Nurses in Australian acute care settings: experiences with and outcomes of e-health. An integrative review

The World Health Organization (WHO) defines e-health as the "use of information and communication technology for health". The use of e-health, including electronic medical records (EMR), is a growing trend. This integrative review of the literature examines nurses' experiences of e-health in Australian acute care settings. A search of the literature identified 21 papers for inclusion in this review. Two discernable themes in the literature are apparent. Research to date largely focuses on nurses' experiences of e-health, including its usefulness in their work. Findings indicate that nurses' attitudes to e-health and computer usage are positive, however there are indications that nurses currently using e-health in practice are often dissatisfied with the implementation of new e-health systems in their workplace and that there are a number of barriers to its successful implementation. Secondly, a discernable gap in the literature regarding the impact of e-health, and in particular EMRs, on nursing outcomes is identified with research to date limited to findings related to nursing documentation and multi-disciplinary discharge planning. Future research that considers nurses' experiences in implementing e-health and applies focused strategies across a range of health settings, both in Australia and around the world, can influence successful adoption and implementation of e-health.


INTRODUCTION
E-health refers to the "use of information and communication technology for health" [1], to enable and drive health system reform with the aim of improvements in efficiency, productivity, health outcomes and consumer satisfaction [2,3]. E-health is recognized as a major health priority in many developed countries, including Australia, New Zealand, the USA, Canada, UK, Korea, Brazil, Germany and Sweden, together with the implementation of various tools to support e-health in varying stages across the globe [1,[4][5][6][7]. E-health initiatives are premised on the implementation of electronic medical record (EMR) (also known as the electronic health record or electronic patient record) with a vision for the future of a paperless healthcare system [8]. EMRs have existed in various forms for the past 30 years and its definition has evolved over time [9]. An EMR can be as simple as (computerised) information about a patient in digital/electronic format, to as complex as a fully integrated patient care record. Currently, the World Health Organization defines an EMR as "a real-time longitudinal electronic record of an individual patient's health information that can assist health professionals with decision-making and treatment" [1]. An earlier International Organization for Standardization (ISO) definition is more specific, referring to an EMR as "a repository of patient data in digital form, stored and exchanged securely, and accessible by multiple authorized users. It contains retrospective, concurrent, and prospective information and its primary purpose is to support continuing, efficient and quality integrated health care" [cited in 9]. While the WHO definition is succinct, the ISO definition is more congruent with contemporary developments in e-health. Healthcare informatics, including nursing informatics, is a rapidly advancing and growing field. Nursing informatics is a sub-discipline of health informatics [2] that emerged in the literature in the mid-1980s [10]. It is defined as "a specialty that integrates nursing science, computer science and information science to manage and communicate data, knowledge and nursing practice" [10]. With nurses representing the largest proportion of healthcare professionals, nursing informatics is set to play an increasing role given that e-health is now widely accepted as the way forward for healthcare around the globe [3,7,11]. This review of the literature highlights the use of various terminologies in relation to electronic systems within a health care context. Terminologies include: information and communication technology (ICT), information technology (IT), clinical information technology (CIT), computerized patient information systems (CPIS) and health information systems (HIS). The authors acknowledge that there may be differences in each of these terminologies, however for consistency and ease of readability and in view of the WHO definition, the terminology 'e-health' (discussed above) [1] will be used in this article in reference to electronic systems within health care. Over time, implementation of e-health has evolved from computerised task systems, to unit and hospital wide systems, to the concept of an integrated system, which includes EMRs. However, many systems implemented over the past 15 years have focused on just one aspect of patient record keeping. The challenge for the future is to establish how each of these systems can be integrated to better inform the provision of healthcare that ultimately supports and benefits patients. In working towards the goal of a fully integrated e-health system that includes secure EMRs, it is important to take the opportunity to learn from the past in planning for a future, including the involvement of nurses in the design and implementation of e-health and its components [12][13][14]. The purpose of this paper is to report on a review of the literature pertaining to nurses' experiences of the implementation and use of e-health and its impact on nursing outcomes in Australian acute care settings.

METHODS
This integrative review was conducted in two phases using methods outlined by Evans [15] and Whittemore [16]. The first phase comprised a search of four online databases, CINAHL, MEDLINE, SCOPUS and Science Citation Index (Web of Science) for papers published between 1995 and 2010. Search terms included are outlined in Table 1. Search results were limited by combining with Nurs*. This search yielded 19137 results. All citations were imported in to the Endnote program [EndNote X4, 17] and 7890 duplicates eliminated. The second phase of this search was conducted in Endnote using the terms 'implementation' and 'acute care'. The titles and abstracts of these citations (n=286) were manually reviewed by the researchers and categorised for ease of analysis. References were further refined based on the following inclusion criteria: written in English, available in full text, and with a focus on implementation of information technology in the context of nursing in an acute care setting. A total of 161 papers were identified. At this point a decision was made to limit the search to studies conducted in Australia and New Zealand. The search did not identify any studies conducted in New Zealand. Review of the full text articles of Australian studies (n= 33) identified 12 exclusions, resulting in a total of 21 papers for inclusion in this review. Comparative analysis of studies chosen for this review was difficult given the wide variety of study designs, study questions and methodologies used; a narrative summary [19] was therefore used to summarise studies.

