Shih, D. and Rosenblum, R. (2017). Attitudes and perceptions of advanced practice nurses towards health information technology and its effects on caring. Online Journal of Nursing Informatics (OJNI), 21(3), Available at http://www.himss.org/ojni
Aim: The aim of this study was to explore the attitudes and perceptions of advanced practice nurses (APNs) toward health information technology and its effects on caring.
Background: Technology is rapidly, constantly evolving, and affecting healthcare. Nurses are continually challenged to meet demands of learning new skills involving technology while maintaining quality care. Although there are studies looking at nurses’ and nursing students’ attitudes towards technology in the tertiary care environments, there is very little examination of the perceptions and attitudes of APNs toward this evolving technology.
Design: This is a cross sectional study of APNs’ (APNs and physician assistants) attitudes and perceptions using a descriptive research design where nominal and categorical data was collected and analyzed using frequencies and Chi-square analysis.
Methods: The Information Technology Attitude Scales for Health (ITASH) survey was disseminated to 150 APNs in a large multispecialty, multi-location outpatient health care organization located in northern California.
Results: Age, educational level, gender and ethnicity did not contribute any significant differences in the attitudes toward care value of information communication technology (ICT), training of ICT skills, ICT confidence or workload value. However, nurse practitioners (NPs) had higher care value ICT scores compared to certified nurse midwives (CNMs) and physician assistants (PAs). Primary care as a department also scored higher than specialty departments in the care value of ICT factor.
Health information technology (HIT) and communication technology (CT) have greatly impacted health care in many different ways. They have increased efficiency in communication of information for healthcare team members as well as patients. Technology is evolving rapidly and while it has the ability to improve healthcare outcomes, it has also affected patient and nurse relationships (Korhonen, Nordman, & Eriksson, 2015).
Nursing and caring requires physical presence and touch for relationships to develop, and these relationships impact quality health outcomes (Korhonen, et al., 2015; Nagel, Pomerleau, & Penner, 2013; Turpin, 2014). More and more interactions that occur between patients and healthcare providers via physical presence are being replaced by electronic or virtual presence. Caring is changing in the face of technology. Creativity and innovation are needed to continue the expression of genuine care and concern, not only through human contact, but also through the use of technology (Hawkins, 2012; Nagel, et al., 2013). The number of advanced practice clinicians (APCs) is growing: they can address the changes and the needs of a population surrounded by technology. Unfortunately, there is a gap in the literature exploring the attitudes of these APCs toward technology or how it has impacted them as a profession.
APC- Advanced practice clinician
Physician assistant, any APRN (advanced practice registered nurse)
APN/APRN- Advanced practice nurse/Advanced practice registered nurse
Nurse practitioner (NP)
Clinical nurse specialist (CNS)
Certified nurse midwife (CNM)
Certified nurse anesthetist (CNA)
Health information technology (HIT) is a broad concept that encompasses an array of technologies to store, share, and analyze health information, including electronic medical records (EMR), protected health information (PHI), e-tools, e-prescribing, meaningful use, etc.).
Information/Communication technology (ICT/CT) is an umbrella term that includes any communication device or application, encompassing radio, television, cellular phones, computer and network hardware and software, satellite systems and so on, as well as the various services and applications that network and support them.
The purpose of this project was to explore and increase awareness of communication and expression of care of APNs in outpatient interactions while using computer technology. The attitudes of the end-users - the APNs and the patients they serve, can impact the successful use of technology (McGonigle & Mastrian, 2014, Ward, Stevens, Brentnall, & Briddon, 2008) and therefore needs constant monitoring. However, while the focus of this project was APNs, PAs are often employed alongside APNs. Therefore, attitudes among APNs and PAs were compared.
1a. What are the perceptions and attitudes of APNs towards health information technology and its effect on caring?
b. How do these perceptions and attitudes compare among the APNs and PAs?
2. How has health information technology impacted the way APNs care for their served population?
Joanne R. Duffy (2005) developed the quality caring model in 2003. The purpose of this model was to expose the hidden work of nursing and support the link between nurse caring and quality health outcomes. Duffy stated that nurses have made significant contributions to the success of patient outcomes and increased patient satisfaction but that their work is sometimes hidden or undocumented as to how much and what nurses actually do to achieve this.
The four types of caring relationships encompassed in this theory are self, patients and their families, each other, and communities. Caring relationships result in feeling cared for, which ideally supports self-advancement, a concept that was added to the revised quality caring model (Duffy, 2009). Feeling cared for stimulates patients and their families to participate, learn and persevere toward better health outcome goals (Duffy, 2015).
