Exploration of Nurses’ Experience with Using Electronic Documentation Systems in Home Care

BY Sarah Ibrahim, RN, MN, PhD(c), Lorie Donelle, RN, PhD, Sandra Regan, PhD, and Souraya Sidani, PhD

Citation:

Ibrahim, S., Donelle, L., Regan, S., Sidani, S. (Summer 2019). Exploration of Nurses’ experience with using Electronic Documentation Systems in Home Care. Online Journal of Nursing Informatics (OJNI), 23(2).  Available at http://www.himss.org/ojni

Abstract

BACKGROUND: Electronic documentation systems (EDS) have become integral aspects of healthcare systems both nationally and internationally. Despite the growing efforts to understand registered nurses (RNs)’ experience with EDS usage in practice, limited knowledge exists in the context of home care.

AIMS: To explore registered RNs’ experience with EDS usage in home care. 

METHOD: A descriptive qualitative study was used. Registered RNs (N = 13) practicing in the home care sector took part in one-on-one, semi-structured, telephone interviews. Simultaneous data collection and analysis was conducted. Data were analyzed using inductive thematic analysis.

FINDINGS:  RNs’ individual, technological, and organizational characteristics were perceived to influence registered RNs’ EDS usage and workarounds were used to overcome system barriers.

CONCLUSION: Findings highlight the importance of: a) having a role for RNs in the EDS design and implementation processes; and b) leadership fostering a supportive environment and employing the necessary technical support for RNs using EDS in practice.

Background

Recent increases in the number of older adults, their complex and palliative care needs, their health care services usage, and financial constraints constitute significant challenges to the health care system (Kitchen, Williams, Pong, & Wilson, 2011; Qu & Sun, 2015). These challenges have contributed to a shift in the delivery of care from acute care to the home care sector, which has become the fastest growing sector in national (i.e., Canada) and international (i.e., Europe and United States) healthcare systems (Canadian Home Care Association, 2015; Home Care Ontario, 2016; De Vliegher, Declercq, Aertgeerts, Gosset, Heyden, & Moons, 2014). Such challenges and developments highlight the need for the provision of high-quality care. Health information technology, specifically the integration of electronic documentation systems (EDS) within healthcare organizations, holds promise in offering ways to enhance care (Manca, 2015). 

Empirical evidence has shown that EDS offer health care providers (HCPs) such as registered nurses (RNs) access to complete, comprehensive, accurate and timely patient health and care-related information (Canada Health Infoway, 2013; Kitchen et al., 2011). Further, EDS have the potential to enhance patient safety; facilitate continuity of care and efficiency of care delivery; streamline RN workflow; and enhance real-time communication, collaboration and decision-making (Bowles, Dykes, & Demiris, 2015; Canadian Home Care Association, 2015; Carretero, 2015; Hsiao & Chen, 2016; Canada Health Infoway, 2013; Jamal & Grant, 2014). While there are noted benefits of EDS, differences in technology experience, attitude and perceptions of EDS are influential determinants of RN satisfaction, intention and actual system usage in practice (Kim, Le, & Yoo, 2015; Kipturgo, Kivuti-Bitok, Karani, & Muiva, 2014). Several studies have examined RN implementation of EDS and factors influencing their satisfaction, intention and actual EDS usage in practice within acute care hospitals (Zhang & Zhang, 2016). However, there is limited research exploring RN perceptions and experiences with EDS usage in the context of home care (Abu Raddaha, Obeidat, Al Awaisi, & Hayudini, 2017; De Vliegher, Paquay,  Vernieuwe,  & Van Gansbeke, 2010).

Understanding home care RNs’ perspectives is important because they are the most widely used professional resource in the home care sector (Canadian Nurses Association (CNA), 2013).  Home care is the fastest growing sector in Canada, specifically within the province of Ontario as well as worldwide (CNA, 2013; Home Care Ontario, 2016; Institute of Medicine, 2003; Kitchen et al., 2011). The home care sector is unique from other workplace settings (i.e., acute care and long-term care facilities) (Tourangeau et al., 2014), which may influence and shape RN experience with EDS usage. For example, home care RNs spend a great proportion of their time working independently and autonomously in patient-controlled environments (CNA, 2013; Lundy & Janes, 2014; Tourangeau et al., 2014). Further, home care RNs work in diverse locations such as patient’s homes, RNs’ cars, and agency offices, potentially impacting the availability of resources, supplies and IT support (Tourangeau et al., 2014). In comparison, RNs working in the acute and/or long-term care sectors tend to work in environments that enable collaborative practice with multi-disciplinary HCPs and material resources (Lundy & Janes, 2014).