RESULTS
A total of 21 papers were included in this review. A summary of each paper, including a brief outline of the focus of the paper, study design, main findings and a hierarchy of evidence score [20] is presented in Table 2. Twenty of the twenty-one papers are qualitative studies and the remaining paper is a commentary paper. The majority of papers (n=18) focus on nurses' attitudes and/or perceptions towards various aspects of e-health and computer usage. Three of the remaining papers focus on outcomes following implementation of e-health, while the final paper examines a tool for assessing the effects of e-health on clinicians' workflow and communication. Development of a PDA based tool to assess clinicians work patterns pre-and post implementation Observational, study

nurses
The results indicate that this tool is a reliable and valid tool for assessing the effect of implementation of health IT. This tool will be applied in future studies.

Attitudes/Perceptions
A key theme identified in the literature is nurses' attitudes and perceptions of computer usage and e-health. Nurses are generally confident and have a positive attitude towards both [21][22][23][24], with many nurses recognizing the benefits of e-health in service delivery [25,26]. While most studies only included registered nurses, two studies offered the perspective of student nurses, one cohort in 2nd year [27] and the other in 1st year [28]. Although sample sizes (n=56 vs. n=971) and research designs were different between the two separate studies, similar conclusions can be drawn from the findings. In general, student nurses were confident and knowledgeable in using computers, e-health and the internet. Not all students, however, recognize the importance of e-health or information technology in healthcare practice; only 23% in one study [27] and 71% in another [28]. These findings contrast with another study that found more than 85% of registered nurses believe computers are valuable to their practice [21]. The number of years experience as a nurse also influences nurses' attitudes towards e-health. In a study by Marasovic et al. [29] less experienced nurses, were more motivated to use e-health than nurses with more years experience, irrespective of age.
Attitudes and perceptions of current users of e-health in practice are mixed. While some studies indicate positive views of nurses towards particular elements of e-health initiatives [24,30,31], others report that in general, nurses currently using e-health in practice have more negative views and attitudes [31][32][33][34][35]. Two studies by Callen [24,31] that explore nurses' attitudes further, suggest that organizational culture can be influential in nurses' receptiveness towards ehealth in the workplace. More positive attitudes were found in constructive cultures, which encourage cooperative teamwork, whereas negative attitudes towards e-health were found in aggressive/defensive cultures where there is an expectation that team members will oppose new ideas, members appear independent and competent and where there is a culture of competitiveness amongst individuals. In the literature, many barriers to successfully implementing e-health are identified [22,25,26,[33][34][35][36][37]. Barriers include lack of knowledge about e-health [25,26], limited or lack of training in e-health [22,36,37] and limited access to computers [22,25,26,33]. Registered nurses commonly found accessing e-health in their work time consuming, with it creating too many demands on them during their working hours [22,25,26,33]. They also found that a lack of technical support [22,26,37] and security issues were barriers to successful use of e-health in their practice [22,34,37]. When registered nurses believe that implemented e-health initiatives do not reflect the nursing process [33,35] and when there has been a lack of consultation prior to implementation [35] nurses were resistant to change.
Two papers reported on studies that assessed outcomes relevant to nursing as a result of implementing e-health initiatives. While electronic charting (vs. traditional paper charting) was found to improve nurse's ability to detect changes in patient parameters in one of the studies [38] the other study reported no effect from electronic documentation (vs. paper based documentation) on frequency of nursing activities [39]. It is worth noting that in the latter study findings were not statistically significant. A third paper comments on the positive improvements in timeliness and legibility of discharge information as a result of the implementation of an electronic multidisciplinary discharge summary [40].

DISCUSSION
Two major themes were identified from this integrative review of the literature. The first theme is nurses' attitudes and perceptions of e-health and its implementation and use in healthcare. The second theme relates to the outcomes of implementing e-health on nursing practice.

