Citation: Rangrazejeddi, F., Akbari, H., Esmaili, S. & Farrahi, R. (2020). Functional evaluation of a nursing information system to support the nursing care plan. Online Journal of Nursing Informatics (OJNI), 24(2). https://www.himss.org/resources/online-journal-nursing-informatics
Purpose: The aim of the study was to assess the readiness of the hospital information system nursing module to support the nursing care plan.
Methods: This study was conducted in 30 general hospitals of Mazandaran Province, Iran, in 2015. A researcher-made checklist was performed at three sections of the nursing module "recording of descriptive-diagnostic notes," "recording of the assessment of nurse and patient education," and "preparing discharge report" with two choice options (presence or absence). The face and content validity of the checklist was confirmed, and its reliability was obtained (0.88) using the Kuder-Richardson Coefficient. Data collection was conducted through the system observed by the researchers. The data were analyzed by descriptive statistics.
Results: In the section of the recording of descriptive-diagnostic notes, statistical representation of beds (100%) and documentation and nursing notes (0%) had the highest and lowest frequencies, respectively. Nurse assessment (83.3%) and the ability to support the decision (0%) had the highest and lowest frequencies in the recording of the assessment of nurse and patient education section. The preparation of the discharge report, the function of the transfer of patient information to other wards (96.7%), had the highest frequency, and reporting the medication errors had the lowest (0%) frequency in preparing discharge reports.
Conclusion: In hospital information systems, recording of diagnostic notes is somewhat provided, but the functions of the system to meet the needs of nurses for patient education, patient assessment, decision support, and nursing care plans are weak, thus it is necessary to improve the system for effective use.
Keywords: hospital, hospital information system, evaluation, nursing assessment, patient care planning
A nursing care plan provides appropriate nursing care for each patient and begins with the process of gathering information. But the increased production and exchange of nursing data have devoted a large amount of nurses' time to record information that is mostly duplicated (Fang, Li, & Wang, 2016). The use of computer technology such as nursing information systems has made the storage, retrieval and analysis of this information more efficient (Ahmadi & Habibi Koolaee, 2010; Haux, 2006). The aim of such a system, in addition to reducing the time to enter nursing records, is to help nurses carry out tasks such as assessing the patient and documenting nursing notes (Malliarou & Zyga, 2009), and improve nursing care, prevent medical errors, and reduce costs (Ahmadi & Habibi Koolaee, 2010; Farzandipur, Jeddi, & Azimi, 2016; Jeddi, Arabfard, Arabkermany, & Gilasi, 2016). Generally, a nursing information system accommodates both clinical nursing and management activities (Han et al., 2012), but the most important part of this system is the clinical aspect that often includes patient records; nursing care plans, assessment and notes; patient education; recording of orders; charting; results reporting; and discharge planning (Ahmadi, Rafii, & Habibi-Koolaee, 2011; Roussel, 2006).
Nowadays, nursing information systems have been implemented in many hospitals. One research paper noted that 73% of nurses stated that the implementation of information systems was effective in saving time; 63% of them mentioned that errors have been reduced because of the implementation of the system; and 88% of them believed that nurses’ attitude and discipline in using the system was better than before (Kamkar & Mostafavi, 2006). However, current information systems do not yet satisfy all the needs of nursing (Farzandipour, Sadoughi, & Meidani, 2011), and only between 35.7% to 60% of the systems are able to meet the needs of nurses. Nurses needs were met in the field of patient care by only 28%, management processes 19.2%, communication processes 43.3%, and education and training processes by 22.2%. It was also reported that 87% of hospitals do not have the required equipment to record nursing data at the time of service delivery and through bedside terminals (Ahmadi & Habibi Koolaee, 2010; Farzandipour et al., 2011). The Netherlands and South Korea have reported the successful implementation of nursing information systems (Han et al., 2012; Michel-Verkerke, 2012). However, the results of a study conducted in Greece revealed that, despite the benefits provided by nursing information systems, these systems could not be used widely, and lack of attention to the needs of nurses has caused nursing system failure (Malliarou & Zyga, 2009).
The nursing information system in Iran has been considered as a module in the wider hospital information systems, and no specific system has been implemented solely for nursing care. These information systems play an undeniable role in increasing efficiency, effectiveness, quality of service, and patient satisfaction. This study was conducted to evaluate the clinical nursing information module functions designed in the health information systems in the hospitals of the Mazandaran Universities of Medical Sciences in 2015.
