Data Analysis Stage
Data analysis for the studies was performed by summarizing the studies in a data extraction matrix (Table 3). This matrix summarized research methodology, as well as study purpose and thematic findings, in table format. A descriptive summary is presented in the following section.
This review contained quantitative, qualitative, and mixed-methods research studies from which the following major themes were identified:
- nurses’ attitudes toward meaningful use technology implementation
- nurses’ attitudes toward postimplementation improvement attempts
- nurses’ overall acceptance of meaningful use technologies
General resistance to change is one of the primary factors that impede EHR adoption.30,34,38 Other barriers to implementation often have less to do with functionality of the technology than with changes in nursing workflow or processes.31,39 Process changes, although potentially appearing minor in implementation plans, are often what is most important to end-users (individuals who use a product once it has been fully developed) when the product is implemented.31 Changes to workflow that affect job efficiency compromised the greatest barrier to acceptance.31,39 Having nurse involvement from the inception and planning phases may help increase both acceptance and positive perceptions of the relevant technology.22,39 Other suggested methods for improving the perceptions of meaningful use technologies during the implementation phase include simulated training sessions, peer support in the form of expert peer users, increasing organizational commitment, and a focus on clinical communication immediately after implementation.28,30,33–35,38,39
A phenomenon known as the “Valley of Doom”21(p527) is used anecdotally to refer to feelings of despair or frustration after EMR implementation. This implies that satisfaction and acceptance are likely to decline immediately after implementation and rise after system improvements have been made. Nursing input into design and improvement of technologies was cited as a significant factor in improving perceptions of usability and usefulness over time.22,31 In contrast, the one longitudinal study that showed a decrease in satisfaction 18 months after implementation indicated that nursing input was largely ignored,21 leading to negative perceptions of an EHR. Changes suggested by nursing that resulted in improved perceptions included decreased login times, reduced redundancy, and increased focus on nursing sensitive documentation.21,22,31,38 One study noted no significant difference in nurses’ attitudes toward technology based on stage of meaningful use implementation.37
Perceived ease of use (usability), perceived usefulness, and performance expectancy (relevance) are important predictors of meaningful use technology acceptance.22,29,35,36 An awareness of the positive impact of the technology on patient care also had an impact on acceptance.22,33,34,39 Peer support, the encouragement and assistance of fellow nurses, was noted as having a significant positive effect on the perceived ease of use, perceived usefulness, and intention to use technologies.33,35 Nurses were more concerned with the perceptions of other nurses than of improved workflow or patient safety.35 Thus, the support of nursing peers in the form of superusers and system trainers is likely to increase meaningful use technology acceptance.
The factor that most dominated the results when analyzing acceptance was usability. Usability, or ease of use, refers to the “efficiency and effectiveness of an application.”3(p123) Excessive login time was commonly cited as negatively affecting usability.21,22,31 Time required to complete tasks using the technology was another frequent negative perception.21,30,34,36,38 Intuitively, the easier a technology is used, the more likely an individual is to use it. This a priori knowledge was found to be true in several studies.21,22,31,34,36,38 The newer technologies of BCMA and CDS were not generally found to be as user-friendly as the EMR.29,32,38,39 Thus, variation in nurses’ acceptance was noted.
Barcode medication administration acceptance was manifested in the studies as a lack of workaround (deviations in the work process to bypass a block in workflow29) usage. Both the total number of workarounds and the amount of different workaround types were inversely related to satisfaction with the technology.29 Mixed results were seen when correlating the nurses’ age or years of experience with increased use of workarounds.29,39 Similar to obstacles to EMR implementation, obstacles to full BCMA acceptance tended to be more related to changes in nursing workflow and processes than with the barcode technology itself.39 As a result, increased satisfaction with the barcoding process resulted in a reduced number of workarounds.29 Nurses indicated that their satisfaction would be higher if they felt that the system were less prone to errors.29,39
Clinical Decision Support
Either the CDS was ignored as a meaningful use technology, or the functionality was overridden by the end-users in the selected studies. Mistrust of the technology, redundancy, and lack of task relevance were implicated as the main factors for the lack of acceptance.32,38 One study indicated that nurses had less confidence in the CDS system after receiving training than prior to training.38
Age as a Factor
A negative correlation between age and technology acceptance was seen in 5 studies.21,29,32,33,38 A sixth study showed a similar correlation, but the difference was not judged to be statistically significant.37 The positive effect of peer influence on acceptance and perceptions, however, was not limited by the age of the nurse.33,35
Several studies examined computer anxiety as a variable in measuring acceptance. A lack of previous computer use or computer anxiety only seemed to affect nurses during the implantation period.27,30,31,33,39 Elapsed time since implementation appears to be predictive of overall technology acceptance, regardless of computer anxiety or previous experience.22
Relationship of Findings to Other Reviews
A recent integrative review of nurses’ acceptance of healthcare technology using the technology acceptance model as an explanatory framework7 resulted in several of the same themes as those found in this review. Despite having no sources in common, themes such as organizational commitment, high-quality training, social influence, and perceived usefulness were common to both reviews. A 2010 review of factors affecting nurses’ attitudes toward healthcare information technology found that increased computer experience is the main factor leading to positive attitudes, and usability issues are the main cause of negative attitudes.5 The aforementioned study also reached a similar conclusion to this review, that nurse involvement in the implementation phase would likely lead to increased satisfaction.5
There are several limitations inherent to this review. Some studies combining nurses with other healthcare professionals or exploring other aspects of meaningful use may have contained relevant information, which was not included in this review. Although every effort was made to find meaningful use–specific technologies, there was no indication in any study that the technology used was implemented specifically for the meaningful use program. Because this was a difficult variable to account for, the inclusion criterion date of 2010 and forward was important in order to make it more likely that technologies were implemented to comply with meaningful use.
