Nurses’ perceptions of their documentation experiences in a computerized nursing care planning system

Abstract

To explore how the content design of a computerized nursing care plan affects nurses' perceptions of their documentation experience, specifically in making care plans. Nurses' attitudes towards and experiences of computer use in daily practice have been studied. However, no studies have examined how using a computerized nursing care planning system affects nurses' perceptions of the documentation process. A descriptive, exploratory qualitative approach was used to conduct one-on-one, in-depth interviews with 20 nurses. The major interview question was, 'What do you think the content of the computerized care plan provided in making care plans?' Data analysis was based on Miles and Huberman's data reduction, data display, and a conclusion verification process. Nurses generally viewed the content of the computerized nursing care planning system as a reference to aid memory, a learning tool for patient care, and a vehicle for applying judgement to modify care plan content. Although computer technology is designed to streamline nurses' work, using a computerized care plan system can also enhance their knowledge, experience and judgement of descriptions of patient problems and care strategies. Thus, the effects of using technology on documentation behaviours or patterns may deserve further exploration. While computerized documentation systems have been used widely in patient care, little attention has been given to how the design of care plan content affects the documentation process. Electronic documentation systems can introduce nurses to new skills and knowledge that may improve care quality.