Setting and Research Population
This cross-sectional study was conducted in 30 general hospitals of the Mazandaran Medical Sciences Universities: these hospitals were selected by census method.
The study protocol was approved by the institutional review board and the research ethics committee of Kashan University of Medical Sciences (Project No. 9370). Permissions were also obtained from hospital authorities. The research team was sensitive to preserve the participants’ rights in accordance with the Declaration of Helsinki’s ethical principles .
Data on the performance evaluation of a nursing module in health information systems were collected using a checklist designed after reviewing these references: (BCCNP, 2013; Levine, 2012; Rafiee, 2006) and confirmed through a validation process as outlined below.
Validity of the Instrument
The instrument’s face validity was confirmed by four professors of health information management technology and nursing. The content validity, the necessity of each question and the simplicity, relevance, and clarity of the questions were confirmed by 15 professors and health information management (HIM), nursing and information technology (IT) specialists (five people in each field) through two questionnaires.
The criterion to determine the necessity of each question was the content validity ratio (CVR) assessed by three options: it is necessary, it is useful but not necessary, and it is not necessary (Mortazavi, Mousavi, Chaman, Khosravi, & Janke, 2015).
The content validity index (CVI) of every question was obtained based on simplicity, relevance, and clarity of the questions. Options and scores of CVI questions included:
Questions with CVI > 0.7 were confirmed and questions with CVI < 0.7 were rejected or reviewed. Questions with CVR > 0.49 were confirmed and with CVR < 0.49 were rejected or revised.
Reliability of the Instrument
To determine the reliability of the data collection tools, the Kuder-Richardson Coefficient was used, with an obtained value of 0.88 using the split-half method.
Sections of the Instrument
The checklist had three functional sections and the options had two choices, presence or absence.
First section: The possibility of inclusion and recording of descriptive-diagnostic notes including the recording of patient records, nursing progress notes, vital signs, and recording of physician's orders .
Second section: The feasibility of nurse assessment and patient education to assess the system functions regarding patient assessment, nursing care plans and patient education.
Third section: The possibility of preparing the discharge report to evaluate the system functions regarding reports of diagnostic results and patient discharge planning.
Data collection and analysis
Data collection was conducted by the researcher's detailed observations of hospital and nursing modules designed in the health information systems. Data were expressed in descriptive statistics (frequency and percentage). Additionally, scores of zero and one were assigned to the presence or absence of each item respectively, and the sum of the scores for each dimension (subscale) was calculated as an assessment indicator. A mean score below 30 was an unfavorable situation, the score between 30 to 70 was a semi-favorable situation, and a score over 70 was regarded as a favorable situation.
Among 30 hospitals studied, 86.6% of health information systems were implemented by one company. Results related to the evaluation of implementing system functions showed that in the first section, "the possibility of inclusion and recording of descriptive-diagnosis notes" in the nursing module of health information systems, statistical representation of the beds in all systems (100%) were implemented, while the possibility of recording of nursing notes and actions were not predicted in any of the implemented systems (0%) (Table1).
In the second section, in terms of the possibility of recording nurse assessments and patient education using a nursing clinical information system, it was possible to see patient history in the systems (83.3%). However, the decision support capability was not considered in any of the systems (Table 2).
In the third section, it was possible to prepare and submit a discharge report that was released by the system and transfer patient information to another section (96.7%), but the possibility of medical errors reporting in the system was not considered (0%) (Table 3).
Other results showed that the possibility of recording the records of patients (15.20 ± 68.80%) had the highest frequency score and patient assessment had the lowest frequency score (5.40 ± 3.30%). The functions of systems for recording patient records (53.3%) and recording vital signs (43.3%) were desirable and the studied hospitals can meet over 70% of the needs of nurses in these areas. However, the system's functions regarding the feasibility of patient assessment (96.7%), patient education (1.7%), nursing care plan (12.5%) and nursing progress notes (16.1%) were at the lowest level, and surveyed hospitals could only meet the needs of less than 30 items (see Table 4).
This study was carried out to assess the nursing module of health information systems to support nursing care plans for hospitals of the Mazandaran Universities of Medical Sciences in Iran in 2015. The results of the current study manifested that the inclusion and preparation of descriptive notes with mean scores of recording patients’ records of 68.8%, recording medical orders of 54.4%, and recording vital signs of 52.7% were desirable and thus able to meet over 70% of the functional needs of nurses through the nursing information system. However, in the domain of recording nursing progress notes, scores were low and 16% out of 30 hospitals studied in this research met below 30% of the functional needs.
