Barriers to use of information and computer technology by Australia's ...

C O M P U T E R U S E IN C L I N I C A L N U R S I N G

Barriers to use of information and computer technology by Australia’s nurses: a national survey Robert Eley, Tony Fallon, Jeffrey Soar, Elizabeth Buikstra and Desley Hegney

Aims and objectives. To support policy planning for health, the barriers to the use of health information and computer technology (ICT) by nurses in Australia were determined. Background. Australia, in line with many countries, aims to achieve a better quality of care and health outcomes through effective and innovative use of health information. Nurses form the largest component of the health workforce. Successful adoption of ICT by nurses will be a requirement for success. No national study has been undertaken to determine the barriers to adoption. Design. A self-administered postal survey was conducted. Method. A questionnaire was distributed to 10,000 members of the Australian Nursing Federation. Twenty possible barriers to the use of health ICT uptake were offered and responses were given on a five point Likert scale. Results. Work demands, access to computers and lack of support were the principal barriers faced by nurses to their adoption of the technology in the workplace. Factors that were considered to present few barriers included age and lack of interest. While age was not considered by the respondents to be a barrier, their age was positively correlated with several barriers, including knowledge and confidence in the use of computers. Conclusions. Results indicate that to use the information and computer technologies being brought into health care fully, barriers that prevent the principal users from embracing those technologies must be addressed. Factors such as the age of the nurse and their level of job must be considered when developing strategies to overcome barriers. Relevance to clinical practice. The findings of the present study provide essential information not only for national government and state health departments but also for local administrators and managers to enable clinical nurses to meet present and future job requirements. Key words: Australia, barriers, computers, information technology, nurses, nursing Accepted for publication: 2 January 2008

Introduction Information and computer technology (ICT) is changing the way the health professionals deliver patient care (Smedley 2005). There are government initiatives in many countries to Authors: Robert Eley, MSc, PhD, CBiol, MIBiol, Senior Research Fellow, Centre for Rural and Remote Area Health, University of Southern Queensland, Toowoomba, QLD, Australia; Tony Fallon, BSc, PhD, Research Fellow, Centre for Rural and Remote Area Health, University of Southern Queensland, Toowoomba, QLD, Australia; Jeffrey Soar, GDCommDP, GDEd, MEd, PhD, Associate Professor, Collaboration for Ageing and Aged Care Informatics Research, University of Southern Queensland, Toowoomba, QLD, Australia; Elizabeth Buikstra, BSc, PhD, Research Fellow, Centre for Rural and Remote Area Health, University of Southern Queensland,

support increased adoption of ICT into health care with ‘e-health’, the generally accepted term used to describe the use of ICT in health. Australia is no exception with national and state/territory governments investing heavily in health information systems, in particular at the point of care. Health Toowoomba, QLD, Australia; Desley Hegney, BA, PhD, DNE, RN, FRCNA, FCN, Director, Centre for Rural and Remote Area Health, University of Southern Queensland, Toowoomba, and Professor of Nursing, Research and Practice Development Centre, University of Queensland and Blue Care, Toowong, QLD, Australia Correspondence: Robert Eley, Senior Research Fellow, Centre for Rural and Remote Area Health, University of Southern Queensland, Toowoomba, QLD 4350, Australia. Telephone: +61 (07) 4631 5477. E-mail: [email protected]

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1151–1158 doi: 10.1111/j.1365-2702.2008.02336.x