In Ontario, a variety of EDS are used within the home care sector; however, two systems that are consistently used are Clinical Health and Related Information System (CHRIS) and Document Management System (DMS) (Clinical Connect, 2016; Ontario Association of Community Care Access Centres, 2013). Understanding RN experiences with EDS usage in practice is imperative because they are the largest group of regulated HCPs and user groups of EDS (Cho, Kim, Choi, & Staggers, 2016; World Health Organization, 2013). Such systems cannot be reasonably expected to contribute to improving access to information and quality of care if they are not used as intended or if they render little value (Oye, Iahad, & Ab-Rahim, 2012). Therefore, the aim of the study was to explore RN experiences with EDS usage in the home care sector. 

Methods

Design

A qualitative descriptive study (Sandelowski, 2000) was conducted as part of a larger investigation of home care RNs’ intention to use EDS; this study was reported separately (Ibrahim, Donelle, Regan, & Sidani, submitted). Telephone, one-on-one, semi-structured interviews were conducted. The Institutional Research Ethics Board approved the research protocol (REB approval #: 109426).

Sample

RNs working in the home care sector were the target population for this study. RNs were eligible to participate in the study if they were: a) registered with the College of Nurses of Ontario (CNO); b) employed part time or full time in home care settings; c) provided direct or coordinated patient care; and d) had participated in the online survey and agreed to take part in the qualitative interviews. RNs were excluded if they reported being in managerial positions, self-employed or concurrently working in both acute and home care sectors.

A convenience sampling method was employed (Etikan, Musa, & Alkassim, 2016). According to empirical research, a minimum approximated sample size of 12 participants is recommended for qualitative interviews (Guest, Bunce, & Johnson, 2006). The final sample was determined based on the evidence of data saturation (Saunders et al., 2018).

Recruitment of Participants

The 80 RNs who participated in the quantitative arm of the study responded to the invitation for a follow-up interview. However, only 58 RNs actually provided their contact information. RNs that provided their email addresses were informed of the study and provided a letter of information electronically. For RNs that provided their phone numbers, the researcher called potential participants to verbally explain the study and/or left a message if there was no answer. Some potential participants did not respond to either the email or telephone contact following several attempts to establish contact. Recruitment took place over the spring and summer of 2018, potentially contributing to the slow participant recruitment and response rate. Written consent was obtained from RNs who agreed to take part in the study. 

Data Collection

One-on-one, telephone, semi-structured interviews were conducted. The interviews were 30 to 60 minutes in duration. Telephone interviews were conducted to reduce travel associated costs, mitigate physical distance between the researcher and RNs, and enhance participation of RNs from across the province (Farooq, 2015; Vogl, 2013). The semi-structured interview questions evolved to generate greater inquiry into themes (i.e., training, workarounds, and ways in which RNs provided feedback and input towards the EDS design) that emerged from the concurrent analysis of the interview data. A sample of the interview questions are presented in Table 1. Participants were offered a $20 gift card to a store of choice as a token of appreciation for taking part in the interviews.

Data Analysis

The semi-structured interviews were audio-recorded and transcribed verbatim. Identifiable information (i.e., participant name, name of employment agency or coworkers) were removed from the transcripts to enhance confidentiality of participant data and to facilitate participant anonymity. Simultaneous data collection and analysis to accommodate the emergence of codes and themes (patterns) from the text data were conducted (Vaismoraid, Turunen, & Bondas, 2013).

An inductive thematic analysis was conducted. The six phases of thematic analysis as outlined by were applied to identify, analyze, describe and report the data. NVivo software (NVivo Version 11, QSR International) was used to facilitate the analysis. The transcripts were independently reviewed and coded by the first author. All transcripts were read and reviewed by the second author. To ensure trustworthiness, the following strategies were employed: reflexivity, interview and step-wise techniques, peer-debriefing, investigator triangulation, code-to-code procedures and thick description (For example, the researchers reflected upon their positionality (e.g., backgrounds, experiences, personal and professional roles) as part of the data analysis process. The first author, an RN, has quantitative research experience and is coming from a lens that is influenced by the Unified Theory of Use and Acceptance Model (UTAUT). The second author, an RN, has extensive clinical and research experience with health and nursing informatics among HCPs and clients. This process better prepared the researchers in acknowledging their positionality and, in turn, created transparency in relation to the data analysis processes (Coding and analysis were discussed between the first and second author. Further, any discrepancies regarding the data and emergent themes were resolved through consensus between the authors. The overall emerging themes were discussed and approved by all authors.