These caring relationships make nurses’ work more meaningful and satisfying and thus congruent with professional nursing values (Duffy, 2015; Turpin, 2014). It has been shown that relationships that develop between patients and healthcare providers have reciprocal benefits: _ patients gain measurable quality outcomes and healthcare providers feel job satisfaction and professional growth (De Milt, Fitzpatrick, & McNulty, 2011; Duffy, 2015; Shea, 2008).
Existing studies that explore the attitudes of APNs toward information technology are limited in that most studies are related to registered nurses and not APNs. These studies encompass the attitudes of nurses as students or practicing in specific specialty areas such as intensive care, emergency departments, surgical or psychiatric units. The studies that explored caring and technology showed these are two very large topics, and the literature is full of controversy about not only how one should measure caring but the very definition of caring. Furthermore, the debate encompasses diversity in the definition of technology in the literature as well. There is much confusion on how terms such as health information technology, communication technology, e-messaging, and telehealth are used. The literature review for this study focused on existing studies of nurses’ attitudes towards technologies in healthcare that used a variety of research designs.
In clinical practice, technology has posed some barriers to frontline nurses in adopting telehealth, as seen in the slow implementation of telehealth in the United Kingdom. Telehealth has been defined as the remote exchange of data and information between patients and healthcare professionals to assist in diagnosis and management of health conditions (Sanders et al. 2012). Taylor and colleagues (2015) conducted a thematic analysis of qualitative interviews to identify barriers to the successful adoption of telehealth. Semi-structured interviews were conducted with 105 registered nurses located in four community clinics in the United Kingdom. Results of the study indicated that frontline staff acceptance of telehealth was fragile, uncertain, and was hindered by organizational, professional and technological barriers. This study added depth to the current understanding of factors affecting staff acceptance of telehealth but was limited in that findings were based on retrospective and somewhat partial accounts of implementation.
A cross sectional study by Ifinedo (2016) explored demographic (educational level, age) and individual characteristics (years of nursing experience and computer knowledge) and their influence on nurses’ acceptance of information systems (IS). This study used the Technology Acceptance Model as its theoretical framework and included 197 registered nurses in Nova Scotia, Canada. The study demonstrated that the number of years of nursing experience and age did not show any meaningful results. However, attitudes toward IS did have a significant impact on behavioral intentions to use IS, which in turn positively affected the nurses’ use of IS. This study provided useful insight on how to effectively implement IS with successful acceptance in the workplace.
Price (2013) used ethnography to explore and identify what enhances or inhibits registered health professionals’ ability to care for patients within the technological environment of a critical care unit. The themes included crafting process, vigilance, focus of attention, being present, and expectations. The end goal of these themes was achieving the best interest of the patient. This study highlighted that the concepts of caring and technology could not be separated but the way technology is delivered is important. However, the weakness of the study was that data were collected 2008-2009 and the ICU setting has since changed.
These studies all involved registered nurses in various settings using different research methods to explore attitudes and acceptance of technology in the work environment. Although there are many ways to explore attitudes, these studies all focused on attitudes to address barriers and perceptions and to facilitate the successful implementation of some form of technology in the work setting. Job satisfaction and patient quality outcomes are also common core concepts in these studies.
Gaps in the Literature
Review of the literature on the effects of HIT on caring is limited. There are many commentaries and systematic reviews of the literature indicating concerns about how technology affects caring, both positively and negatively. While there are many tools to measure caring, the definition of caring is obscure and therefore many controversies on how to interpret these measurements exist. Furthermore, the definition of HIT in the literature is obscured by lack of consistency in its use and definition. For example, HIT is often used interchangeably with health informatics (HI) and/or health information systems (HIS). The rapid evolution of technology used in healthcare coincides with increased terms such as mHealth/eHealth (mobile health and electronic health), contributing to more complexity in the literature (Sezgin & Yildirim, 2014).
There were no studies found in the literature that specifically focused on APNs’ perceptions or attitudes toward caring or the effects of technology on caring. Measurement of nurses’ attitudes toward ICT is difficult, mostly due to the complex and diverse factorial structures that influence attitudes. Although studies may exist that focus on tools that are available to explore attitudes toward technology, the report of their validity and reliability is inconsistent (Ward, Stevens, Brentnall, & Briddon, 2008).
This is a cross sectional study of APNs’ (APNs and physician assistants) attitudes and perceptions using a descriptive research design where nominal and categorical data was collected and analyzed using frequencies and Chi-square analysis.
A convenience sample of a 150 APNs within a nonprofit, multi-specialty, multi-location healthcare organization located in northern California was surveyed. Inclusion criteria were APCs who had been employed for more than three months and had been working with health information technology for the same amount of time. APCs are defined as NPs, CNMs and CNSs, and PAs. PAs and NPs are employed equally at this healthcare organization and while this study focuses mostly on APNs, PAs were included in the study. Exclusion criteria are anyone not identified as an APC as defined in the inclusion criteria and who has not been using information technology for at least three months.