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Online – A Health Information Action Plan for Australia (National Health Information Advisory Council 2001) contains policies to improve the delivery of health care and to achieve a better quality of care and health outcomes through effective and innovative use of health information. The major project of Health Online is HealthConnect, a national government initiative that is developing a system of electronic health records to improve the flow of information across health in Australia. The National E-Health Transition Authority has responsibility for developing national health information management and ICT standards and specifications (http://www.nehta.gov.au). The vast majority of nurses demonstrate positive attitudes towards computer use and acknowledge the benefits of ICT to clinical care. This has been determined in studies from both outside (Hillan et al. 1998, Levy & Williams 1999, Parish 2000) and within Australia (Darbyshire 2000, Webster et al. 2003). Past experiences with computers in the workplace and at home make a major contribution to this positive attitude (Stricklin et al. 2003, Honey 2004). Nurses represent, by far, the largest group in the Australian health workforce (Productivity Commission 2006); their adoption of ICT is essential to the success of e-health. Nevertheless, barriers to adoption by nurses have been documented. These include barriers of incompatibility of computers with the traditional nursing values of physical touch in patient care (Frantz 2001, Timmons 2003), lack of training (Parish 2000, Edirippulige 2005) and lack of access to computers and technical support (Turner & Stavri 2003). Australian studies that have demonstrated barriers to ICT by nurses have been undertaken either in individual hospitals or in specific sectors of employment (Webster et al. 2003, Edirippulige 2005, Klotz & Reis 2005, Pascoe et al. 2007). However, no studies had been undertaken to determine the national picture in Australia. In 2005, a national survey was commissioned by the Australian national government’s Department of Health and Ageing through the Australian Nursing Federation (ANF). The study’s objective was to determine how ICT use and adoption by nurses is affected by attitudes, access, education and training, and barriers to use. This paper reports on what barriers, nurses considered, affect their use of ICT in the workplace. The results of this research are intended to inform national policy.

Methods Questionnaire A questionnaire was developed following a review of extant literature and consultation with stakeholders. Consulted were 1152

55 representatives of government agencies, other health and aged care organisations and the national nursing organisations. The majority of those involved in the consultation process were nurses. Over 200 questions were generated by the research team to meet the study’s objectives. The number of questions was reduced by the consultative process to 78 questions in 14 categories, including personal background, education, current employment, access to computers, uses of information technology and training and education in information technology. A category entitled Barriers to your Use of Computers (Q65) asked ‘do any of the items listed below restrict the use of computers in your workplace’. Twenty items were identified by stakeholders and from the literature as possible barriers (Table 1). Respondents answered on a five point Likert scale with ‘never’, ‘rarely’, ‘sometimes’, ‘very often’ or ‘always’ as the choices. Space was offered to list additional items/barriers and at the end of the survey, respondents could add comments about any aspect of the survey. The survey underwent several iterations to ensure clarity and comprehension. Minor modifications to the wording of questions and appearance of the survey followed review by the 11-member project steering group and in two separate pilot studies. The first of these consisted of six nurses associated with a tertiary nursing establishment and the second of 10 clinical nurses who were attending a workshop. For the purposes of this study, ICT was defined as computerbased systems or applications that assist in the management and processing of information to support health care and health care delivery. The systems and applications identified in the questionnaire were those that required users to interact directly with a computer, e.g. entry of patient data, accessing evidence-based practice or interrogating a database, as opposed to those in which an inbuilt computer functioned independently of the user, e.g. swipe cards or bar code readers.

Selection of participants Considerable discussion was held with stakeholders with respect to stratification of the participants. Choices included a random distribution from the entire ANF member’s database and stratification based on variables such as age, level of job or sector of employment. To best suit the objectives of the study, the chosen stratification of the sample was by Australian Standard Geographical Classification (Australian Bureau of Statistics 2001), which is based on population density or remoteness. Nurses working in metropolitan, inner regional, outer regional and rural/remote (combined) areas each received 25% of the surveys.

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1151–1158

Computer use in clinical nursing

Barriers to ICT use by Australia’s nurses

Table 1 Barriers to use of computers Percentage of responses Barrier to use of computers

n

Never

Rarely

Sometimes

Very often

Always

Too many other work demands IT does not fit with other demands Not enough computers Lack of technical support IT knowledge Lack of encouragement Location of computers Confidence in use Seniors take priority in use Computer too slow Resentment by clients Log-on time Unreliable network Attitudes of IT department Staff turnover No credit card for training on-line Discouraged by others No interest in computers My age Health and safety issues

3370 3257 3340 3231 3321 3215 3254 3302 3208 3177 3140 3205 3167 3063 3091 2933 3145 3092 3168 3066

