Discussion: Defining HIT And Assessing Attitudes Toward Its Implementation

Factors Affecting Nurses’ Attitudes Toward Computers in Healthcare

NURTEN KAYA, PhD, BSN

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Adapting to technological innovations represents a key process for improving and restructuring healthcare. Tech- nological developments have, in addition to many existing assignments, exposed nursing personnel to new tasks and responsibilities in many areas of practice including home- care, clinic settings, schools, and hospitals.1–4

Although the introduction of computers, representing a significant facet of technologic developments, to both daily and professional lives of nurses has been rapid, the literature indicates a resistance by nurses to use of com- puters in healthcare. Nurses argue that use of computers in healthcare is not in accordance with holistic and hu- manistic approaches, which represent the main philoso- phy of nursing, and that computers are complex devices to work with, to justify their resistance to use computers in healthcare.5–12 However, it is being increasingly ac- knowledged in recent years that technology and therefore computerization will contribute to the decision-making capabilities and skills of nurses, improve the quality of healthcare, and reduce the costs of services.5,13 Discussion: Defining HIT And Assessing Attitudes Toward Its Implementation

Because of the accelerated development of technology, hospitals have expanded the use of computers to many areas. Initially, areas such as human resources, financial, and logistics systems were computerized. Later on, these systems expanded to include clinical communications and storage of patients’ historical data, such as physi- cians’ orders, laboratory results, and computerized nursing care plans. The growth of hospital information systems has also had significant impacts on nursing practice. Integration of computers in the work per- formed by nurses is an innovation that requires nurses to change their working methods and even their function

in the department. The successful implementation of computer systems in nursing practice is likely to be directly related to users’ attitudes toward computer- ization. Thus, the attitudes nurses have toward the use of computers are very important, and use of computers in healthcare requires that objective and comparative in- formation on how nurses view the use of computers and the factors affecting these attitudes is available. If

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The purpose of the study was to determine fac-

tors affecting nurses’ attitudes toward com- puters in healthcare. This cross-sectional study was carried out with nurses employed at one

state and one university hospital. The sample of the study included 890 nurses who were selected via a purposive sampling method.

Data were collected by using a questionnaire for demographic information and Pretest for Attitudes Toward Computers in Healthcare As- sessment Scale v.2. The nurses, in general, had

positive attitudes toward computers. Findings of the present study showed a significant differ- ence in attitudes for different categories of age Discussion: Defining HIT And Assessing Attitudes Toward Its Implementation

(P G .001), marital status (P G .05), education (P G .001), type of facility (P G .01), job title (P G .001), computer science education (P G .01), computer experience (P G .001), duration of computer use (P G .001), and place of use of computer (P G .001). The results of the present study could be used during planning and implementation of

computer training programs for nurses in Turkey and could be utilized in improving the participa- tion of Turkish nurses in initiatives to develop

hospital information systems and, above all, in developing computerized patient care planning.

K E Y W O R D S

Attitudes & Attitude toward computers & Computers &

Nursing

I N T E R N A T I O N A L

Author Affiliation: Istanbul University, Florence Nightingale School of Nursing, Department of Fundamentals of Nursing, Turkey.

Correspondence: Nurten Kaya, PhD, BSN, Istanbul University, Florence Nightingale School of Nursing, Department of Fundamentals of Nursing, Turkey, Abide-i H[rriyet Cad, 34381, Istanbul, Turkey (nurka@istanbul.edu.tr; nurtenkaya66@gmail.com).

DOI: 10.1097/NCN.0b013e3181f9dd0f

Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.1

attitudes of nurses are adequately assessed, then imple- mentation strategies can be developed to support nurses who are less willing to accept computerization.1,4,14–16

The study of nurses’ attitudes toward computers be- gan in the late 1960s. Numerous studies have examined the importance of nurses’ attitudes toward how success- fully computers are introduced into a nursing unit. Study designs ranged from one-time descriptive studies exam- ining demographic variables influencing computer ac- ceptance, to studies comparing users with nonusers, and measurement of attitudes before and after computer- ization. Descriptive studies attempted to correlate nurse attitudes with such variables as age, educational level, and previous computer experience.16

Summers17 reviewed more than 11 studies about the attitudes and anxiety of nurses toward hospital computer systems and, based on these studies, reported that nurses expressed fears that computerization may contribute to loss of jobs and/or loss of data and that nurses also ex- pressed fears that more time would be spent with com- puters and less time with patients.

