Table 5 Merging quantitative and qualitative data using the PIP

Net benefits: only 26.59% of respondents agreed/strongly agreed that “The system reduced the time required to complete the tasks.” (Below average score)

Net benefits: 31.5% of respondents disagreed/strongly disagreed, and 33.53% were unsure that “The system could better streamline the process of nursing practice.” (Below average score)

Increasing the complexity of nursing documentation

Record templates increasing documentation burden

Limited value of nursing process-based templates

(The admission assessment is) too complicated. These things may take a long time to complete for each patient, and they will feel “why the nurse needs to ask me these things, which has little to do with my disease”. (P9, nurse)

Some patients are (in) particularly good (condition). They have no past history or anything, but by default, you have to include two (nursing diagnoses), so you just add them by yourself… In fact, it’s meaningless. It’s about completing the process and you can't leave one stage unfinished. (P13, nurse)

(Shift handover summary) contains too much stuff. We all pay attention to the key points during handover, but we won’t be able to find the key points in a pile of texts. For example, I hope to see clearly that this patient has a catheter, but it’s is buried in a paragraph of texts which can't be found (easily). (P6, nurse)

System quality: Only 26.59% of respondents agreed/strongly agreed that “The system can flexibly switch between various screens.” (Below average score)

Inflexibility switching between various screens

Documentation burden caused by navigation between screens

It is cumbersome to document the I/O, the time needs to be re selected for each input (for each patient). (Survey response)

Not all content can be integrated in one interface. (Survey response)

Care Direct requires nurses to shift between various screens to complete observation and care items as opposed to documenting directly next to the narrative texts as in the paper records. (Observation notes)

Information quality: 14.81% of respondents disagreed/strongly disagreed, and 42.28% were unsure that “The information provided by the system is continuous and dynamic, which can reflect the change process of the patient's condition.” (Below average score)

Information not reflective of the dynamic change of patient condition

Problematic Information linkage

Unavailability of information linkage within the system

The system can capture the abnormal data, for example, the labs, but it will not give you suggestions… Generally, you will not reassess the patient unless there is a change in his care demand. But the patient's situation is actually a dynamic process. This thing (system) is dead, it is not that dynamic… In fact, I see the doctors’ (system) doing quite well, for example, when the labs report that the patient’s blood potassium is high, it will remind you with suggested actions, but ours won't and you have to add it manually. (P13, nurse)

Information quality: 19.13% of respondents disagreed/strongly disagreed, and 42.28% were unsure that “The system can obtain the required information within the timeframe required of nursing practice.” (Below average score)

Information not generated in a timely manner to support the user

The timing of interventions generated on the schedule not conforming to practice routines

Why would preoperative education be triggered on the night shift the day before operation? Generally, we do this education on the day shift before the operation, and the patients who do surgery on Monday are educated on Saturday. (Survey response)

Now the doctor makes a new diagnosis, it (the system) will generate a care bundle corresponding to the diagnosis and inexplicably auto-select all the corresponding interventions… directly reflected in the schedule… It is completely inexplicably presented. Then you have to go back to the care planning module to choose what you need or delete them whole… (P9, nurse)

Information quality: 17.28% of respondents disagreed/strongly disagreed, and 35.80% were unsure that “The information provided by the system is consistent with the actual situation and there are no errors in the record.” (Below average score)

Information generated by the system lacking accuracy

The error-prone information generated by the system adding to documentation burden

We're worried that we cannot control the system-generated record sheet after it goes live… We can't see the final appearance of what we document in the system. If we want to see it, we have to generate it separately… You won’t be able to check on every shift to see whether the documentation for each patient is right. I don't have time to check. (P8, nurse specialist)

Net benefits: 40.43% of the subjects agreed/strongly agreed that “The system had the ability of analysis and prediction in the nursing process.” (Above average score)

Analysis and prediction function of the system

Value of CDS

Various perceived benefits from CDS

When I need to raise nursing problems for my patient, CCC (the system) automatically jumped out (recommended) her related nursing problems… I just need to choose among them without thinking about them on their own. (P10,nurse)

For staff who have worked for many years, they have formed a working mode. If they know what to do at each point on the shift, they won’t follow this system and may have formed an inherent thinking. It's actually quite difficult to change this inherent thinking. If you ask us to completely follow the care plan, we may feel that we won’t be able to do it. (P8, nurse specialist)

Serving as a reminder

Maybe it provides more options, which can give us a hint. Sometimes we can't think of it. There's a hint in the system. (P14, nurse)

Sometimes it's not the nurses deliberately don't implement it (the tasks), but they really forget about it, right? They may pay more attention to dealing with physician orders or do treatments, but they will neglect some other interventions. Then we (the system) push them (all the schedules) out to remind them, which can guarantee the care quality. (P16, nurse manager, project champion)

The schedule can better remind nurses of some hidden nursing interventions that are easy to be neglected. (Survey response)

Service quality: 18.52% of respondents disagreed/strongly disagreed, and 38.58% were unsure that “The training on system use could meet the needs of clinical practice.” (Below average score)

Training on system use not meeting user needs

Insufficient training on system use

Inefficiency of training organization

At that time, we went over there (the venue) for centralized training. The place was large, (we sat) too far away and could not see clearly, and it was noisy on the scene… (P3, nurse)

He just told you in a very general way what there are in each module…I can see these as long as I click them by myself. Anyway, it was of little use. What I need is after the patient come back from surgery, what are the actions to be taken in the system step by step. (P3, nurse)