Other studies show that in clinical information systems, patient records are documented in various ways, such as the recording of physician's orders, especially drug prescriptions (Ahmadi & Habibi Koolaee, 2010; Imani, Khademi, Yusefi, Bahrami, & Naghizadeh, 2012; McBride, Delaney, & Tietze, 2012; Michel-Verkerke, 2012; Roshidi, 2012), vital signs recording (Ahmadi & Habibi Koolaee, 2010; Fang et al., 2016; Porcella, 2001), and recording of laboratory results (Dykes et al., 2007; Michel-Verkerke, 2012) which is consistent with the results of this research.
In this study, recording nursing actions and notes was electronically impossible in all of the hospitals; this finding is compatible with the results of Littlejohns, Wyatt, & Garvican (2003) who reported that there are no nursing progress notes in the system. However, the results are not in line with other studies that showed nursing notes were included in the system (Ammenwerth, Rauchegger, Ehlers, Hirsch, & Schaubmayr, 2011; Michel-Verkerke, 2012). As the results showed, nurses now have the knowledge and skills to use computers (Ammenwerth et al., 2001) and these systems help to reduce the errors, especially medical errors. Moreover, reduction of medical errors and other deficiencies in providing care have been improved by the establishment of information systems (Ohsfeldt et al., 2005). On the other hand, this has left more free time for nurses to spend on patient care, nursing assessment, patient education and providing emotional support to their patients (McBride et al., 2012).
Paying careful attention to resolve the weaknesses of the systems and improving the quality of patient treatments is absolutely essential. It is also valuable to pave the way to higher use of a nursing information system by providing national development plans and supporting the use of information technologies. The results showed that the area of patient assessment met 3.3% of needs, while the nursing care plan met 12.5%, and patient education met only 1.7% of needs. In total, all hospitals met below 30% of needs and they were not at a standard level.
The findings of the study conducted by McBride et al., (2012) showed that the assessment system did not have the patient education module and support of the nurses’ decision to help perform better assessments and complete a more comprehensive care. In a study done by Bakken et al., (2008), results showed that it was not possible to have access to online resources, and users would not have access to basic pharmacy guidelines (Bakken et al., 2008). In a study conducted on a health information system, the findings showed that the system did not have patient education modules, care plans, and access to decision-support resources (Littlejohns et al., 2003). In a study aimed at developing and assessing the nursing information systems value to the clinical care of hospitalized patients, there was no decision-support module to provide notifications, reminders, and online access to medical sources (Fang et al., 2016). These results were consistent with the results of the present study, which stated that some modules such as patient assessment, care plans, and patient education were not included, and due to the lack of decision-support, many errors were apparent in the systems. A study conducted in this area reported that in the current system, patient education and care plans were not available, and the current system could not provide services in nursing diagnoses (Hao et al., 2007).
However, they are not consistent with the Ammenwerth, et al., study (2001), which aimed to assess the access of management information systems users in hospitals. The study’s findings indicated that the information systems included decision support modules and allowed users access to clinical knowledge. These results also were not compatible with the results of a study that reported that information systems included patient assessment, diagnosis, care plans, intervention, and evaluation results to assist in decision-making within the nursing process (Matney, Bakken, & Huff, 2003). They are also inconsistent with other studies in this regard in which there was access to resources and decision support systems and could facilitate patient education and care plans (Ammenwerth et al., 2011; Bakken et al., 2008).
Assessed nursing information systems are not able to provide decision support and alerts in non-natural conditions; access guidelines, patient education, integration and communication with the medical system such as CPOE; provide accuracy control of medicine using barcoding equipment and reporting medical errors; or provide the summary of discharge based on the type of care. Furthermore, they cannot provide the required pieces of information regarding patient assessment and clinical decisions. Therefore, it can be said that these systems can record data but have a weak function as a nursing information system.
Improving existing systems and adding patient education and care plan functions are essential . Research results showed that the report results in 83.3% of hospitals and discharge planning in 90% of hospitals met the needs of users between 30% and 70% of the time. In the study by Ahmadi et al., the possibility of reporting of the results of patient requests and financial reports was provided, but it was not able to provide a summary of patient discharge based on the type of care (Ahmadi & Habibi Koolaee, 2010).