On the other hand, there are many studies in the lit- erature emphasizing the importance of health infor- matics.2,9,16,18–20 These studies, on this basis, point out a requirement for revision in both the education of nurse candidates and continuous education programs of nurses to include health informatics. Possession of computer skills is a key prerequisite for nurses and nurse candidates to be able to utilize health informatics. In this sense, negative attitudes toward computers represent a potential barrier to computerization of medical records.21 In fact, some investigators have reported that nurses experienced difficulties regarding information technology. According to Darbyshire, ‘‘Clinicians were finding the everyday use of computerized patient information systems and com- puter technology far more troublesome and problematic than manufacturers, software developers, and information technology advocates may appreciate.’’22(p94) However, successful implementation of information technologies would be a significant acquisition for nurses. Pabst et al23(p25) had reported that ‘‘nurses who used compu- terized documentation were able to decrease time spent in documentation activities, and they were able to increase time spent in direct patient care.’’ Johnson et al24 inves- tigated the differences in three areas (nursing time dis- tribution, nurse attitudes toward computerization, and compliance with charting standards) before and after im- plementation of computerized charting. They found that implementation of computerized charting made up pos- itive changes in these areas.24

Turkish nurses, currently, cannot fully utilize com- puter technology in their practices, and their use of com- puterized systems is, in general, limited to some certain functions including recording of nursing practices such as vital signs measurements, keeping records of health-

care products and materials used, supplying these pro- ducts and materials, implementing nursing management functions, obtaining therapeutic information, recording laboratory function requests and physician requests, and supplying drugs from pharmacies.25 On the other hand, major changes are taking place in healthcare policies in Turkey, and information technology is becoming in- creasingly involved in the healthcare domain. Nurses in Turkey are required to adapt to this evolution. To achieve this, nursing practices should be integrated to computer- ized patient information systems in accordance with the nursing process. As a critical step in this process, nurses’ attitudes toward computers in healthcare and potential influential factors should be determined. Strategies to en- able nurses to use computers in healthcare may be de- veloped in light of the analysis presented herein.

Many nurses use computers in their personal lives as well as during professional practice to collect data, ac- cess information, implement actions, and record responses. Nursing educators, leaders, and nurses believe that com- puter competencies are now essential for nurses. Therefore, attitudes of nurses as members of the healthcare team to- ward computers should be investigated. Several studies have been conducted worldwide to examine nurses’ atti- tudes toward use of computers and factors affecting their attitudes.4–7,9–12,14,15,26–32 However, the number of such studies in Turkey is limited.25,33 Therefore, the present study was performed with the purpose of identifying the attitudes of Turkish nurses toward the utilization of com- puters in healthcare and factors affecting their attitudes. Discussion: Defining HIT And Assessing Attitudes Toward Its Implementation

PURPOSE AND RESEARCH QUESTIONS

The purpose of the present study was to determine fac- tors affecting nurses’ attitudes toward computers in healthcare. The research was carried out using a cross- sectional design. Research questions were the following:

(1) What are nurses’ attitudes toward computers in

healthcare?

(2) Are nurses’ attitudes related to demographic factors

such as sex, age, marital status, education, years of

nursing experience, type of facility, job title (nursing

director/assistant director/instructor, head nurse of unit,

nurse), shift worked (days, nights, or rotation), computer

science education, computer experience, duration of

computer use, and place of use of computer?