11Æ7 26Æ4 30Æ5 25Æ4 30Æ7 38Æ6 43Æ1 32Æ2 45Æ9 32Æ5 43Æ5 45Æ9 38Æ7 47Æ4 51Æ1 84Æ1 58Æ9 70 77Æ5 86Æ0

5Æ8 13Æ8 16Æ0 19Æ6 16Æ7 21Æ6 15Æ7 17Æ9 17Æ6 27Æ1 20Æ2 23Æ3 29Æ8 24Æ5 20Æ7 4Æ2 22Æ8 12Æ5 10Æ3 8Æ6




r2 0Æ01 0Æ03 0Æ10* 0Æ14* 0Æ25* 0Æ05** 0Æ06* 0Æ26* 0Æ02 0Æ05* 0Æ05* 0Æ05* 0Æ09* 0Æ05* 0Æ02 0Æ04** 0Æ05** 0Æ09** 0Æ26** 0Æ04*

n = Number of responses (possible responses = 3680) r2 = Correlation of item being identified with age of the nurse where *p < 0Æ01 and **p < 0Æ05

Recipients were assistants in nursing (AIN), enrolled nurses (EN) and registered nurses at levels 1–5 (RN1–RN5).

also by age, length of time in nursing, geographical region, level of job and health sector.

Distribution of questionnaires

Consent

In July 2005, the questionnaire was posted to 10,000 members of the ANF by the eight ANF State and Territory branch offices. Questionnaires were returned in reply-paid envelopes. A second mail-out was sent to all non-respondents three weeks after the first mail-out. The questionnaires were coded by the ANF branches. Only the post code of the respondents was known to the research team.

The study was approved by the University’s Human Research and Ethics Committee. A plain language statement was enclosed with the questionnaire. Informed consent was implied if the participant returned a questionnaire.

Analysis Quantitative data were entered using TeleForm (Verity Inc. Sunnyvale, CA, USA) and qualitative answers were entered manually. Analysis was undertaken using SPSS version 12 (SPSS Inc, Chicago, IL, USA) using descriptive and inferential statistics as appropriate to the scale of measurement. Likert scale responses were enumerated from 1 = never–5 = always. Dichotomous and categorical variables were described using frequencies and proportions. Continuous variables were described using mean values and 95% confidence intervals. Each question was analysed on the basis of all responses and

Results Results on barriers to the use of ICT are presented as overall responses and by age, length of time in nursing and level of job. Results by geographical location, sector of employment and from the other categories within the questionnaire are not discussed as they are the subjects of other publications. The overall response rate was 43Æ3%, the mean age of respondents was 45Æ3 (SD 9Æ7) years and 92Æ8% were women. Eighty-five per cent (n = 3680) of the 4330 respondents used computers at work. Only 20Æ4% AIN used computers at work when compared with 74Æ7% of EN, 87Æ9% RN1 and over 94% for RN2–RN5. Each of the 20 sub-questions on barriers to the use of computers in Q65 was answered by between 79–92% of the 3680 respondents.


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Overall responses to the question on barriers are shown in Table 1. ‘Too many work demands’ was by far the largest barrier to the use of computers. Over 55% of the nurses indicated that this was a barrier ‘very often’ or ‘always’ and only 11% noted it was never a barrier. ‘Not enough computers’, ‘lack of IT support’ and ‘lack of IT knowledge’ were considered to be barriers ‘very often’ or ‘always’ by between 20–25% of the nurses. At the other end of the scale were factors that were considered barriers by small numbers of respondents. ‘Health and safety’, ‘my age’ and ‘no interest’ were each considered to be never or rarely a barrier to their use of computers by over 80% of the respondents.

Other identified barriers Additional barriers were listed by 76 (2%) respondents. The vast majority of these ‘new’ barriers actually duplicated one of 20 barriers that had been offered. These related to work demands, general access, technical support, reliability of equipment, confidence in use and knowledge. One additional barrier not offered in the list and noted by eight respondents was restriction to and delays in issuing passwords.

Table 2 Confidence in using computers as a barrier and length of time in nursing Years nursing

Mean

SEM

0–5 6–10 11–15 16–20 21–25 26–30 31+

0Æ997§ 1Æ044§ 1Æ333– 1Æ349 1Æ456 1Æ592 1Æ681

0Æ064 0Æ063 0Æ060 0Æ050 0Æ049 0Æ052 0Æ057

Mean calculated from Likert scale where never = 0, rarely = 1, sometimes = 2, very often = 3 and always = 4. The higher the mean the more the item was considered to be a barrier Standard error of the mean § More confident than nurses with 11 or more years in nursing (p < 0Æ05) – More confident than nurses with 31 or more years in nursing (p < 0Æ05)

example is given in Table 2, where confidence in the use of computers was more of a barrier as numbers of years in nursing increased.