Attitudes / Perceptions of e-health
The majority of studies included in this review focus on nurses' attitudes towards the use of computers, recognition of the importance of e-health and EMRs, and nurses' experiences of using e-health in clinical practice. Studies, which reported positive findings in these areas, include Axford & Carter [30], Callen et al. [24], Edirippulige [25], Eley, Soar et al. [26], Hegney et al. [22] and Webster et al. [21]. These findings are supported in the broader literature with regard to nurses in countries including Kuwait [41], China [42], Holland [43], Canada [44] the UK [45] and the US [46]. Two studies in the broader literature, which focus more specifically on the implementation of EMRs, reported respectively negative attitudes towards EMRs preimplementation of a new e-health system [47] and positive attitudes pre-implementation compared to postimplementation [46]. Reports of nurses' experiences of using e-health in practice are mixed however, particularly in relation to its implementation. Few studies in this current review report nurses having a positive experience in relation to the implementation of e-health [24,30,31], as compared to the number of studies reporting nurses having a negative experience [32][33][34][35]. These mixed results are supported in the wider literature with one review of 13 papers suggesting nurses in general have positive experiences of e-health [14], while another review of five papers reports widespread dissatisfaction with various e-health initiatives [48]. Other studies not included in the two afore-mentioned reviews also indicate both satisfaction [49] and dissatisfaction with ehealth [50]. Papers identified in this current review are more strongly aligned with nurses' experiencing dissatisfaction in their experiences with e-health in the workplace. Given the findings of generally positive attitudes towards e-health prior to the implementation of initiatives in the workplace followed by nurses then reporting negative experiences, these results suggest issues with implementation processes of new initiatives. Although the majority of literature, particularly in the Australian context, reports that nurses experience dissatisfaction with e-health after the implementation of new initiatives, there is evidence in the wider literature to suggest that these negative attitudes post implementation improve over time. Some studies show greater acceptance and more positive attitudes in the months following implementation [51][52][53][54][55], which reinforces the importance of effective change management during the e-health implementation process.

Outcomes of implementing e-health
The benefits of e-health, including EMRs have been documented with outcomes of improved patient safety and quality of care resulting from increased efficiency, accuracy, management, accessibility and decision-support [56]. More specifically in relation to nursing, the benefits of EMRs include improved documentation, legibility, evidenced based decision support, interdisciplinary communication and reduced duplication and medical errors, all of which result in streamlined clinical workflow leading to enhanced quality of care [57][58][59]. While there are many expected benefits of e-health and EMRs in general these are not always assessed in terms of their effects on nursing practice as reflected in the limited evidence found in this review. In this review, journal articles related to outcomes for nursing practice, in relation to implementing ehealth, are confined to outcomes associated with electronic versus paper documentation [38][39][40]. Positive effects of electronic documentation on various aspects of nursing work, including improvements in completeness, quality and quantity of documentation and time for patient care are also evident in the wider literature [46,[60][61][62][63]

Relationship between attitudes and outcomes of implementation: Are the two related?
While this paper has so far separated studies reporting both nurses' attitudes towards, and experiences of, computers and e-health from papers concerned with the outcomes of implementing e-health, these two areas are not mutually exclusive. Our review of the literature suggests that there is a close relationship between the success of an implemented system, the implementation process and the feelings of affected nursing staff [14,64]. Indeed, numerous studies included in this review identified barriers to successfully implementing e-health [22,25,26,[33][34][35][36][37]. Barriers that influence the implementing of new e-health initiatives contribute to nurses' levels of dissatisfaction reported after implementation of such initiatives. Indeed, the Australian study by Callen et al. [24,31] indicates the importance of organizational culture in effectively implementing change such as the introduction of e-health. Barriers to the implementation of e-health identified in this study are not dissimilar to those reported in the wider literature [12,50,[64][65][66]. Given the commonality of barriers to successfully implementing e-health in different circumstances and environments around the world, it is important that they be considered and addressed prior to future rollouts [67]. Whilst identified barriers do not prevent the implementation of e-health initiatives they may contribute to patterns of resistance that Timmons [50] defines as 'resistive compliance' (p.257).

LIMITATIONS
The paper by Westbrook and Ampt [68], included in this review, highlights one important limitation of this review, which is the difficulty of evaluating the implementation of ehealth. There are many aspects of implementation that need to be considered in a comprehensive evaluation process [67], which are emphasized by the range of barriers identified in this review. Furthermore, as there is no gold standard for evaluating implementation of e-health, it is difficult to compare different studies. The need to comprehensively evaluate the implementation of nursing informatics is also highlighted in the wider literature with the publication of two reviews in this area [69,70], one specific to nursing practice [71]. While there is a need for valid and reliable evaluation tools, they are only in the early stages of development [68,71]. Tools currently being developed, along with others likely to be developed in the future given the emerging interest in this area, will be invaluable to the evidence base related to the implementation of e-health and EMR.

CONCLUSION
This integrative review highlights the need for further studies regarding the implementation of e-health, including EMRs, and their impact on nursing practice in Australia. Further evidence is required regarding nurses attitudes to e-health, and secondly to assess the effect of implementing e-health on various nursing outcomes in order to understand what works and why, with the ultimate aim of determining best practice for nursing in the Australian context. To support future goals, including the successful implementation of fully integrated ehealth systems, it is important to understand nurses' roles in the implementation process and impacts on nursing practice, particularly given that nurses represent the largest proportion of the health workforce. Insights from the literature highlight various factors that are important considerations in the process of implementing e-health, including health professional's lack of knowledge and training and a lack of access and technical support. Even though e-health, in its various guises is becoming commonplace in Australia and other developed countries, focused research in this area is limited. Future research that applies focused implementation strategies and considers nurses' roles and experiences in implementing ehealth, both in Australia and around the world across all health settings, can influence successful implementation and adoption of e-health.