METHODS

Population and Sample

The population of the study included nurses employed at one state and one university hospital. The total number

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of nurses employed at these two hospitals at the time of study was 1085: 320 nurses in the state hospital and 765 nurses in the university hospital. The sample included 890 nurses in total (82.03% of all nurses employed at the two hospitals): 268 nurses from the state hospital (83.75% of nurses employed at the state hospital) and 622 nurses from the university hospital (81.31% of nurses employed at the university hospital) chosen among those who were willing to participate via purposive sampling. The paper- based survey was distributed by the nursing director of the university hospital and by the education nurse of the state hospital directly to the nurses in all units. Participants were requested to complete the survey within 24 hours of receipt. Completed surveys were collected back by the nursing director and the education nurse. Discussion: Defining HIT And Assessing Attitudes Toward Its Implementation

Instruments

A questionnaire made up of two parts was used in the study:

Part 1

A structured questionnaire for examining demographic details (sex, age, marital status), professional back- ground (education, years of nursing experience, type of facility, job title, shifts mainly worked), and computer use (computer science education, computer experience, duration of computer use, place of use of computer) was used. The questionnaire was developed by the researcher in light of the literature.4–6,9,11,15,27–29

Part 2

The Pretest for Attitudes Toward Computers in Health- care Assessment Scale v.2 (PATCH Assessment Scale v.2) was used for examining the nurses’ attitudes toward computers in healthcare. The PATCH Assessment Scale

was developed by Kaminski34 in 1996, and its second version was published in 2007. The second version was used in the present study. The scale measures nurses’ perceptions and attitudes toward use of computers in healthcare settings. The 40-item, 5-point Likert scale questionnaire consists of positive and negative worded statements. Data on attitude statements were scored as 1 point for ‘‘agree strongly,’’ 0.5 point for ‘‘agree,’’ 0 point for ‘‘not certain,’’ j0.5 point for ‘‘disagree,’’ and j1 point for ‘‘disagree strongly’’ (items 1, 2, 4, 6, 7, 8, 11, 12, 16, 17, 18, 19, 21, 24, 29, 31, 33, 34, 36, and 37 of the PATCH Assessment Scale) for positive state- ments and reverse for the negative statements: j1 point for ‘‘agree strongly,’’ j0.5 point for ‘‘agree,’’ 0 point for ‘‘not certain,’’ 0.5 point for ‘‘disagree,’’ and 1 point for ‘‘disagree strongly’’ (items 3, 5, 9, 10, 13, 14, 15, 20, 22, 23, 25, 26, 27, 28, 30, 32, 35, 38, 39, and 40 of the PATCH Assessment Scale). The scores for each state- ment were added to give an attitude score for each sub- ject. The score range of the PATCH Assessment Scale is j40 to 40, and high scores are indicators of favorable attitudes toward computers in healthcare. Continuous scores were also used to categorize the participants by their attitudes toward computers in healthcare. Each participant was appointed to one of the groups listed in Table 1, based on his/her score from the scale.34 Discussion: Defining HIT And Assessing Attitudes Toward Its Implementation

INSTRUMENT VALIDITY AND RELIABILITY

The validity and reliability of the Turkish version of the PATCH Assessment Scale were established by Kaya and AztN.35 The adaptation of the scale to Turkish language was performed via back-translation, and the translated scale was submitted for expert review to determine the content validity. Its reliability was examined with test- retest reliability and internal consistency, while its validity was examined with criterion-related validity

T a b l e 1

PATCH Assessment Scale Score Interpretations

Points Interpretations

j40 to j28 Points (group 1)

Positive indication of cyberphobia. Beginner stage in experience with computer basics or applications. Ambivalence or anxiety may occur, related to the use of computers in healthcare.

May appreciate help in learning basic computer skills j27 to j15 Points (group 2)

Indicates some uneasiness about using computers. Very basic knowledge of computer basics and applications. Unsure of usefulness of computers in healthcare

j14 to j4 Points (group 3)

Moderate comfort in using computers. Has basic knowledge of computers and applications. Limited awareness of applications of computer technology in healthcare

j3 to 12 Points

(group 4)

Feels comfortable using user-friendly computer applications. Aware of the usefulness of computers

in a variety of settings. Has a realistic view of current computer capabilities in healthcare 13 to 26 Points (group 5)

Confident of ability to use a variety of computer programs. Sees computers as beneficial in the development of society. Enthusiastic view of the potential of computer use in healthcare Discussion: Defining HIT And Assessing Attitudes Toward Its Implementation

27 to 40 Points

(group 6)

Very confident that they can learn to use a computer to boost creativity and perform routine functions.