Wasn’t it first carried out in the pilot places (wards)? Staff at other departments didn't know about it. I learned from the colleagues after I went to the pilot place (ward). (P5, nurse)

It (the training) was good, but I don’t want (the leaders) to force nurses to take the training during rest time. It can be made into a paper version or an electronic version, distributed to the workgroup and learn by ourselves. (P10, nurse)

Service quality: 29.94% of respondents disagreed/strongly disagreed, and 37.96% were unsure that “Technical staff can understand the special needs of nurses.” (Below average score)

Technical staff having difficulty understanding user needs

Cooperation between nurses and technical staff

Interprofessional barriers

When communicating with technical staff, my strongest feeling is powerlessness. They can't understand many of the requirements we put forward, and the final product is not what we want. (P20, nurse manager)

Service quality: 11.73% of respondents disagreed/strongly disagreed, and 38.27% were unsure that “Technical staff sincerely and timely solve the problems encountered during system use.” (Above average score)

Technical issues not solved quickly enough

Nurses disenchanted with system improvement

When the problems you reported repeatedly not solved after a long time, it's a heavy blow to us… (P2, charge nurse)

Just don’t bother to talk to them… Some problems may be raised at the beginning, but you found that after a long time, why it still hasn’t been solved? There's just no big progress. (P6, nurse)

Experience of technical support: 81.79% of respondents agreed/strongly agreed that “Technical staff modify and improve the system according to our needs”

Technical staff value user requests

Recognizing efforts made by technical staff

Certainly, there is no way to solve all the technical problems in the short term. We can see that the engineers have been making modifications and it (the system content) is closer to what we want, but it has not completely reached that point, there is still a little distance. (P17, nurse)

Experience of technical support: 86.69% of respondents agreed/strongly agreed that “The management take our opinions and experience seriously”

Management value feedbacks from the nurses

Leader role

Leader Supervision

We do what the leader says about. (P1, nurse)

Especially when the leader (charge nurse) comes to ask you why this is not properly documented (in the system), we will give her an explanation. Then she will ask you to display it (in the system), try it, and then she will also operate it herself (to identify the problems with the system) so she could report it to the higher (management). (P5, nurse)

Now the charge nurse will review this (the nursing record exported from the new system) and point out our mistakes. After all it is still in the pilot stage and has not been included in nursing quality assurance, but it will certainly be included later. (P13, nurse)

Rational arguments

I have been telling them that this is about a state of mind. This (the system) is a new stuff. It would probably be better if you could do it with a learning and accepting mindset. (P16, nurse manager, project champion)

Experience of technical support: 84.61% of respondents agreed/

strongly agreed that “According to my experience, the problems I reported can reach technical staff all the way up”

A smooth feedback channel

Cross-level collaboration

Communication between nurses on different levels

There is no problem in our communication with ward nurses. I can clearly their requests. After the nurse gives me feedback, we will check whether it is minority opinions or majority opinions, and then we decide to communicate with the technical staff. (P20,nurse manager)

Sort out (documentation requirement) according to the practice routines in our hospital. For example, the catheters, each head nurse sorted out (the types of) catheters in use in her unit. (P15, charge nurse)

Problems were discussed in person among nurse leaders and the project champion and common problems summarized before being put forward on the project meetings. (Observation notes)

During 13-month observation period, the system underwent 45 formal version upgrades, with 103 system-related bugs repaired, 131 system optimizations achieved and 50 new functions & contents added. (Observation notes based on documents review)

In terms of coordination and communication, we all go in the same direction. However, I think there must be a consistent way (of communication). (P16, nurse manager, project champion)

Top management did not attend discussion sessions regarding system content revision as proposed by her despite repeated invitations made by the project champion; therefore, she was unconscious of the appropriateness of content revision. (Observation notes)

Information quality: 43.21% respondents agreed/strongly that “The information provided by the system can meet the types and contents of information required of nursing practice.” (Above average score)

Integrity of information content provided by the system

Positive outcomes of collaboration

The (system) function has also been constantly improving, which is indeed much more convenient. (Survey response)

It (the system) has an option for basically anything you want. This is the biggest improvement. At the beginning, it may not have so many options, that is, for example, the location of the catheter is not so clear. Now it is basically perfect, and this progress is a huge one. (P3, nurse)

NIS use behavior: 53.40% of the subjects agreed/strongly agreed that “I have get used to the new system”

Getting used to the system

Accepting the new thing

Different levels of adaption to the system

Our old system is very straightforward, while the new system requires us to demonstrate our clinical thinking processes, which requires a certain amount of time to adapt. (P20, nurse manager)

For the less optimized software at the initial stage, it may affect everyone's perceptions of use, but now that we are gradually on the right track, I think we have adapted to its use. (P7, nurse specialist)

I have accepted it very much now. (P1, nurse)

Now there are too many systems, and the work is a little complicated and we feel a little confused. (P12, nurse)

I don't know what will happen later on. If I don't need to write the paper ones in the future, just use the electronic system, I think it will probably be OK after extended use. (P18, nurse)

NIS use behavior: 70.37% of the subjects agreed/strongly agreed that “I actively learn the existing functions of the system”

Learning system use strategies

Proactively learning system use

If I don’t know how to handle it, I will definitely take the initiative to learn, because it relates to my clinical work. (P6, nurse)