Measuring the effect of a computerized nursing documentation system with objective measures and reported perceptions

Abstract

Study objectives: We compare perceptions of clinical information system users about the effect of an emergency department (ED) computerized nursing documentation system on how nurses spend their time, with an objective measure determined by direct observation. Clinical users are very sensitive to changes in process that affect how they spend their time. The success of implementation of clinical information systems is highly dependent on clinical user acceptance. Using an anonymous survey, we determine nurse-user perceptions of how implementation of computerized nursing documentation, along with physician order entry, has affected how they spend their time. Before the implementation, physicians wrote orders on paper, and nurses entered laboratory and radiology orders into a computerized ordering system. Before the implementation, nurses documented triage information in the computerized tracking system but did most of their documentation on paper. Since the implementation, nearly all of nursing documentation has been done in the computerized system, and physicians now place orders directly into a computerized ordering system. The nursing documentation system allows nurses to document using a template made up of lists of items. The nurse documents by selecting items using a computer mouse to click on list items. Additionally, the nurse can supplement the template documentation by typing in text notes at any point in the documentation process. We compare the perceptions of the nurses with more objective measurement obtained from direct observation in a time-motion study. Methods: Nurses who had worked at least 4 months before and after the implementation of a computerized nursing documentation system were asked to complete a survey. The survey used 5-point Likert scales ranging from −2 to 2. One question asked whether the nurse was spending more or less time documenting on patients after the implementation, with negative response meaning less time. The nurse was asked to indicate how often the template options were adequate. In a separate question, nurses were asked how often they had to type in text in addition to the template options. Finally, the nurses were asked to indicate their comfort level with using computers. Measurement of time spent in various activities was performed by direct observation as part of a time-motion study done in the ED. Nurses were observed during 34 nursing sessions of approximately 4 hours each (17 sessions before the change in the information system and 17 after). Using SPSS 12.0 software, we calculated correlations (Spearman's ρ) for selected survey items and the means of the percentages of time spent in various activities for the 2 sets of observations (before and after implementation), along with 95% confidence intervals (CIs) on the means. Results: The percentage of nursing time spent using a computer was 10.1% (95% CI 7.8% to 12.5%) before implementation and 26.0% (95% CI 23.2% to 28.9%) afterward. The percentage of time spent on paper documentation was 17.1% (95% CI 14.4% to 19.9%) before and 1.7% (95% CI 0.8% to 2.6%) after implementation. Combining these, time spent either on a computer or paper documentation was 26.8% (95% CI 22.6% to 30.9%) before and 27.6% (95% CI 24.4% to 30.9%) after implementation. Time spent in direct patient care was 42.0% (95% CI 24.4% to 30.9%) before and 39.8% (95% CI 34.9% to 46.7%) after implementation. Idle or waiting time was 0.7 % (95% CI 0% to 1.9%) before and 2.9% (95% CI 0.6% to 5.2%) after implementation. Time spent documenting while in the patient room (either on paper or on computer) was 0.2% (95% CI 0% to 0.4%) before and 2.1% (95% CI 0.5% to 3.6%) after implementation. We surveyed 55 (85%) of the eligible nurses. The mean score on the question about time spent documenting was −0.2 (between "less" and "about the same"). Mean response to finding available template options adequate was 0.1 (between often and fairly often). The mean response to typing additional information was 0.9 (between fairly often and often). The mean response to comfort level with computers was 1.2 (between comfortable and very comfortable). Feeling comfortable with computers correlated with typing additional information ( r =0.32, P =.008). Significant correlations were not found between the perception of time spent documenting and typing in additional information ( r =0.05, P =.7) or between perception of time spent documenting and comfort level with computers ( r =–0.12, P =.3). Conclusion: Overall, the percentage of time spent on documentation was about the same before and after the implementation of computerized nursing documentation with computerized physician order entry. The perception of the nurses was congruent with the more objective findings of the time-motion study. Nurses who feel more comfortable with computers report supplementing template options with additional typed information.