Factors Affecting and Affected by User Acceptance of Computer-based Nursing Documentation: Results of a Two-year Study

Design: We introduced a computer-based nursing documentation system on four wards of the University Hospitals of Heidelberg and systematically evaluated its preconditions and its effects in a pretest–posttest intervention study. For the analysis of user acceptance, we concentrated on subjective data drawn from questionnaires and interviews. Measurements: A questionnaire was developed using items from published questionnaires and items that had to be developed for the special purpose of this study. Results: The quantitative results point to two factors influencing the acceptance of a new computerbased documentation system: the previous acceptance of the nursing process and the previous amount of self-confidence when using computers. On one ward, the diverse acceptance scores heavily declined after the introduction of the nursing documentation system. Explorative qualitative analysis on this ward points to further success factors of computer-based nursing documentation systems. Conclusion: Our results can be used to assist the planning and introduction of computer-based nursing documentation systems. They demonstrate the importance of computer experience and acceptance of the nursing process on a ward but also point to other factors such as the fit between nursing workflow and the functionality of a nursing documentation system. ■ J Am Med Inform Assoc. 2003;10:69–84. DOI 10.1197/jamia.M1118. from the pilot wards for their enthusiastic cooperation in this project and during the whole study. Some points of the discussion have been inspired by Jytte Brender. Special thanks to Frieda Kaiser for her help with the English language. Correspondence and reprints: Elske Ammenwerth, PhD, University for Health Informatics and Technology Tyrol (UMIT), Innrain 98, 6020 Innsbruck, Austria; e-mail: . Received for publication: 03/06/02; accepted for publication: 8/15/02. Nursing documentation is an important part of clinical documentation. Thorough nursing documentation is a precondition for good patient care and for efficient communication and cooperation within the health care professional team. Nursing care is usually oriented toward the so-called nursing process. The nursing process provides a systematic methodology for nursing practice. It consists of six phases: (1) assessment of relevant patient information; (2) definition of nursing problems and resources of the patient; (3) derivation of nursing goals; (4) planning of nursing tasks; (5) execution and documentation of these tasks; and (6) evaluation of nursing care and possibly redefinition of the care plan. Paper-based documentation systems have been introduced to support nursing process documentation. Frequently, however, large investments in documentation efforts, low quality and limited general acceptance of the nursing process have been reported.1–4 Therefore, there have been some attempts and discussions about how to support the nursing process using computer-based documentation systems.5–8 Motivation is essential for learning, and important success factors for new computer-based system are, therefore, users’ motivation and acceptance of new ways of working.9,10 User acceptance is often even seen as the crucial factor determining the success or failure of a new project.11 This article concentrates on the question of what determines user acceptance of a new system. Previously, the evaluation of user acceptance after the introduction of a computer-based nursing documentation system showed varying outcomes. For example, we found high acceptance scores on one ward after 3 months of use of a computer-based documentation system,12 whereas Newton found very low acceptance after 3 months and again after one year of use of computerized care planning.13 It seems rather obvious that different factors such as functionality and usability of the documentation system, training and support, previous paper-based documentation processes, and other differences in the environment can influence a user’s acceptance of a new computer-based system and thus its overall success. A detailed analysis of such factors is difficult due to the complexity of the often interrelated factors. A deeper knowledge of such factors, however, may help to plan the introduction of such a documentation system and to avoid project failures. Various models describe the adaptation of computers in an organization. Lewin’s field theory,14 for example, describes three main phases: unfreezing of old patterns, moving and experimenting with new behaviors and refreezing when new behavior becomes part of every-day business processes that are considered normal. Lorenzi15 described three kinds of organization change: first-order change with limited effects on staff and tasks, middle-order change with larger changes, and second-order change with dramatic changes in the overall organization. Both models were too general for our needs because they do not concentrate on user acceptance but rather on technology adoption in an organization in general. A model that specially deals with user acceptance is the technology acceptance model (TAM) developed by Davis.11 According to this model, user acceptance is strongly influenced by the perceived usefulness of a system. This perceived usefulness itself can be divided, according to Vassar,16 into four main parts: characteristics of the information system itself, characteristics of the users, characteristics of the task processes, and other environmental characteristics. Dixon17 extended the TAM model to the Information Technology Adoption Model (ITAM), further refining the individual characteristics of the users, using the notion of a “fit” between the IT and the user. For our study, we first concentrated on individual characteristics (such as computer knowledge, acceptance of computers, and acceptance of the nursing process) as important factors supposed to influence overall nurse user acceptance. Nurses are often seen to be reluctant to use computers in areas closely connected to patient care for diverse reasons such as the fear of being alienated from the patient.18 Low acceptance of computers may make the introduction of computer-based systems difficult. However, it still seems unclear which level of acceptance of computers is necessary for the successful introduction of a computer-based documentation system. Another important issue is the acceptance of the nursing process which can be supported by computer-based nursing documentation.19 However, unless nurses accept and understand the nursing process, computer support may be useless or even harmful. For example, nurses may now use predefined care plans without sufficiently adapting them to individual patients.3,6 Or, because of low understanding of the nursing process, nurses may complain about the now more time-consuming documentation13 without exploiting possible benefits. This can lead to user boycott as well. On the other hand, the use of comAMMENWERTH ET AL., User Acceptance of Computer-based Nursing Documentation 70