The Information Technology Attitudes Scales for Health (ITASH), developed by Ward, et al., (2008) was disseminated to the 150-180 APCs via Survey Monkey. This method was chosen because the organization is multi-specialty and multi-location and electronic means was more convenient for dissemination and return of the survey. Permission to use and adapt the shortened ITASH by Lee & Clarke (2015) for the purposes of this study was granted by the author and the originator of the tool.
A cover letter/consent form explained the importance and significance of the study and that participation was voluntary and confidential. This contained the link to Survey Monkey, which had demographic questions and the ITASH survey. Survey Monkey was used not only for data collection but also its quantitative analysis. Electronic survey and any other communication from the researcher to the participants occurred within the PAMF network using employee email addresses. Reminders were sent two weeks later to encourage increased participation. There was no labeling by name or number to provide confidentiality. The survey was disseminated directly to the APC by the primary investigator while the associate VP of organizational effectiveness encouraged participation in the study.
Reliability and validity of the shortened ITASH used in this study was attained by the study conducted by Lee and Clarke (2014), who looked at the attitudes of nursing students toward ICT in their instrument development.
There were no risks noted to the participants, however, participating in any study can potentially cause stress or anxiety while filling out a survey. Confidentiality was maintained by not linking any results to the participants through surveys disseminated by Survey Monkey. Only group results were reported. There was no compensation offered to the participants volunteering to fill out the survey.
Out of a 150 APCs, 64 responded (43%). The majority of the participants’ age ranged from 51-60 (36%), 41-50 (28%), 31-40 (20%), 61-70 (11%) and 20-30 (5%) years old.
The level of education of the respondents was 75% having a master’s degree, 16% having a bachelor’s degree, 8% with an associate’s degree, and 1% having a doctoral degree. The sample size consisted mostly of females (84%) and 16% males. 50% of the participants were NPs, 44% PAs, and 5% CNMs. 65% of the participants worked in specialty areas, 19% worked in primary care and 16% worked in other areas.The race of the sample consisted of mostly White (73%), Asian/Pacific Islander (11%), 5% Hispanic/Latino, 2% Native American Indian and 9% other.
SPSS version 23 was used for data analysis. The first part included demographic descriptive statistics followed by a comparison of mean factor scores between age, educational level, gender, occupation, department, and ethnicity. One-way ANOVA for each factor score was used for all, except for gender, which was analyzed using a two-sample t-test for each factor score. Tukey's post hoc tests were applied to determine exactly which groups differed. A significant ANOVA only indicated that there was a difference somewhere between the groups, and the post hoc tests were needed to determine exactly which means differed. Descriptive statistics and power for each analysis were also performed.
The four factors assessed in the ITASH survey were: 1) care value of information communication technology (ICT), 2) training of ICT skills, 3) ICT confidence and 4) workload value of ICT. The four factors described the conceptual domain: ‘care value of ICT’ that is a subscale measuring how APCs regard the contribution of ICT towards care; ‘training of ICT skills,’ which investigates the attitudes of APCs towards their ICT training and their desire for further ICT training; ‘ICT confidence,’ a subscale assessing APCs confidence in dealing with ICT; and the subscale, ‘workload value of ICT’ that examines their attitudes towards work efficiency in using ICT (Lee & Clarke, 2015).
A separate analysis of variance (ANOVA) was done for each factor. There are no significant differences in factors 1 to 4 scores (Factor 1: care value of information communication technology (ICT); factor 2: training of ICT skills; factor 3: ICT confidence; factor 4: workload value of ICT) with respect to age, educational level, gender and ethnicity. There were noted significant differences in factor 1, 2, and 4 scores in the occupational category between CNMs and NPs and between NPs and PAs (Figure 1). NPs had higher factor 1 scores than both CNMs and PAs. NPs also scored higher than PAs in factor 2 and 4 scores. By departments, the primary care department scored higher than specialty departments in factor 1 scores (Figure 2).
It is suggested in the literature that there may be influences of gender, age and educational level in attitudes toward ICT. This study did not show any significant influence; this is consistent with the systematic literature review conducted by Ward et al. (2008). The workload factor in this study was also not affected by age, educational level, gender, ethnicity, specialty department or profession; this is inconsistent with literature (Infinedo, 2016) in which educational level and computer knowledge had positive effects on attitudes toward ICT. Infinedo (2016) also found that number of years of nursing experience and age did not have meaningful results. Interestingly, primary care physicians felt an increased workload due to ICT in prior studies (Ward et al., 2008) whereas in this study, the workload was not affected or influenced by the different types of APCs (CNMs, NPs or PAs). However, analysis by specialty departments showed that the primary care department had a higher care value ICT score than any other department.
The outcomes of this study suggest that NPs overall have a positive attitude regarding the care value of ICT, training of ICT skills and workload value of ICT when compared to CNMs and PAs. Health information technology, overall, had a positive impact on their served population and thus improved quality of care.
This study has several limitations. This was a convenient sample of APCs in a healthcare organization located in northern California. The results, therefore, cannot be generalized to any other location that may not have the same demographics or level of experience with health information technology. Moreover, the population may have been self-selected to those interested in the topic of health information and communication technology, and due to location in Silicon Valley where technology is more advanced, the participants may be heavily biased compared to the general population. The shortened version of the ITASH was developed to be used to evaluate attitudes of nursing students (Lee & Clarke, 2014) and not APNs; the duties and experiences between them are quite different.
Technology is rapidly evolving and exposure to re-training to use a new system or crashing of an electronic system can bias the response to the surveys. The leadership structure within healthcare is also constantly changing. Any change that affects or increases the stress of the subjects can potentially decrease the response rate and or influence the response to the survey. These are potential limitations to the study that are not within the control of the researcher.
There are many terms that are being developed and used as a result of the rapid evolution of technology. The term “health information technology” can be interpreted in many different ways from communication between health professionals to communication of health professionals to patients. Information communication may involve electronic health and mobile health. Therefore, it may be difficult to accurately assess how the APCs were defining ICT/HIT in the survey.
Technology and its increased use in the healthcare field is constantly evolving and changing. The attitudes of the end-users, such as APNs, can impact the successful use of that technology (McGonigle & Mastrian, 2014) and therefore need constant monitoring. In so doing, educational and training needs of APNs can be identified and addressed thus improving not only competency, but also job satisfaction, quality of care, and improved collaboration/teamwork (Ancker, Silver, Miller, & Kaushal, 2013; Jennings et al., 2014; Koivunen et al., 2015; Korhonen et al,, 2015).
Due to the limitations mentioned, it is recommended that more research on attitudes toward information technology be conducted to identify other factors and educational needs that can strongly influence nursing practice and the healthcare industry as a whole. Additional research can also place the new concept of nursing informatics more strongly in healthcare organizations, creating a stronger voice for the nursing profession as a whole (McGonigle & Mastrian, 2014). With more research, perhaps a more consistent and unified use of terminologies can be developed when describing the various communication platforms that are rapidly developing in healthcare. Furthermore, attitudes may differ in more rural areas where technology in healthcare has not yet evolved rapidly or is just starting to be accepted as part of the healthcare industry, and should be studied. Most importantly, the rapidly evolving technology drives the need for constant assessment and evaluation of attitudes of end users in the healthcare industry to not only have that technology succeed but also to improve patient quality outcomes.
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Debbie R. Shih, DNP, MSN, RN, FNP-BC, has been in practice as a family nurse practitioner (FNP) for 19 years and a registered nurse for 25 years. She is currently in clinical practice at Bay Area Sutter Health affiliate Palo Alto Medical Foundation. Having a special interest in women’s health and office surgical procedures, she graduated in May 2017 from California State University Northern California Consortium Doctor of Nursing Practice Program (San Jose State University/California State University, Fresno). Her doctoral project relates to technology and how it impacts patients and the nursing profession. Further educational background includes a Master’s of science in nursing, with an emphasis in clinical case management from San Francisco State University (1994). She authored a study, published in the Journal of Women’s Health, on genital HPV infections and non-clinic population of young women (1997). She later received her FNP/physician assistant certificate from UC Davis, California (1998). Her undergraduate studies included a Bachelor of science degree in biological sciences with a minor in psychology from UC Davis (1989).
Ruth Rosenblum, DNP, MS, RN, PNP-BC, CNS, has been an APN for more than 30 years. She is currently an assistant professor at the Valley Foundation School of Nursing at San Jose State University, where she is also interim director of the California State University Northern Consortium Doctor of Nursing Practice Program. Additionally, she maintains a pediatric NP practice in child neurology at Santa Clara Valley Medical Center in San Jose, where she manages children with seizures, headaches, tics, concussions, and other neurologic disorders. She is also the medical provider for the High-Risk Infant Follow-up Program at SCVMC. Ruth has an interest in pediatric headache management via the use of mobile healthcare technology; she also is interested in innovation and evidence-based practice. She is immediate past director of clinical practice for the Association of Child Neurology Nurses.