Behavioral Feasibility of the Clinical Nursing Information System

1. INTRODUCTION

A Clinical Nursing Information System (CNIS) is a software system, which is exclusively designed and implemented for the use of nurses to perform all or part of the nursing services and activities [1]. Advantages of nursing information systems include: a) improvement of workflow and faster performance of high volume of work; because of determining the required staffing levels and combining proper skills for each shift; b) better care planning; due to reducing the time spent on care planning, increasing the quality of data registration and better evaluation of the patient; c) better drug prescription; due to readability increase and medication errors reduction in drug administration through electronic drug prescription [2]. All system development projects such as CNISs cause changes in the organization and its users are generally afraid of it. User resistance to these changes may be in the form of system malfunctions, such as incorrect data entry or deriding new user from the new system or potential resistance of the staff, so they prefer to use the old system instead of the new one [3]. For these reasons, the implementation of information systems has its own challenges, so feasibility studies and analysis of problems at all stages of the implementation cycle and system development, including the review, analysis, designs, imple-mentation, maintenance and evaluation [4-7] are essential. Feasibility studies are one of the key steps in the analysis phase to increase the success of system development projects, prevent costly errors, provide opportunities for beneficiaries to make decisions and determine the criteria for system evaluation in order to achieve various goals [5]. The purpose of these studies is to identify the cultural, time, budget, and legal limitations and analyze the effects on the organization in order to provide the best implementation method [8, 9]. Feasibility analysis is conducted with technical, economic, legal, behavioral and timing perspectives [10]. Most feasibility studies focus on the behavioral aspect because it assesses human issues and their behavior and attitude towards the development of new systems. Also, it determines whether the system needs to train, retrain, transfer and change employees' work status for the new way of doing things [3]. Kedwan et al. (2016) studied the feasibility of an online patient registration system and identified some reasons of outpatient and employee for choosing this system which included: saving time and cost, patient convenience, data sensitivity, less Effort, ease of use, accuracy, and errorless [11]. Fontil et al. (2018) in a study of the adaptation and feasibility of a digital health program stated that most participants in the focus group accepted the program. In the feasibility study, 54% of the patients were willing to enroll. Although computer access and literacy had created challenges for some participants, the majority were satisfied with the system and at least 80% of the participants used the system at least once a week [12].

However, it seems that most of the CNISs have difficulty due to behavioral reasons and the lack of preparation of nurses in cultural and knowledge aspects. The same studies, also, emphasized that the nurses who are not familiar with information systems and have poor computer skills believe that the performance of these systems are complex and time-consuming, and are not eager to use them [13-22]. However, nurses who have the skills, experience and motivation to work with a computer or acquire the necessary confidence before setting up the new system by culture-building in a consulting environment tend to use these systems and have a sense of job security [23-25]. For this reason, often in the development or implementation of systems, the feasibility of behavior that addresses the human issues affecting the project is at the top of the research, and its results are analyzed to properly understand the system's ability to solve problems, use opportunities and determine whether a project can enter into an action or action step [4, 8]. Especially, in the analysis, rational and incentive considerations of change acceptance are examined to determine the effect of system implementation on the staff. Is there a need to retrain? Is there a need to create change in a business method? Are the changes accepted by the staff? And what is the impact of these changes on other sectors and processes [4, 26]. Since the implementations of the national projects of E-Health and Paperless are being studied and run in Iran and other countries, the current study was conducted to assess the behavioral feasibility of the CNIS. The results of this study may help to understand human problems of the implementation and development of CNISs and guide authorities for the development of these systems.

2. MATERIALS AND METHODS

This descriptive study was conducted in 2015 at general hospitals affiliated with the Mazandaran University of Medical Sciences, Sari, Iran, in which Hospital Information Systems (HISs) were implemented.

3. RESULTS

4. DISCUSSION

This study aimed to assess the behavioral feasibility of CNIS. Behavioral feasibility is a scale of how the proposed system solves the problems, to what extent it takes the advantage of the opportunities identified during scope definition and how much it satisfies the requirements identified in the requirements analysis phase of system development. Moreover, the behavioral feasibility assessment focuses on the suitability of development projects proposed for the existing

business environment and the objectives designed according to the schedule, the date of delivery, corporate culture and business processes. The results of the present study showed the necessity of system deployment in the clinical nursing sector (88.2%) and the need for change in methods to maintain the financial and job security of nurses for system acceptance were 88.2% and 82.6%, respectively.