A study conducted by Porcella (2001) revealed that nursing information systems support issues related to patient discharge and provide discharge summaries based on care type. In the study conducted by Michel-Verkerke (2012), the results manifested that a patient discharge function within the system was possible. Dykes et al. reported that in the system they studied, discharge modules, report of results and recording of instructions were available (Dykes et al., 2007). These results are consistent with the results of the present study. In a study conducted by Yam et al., results showed that the transfer of patients in discharge planning was not an easy task, and a summary of the patient's discharge was not provided based on the type of care (Yam et al., 2012). In a study conducted by McBride et al., (2012), it was stated that the information system cannot provide a summary of the patient's status according to the type of care. These results are inconsistent with the results of the present study . In general, it can be concluded that the assessed areas – clinical nursing information system, areas of patient assessment, and patient education – were satisfied in a poor manner, indicating that nursing functional items were weak. In the process of designing the system, the areas of patient assessment, nursing care plan and patient education are not considered.
The implementation of the plan for improved nursing modules in all hospitals in Mazandaran province (with an area of 24,091 square kilometers and (30 hospitals) and approximately 4,000 hospital beds and services to 3 million people), as well as the pilot projects of the e-health and paperless countries, are strengths of this study. One of the strengths of this study is the presence of researchers in hospitals and the direct observation of the hospital information system of each hospital, as well as the existence of a variety of hospital information systems in the hospitals of this province, which adds to the generalization of the results within Iran. Performing a quantitative evaluation and not paying attention to qualitative clinical features in this system is one of its weaknesses.
The results of the evaluation of nursing clinical information system functions showed that in health information systems, diagnostic-descriptive notes functions – especially recording the instructions, recording vital signs, and recording patients’ history – were provided in most of the hospitals. However, nursing assessment functions, patient education, and nursing care plans were lacking. A nursing information module in the health information systems does not support decisions, while nurses need to have a comprehensive information system that helps them to make appropriate clinical decisions and thereby be able to spend more time caring and interacting with their patients.
The present paper is the result of an approved project (Project No. 9370). The vice chancellor for research of Kashan University of Medical Sciences is highly appreciated for providing financial support to carry out the present study, and we would like to thank the participants in this collaborative project.
Conﬂicts of interest
The authors declare that they have no conﬂict of interest.
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Ahmadi, M., & Habibi Koolaee, M. (2010). Nursing Information Systems in Iran. Hakim Research, 13(3), 185-191 .
Ahmadi, M., Rafii, F., & Habibi-Koolaee, M. (2011). Nursing Information Management. Tehran: Jafari .
Ammenwerth, E., Eichstädter, R., Haux, R ., Pohl, U., Rebel, S., & Ziegler, S. (2001). A randomized evaluation of a computer-based nursing documentation system. Methods of Information in Medicine, 40(02), 61-68 .
Ammenwerth, E., Rauchegger, F., Ehlers, F., Hirsch, B., & Schaubmayr, C. (2011). Effect of a nursing information system on the quality of information processing in nursing: An evaluation study using the HIS-monitor instrument. International Journal of Medical Informatics, 80(1), 25-38. doi:10.1016/j.ijmedinf.2010.10.010
Bakken, S., Currie, L. M., Lee, N.-J., Roberts , W. D., Collins, S. A., & Cimino, J. J. (2008). Integrating evidence into clinical information systems for nursing decision support. International Journal of Medical Informatics, 77(6), 413-420 .
British Columbia College of Nursing Professionals (BCCNP). (2013). Documentation. https://www.bccnp.ca /Standards/RN_NP/resourcescasestudies/clientcare/documentation/Pages/Default.aspx
Dykes, P. C., Carroll, D. L., Benoit, A., Coakley, A., Chang, F., Empoliti, J., . . . Rath, G. (2007). A randomized trial of standardized nursing patient assessment using wireless devices. Paper presented at the AMIA Annual Symposium Proceedings .
Fang, Y.-W., Li, C.-P., & Wang, M.-H. (2016). The development and evaluation of a nursing information system for caring clinical in-patient. Technology and Health Care, 24(s1), S401 -S406 .
Farzandipour, M., Sadoughi, F., & Meidani, Z. (2011). Hospital information systems user needs analysis: a vendor survey. Journal of Health Informatics in Developing Countries, 5(1).
Farzandipur, M., Jeddi, F. R., & Azimi, E. (2016). Factors Affecting Successful Implementation of Hospital Information Systems. Acta informatica medica : AIM : Journal of the Society for Medical Informatics of Bosnia & Herzegovina : casopis Drustva za medicinsku informatiku BiH, 24(1), 51-55. doi:10.5455/aim.2016.24.5
Han, J. M., Chae, Y. M., Boo, E. H., Kim, J. A., Yoon, S. J ., & Kim, S. W. (2012). Performance analysis of hospital information system of the national health insurance corporation ilsan hospital. Healthcare Informatics Research, 18(3), 208-214 .