Level of job Age of nurses The frequency of reporting of 16 of the 20 barriers was correlated with age of the nurse (final column, Table 1). Of the four exceptions, two were the most frequently reported barriers of ‘work demands’ and ‘other demands’ and a third was the workload related item of ‘staff turnover’. Older nurses were more likely to indicate that their ‘IT knowledge’ and ‘confidence in use’ of computers and the ‘lack of technical support’ were barriers than did younger nurses. There was also a significant positive correlation between the perception of ‘my age’ being a barrier and the actual age of the nurse. Young nurses were more likely than older nurses to report barriers of ‘not enough computers’ and ‘location of computers’ and ‘resentment by clients’.

Number of years in nursing Number of years in nursing ranged from fewer than one to over 40. Over 30% of the respondents were 40 years of age before they entered nursing. Nurses who had worked for a longer time in nursing considered that the ‘number’ and ‘location’ of computers were less of a barrier. However, the longer the time in nursing, the more that ‘IT knowledge’, ‘confidence in use’ and ‘technical support’ were noted. An 1154

The barriers that differed significantly among nurses at different job levels are shown in Table 3. ‘Work demands’, ‘access to computers’ and ‘lack of seniority’ were all seen as less of a barrier as job level increased. EN, RN1 and RN2 reported ‘encouragement to use computers’ and ‘resentment by patients/ clients/visitors’ more often than did the RN3–RN5. Thematic analysis: barriers to the use of computers in the workplace Additional comments to the entire questionnaire were offered by 1174 (27%) respondents. Ten per cent of the comments related to barriers under the themes of ‘Workload’, ‘Role in caring’ and ‘Access’. Workload Many of the 204 respondents who raised this issue saw the use of computers as extra work, rather than something that would decrease their workload: Workload levels are already high in wards. Priority must be patient care not the additional chore of data input.

Other respondents noted that computers were important but that time was an issue: Quite frankly, I would love to have time to learn more and have time to use the computers, but we are so busy and so understaffed




Table 3 Level of nurse and barriers to use of computers

Mean response for each level of nurse AIN Too many other work demands ICT does not fit with other work Not enough computers Lack of encouragement Location of computers Seniors take priority Resentment by clients Log-on time

3Æ0 2Æ36 2Æ14 1Æ71– 2Æ09 1Æ89 0Æ78 0Æ95

EN

2Æ61 1Æ90 1Æ82 1Æ40 1Æ43 1Æ81 1Æ23 1Æ06––

RN1

RN2

§

2Æ69 1Æ96 1Æ76 1Æ41 1Æ40 1Æ44§§ 1Æ24 0Æ98

2Æ57 1Æ79§ 1Æ82§ 1Æ24§ 1Æ50§ 1Æ12§ 1Æ17§ 1Æ2§

RN3

RN4

RN5

2Æ07 1Æ38 1Æ11 0Æ96 0Æ75 0Æ58 0Æ87 0Æ84

2Æ06 1Æ16 0Æ82 0Æ76 0Æ60 0Æ42 0Æ84 0Æ71

2Æ02 1Æ29 0Æ94 0Æ96 0Æ71 0Æ57 0Æ77 0Æ70

AIN = Assistant in nursing, EN = Enrolled nurse, RN1–RN5 = Registered nurse levels 1–5 Mean values calculated from Likert scale, where never = 0, rarely = 1, sometimes = 2, very often = 3 and always = 5. The higher the mean the more the item was considered to be a barrier AIN, EN and RN1 significantly higher than RN3–RN5 (p < 0Æ05) § RN2 significantly higher than RN3–RN5 (p < 0Æ05) – AIN significantly higher than RN4 (p < 0Æ05) EN and RN1 significantly higher than RN3–RN5 (p < 0Æ05) EN significantly higher than RN1–RN5 (p < 0Æ05) §§ RN1 significantly higher than RN2–RN5 (p < 0Æ05) –– EN significantly higher than RN4–RN5 (p < 0Æ05) RN1 significantly higher than RN2 and RN4–RN5 (p < 0Æ05) we’ve only got time to do the basics – we need MORE

computers in it! Nurses have to wait for a break in usage or stand

NURSES!!!!

in line to get their own work done.

Role in caring Seventy-one respondents believed that information technology was an asset to nursing care: It is the way of the future! I love the time-saving factor when completing care-planning.

Similarly, other staff noted that it was the more senior nurses who were seen to be legitimate users of information technology: We have an inequality in our workplace in that all medical staff are given access to the internet (provided with passwords) upon arrival at workplace. Nurses however are not allowed access unless you are a

Others saw it as increasing safety within the workplace:

senior nurse.

Information technology is definitely a plus towards better client care

Enrolled nurses and AIN also noted that information technology was often not seen as part of their job and thus access was not available to them:

and management. Written material is legible and so mistakes are minimised.

A contrasting view was shared by the 29 nurses who offered comments stating that computers were not part of nursing work: Time spent on computers reduces time being spent giving clinical care to patients and after all – healthcare is only concerned with the person delivering the care and the person receiving the care ….. Nothing at all to do with computers!

As an enrolled nurse I wasn’t required to use the computer for workrelated purposes, the registered nurses were responsible for the input of client numbers.

Age of the nurse A total of 56 nurses commented that their age influenced the adoption of ICT: I have seriously considered retiring from the workforce because I feel

Access One hundred and thirteen nurses provided comments, which were categorised into this sub-theme. Many nurses commented on a conflict between nurses and doctors. For example: Other staff, especially doctors and medical students, use our nurses’ work station computers despite having a near-by office with

that I have been left behind. Computers were not a part of my general education and I have been busy in my nursing career so no time to spend learning and using computers on a regular basis.

Some nurses noted that it was important that older nurses did not feel excluded and that the provision of training would help retain these experienced nurses in the workforce:


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R Eley et al. Offering IT training in computers to older nurses will retain their valuable experience in the clinical fields. If they want us to use computers the management need to put time and money into teaching and up-skilling staff – especially older staff who are not familiar with computers.

Discussion Limitation to the study Approximately 60% of the 250,000 nurses in Australia (Australian Institute of Health and Welfare 2006) are members of the ANF. Demographics of the study’s EN and RN are consistent with the national workforce and our results are deemed to representative of that workforce. However, results from AIN may not be entirely representative. Published figures for this cadre of nurses are highly variable (Health Workforce Australia 2004, Richardson & Martin 2004, Australian Institute of Health and Welfare 2005), but all would suggest that the proportion of AIN who are members of the ANF is probably lower than the national average.

Response rate For a national postal survey to achieve such a high response rate was excellent. The survey was lengthy and the high response rate suggests that this topic is one which is very important to nurses. This is substantiated by studies, where the importance of computers and ICT to the provision of health have been acknowledged by nurses (Darbyshire 2000, Ho 2004, Edirippulige 2005, Nursix 2006). In agreement with nurses from one Brisbane hospital, (Webster et al. 2003) very few nurses indicated that a lack of interest was a barrier to computer use. The proportion of nurses who lacked interest was lower than the third of Scottish nurses surveyed in 1998, who stated that they had no interest (Hillan et al. 1998). Increasing prevalence and exposure to computers in everyday life is suggested to be the cause of this change rather than any geographical differences. However, our results do confirm reports that for some nurses and indeed patients and their visitors, nursing work and computer use are viewed as separate activities (Timmons 2003, Webster et al. 2003, Yu & Comensoli 2004). This is despite the role of computers in so many aspects of everyday life. Resistance to using computers was noted by Timmons (2003) to be a ‘complex, variable phenomenon’. The issue is not easily resolved; however, the separation of IT and ‘real