Findings

Sample Characteristics

Thirteen RNs were interviewed. The majority of participants were female (92.3%) with an average age of 53.15 years (range 34-65). Most RNs reported being in the role of care coordinator (n=10, 77%) and three (23%) were direct patient care providers. Ten (77%) of the RNs reported working full-time. All RNs reported EDS usage in their home care practice.

Themes and Subthemes

Five themes emerged from the analysis of the data; each theme reflected an aspect of RN experience with EDS usage within the home care setting. The themes reflected factors that influenced RNs’ usage of EDS and strategies to overcome technological barriers. The factors were: 1) individual characteristics, 2) technological characteristics, 3) workarounds, 4) organizational characteristics, and 5) nurse-patient interactions (Figure 1).

Theme 1: Individual characteristics

This theme described the influence of RNs’ previous experience with technology, which was influential to their overall experience with EDS usage in their home care practice.  =RNs reported that having technology-related experience, knowledge and skills contributed to their positive and favourable experience with EDS usage within the home care setting. More specifically, having greater personal (for younger RNs) and/or professional experience (for more experienced RNs) reportedly allowed RNs to understand, navigate and use the EDS proficiently. RNs explained that with personal and/or professional experience, they were able to apply and assimilate their knowledge and skills attained from general technology usage, similar systems, various clinical settings and roles toward EDS usage, supporting workplace digital usage. For example, an RN commented:

I've used electronic documentation systems since the 90s. Just software things. You know, how do you use that, just comfort with software.
(Participant 9)

RNs who reported limited technology experience described having more negative experiences with EDS usage. RNs explained that this negative experience was related to the lack of comfort and, in turn, high levels of anxiety and stress associated with having to learn and use the EDS in a home care setting. Regarding the influence of personal technology usage, RNs expressed:

I think I would have to say when I look at the younger staff who have no issues with using anything electronic, I had always considered myself to be fairly comfortable, but I certainly can see that I’m not as comfortable as they are, when they were raised with, as babies, using these things practically.
(Participant 13)
I do know one person who was in orientation at the time I was. When she was just struggling during the orientation and about a month after, she actually resigned because she just said, ‘oh my God, I can’t, I just can’t, every time I think I’m doing something, I’m in the wrong place and putting a note in and then it’s gone because I didn’t save it properly,’ And so, she decided that it just wasn’t for her and she actually went back to the hospital.
(Participant 6)

Theme 2: Technological characteristics

This theme described the influence of the technological characteristics on RNs’ overall experience with EDS usage in their home care practices.

I’m better informed and more efficient.

The majority of RNs reported that EDS usage positively influenced their work and performance while enhancing their communication, collaboration and patient-related decision-making experience. More specifically, EDS usage was said to have enhanced RNs’ performance, communication and collaboration by enabling: a) legible, organized, and comprehensive documentation; b) improved and timely access to accurate, complete and up-to-date patient health and care-related information regardless of physical location; c) better information at the point of care resulting from real-time access to patient health and care-related information, procedure and test results, interventions, referrals and orders; and d) convenience, portability (i.e., EDS usage in various settings such as hospital, patients’ homes, RNs’ car, agency office, and parking lot) and efficiency (i.e., documenting at the point of care, less time spent documenting by hand and transferring notes). Several RNs expressed: 

“I’m better informed, number one. I’m also, I’m more efficient in a way. I get my job done quicker than I used to in the old days when I would write notes. Then I would go back to the office and then transcribe my notes, even though they were very point form, it still was kind of doing double duty. Now, I write my notes right up in client’s homes. My assessment is pretty close to being complete before I leave a client’s home.” (Participant 12)

 “We’re more accessible to each other, because we’re in community and we’re on our own… also, the ability to pull up and see what we’re doing versus relying on having to go to somebody and have them answer the phone and be able to tell us what we need to know in terms of orders. …so I think that has really made a big difference.” (Participant 13)

It all comes down to connectivity.