Hao, A. T.-H., Lu, Y.-L., Hsu, C.-K., Chu, S.-F., Rau, H.-H., Jian, W.-S ., . . . Chang, H.-K. (2007). A feasibility study of constructing electronic nursing record with nursing clinical pathway. Paper presented at the Medinfo 2007: Proceedings of the 12th World Congress on Health (Medical) Informatics; Building Sustainable Health Systems .
Haux, R. (2006). Health information systems–past, present, future. International Journal of Medical Informatics, 75(3-4), 268-281 .
Imani, E., Khademi, Z., Yusefi, P., Bahrami, Z., & Naghizadeh, F. (2012). Experiences of nursing managers about hospital information system: a qualitative study. Bimonthly Journal of Hormozgan University of Medical Sciences, 16(3), 223-232 .
Jeddi, F. R., Arabfard, M., Arabkermany, Z., & Gilasi, H. (2016). The diagnostic value of skin disease diagnosis expert system. Acta Informatica Medica, 24(1), 30 .
Kamkar , N., & Mostafavi, H. (2006, 2006 March 8-9). Attitude of Hospital Personnel to Vali-Asr Hospital Information System. Paper presented at the the National Congress of Hospital and Information Technology, Kermanshah, Iran .
Levine, K. (2012). Nurse-patient Education Revolution. https://www.elitecme.com/resource-center/nursing/nurse-patient-educatio… /
Littlejohns, P., Wyatt, J. C., & Garvican, L. (2003). Evaluating computerised health information systems: hard lessons still to be learnt. BMJ, 326(7394), 860-863 .
Malliarou, M., & Zyga, S. (2009). Advantages of information systems in health services. Choregia, 5(2), 43-53
Matney, S., Bakken, S., & Huff, S. M. (2003). Representing nursing assessments in clinical information systems using the logical observation identifiers, names, and codes database. Journal of Biomedical Informatics, 36(4-5), 287-293 .
McBride, S., Delaney, J. M., & Tietze, M. (2012). Health information technology and nursing. AJN The American Journal of Nursing, 112(8), 36-4 .
Michel-Verkerke, M. B. (2012). Information quality of a nursing information system depends on the nurses: a combined quantitative and qualitative evaluation. International Journal of Medical Informatics, 81(10), 662-673 .
Mortazavi, F., Mousavi, S. A ., Chaman, R., Khosravi, A., & Janke, J. R. (2015). Cross cultural adaptation, validity, and reliability of the farsi breastfeeding attrition prediction tools in Iranian pregnant women. Iranian Red Crescent Medical Journal, 17(3 .(
Ohsfeldt, R. L., Ward, M . M., Schneider, J. E., Jaana, M., Miller, T. R., Lei, Y., & Wakefield, D. S. (2005). Implementation of hospital computerized physician order entry systems in a rural state: feasibility and financial impact. Journal of the American Medical Informatics Association, 12(1), 20-27 .
Polit, D. F., & Beck, C. T. (2006). The content validity index: are you sure you know what's being reported? Critique and recommendations. Research in Nursing & Health, 29(5), 489-497 .
Porcella, A. (2001). Narrative notes in a nursing information system (NIS). Paper presented at the Proceedings of the AMIA Symposium .
Rafiee, G. (2006). Physical examination for nurses. Tohfeh .
Roshidi, H. (2012). Implementation of total hospital information system (THIS) in Malaysian public hospitals: Challenges and future prospects. International Journal of Business and Social Research, 2(2), 33-41 .
Roussel, L. (2006). Management and leadership for nurse administrators: Jones & Bartlett Learning .
Yam, C. H., Wong, E. L., Cheung, A. W., Chan, F. W., Wong, F. Y., & Yeoh, E.K. (2012). Framework and components for effective discharge planning system: a delphi methodology. BMC Health Services Research, 12(1), 396.
Is an Associate professor of Health Information Management, Health Information Management Research center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran .
Is an Assistant professor, Health Information Management Research center, Department of Biostatistics and Public Health, Kashan University of Medical sciences, Kashan, Iran.
Has a MSc of Health Information Management, Department of Health Information Management and Technology, Kashan University of Medical sciences, Kashan, Iran.
Is a PhD Candidate of Health Information Management, Health Information Management Research center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran.