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Staff experiences within the implementation of computer-based nursing records in residential aged care facilities: a systematic review and synthesis of qualitative research
BMC Medical Informatics and Decision Making volume 14, Article number: 54 (2014)
Since the introduction of electronic nursing documentation systems, its implementation in recent years has increased rapidly in Germany. The objectives of such systems are to save time, to improve information handling and to improve quality. To integrate IT in the daily working processes, the employee is the pivotal element. Therefore it is important to understand nurses’ experience with IT implementation. At present the literature shows a lack of understanding exploring staff experiences within the implementation process.
A systematic review and meta-ethnographic synthesis of primary studies using qualitative methods was conducted in PubMed, CINAHL, and Cochrane. It adheres to the principles of the PRISMA statement. The studies were original, peer-reviewed articles from 2000 to 2013, focusing on computer-based nursing documentation in Residential Aged Care Facilities.
The use of IT requires a different form of information processing. Some experience this new form of information processing as a benefit while others do not. The latter find it more difficult to enter data and this result in poor clinical documentation. Improvement in the quality of residents’ records leads to an overall improvement in the quality of care. However, if the quality of those records is poor, some residents do not receive the necessary care. Furthermore, the length of time necessary to complete the documentation is a prominent theme within that process. Those who are more efficient with the electronic documentation demonstrate improved time management. For those who are less efficient with electronic documentation the information processing is perceived as time consuming. Normally, it is possible to experience benefits when using IT, but this depends on either promoting or hindering factors, e.g. ease of use and ability to use it, equipment availability and technical functionality, as well as attitude.
In summary, the findings showed that members of staff experience IT as a benefit when it simplifies their daily working routines and as a burden when it complicates their working processes. Whether IT complicates or simplifies their routines depends on influencing factors. The line between benefit and burden is semipermeable. The experiences differ according to duties and responsibilities.
Nursing documentation is recognized as a necessity in professional nursing. Until the last century, paper-based documentation systems were those most commonly used in Germany.
Nursing has become more complex, the amount of documentation has increased immensely. Almost all companies are searching for solutions that reduce the effort associated with documentation and at the same time offer a professional and appropriate documentation product. IT-based nursing documentation may be one possible solution [1–3].
During recent years the introduction of electronic nursing documentation systems in nursing homes in Germany has increased rapidly [4–9]. According to a recent non-representative study, 43.5% of the facilities for the elderly in Germany already use a computerized system. Another 11.3 % of Residential Aged Care Facilities (RACFs) plan to implement a computer-based system . Statistically representative data for Germany is currently not available.
The change to computer-based nursing records is associated with capital asset and resource management costs. RACFs implemented IT-based nursing documentation realizing more benefits with the change than effort and cost associated with the change [3, 11]. It should be emphasized that the added value will never be achieved by the IT itself, but always through a process optimization achieved by the IT [6–9].
For example, a) time efficiency resulting from the improvement of documentation quality is a deciding factor for the implementation of electronic documentation systems in hospitals  and nursing homes [3, 13]. In another example b) quality improvements as well as c) better information processing are also key factors for implementing such systems . The above noted aspects can be summarized as process optimization.
However, as of today, there is no empirical evidence that electronic nursing documentation systems add value to nursing, such as a) improved time management or b) improving information handling or c) increasing quality, the latter split in c1) quality of documentation (factual and professionally correct, continuous, complete) and c2) quality of care (more safety and better quality of life for the patient) [14, 15]. Finally, consensus exists that those objectives could be achieved with the full implementation of IT. Nevertheless, at present, there is no evidence that the relevant objectives will actually be achieved and ‘full’ implementation is not clearly defined.
At this point, it must be stated that full implementation includes not only completely paperless records, but is also recognized as computer system success. Moreover and according to DeLone and McLean , user satisfaction is a key factor of computer system success and IT integration, and the impact a computer-based system has on a user’s job directly affects user satisfaction .
At present the literature shows a lack of understanding regarding staff experience in order to possible benefits when using computer-based documentation.
Finally, to integrate IT in the daily working processes, the employee is the pivotal element. Therefore it is important to understand nurses’ experience with IT implementation. The need to carry out a synthesis for a deeper insight and understanding of the phenomena is given by the difficulty of translating knowledge from individual studies to practice and research.
The aim of this study is to explore staff experiences within the process of the implementation of computer-based nursing records. The following question guided the literature search:
How does staff describe their experiences with the benefits observed with respect to the computer-based records and their daily work?
Data was analyzed and synthesized by using the meta-ethnographic approach from Noblit and Hare . The core of the meta-ethnographic approach is the reciprocal translation meaning, “in an iterative fashion, each study is translated into the terms (metaphors) of the others and vice versa : 38”. This method encourages the researcher to understand and transfer ideas, concepts and metaphors across different studies.