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nursing’ will be reduced by ensuring that systems and applications are user-friendly, fit for purpose and do not detract from patient care. The use of ICT must be demonstrated to be beneficial. To this end, one of the recommendations of this study is that representative bodies such as the ANF and the Royal College of Nursing, Australia should produce resources to demonstrate best practice. Change is most effective if the participants’ enthusiasm for that change is maintained. Adoption of technology into health care is no exception and computers must work within their assigned context (Hughes 2003). As has been demonstrated within the National Health Service in the UK, poorly designed systems that do not support nursing practice have a detrimental effect on nurses embracing the technology (Nursix 2006). The fact that Australian nurses consider that the IT industry lacks a sound understanding of the need of their end users (Ho 2004) is not a good sign. The logical conclusion from all the studies is that for IT to be fully accepted practicing nurses must be part of the consultation process during development and prior to implementation of applications and services. Workload was identified as the principal barrier to computer use as it was in two small studies (Edirippulige 2005, Klotz & Reis 2005). The results are consistent with a state-wide workforce study in Queensland, where workload was considered to be too heavy for nurses to complete their work to their satisfaction (Hegney et al. 2005). Although nurses stated that their age was not a barrier to ICT use, the results showed that age was correlated with the incidence of reporting barriers regardless of their level of job. Age, however, was not correlated to the three workforce barriers of work, other work demands and staff turnover. Two of these three workforce barriers were the highest of all the barriers to the use of computers. These results lead to the conclusion that removal of all other barriers will still not create anywhere near complete engagement of nurses in ICT until workforce issues are addressed. Registered nurses at levels 3–5 were less likely to identify work demands as barriers to computer use, which implies for them such use was recognised as part of their job. This is consistent with the literature (Levy & Williams 1999, Curtis et al. 2002, Eley et al. 2008). Nurses with managerial roles were also less likely to see numbers and location of computers as barriers because they are more likely to have access to their own work computers (Webster et al. 2003). The relationship between age and both confidence and knowledge of ICT being barriers is in part a reflection of the rapid adoption of computers. As noted in other studies,



longer serving nurses, largely hospital-trained before computers were the norm, are more likely to lack the ICT skills and, therefore, the confidence of more recently trained nurses (Webster et al. 2003, Chan et al. 2004). Similar results on age and skills have been reported recently across a broad range of health professionals in Australia (Garde et al. 2006). The findings present challenges in ICT training and education detailed elsewhere (Eley et al. 2008). Suffice to say that the amount of training received by nurses in our study was consistent with the data from other studies (Hillan et al. 1998, Liu et al. 2000, Edirippulige 2005). Furthermore, response to the offered barrier of ‘IT knowledge’ was similar to hospital nurses in Brisbane and aged care nurses in New South Wales where lack of education and training was the main constraint to ICT knowledge and skills (Edirippulige 2005, Yu 2005). We can only concur with previous conclusions that ICT training and education is essential for nurses to offer high-quality and efficient health care (Darbyshire 2000, Hughes 2003, Smedley 2005, Garde et al. 2006). Our study endorses the recommendation that a national competency standard in computer use should be introduced (Conrick et al. 2004). Technical support was raised as a significant barrier to computer use, regardless of location with over 40% of nurses, stating that support was ‘poor’ or ‘awful’. In a survey of doctors in Hong Kong, time costs and lack of support were the main reasons for slow uptake of computerisation (Leung et al. 2003) and in a UK study, 71% of nurses stated that round-the-clock technical support was essential (Nursix 2006). Results clearly show that the issue of support requires urgent attention.

Conclusion This study demonstrates clearly that Australian nurses face considerable barriers to their use of ICT and those barriers vary according to age and level of job. The results should prove invaluable in informing policies and, in particular, strategies to address training and education. Barriers should be addressed to enable use of technology and to engender positive attitudes, which will support increased engagement and adoption. Lack of interest in computers and age of nurses are minimal barriers to adoption of ICT and these findings should be used prudently. Policy makers, administrators and managers must work with clinical nurses so that access to the technologies, that support good practice in health care, is not compromised by practices that do not address the needs of nurses and their clients.


Contributions Study design: RE, TF, JS, EB, DH; data collection and analysis: RE, TF, EB, DH and manuscript preparation: RE, JS, DH

Acknowledgements The survey was conducted by the Centre for Rural and Remote Area Health for the Australian Nursing Federation with funding from the Australian Government Department of Health and Ageing.

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