530.
4. Johnson KH, Bergren MD, Westbrook LO. The promise of standardized data
collection: school health variables identified by states. The Journal of School
Nursing. 2012;28(2): 95-107.
5. Turpin PG. Transitioning from paper to computerized documentation. Gastroenterology
Nursing. 2005;28(1): 61-62. Ovid Full Text
6. Carrington JM, Effken JA. Strengths and limitations of the electronic health
record for documenting clinical events. Computers, Informatics, Nursing : CIN.
2011;29(6): 360-367.
7. Zhou L, Soran CS, Jenter CA, et al. The relationship between electronic
health record use and quality of care over time. Journal of the American Medical
Informatics Association. 2009;16(4): 457-464.
8. Dal Sasso GT, Barra DC, Paese F, et al. Computerized nursing process:
methodology to establish associations between clinical assessment, diagnosis,
interventions, and outcomes. Revista da Escola de Enfermagem da U S P.
2013;47(1): 242-249.
9. Hayrinen K, Saranto K, Nykanen P. Definition, structure, content, use and
impacts of electronic health records: a review of the research literature.
International Journal of Medical Informatics. 2008;77(5): 291-304.
10. Gardner CL, Pearce PF. Customization of electronic medical record templates
to improve end-user satisfaction. Computers, Informatics, Nursing : CIN.
2013;31(3): 115-121.
11. Saranto K, Kinnunen UM, Kivekas E, et al. Impacts of structuring nursing
records: a systematic review. Scandinavian Journal of Caring Sciences.
2014;28(4): 629-647.
12. Zarea K, Negarandeh R, Dehghan-Nayeri N, Rezaei-Adaryani M. Nursing staff
shortages and job satisfaction in Iran: issues and challenges. Nursing & Health
Sciences. 2009;11(3): 326-331.
13. Badiyepeymaye Jahromi Z, Keshavarzi S, Jahanbin I. Determination of the
reliability and validity of the Persian version of nurses’ self-concept
questionnaire (NSCQ). The Journal of Nursing Education. 2014;2(4): 63-71.
14. Jasemi M, Mohajal Aghdam A, Rahmani A, Abdollahzadeh F, Zamanzadeh V.
Assessing quality of nursing documentations and effective factors on it in
medical-surgical units. Quarterly Journal of Nursing Management. 2012;1(3):
37-45.
15. Adams DA, Nelson RR, Todd PA. Perceived usefulness, ease of use, and usage
of information technology: a replication. MIS Quarterly. 1992;2: 227-247.
16. Davis FD, Bagozzi RP, Warshaw PR. User acceptance of computer technology: a
comparison of two theoretical models. Management Science. 1989;35(8): 982-1003.
17. Mathieson K. Predicting user intentions: comparing the Technology Acceptance
Model with the theory of planned behavior. Information Systems Research.
1991;2(3): 173-191.
18. Davis FD. Perceived usefulness, perceived ease of use, and user acceptance
of information technology. MIS Quarterly. 1989;3: 319-340.
19. Lin HC. The impact of national cultural differences on nurses’ acceptance of
hospital information systems. Computers, Informatics, Nursing : CIN. 2015;33(6):
265-272.
20. Kim J, Park HA. Development of a health information Technology Acceptance
Model using consumers’ health behavior intention. Journal of Medical Internet
Research. 2012;14(5): e133. Full Text
21. Venkatesh V, Davis FD. A theoretical extension of the Technology Acceptance
Model: four longitudinal field studies. Management Science. 2000;46(2): 186-204.
22. Moretti F, van Vliet L, Bensing J, et al. A standardized approach to
qualitative content analysis of focus group discussions from different
countries. Patient Education and Counseling. 2011;82(3): 420-428.
23. Lincoln YS, Guba EG. Naturalistic Inquiry. Sage; 1985. books.google.com.
Accessed April 24, 2017.
24. Ajzen I. The theory of planned behavior. Organizational Behavior and Human
Decision Processes. 1991;50: 179-211.
25. Taylor S, Todd PA. Understanding information technology usage: a test of
competing models. Information Systems Research. 1995;6(2): 144-176.
26. Schuster DV, Valente TW, Skara SN, et al. Intermedia processes in the
adoption of tobacco control activities among opinion leaders in California.
Communication Theory. 2006;16(1): 91-117.
27. Holmboe ES, Bradley EH, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM.
Characteristics of physician leaders working to improve the quality of care in
acute myocardial infarction. Joint Commission Journal on Quality and Safety.
2003;29(6): 289-296.