Search strategy and sample
The development of IT is progressing rapidly. In addition, the millennium change in 2000 (“Y2K”) and the introduction of the Euro in Europe have led to major changes in the IT industry. The literature search was therefore limited to the period 01.01.2000 - 01.01.2013.
To ensure that all relevant literature was included, the first step consisted of a search of studies concerning computer-based nursing documentation in general.
Therefore a search was carried out in PubMed, CINAHL and Cochrane. The following search terms were used and linked with AND and OR: nursing documentation*, nursing record*, nursing information system*, electronic*, computer*, technolog*, nursing home*, resident*, long-term.Following further reading of abstracts, only those studies were chosen that a) address computer-based nursing records in RACFs, b) have been published in the English or German language, and c) used a qualitative design. To ensure that only studies that fulfill research quality criteria were included, only those were chosen that d) had been published in a peer-reviewed journal. Next, all remaining articles were read in full text and all studies excluded that did not meet the inclusion criteria. In addition, a manual search was conducted from the reference lists of the articles obtained. For search details see Figure 1.
Studies that referred to the setting “hospital” were excluded. Furthermore, studies were excluded that focused on standardized techniques, e.g. nursing languages or Minimum Data Set. Those studies were excluded because the focus of such studies is on the technique rather than on the IT system itself.
This systematic review adheres to the principles of the PRISMA statement .
Accordingly, after reviewing the full text, seven articles were selected. For details of the selected articles see Table 1.
Analysis & synthesis
Phase 1: Getting started
According to Noblit & Hare , ‘getting started’ includes defining a research interest that qualitative research might enlighten. In our case the motivation for synthesizing the body of qualitative evidence is mostly based on the work of Ammenwerth et al.  and Urquhart et al. . The authors stated that quantitative methods might not be sufficient to explore why individual wards react differently to computer-based nursing documentation.
Phase 2: Deciding what is relevant to the initial interest
This next phase involves several decisions on ‘what is relevant’. The rationale for search strategy, inclusion and exclusion criteria is presented in the section ‘search strategy and sample’.
Phase 3: Reading the studies
Even Noblit and Hare  in their original work state that this phase is not particularly clear. They interpret this phase as repeated reading with extensive attention to the details of each study. We understand this to mean that we should familiarize ourselves with the selected studies by reading them many times, mostly in full, but also in part.
Phase 4: Determining how the studies are related
To determine how the studies are related Noblit and Hare advocate forming a list of key metaphors, phrases, concepts and their relation to each other and juxtapose them.
In this study see Table 3 below for examples.
The data within each category formed the basis for the reciprocal translation described in the following.
Phase 5–7: Translating the studies into one another, synthesizing translations and expressing the synthesis
The syntheses cannot be reduced to a set of mechanistic tasks. When a concept arose, all the studies were searched for similar meanings (metaphors). We then built a line-of-argument synthesis, which interpreted relationships between the concepts. This section is merely an effort to express the synthesis. In practice, of course, the phases overlap.
This review includes seven articles which summarize the findings of six studies. The articles of Alexander et al.  and Rantz et al.  report on the same study but synthesize different data. Three of the six studies (represented in four articles) were carried out in the U.S.A. [38–41] and three in Australia [26, 35, 42].
At least 320 semi-structured interviews and 56 focus groups were applied to form the database. The interviews were undertaken with management staff and direct care givers.
The 23 interviews compiled by Alexander et al.  are included in the 120 interviews with Rantz et al. . Therefore they were subtracted from the remainder of the interviews. The same applies to the 22 focus groups in said articles by Alexander et al.  and Rantz et al. . Observation data was compiled in three studies: The study by Cherry et al.  includes 10 one-hour observations. The study by Alexander et al.  and Rantz et al.  involve a series of observations, each consisting of a period of less than five minutes. Information regarding the frequency of observations was not made available in either of the two noted publications. From the study by Munyisia et al.  and Yu  only the qualitative findings were included in this review.
Staff experiences within the implementation process
Different information processing
Quality of documentation and resident care needs
Additional or lost time (1 – 3 shown in Table 4)
Ease of use and ability to use it
Equipment availability and technical functionality
Attitude (4 – 6 shown in Table 5)
Different information processing
The implementation of IT requires a different form of information processing. Some individuals experience that as a benefit, describing easier access to charts and medical information, additional information, or a better and faster overview [26, 38–42]. For those individuals, this leads to the examination of residents’ records without wasting time . For example, they emphasize that missing charts no longer matter because the information is in the computer . They also emphasize the benefit that computerized notes from all the caregivers are much easier to read than paper-based, handwritten records . They appreciate being able to view many things about resident care at once and to know what is being done for their residents at that very moment [38, 42]. They also appreciate that information on residents, including diagnosis and demographics, is now more readily available [26, 40, 41]. Leaders with the duty of guidance and control express their additional experience of being able to check what care has been supplied and of being able to monitor more easily the documentation of residents’ care activities, regulatory compliance issues, or staff education needs [39, 40]. They also report that the IT facilitates their performance appraisal .
On the other hand, for some individuals IT is not experienced as a benefit. For various reasons they find it is more difficult to enter data. This leads to not entering data, to frustration and to using workarounds, e. g. double documentation with paper. For these employees, IT complicates their daily working processes [38, 40–42].
Quality of documentation & resident care needs
Improvement in the quality of residents’ records leads to improvement in the quality of care because of more information and a broader and more holistic view of the residents. A quick response to resident’s care needs is possible, as are quicker and easier care decisions. Therefore the system has an impact on clinical judgment and decision-making [38–42].
More specifically, members of staff report that the system helps thinking and decision-making because of the ability to provide automatic alerts to help check plausibility [26, 40–42]. This again leads to more consistent and legible documentation. In addition assessment templates guide through body systems for documentation and help improve observation skills . Furthermore, the system causes the staff to think about what to assess and helps identify problems that might not be found otherwise [39, 41, 42]. Care feels safer through the use of the system .
In that case, the quality of residents’ records is lacking due to many circumstances, so that some residents do not receive the necessary care .
Additional or lost time
The question of time is a prominent theme within the implementation process. Some individuals experience a “given time” and benefit from the different information processing because of the IT, spending less time charting [26, 39, 40, 42]. For those individuals who do not benefit from the different form of information processing it feels like “time is taken away” because of the system [26, 30, 38, 41, 42].
From a leader perspective, the outstanding expectation is that the IT always saves time for the staff when computer-based documentation is in force .
However, it does not matter how it is experienced: whether it feels as if time is given or lost. The time itself is always connected with what should actually have been done or what can be done in the future within this time, namely spending more time with the residents and giving better care. Given time, of course, is always experienced as a benefit.
There are different views about using IT for documentation, ranging from feeling monitored to receiving greater respect. On the one hand, from a supervisory perspective, the monitoring of staff is viewed as a benefit. On the other hand, being monitored is experienced by the direct care staff both positively and negatively . Some see it as a control, others view it differently: as accurately recording and recognizing tasks carried out and as a medium for greater respect [39, 40]. Frustration has been reported when expectations were not met or problems were not solved in a timely manner. This increases staff suspicion and decreases the desire to work with the system . These reported factors are summarized within the attitude to computers or to electronic systems. The attitude is either a hindering or promoting factor for experiencing benefits through the IT.
Ease of use & ability to use it
Some feel the software is easy to use and suitable for the daily working processes .
Others experience that the system’s terminology does not match what they intend to record [26, 38] which led to double charting  or difficulty navigating . For them, reviewing information is felt as inconvenient because of the way the data is organized in the electronic system. Besides, some could not locate entered data later . That again causes job performance issues.
The ease of use must be seen in connection with the ability to use it. Learning to use the computer is of course a process as can be seen in dependence to Benner . Without guidance staff appears less comfortable [38, 41]. However, it is not only quantity that plays a role [39, 40]. The training space and equipment is a fundamental factor. The ease of use and ability to use it is either a hindering or promoting factor for experiencing benefits through the IT.
Equipment availability and technical functionality
The difficulties encountered with a system collapse, due to technical problems, is always experienced as negative, time consuming and hindering. When such technical problems lead to overtime work or indifferent patient care, frustration follows. A lack of technology support, missing equipment (workplaces) and general maintenance issues increase the feeling of frustration and distrust. The equipment availability and technical functionality is either a hindering or promoting factor for experiencing benefits through the IT [26, 38, 40, 41].
Our line-of-argument synthesis aimed at developing a model to explain staff experiences within the process of IT implementation. One construct resulted from our synthesis, namely: between benefit and burden.
Within the implementation process, the staff is always located between benefit and burden.
If the right promotion factors are available, the different information processing leads to an information value and is sensed as a benefit. This may lead to better quality of documentation and consequently to a better quality of care. The IT simplifies their daily working processes and for this reason connected with the feeling of given time. IT is sensed as a benefit.
If promotion factors are missing, the different information processing leads to information deficiencies and complicates the ability to fulfil the task. This may lead to poorer documentation, perhaps with time-consuming workarounds, and ultimately to a lower quality of care. In that case, IT complicates the daily working processes and is perceived as a burden.
The line between benefit and burden is semipermeable, depending on the impacting factors and may change at any time.