A large number of dissertations (seven of 14 studies) comprised the synthesis matrix. Although these represented primary sources, a possible lack of academic rigor is possible because of the lack of a peer-review process. The included dissertations, with the exception of the 2015 Adams study, all scored favorably on Bowling’s40 critical appraisal checklist, thus limiting this concern.
Publication bias may exist with regard to the published journal articles; however, as the studies presented both positive and negative attitudes toward and acceptance of meaningful use technologies, this was judged to be of minimal concern.
Finally, the number of selected studies (14 studies) and sample sizes of some quantitative studies may not have been sufficient to represent the full scope of information available. In particular, the studies of Adams,28 Crawley,30 and Culler et al31 had sample sizes ranging from 13 to 16. It is the hope of this author that the rigor in which Bowling’s40 criteria were applied mitigates the effects of this limitation.
In general, nurses’ perceptions of meaningful use technologies in this study were positive. Negative perceptions of technology during the implementation phase tended to be more associated with changes in workflow and processes. From the perspective of education, preimplementation training was the suggested intervention to improve nursing perceptions. After implementation, a combination of improving usability, reducing redundancy, and increased familiarity with systems tended to increase positive perceptions of the implemented technologies. Acceptance was affected by several factors; however, peer support played the largest role in increasing nurses’ acceptance. From a clinical practice perspective, this seems to indicate that identification and involvement of early adopters or peer champions might increase acceptance.
The relatively newer meaningful use technologies of CDS and barcode medication technologies were not as easily accepted by nurses compared with acceptance of the EMR. This was manifested by workarounds and system overrides. Analysis suggests that as the technologies become commonplace and are used more often, and usability increases, nurses’ acceptance of these technologies will increase.
Implications for Future Research
There is a significant gap in literature regarding the long-term follow-up of the attitudes toward the investigated technologies. Most of the longitudinal studies examined the changes in attitudes and perceptions up to 6 months after implementation.21,22,31,38 Only one study34 examined nurses’ attitudes toward a technology after a longer period (5 years). This is likely due to the relatively short duration of the meaningful use program, but nonetheless, this knowledge gap exists. Acceptance of BCMA and CDS should be re-examined as the technologies become commonplace and integrated into existing nursing workflow. Several studies utilized frameworks such as the technology acceptance model29,33 to explain or predict nurses’ attitudes toward technologies, but no study identified a theoretical framework used to guide implementation. Locsin’s12,13 theory of technological competence as caring in nursing seems ideally suited for increasing nurses’ perceptions of technology relevance and perceived usefulness.
Nurses compose the largest segment of the healthcare workforce.21 As such, their perceptions of any new technology are important to understand because they may ultimately mean the difference between acceptance and rejection of a product. The results of this review reflect the importance of involving nurses in the planning, development, implementation, training, and continuing evaluation of meaningful use technologies. It is clear from this study that nurses’ perceptions of meaningful use technologies are most influenced by peer support and the overall effect of the technology on existing processes and workflow. Meaningful use technologies are intended to improve healthcare quality, safety, and care coordination. Proactively engaging nurses as full stakeholders in implementing and improving these technologies is the surest way to increase acceptance and positive perceptions and thus ensure improvements in patient care.
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Keywords:Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Bar Code Medication Administration; Electronic Health Record; Electronic Medical Record; Technology acceptance