28. Shokouhi M, Haghdoost AK, Majdzadeh R, Reani F. Nurses impressive features
include: a qualitative study. Iran Journal of Medical Education. 2013;10(2):
175-183.
29. Shirey MR. Lewin’s Theory of Planned Change as a strategic resource. The
Journal of Nursing Administration. 2013;43(2): 69-72. Ovid Full Text
30. Lee GG, Lin H-F. Customer perceptions of e-service quality in online
shopping. International Journal of Retail & Distribution Management. 2005;33(2):
161-176.
31. Harrison D, McKnight NLC. What trust means in e-commerce customer relationships:
an interdisciplinary conceptual typology. International Journal of Electronic
Commerce. 2001;6(2): 35-59.
32. Fishbein M, Ajzen I. Belief, attitude, intention, and behavior: An
introduction to theory and research. Philosophy & Rhetoric. 1977;10(2): 130-132.
33. Schierz PG, Schilke O, Wirtz BW. Understanding consumer acceptance of mobile
payment services: An empirical analysis. Electronic Commerce Research and
Applications. 2010;9(3): 209-216.
34. Elbanna A. From intention to use to actual rejection: the journey of an
e-procurement system. Journal of Enterprise Information Management. 2010;23(1):
81-99.
35. Fecikova I. An index method for measurement of customer satisfaction. The
TQM Magazine. 2004;16(1): 57-66.
36. Gamal Aboelmaged M. Predicting e-procurement adoption in a developing
country: an empirical integration of Technology Acceptance Model and theory of
planned behaviour. Industrial Management & Data Systems. 2010;110(3): 392-414.
37. Davis FD. User acceptance of information technology: system characteristics,
user perceptions and behavioral impacts. International Journal of Man-Machine
Studies. 1993;38(3): 475-487.
38. Nui Polatoglu V, Ekin S. An empirical investigation of the Turkish
consumers’ acceptance of Internet banking services. International Journal of
Bank Marketing. 2001;19(4): 156-165.
39. Hamner M. Expanding the Technology Acceptance Model to examine personal
computing technology utilization in government agencies in developing countries.
Government Information Quarterly. 2009;26(1): 128-136.
40. Kahouei M, Baba Mohammadi H, Askari Majdabadi H, et al. Nurses’ perceptions
of usefulness of nursing information system: module of electronic medical record
for patient care in two university hospitals of Iran. Materia Socio-medica.
2014;26(1): 30-34.
41. Saletnik LA, Niedlinger MK, Wilson M. Nursing resource considerations for
implementing an electronic documentation system. AORN Journal. 2008;87(3):
585-596.
42. Gagnon MP, Ghandour EK, Talla PK, et al. Electronic health record acceptance
by physicians: testing an integrated theoretical model. Journal of Biomedical
Informatics. 2014;48: 17-27.
43. Melas CD, Zampetakis LA, Dimopoulou A, Moustakis V. Modeling the acceptance
of clinical information systems among hospital medical staff: an extended TAM
model. Journal of Biomedical Informatics. 2011;44(4): 553-564.
44. Limayem M, Hirt SG, Chin WW. Intention does not always matter: the
contingent role of habit on IT usage behavior. Global co-operation in the New
Millennium. The 9th European Conference on Information Systems Bled, Slovenia;
June 27-29, 2001. ECIS 2001 Proceedings. 2001;56: 274-286.
45. Triandis HC, ed. Values, attitudes, and interpersonal behavior. Nebraska
Symposium on Motivation. University of Nebraska Press; 1979.
46. Heidarieh SASS, Shahabi A. Simulation of Technology Acceptance Model in Iran
banking using system dynamics modeling approach (case study: Refah Bank).
Journal of Technology Management. 2013;1(1): 67-98.
47. Carayon P, Cartmill R, Blosky MA, et al. ICU nurses’ acceptance of
electronic health records. Journal of the American Medical Informatics
Association. 2011;18(6): 812-819.
48. Gooch P, Roudsari A. Computerization of workflows, guidelines, and care
pathways: a review of implementation challenges for process-oriented health
information systems. Journal of the American Medical Informatics Association.
2011;18(6): 738-748.
49. Langowski C. The times they are a changing: effects of online nursing
documentation systems. Qual Manag Health Care. 2005;14(2): 121-125.
50. Esmaeili M, Eshlaghi AT, Ebrahimi AP, Esmaieli R. Study on feasibility and
acceptance of implementation of Technology Acceptance Model of Davis in staff of
Shahid Beheshti University of Medical Sciences. Pajoohandeh Journal. 2013;18(1):
40-45.
KEY WORDS: Electronic health record; Electronic medical records; Hospital
information system; Nursing process; Nursing records