The results of other studies show that deployment of the system is essential to improve nursing performance and provide better care to patients [30] and leads to satisfaction and nursing quality improvement, acquiring new knowledge and increased job security [31-34] which is consistent with the results of the present study. Also, in this study, interference of redesigning existing structures with the current work was 43.6%, which did not fit with the workflow of nurses. The results of this study are consistent with Lau (2011) who investigated the benefits of successful adoption of clinical information systems in Canada and reported that the information system is not accepted by nurses due to the heterogeneity with clinical practices of nurses and therefore has underlined the redesign of structures and workflows [35]. However, it is not consistent with the results of other studies that examine the structure and processes of nurses' work when designing the systems which reported the compliance of new system structures with their current work [36-38]. The findings show that redesigning the structures parallel with system design is essential for nursing processes and workflow efficiency improvement, especially since the establishment of an information system, problems of existing processes and workflows become clearer [39, 40]. In addition, when redesigning the structures, processes and workplace design, technical capability enhancement, increasing job satisfaction, efficiency, and reducing error rates should also be considered [25]. Because nursing information systems are designed and implemented to improve the performance of nurses and help them in planning, diagnosis, care planning, and decision making, nurses should be trained to use these systems with motivation, satisfaction and a sense of job security. It is suggested that during the design, development and implementation of these systems, the necessary support for nurses, nursing work processes and structures should be designed according to the status and safety of nurses' work. Moreover, in order to prevent the loss of time for nurses, and delay the registration of documentation in nursing information systems, due to the use of other nurses, computer equipment should be provided to them. Also, to improve the flow of information from different parts and to complete the information, a minimum set of nursing data is included and used in nursing information systems.

The results showed that nurses’ familiarity with information systems was 57.8%, the skill to use computer 57.4%, the knowledge to use system 58.4% and their interest to use system 54.8%. Other studies show that nurses do not have sufficient training and have poor computer skills and cannot use the system and need more training [17-19, 21, 22]. Lam-mintakanen’s study (2010) showed that training of nurses working at health centers is not sufficient; moreover, using these systems is time-consuming and nurses are not eager to use them [13]. Izzatty (2013) also reported that the information systems applied for nurses, in Malaysia, are complex and time-consuming, the system adoption level of nurses was low, and they were reluctant to use the system [14]. Mbananga et al. (2002), in a study carried out in North Africa, stated that nurses were reluctant to use the system due to issues such as lack of computer skills, misunderstanding of the system, lack of adequate training, technical defects of the system, the presence of duplicate files, loss of files, and problems in tracking patients [16]. The results of this study are consistent with the study of Bitene et al. (2000) who stated that nurses who lacked sufficient skills and computer literacy were concerned or reluctant to use the system [18]. Furthermore, the study of Imani et al. (2015) reported that most problems that nurses are faced with happen when working with medical information computer programs due to lack of familiarity with computer science and the lack of adequate training [41]. However, it is not consistent with the results of some studies that have reported that at the time of information system application, nurses were familiar with computer, felt good when using its tools and easily recovered their data [23, 24, 42, 43]. Blignaut et al. (2001) stated that a workshop-like consulting environment helped nurses improve their confidence and familiarity with system before launching a new system [25]. The study of Bond (2007) and Just (2008), conducted in Thailand, reported that nurses familiar with computer skills search their needed information easily and apply them when providing care [22, 44]. Emuziene (2009) reported that 70% of nurses have computer knowledge and skills and can work with computers easily to promote their jobs [45]. The increased computer skills of nurses make patient’s information recovery faster and provide better and more efficient care [46]. This also saves time allowing nurses to focus on performing other specific activities [22]. Since nurses’ lack of ability and skills in computer use affects the system adoption, in order to increase the possibility of the establishment of the system in terms of behavioral dimension, it is essential that the universities include computer training in annual programs to provide cultural context for using a computer.

This work has several limitations. The overwhelming workload, which somewhat complicated the completion of the questionnaire by the researcher. A wide range of research scope that should cover all hospitals and lack of papers on the feasibility of health information systems. Because of the inability and lack of skill of the nurses to use computer affect their acceptance of the system, it is imperative to include computer training in hospital education programs. Also, with an increasing use of information systems in hospitals, and especially in nursing units, it is necessary to develop computer information technology and nursing information systems in nursing curriculum planning. Educational programs are successful and increase the motivation to learn computer skills when presented in the student's specialized curriculum.

CONCLUSION

The possibility of CNIS implementation in behavioral dimension is semi-favorable. Suitable environment, education and the promotion of the culture of using information systems, collaboration and the participation of all nurses in the formulation, and implementation of work processes is a prerequisite for achieving the goals of nursing information systems. Nurses’ lack of computer literacy and unfamiliarity with the system along with fear of making a mistake, demoralization, decreased job satisfaction and a sense of insecurity make it necessary to present a new system as a positive change, and also more training for nurses could encourage them to use information systems. Furthermore, more in-service training is required to increase the level of literacy and computer skills of employed nurses.

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