This study provides insights into staff experiences of benefits through the IT and the issues that hinder or promote the experiencing of benefits.
While IT-outcomes are extremely difficult and costly to measure [6–9], the method of asking the end-user seems to be an adequate and promising solution. As mentioned in the beginning of this study, Ammenwerth et al.  and Urquhart et al.  stated that quantitative methods might not be sufficient to explore why wards react differently to computer-based nursing documentation.
However, the implementation of an electronic documentation system does not lead automatically to a perceived benefit for the staff [3, 25]. The staff is more likely to experience IT within the implementation process depending on the benefit gained through IT. Implementation strategies should address this consideration. Various factors affect experience and therefore the benefit. In principle, the impacting factors are known although the findings differ in sort and shape e.g. [4, 11, 18–20, 22, 24, 28, 29, 33, 39, 43, 45]. The known factors also appear in this underlying study but equipment availability and technical functionality is more prominent than in other studies. This allows the hypothesis that regulating this facilitating factor might suffice to receive a full information system success and could be a key to full computer system success.
Therefore, it is astonishing that none of the studies characterize the selection phase. With a specification sheet or a visiting reference, low technical functionality could be better controlled . In respect of this selection phase, Alexander et al. and Rantz et al. [38, 41] propose that staff should lower their expectations. But a different way to deal with this is to expand the planning phase and turn the attention from other specific preparations to a detailed system specification with fewer options for interpretation .
It is widely anticipated that the implementation of IT will reduce time on documentation but that must be differentiated. IT could minimize documentation time e.g.  but must not e.g. . Many factors influence the outcome. It seems there is no linear increase. Instead the separation line is semipermeable. This means if an employee experiences a benefit in the form of reduced documentation time at point “A” that might change at point “B” due to modified influencing factors.
Studies thereby confirm that quality of care is directly related to quality of information [13, 15]. But the quality of information is controlled by the outcome of the different information system and if this is expressed as a burden, care as well as satisfaction and the experience of benefits might be lacking. It is a vicious circle. It is therefore imperative to find out what is needed in order to simplify the daily working processes with IT and to satisfy staff.
So how much resource is necessary to ensure the simplification of their daily work? There is as yet no suggestion pointing to how much resource the management should invest and how much and what kind of resource is needed to definitely satisfy the staff and simplify their daily working processes. There is also as yet no suggestion as to how the change of resource during the project changes the satisfaction and, respectively, the sensed benefit through IT.
It is interesting to see that all the studies reviewed conclude that IT is worth the cost expenditure. The studies are generally positive about the benefits of IT even if the studies’ details represent another situation, namely staff reactions between benefit and burden.
To conclude, costs and benefits should be well balanced. Therefore RACFs should define the aims they are searching for with IT and relate these aims with the realistically reachable and possible benefits that staffs could experience. Finally, IT could benefit the daily working processes.
Recommendations for further research
More qualitative research is needed to confirm the latter assumptions. Due to the fact that the reported experiences of nursing leaders were different to those of the direct, front-line nurses, more research is also needed on this topic. According to Patter, DeLone and McLean  more research is needed on the relationship between information quality and use, user satisfaction, and net benefits. Future studies should apply more comprehensive and consistent measures of usage in order to better understand the effect of the use of IT systems on user satisfaction and net benefits : 258.
Study limitations include the different settings in which these studies were conducted. This limits the ability to generalize the findings. Secondly, the timing of data collection was different in all studies, which could mean that experiences may differ.
In summary, the implementation of an electronic documentation system does not lead automatically to a received benefit for the staff. Instead, the findings showed that within the implementation process the staff are always located between benefit and burden. Staff experience IT as a benefit when it simplifies their daily working routines. On the other hand, when IT complicates their daily working routines IT is experienced as a burden. Whether IT complicates or simplifies their routines depends on influencing factors. The edge between benefit and burden is semipermeable and may change at any time. The staff experience differs according to duties and responsibilities.
Anne Meißner has overseen the implementation of Electronic Nursing records in Long Term Care for many years. Due to her practical experience, her desire for deeper insight arose. She is undertaking her PhD on this topic in part-time study with no funding.
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The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6947/14/54/prepub
The authors declare that they have no competing interests.
AM carried out the literature search, included and excluded documents, and wrote the manuscript. WS revised it critically for important intellectual content. All authors read and approved the final manuscript.
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Meißner, A., Schnepp, W. Staff experiences within the implementation of computer-based nursing records in residential aged care facilities: a systematic review and synthesis of qualitative research. BMC Med Inform Decis Mak 14, 54 (2014) doi:10.1186/1472-6947-14-54
- Electronic health record
- Health information technology
- Technology adoption
- Benefit and costs
- Cost benefit analysis
- Net benefit
- Information system success