The majority of RNs indicated they experienced technical issues with EDS usage in their home care practices. The technical issues were reportedly related to poor or lack of internet connectivity, unscheduled EDS downtime, and the EDS slowing down or not working. The resultant technical issues were often experienced by RNs in rural and remote areas and less often in and around the agency offices. The technical issues were said to negatively influence RNs’ experience with EDS usage in their home care practices, hindering their ability to work, access patient-health related information, communicate with allied HCPs, and document at the point of care, compromising care delivery and patient-related decision making. For example, RNs expressed: 

“The other negative to it... that the system goes down and then you’re blind really…That impacts the work and it impacts the patients because you can’t help them, can’t service them and then we try and revert to what’s called a downtime system and that takes even longer because they are all separate papers that you have to fill out and now you’re faxing things to people, specifically, because we have to get the service in the homes. And it’s just chaos.” (Participant 9)

“If the connectivity went down…  you can’t do anything. We had an issue like this a few weeks ago actually where our internal server had gone down and people didn’t even want to answer the phones. So, because you can’t access client files, you don’t want to pick up a phone call because there’s nothing you can do about the information that the person is going to say to you anyways. You can’t open the file, you can’t book an appointment, you can’t do any of that stuff. So, it would be definitely the fact that it all—if the web, if the internet goes down, web access goes down then you are kind of stuck.” (Participant 11)

It's the interface.

RNs reported both positive and negative experiences with EDS usage in their home care practices based on the overall EDS design. For those that expressed having positive experiences, this was related to the EDS being: a) user-friendly, easy to navigate, intuitive, and free of complications; b) able to interface with other systems; and c) a good fit with RNs’ workflow and needs. Several RNs expressed:

We can access the region files a little bit easier because everything is interfaced in the one program.
(Participant 1)
…once you’re used to it and you just work through, you know, from left to right, through those tabs, as you’re entering information. It’s designed in very logical and sequential manner.
(Participant 6)

The RNs’ negative experience with EDS usage was reportedly related to the overall design, specifically: a) the system not being designed in a user-friendly manner (i.e., too many tabs to navigate through) and not fitting with RNs’ workflow and needs; b) the system not capturing or reflecting RNs’ professional judgement; and c) the EDS not interfacing with other systems. For example, an RN expressed:

So, based on how you answer the assessment questions, it creates an algorithm and it creates a score and so, now the home care agency have decided if you’re in the low score or the medium score, you go on a wait list for services. If you’re in the high, you can get maybe two hours of personal support and if you’re in the very high, you can maybe get seven, right. The thing is, is that if you don’t have cognitive issues, you score very low, but your ADL needs are really high, but you still don’t get the service. So, you’re always having to fight with the supervisors to get service because even though the score is low, I mean for example, we had a paraplegic who was basically bedridden and needed all kinds of physical care and didn’t score high enough to even get service and we said, this is insane. But and that’s where it goes bad, is when they rely on numbers instead of the RNs’ professional assessment for giving service.
(Participant 9)

Theme 3: Workarounds

This theme described the workarounds developed by RNs when using the EDS in their home care practices. Workarounds represent implementation of temporary behaviours and/or practices by end-users to overcome technology-related limitations (Creswell, Bates, & Sheikh, 2013). The workarounds resulted from RNs’ negative experiences with the technical issues (i.e., poor  connectivity, unscheduled EDS downtime, slow function of EDS and EDS being compromised) and shortcomings in the system design. To address the technical issues, RNs developed workarounds including: a) downloading all patient-related documents to have a hard copy back-up of the information; b) writing notes on paper and/or in a Word document at the point of care and transferring information to the EDS at a later point in time; c) developing a cheat sheet of all key questions from the assessment tools; d) using “downtime forms” developed by the agency; e) using the “offline” option in the EDS when working in remote areas; and f) using phones to coordinate and deliver care when the system was compromised. For example, an RN expressed:

I’ll open different documents and then I don’t lose them because they’re already there, I don’t lose them when I lose my connectivity so no big deal. Also, I write my notes in Word…  I’ve uploaded the template that I need into a Word document and I do everything in Word and then I transfer it into our documentation system that all can access it. But I just find, because if I lose the documentation system right in the middle of something, I lose everything, and I can’t get it back. Whereas, I don’t lose a Word document.
(Participant 12)

The workaround developed to address shortcomings of the EDS design were related to data entry. More specifically, RNs reported having to enter data in a specific way to generate a certain score that was reflective of the patients’ needs and care required. This shortcoming was said to be “quite frustrating” as some RNs indicated that their professional judgement was being replaced by the algorithm embedded within the EDS. For example, an RN stated:

You really have to be thoughtful in how you score people and that… Like what are the triggers or what are the identifiers that trigger the system to influence the outcome… Because certain things about the program, if you are mentally capable but physically heavy, you do not score the same as someone who is suffering from dementia but mobile.
(Participant 4)

Theme 4: Organizational characteristics

This theme described the influence of the organizational characteristics on RNs’ overall experience with EDS usage in their home care practices. The four subthemes were: “it’s the training,” “information technology (IT) support is very reachable,” “just leaning on colleagues,” and “we can provide feedback.”

It’s the training.

RNs reported receiving training during orientation and on an ongoing basis when upgrades were made to the EDS. Training ranged from three hours to two weeks and was delivered by an interdisciplinary team (i.e., RNs, physical and occupational therapists, social workers, IT personnel and education specialists). Training was delivered through different media: webinars, e-mail and classroom, and in both passive (i.e., lecture) and interactive (i.e., hands-on practice) means. The training was geared towards RNs learning how to operate the system and understanding the features (i.e., tabs, sections, templates, shortcuts), documentation, ordering and referral procedures.

RNs had various opinions about the training and its influence on their experience. Overall, RNs were satisfied with the training received and expressed that it positively influenced their EDS usage experience. This finding was prominent among RNs who had a longer training period (i.e., two weeks) that was interactive and delivered through different media. Through such training, RNs reported that their learning needs were met and that they had adequate time to attain mastery of EDS usage. An RN expressed:

There’s weeks of orientation for new people including classroom as well as pulling up a chair beside someone and actually working through with someone else looking over your shoulder. And when there are major computer upgrades within the training environment, often each person has a computer, so that you actually work through the steps while the trainer is saying, you know, click on this tab, and you do the same in yours just to make sure that you’re comfortable with it, seeing the same thing.
(Participant 6)

Some RNs on the other hand reported being dissatisfied with the training received, negatively influencing their EDS usage experiences. This was noted by RNs who had a short training period (i.e., three hours) that was passive, with limited time to attain proficiency of the necessary knowledge and skills to use the system competently in their home care practices. An RN commented: 

It was provided like very quickly. The roll out was let’s get everybody trained as fast as we can. Because we were all at different levels of computer usage, it should’ve been, I felt, individualized to the person’s ability to use a computer, never mind use this documentation system.
(Participant 13)

IT support is very reachable.

All RNs reported having a positive experience with the availability of IT support while using EDS. The positive experiences were associated with RNs: a) receiving adequate IT support, regardless of their physical locations (i.e., agency office, patient’s home) and time of the day; b) having issues resolved within a timely manner (i.e., 30-60 minutes); and c) having access to organizational resources (i.e., documents, summary notes, and cheat sheets) made available through the organization’s intranet. For example, RNs expressed:

“IT support are very reachable. And they are there 24 hours if I would be working after hours and have a major issue, they’re there…They just get onto my screen and  just do whatever they need to do.” (Participant 8)

We can go to our intranet and find those documents to walk me through the a, b, c, d. So, they set that up very, very easily. Like this morning I hadn’t done an assisted living application in a year, I had no idea how to process that, so they walked me through the software… So, it’s been very good you know, the how to set the A-Z for every process, so every new user, I could get how do I do a referral to a pathologist, so they can go in and get that workflow sheet for any process because we do so many processes. They’ve been very good about where I find the information to walk me through the software.
(Participant 10)

Just leaning on colleagues.

RNs indicated that they received a significant amount of support from their colleagues to help them use the EDS and navigate data entry approaches and come up with shortcuts. Some RNs also reported having champions in the agency to assist and support when they expressed a need. The champions were RNs who were comfortable and well experienced with technology and EDS usage. Through such a collaborative and supportive approach, RNs had a positive and favourable experience with system usage in their home care practices. For example, an RN expressed: 

My colleagues are really helpful. I’m on the older end of the spectrum and I find that my younger colleagues are really, really helpful.
(Participant 12)

We can provide feedback.

The majority of RNs indicated that they had the opportunity to provide feedback into the EDS design. Further, some RNs reported having their feedback incorporated into the system upgrades. The feedback provided by RNs for the design of the EDS were associated with: a) features (i.e., including back arrows and templates) and b) layout (i.e., presentation of information, categories and labels) to make it more user-friendly. For example, an RN expressed: 

We get an opportunity when we do our education or as things come up, we do have an opportunity to say I don’t think this works as well or we are able to make suggestions or enhancements or changes to the program. That goes forward to a provincial committee and its sort of determined if it’s something that affects the whole province, all the users provincially, they might change it.  If it’s just for us, not likely it would be changed. But you do have an opportunity to bring forward any ideas or suggestions you might have to make improvements or changes.
(Participant 4)

Theme 5: Nurse-patient interactions

The majority of RNs indicated that their interaction with patients amidst EDS usage influenced their experiences. The influence was associated with both patients and RNs’ level of comfort with EDS usage during the interactions. Some RNs commented that patients felt they were not receiving the necessary attention, were not being heard as the RNs’ attention was geared more towards the EDS, and that the interaction was impersonal. For example, an RN expressed:

I think people feel if you’re not making eye contact, you’re not listening to their story.
(Participant 4).

Some RNs commented that they had to find a balance with maintaining eye contact, not focusing all of their attention toward the system, and being mindful of their body positioning with the laptop and EDS usage during sensitive conversations with patients. For example, an RN expressed:

Well, I used to work in the community and I found it very impersonal when I would go to a home and I would have to sit my laptop up and ask all these questions and type it in when I’m sitting beside the person, instead of making eye to eye contact because my way of nursing has always been you assess the person while you’re talking to them and you pick up queues with regards to pain or you pick up queues if their emotional state is different or anything like that, but when you’re so focused on this computer program and a generic questionnaire that some things don’t even relate to them, I find that it really hinders how you develop a relationship with your patients.
(Participant 9)

Discussion

The results of this study showed that RNs’ experiences with EDS usage in their home care practices were related to RNs’ individual, technological and organizational characteristics, as well as their interactions with patients. They also devised workarounds to address technological barriers/characteristics.

RNs’ individual characteristics 

RNs’ previous technology experience influenced their experiences with EDS usage in home care practices. RNs with more personal (often younger RNs) and/or professional (often experienced RNs) technology experience reported having a more favourable EDS usage experience in practice. This finding is in alignment with the existing literature. For example, van Howelingen et al. (2015), Aldosari, Al-Mansour, Aldosari and Alanazi (2018), Dharmarajan and Gangadharan (2013) as well as Tubaishat (2017)> found that RNs with more technology experience (in comparison to those with less) were more comfortable, accepting, and had a more positive perception of the perceived ease of use and usefulness of the HIT in practice respectively. Lin et al. (2016) also found that technology experience moderated the relationship between RNs’ intention and actual usage of HIT in practice; those with more professional experience had higher intention to use HIT in practice.

A potential explanation to this finding is that historically, nursing programs did not include nursing informatics in the curricula because HIT was not as well integrated in practice. Within schools of nursing, the lack of health information education was coupled with the lack of awareness of the technology-related skills and knowledge RNs were required to attain (Borycki, Joe, Armstrong, Bellwood, & Campbell, 2011). As such, some RNs (often those that were older) were less likely to attain adequate nursing education related to HIT, possibly contributing to job stress and anxiety, and influencing practice competence (Valencia & Raingruber, 2010). Although inconsistencies with the integration of nursing informatics in nursing curricula has been noted in the literature (Hunter, McGonigle, & Hebda, 2013), today, educational institutions have recognized the importance of nursing informatics competences and increased learning opportunities and efforts for nursing students within the curricula and clinical practice (Canadian Association of Schools of Nursing (CASN), 2013). Further, younger RNs, who are often referred to as digital generation RNs, have generally grown up with more access and exposure to technology within their personal lives (Singh & Senthil, 2015). Such exposure may potentially influence younger RNs’ overall level of comfort, technology-related literacy, skills and knowledge in comparison to older RNs who did not grow up within technology-driven environments.

Technological Characteristics

Mixed findings were reported regarding the overall influence of the technological characteristics on RNs’ experience with EDS usage. RNs who reported positive experiences with EDS usage indicated that the system influenced their performance, communication, collaboration and timely access to patient health and care-related information and was user-friendly. This finding is in alignment with other studies examining RNs’ attitude, acceptance, willingness, intention and actual HIT usage in acute and home care sectors (Chung, Ho & Wen, 2016; Ifinedo, 2016; Kim et al., 2015; Sharifian, Askarian, Nematolahi, & Farhadin, 2014; van Howelingen et al., 2015; Vitari & Ologeanu-Taddei, 2018). For example, van Howelingen et al. (2015) and Vitari and Ologeanu-Taddei (2018) found that perceived usefulness (also referred to as performance expectancy) and perceived ease of use (also referred to as effort expectancy) were strong predictors of RNs’ willingness and intention to use home telehealth and electronic health records in practice respectively. Further, Chung et al. (2016) found that perceived usefulness positively and significantly affected RNs’ intention to use patient personal health records in practice.

RNs who did not have a favourable experience with EDS usage related it to technical issues and the EDS design. This finding is in alignment with empirical evidence about RNs’ perception, satisfaction, concerns, barriers, facilitators of HIT and EDS usage in practice (Black Book Market Research, 2014; Saleem et al., 2015; Sockolow, Liao, Chittams, & Bowles, 2012; Stevenson, Nilsson, Petersson, & Johansson, 2010; Strudwick, McGillis-Hall, Nagle, & Trbovich, 2018; Topaz et al., 2016). For example, RNs working in community-based healthcare settings in Philadelphia were unable to fully use the EDS as intended because of poor system usability and navigation (Sockolow et al., 2012). Further, home care RNs working in Belgium experienced challenges with the electronic nursing system crashing and the strength of the hardware battery, which resulted in a constant need to recharge the battery (De Vliegher, et al., 2010). Topaz et al. (2016) also noted that the EDS functionality, usability and interoperability were reported as barriers, contributing to RNs’ low satisfaction with EDS usage in clinical practice. Similarly, Zhang et al. (2016) and Strudwick et al., (2018>) reported that EDS functionality, usability and navigation negatively influenced RNs’ work practice, patient care delivery, perception, and EDS usage respectively.

Workarounds

Some RNs reported employing workarounds with EDS usage in their home care practices. The workarounds resulted from technical issues and EDS design. The reported workarounds are in alignment with those reported in the literature. For example, Blijileven, Koelemeijer, Wezels, and Jaspers (2017), found that RNs resorted to writing down information on paper when the EDS was inoperable and having to copy and paste data because of challenges with standardized data entry templates. Similarly, Cifuentes et al. (2015) found that providers developed workarounds related to system challenges (i.e., use of multiple systems, inability to track and document pertinent patient health information, support communication and coordination among HCPs, and interoperability with other systems). The reported workarounds included duplication of data entry and documentation, as well as scanning documents and relying on patients and providers when information was not readily available in the electronic health record system. The use of workarounds may improve workflow and efficiency for RNs but they are often an indication that the system design is not supportive to end-user’s practice (Debono et al., 2013). A potential explanation for the development of workarounds by RNs is that such systems are often designed by software engineers and non-nursing personnel who have a limited understanding of nursing practice (Stevenson et al., 2010).

Organizational Characteristics

Organizational infrastructure, training, information technology (IT) support, availability of organizational resources, peer social support, and the ability to provide input towards the EDS design all influenced RN experience with the system usage in their home care practices. The findings are in alignment with those of other studies examining RNs’ attitude, intention, acceptance and HIT usage in practice (Bennani & Oumlil, 2014; Chung et al., 2016; Kim et al., 2015; Sharifian et al., 2014; Song, Park,  & Oh, 2015; Strudwick, 2015; Zhang, Cocosila, & Archer, 2010). For example, peer support through provider champions was preferred by clinicians 78% of the time (Dastagir et al., 2012). In addition, Sharifian et al. (2014) found that social influence and facilitating conditions had a statistically significant and positive influence on RNs’ utilization of hospital information systems in practice. This finding was further corroborated by van Howelingen et al., (2015) who found social influence to be a significant predictor of RNs’ motivation to use a home telehealth system in practice.

Nurse-Patient Interactions

The majority of RNs expressed being mindful of patient needs (i.e., emotional state) and the importance of communication amidst EDS usage in their practices. A few researchers have considered the potential influence of the interaction between HCPs (i.e., RNs, nurse practitioners and physicians) and patients with EDS usage and noted similar findings to this study. Rose, Richter and Kapustin (2014) conducted a qualitative phenomenological study and reported that maintaining eye contact during interactions was important to patients as it provided a sense of personal connection, being cared for and not ignored. Ajami and Bagheri-Tadi (2013), on the other hand, found that physicians and RNs were unintentionally spending more time interacting with the EDS than with patients during visits. The clinicians saw and understood the value of the face-to-face interaction with patients and decided to write down notes during interactions and transfer the information into the EDS at a later point in time. Similar challenges were noted by Duffy, Kharasch and Du (2010) who found that RNs were distracted with the EDS during patient interactions, with more than 60% of their time with patients being spent on the system. Further, there were reports of extended periods of silence, reduced eye contact and “time out” episodes in which RNs had to manage the system during interactions.

Implications

The findings from this study have several practice, policy and research implications. Specific to practice, it is important that the EDS design appropriately fits with nursing practice. RNs practice in demanding and complex environments and are the largest user-groups of EDSs (Cho et al., 2016), highlighting the importance for such systems to facilitate their work rather than add to it (Nimako, Azumah, Donkor, & Adu-Brobbey, 2012). Designing EDS that fit nursing practices can be achieved by having: a) software engineers understand (through shadowing, observing and engaging in dialogue) the complexity of the role, needs and workflow of RNs; and b) a role for RNs at the decision-making table during the design, procurement and implementation of EDS (Hagedorn, Krishnamurty, & Grosse, 2016; Saleem et al., 2015; Stevenson et al., 2010; Strudwick et al., 2018). In addition, it is imperative for leadership to foster a supportive environment that leverages peer support to engage others and IT support to help address technical challenges that may arise from system usage in practice (De Vliegher et al., 2010; Gagnon, Orruño, Asua, Abdeljelil, & Emparanza, 2012). This is particularly important with RNs working in the home care sector because of the differences in working environment and availability of resources in comparison to RNs employed in the acute care sector (Lundy & Janes, 2014; Tourangeau et al., 2014).