Recognizes the unique value of using information technology in society. Idealistic, positive view related to computer applications in healthcare

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(concurrent validity). The test-retest reliability of items of the PATCH Assessment Scale was 0.20 to 0.77, and 0.85 for the total scale. For internal consistency, the scale’s corrected item-total correlation was 0.06 to 0.68, and Cronbach ! was .92. Concurrent validity was ex- amined with correlation between Attitudes Toward Computers Scale and PATCH Assessment Scale scores, and there was positively significant correlation (r = 0.66, P G .01). The findings concerning the reliability and validity of the Turkish version of the PATCH Assessment Scale indicate that this instrument can be used in the studies conducted in Turkey. In this study, Cronbach ! values were determined to be 0.92 for PATCH Assessment Scale. In another evaluation that was directed toward the internal consistency of the scale, PATCH Assessment Scale’s corrected item-total correlation was found to be 0.05 to 0.60. The data of this study showed parallelism to the study by Kaya and AztN.35 Therefore, the PATCH Assess- ment Scale data obtained from the sampling group in the present study were concluded to be reliable.

Ethical Considerations

Approval for using the PATCH Assessment Scale was re- ceived from Kaminski. A written approval for the exe- cution of the research was received from the ethics committee of the hospitals where the research data were gathered. The participants were assured that there were no correct or wrong answers, and they were asked to be as genuine as possible. The participants were also told that their responses would be anonymous and that the data were to be used for scientific purposes only.

Data Analysis

The obtained data were analyzed using SPSS version 11.0 (SPSS Inc, Chicago, IL) for Windows. Cronbach ! anal- ysis and corrected item-total correlation were used in determining the internal consistency of the scale. Ordi- nal data were evaluated by means of arithmetic aver- age, SD, and minimum and maximum values, while nominal data were evaluated by frequency and percent- age measurements. Differences in proportions between groups were calculated using analysis of variance (ANOVA) models for continuous data.

RESULTS

Nurses’ Demographic Data, Professional Characteristics, and Computer Use Background

Ninety-nine percent (n = 881) of the participants were female, and the mean age was 34.24 (SD, 7.77) years

(range, 19–59 years). Of the participants, 12.5% (n = 111) were graduates of an occupational high school of health, 50.2% (n = 447) had an associate’s degree, 30.1% (n = 268) had a bachelor’s degree from a university with 4-year education, and 7.2% (n = 64) of the participants had a master’s degree or higher. The mean duration of nursing experience was 13.39 (SD, 8.11) years (range, 3 months to 40 years). Of the participants, 81.3% (n = 724) were nurses, and 16.1% (n = 143) were head nurses of a unit; 77.9% (n = 693) indicated that they had an experience of using computers. The variables ‘‘duration of computer use’’ and ‘‘place of use of computer’’ were studied in nurses who had a previous experience of com- puter use (N = 693). Among the nurses who had a pre- vious experience of working with computers (N = 693), the mean duration of computer use was 4.45 (SD, 2.77) years (range, 1 month to 12 years). Of the nurses who had an experience with computers (N = 693), 32.8% (N = 227) had access to computer at home only, while the majority (52.5%; n = 364) had access to computers at both work and home (Table 2).

Nurses’ Attitudes Toward Computers in Healthcare

The average score the nurses received from the PATCH Assessment Scale was 12.94 from a potential score range of j40 to 40 of the scale (SD, 10.03; range, j19.50 to 40.00) (Table 2). The nurses were categorized into groups shown in Table 1 according to scores they re- ceived from the PATCH Assessment Scale, and the dis- tribution demonstrated in Figure 1 was obtained. None of the nurses were assigned to group 1. Most of the nurses were allocated to group 4 (38.2%; n = 340) and group 5 (47.2%; n = 420), while very few to group 2 (0.4%; n = 4). The percentage of nurses in group 3 was 5.7% (n = 51). Of the nurses, 8.4% (n = 75) were in group 6, which represents the group with the most pos- itive attitude toward computers in healthcare. Discussion: Defining HIT And Assessing Attitudes Toward Its Implementation