Specific to policy, it is important for organizational leaders to provide RNs with adequate education and training (De Vliegher et al., 2010) prior to EDS implementation, as well as ongoing training when updates are made. Basic computer training sessions for RNs that express a lack of technology experience should also be offered (Tubaishat, 2017). Through such sessions, RNs may attain the necessary technology-related skills and understanding that can be applied and transferred to EDS usage in practice, enhancing their perception and overall experience with such systems. In addition, it is imperative to integrate informatics competencies within nursing education programs to enhance the technology-related knowledge and skills of future RNs and, in turn, position them to be successful users of such systems (Tubaishat, 2017). 

Specific to research, seeing as this was the first study, to our knowledge, that explored RNs’ experience to EDS usage in the context of home care in Ontario, further research in this area is warranted. More specifically, future research may include: 1) observational studies to explore and understand how RNs interact (i.e., development and implementation of workarounds) with EDS in their day-to-day home care practices and 2) qualitative studies to explore and understand patients’ perspectives, experiences and satisfaction related to the quality of care delivery and nurse-patient communication and interaction amidst the implementation and usage of EDS in the home care sector. Further, longitudinal research studies may also be designed and conducted to explore how RNs’ experience with EDS usage may change over time (i.e., based on increased frequency of system usage).

Limitations

The study had some limitations. First, the experiences of the RNs that participated in this study may differ from those who did not consent to taking part in the research study. Second, despite reaching data saturation through the repetition of similar themes and topics during analysis, it is possible that not all of the information related to RNs’ experience with EDS usage was communicated during the interviews that would further allow for a better understanding of RNs’ experience with EDS usage.

Conclusion

EDS remain a permanent fixture within national and international healthcare systems to improve timely access to up-to-date and accurate patient-health related information, patient-related decision making and patient health outcomes. This study was the first, to our knowledge, that sought to understand RNs’ experiences with EDS usage within the context of home care. RNs’ experience with EDS usage in their home care practice was found to be influenced by: a) RNs’ individual characteristics, specifically previous technology experience; b) technological characteristics, specifically the influence of the EDS on RNs’ work and performance, on enriching RNs’ communication, collaboration and patient-related decision making, and on technical issues and the EDS design; c) employment of workarounds related to technological characteristics; d) organizational characteristics, namely training, peer/social support, IT support, availability of organizational resources and opportunity for EDS design input; and e) the influence of EDS usage amidst nurse-patient interactions. Understanding RNs’ experience with EDS usage may inform leadership and software engineers on strategies that can be employed to foster a positive experience and, in turn, position RNs to be successful users of such systems (Tubaishat, 2017), particularly as they continue to evolve into roles supported by technology (Li, Talaei-Khoei, Seale, Ray, & Macintyre, 2013; Qu & Sun, 2015).

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Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Iota Omicron Chapter Research Grant and Age Well Graduate Student and Postdoctoral Award in Technology and Aging.

Declaration of Conflicting Interests:  The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Bios 

Ms. Sarah Ibrahim

Sarah Ibrahim, RN, MN was a Doctoral Candidate in the Arthur Labatt Family School of Nursing at Western University and this work was part of her dissertation. Ms. Ibrahim’s area of interest in in health information technology, home care, development, implementation and evaluation of health interventions.

Dr. Lorie Donelle

Dr. Donelle, RN, PhD is an Associate Professor and Research Chair Arthur Labatt Family School of Nursing at Western University. Dr. Donelle’s area of expertise is in digital health and specifically in health information technology use among health care providers and patients, (digital) health literacy and health promotion.

Dr. Sandra Regan

Dr. Regan, PhD is an Adjunct Associate Professor in the Arthur Labatt Family School of Nursing at Western University and Deputy Registrar, Education Program Review at the British Columbia College of Nursing Professionals. Dr. Regan’s areas of expertise are in health services research, policy development and analysis, and successful transition and retention in new graduate nurses. 

Dr. Souraya Sidani

Dr. Sidani, PhD is a Professor at Ryerson's Daphne Cockwell School of Nursing and Canada Research Chair in Design and Evaluation of Health Interventions. Dr. Sidani’s areas of expertise are in quantitative research methods, intervention design and evaluation, and measurement.