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Caregivers’ Time Utilization before and after the Introduction of an Electronic Nursing Documentation System in a Residential Aged Care Facility

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Caregivers’ Time Utilization before and after the Introduction of an Electronic Nursing Documentation System in a Residential Aged Care Facility
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  See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/236908436 Caregivers' Time Utilization before and afterthe Introduction of an Electronic NursingDocumentation System in...  Article   in  Methods of Information in Medicine · May 2013 DOI: 10.3414/ME12-01-0024 · Source: PubMed CITATIONS 8 READS 39 3 authors:Some of the authors of this publication are also working on these related projects: Mobile technology to support self management of hypertension   View projectData management and quality in clinical research   View projectEsther MunyisiaLa Trobe University 12   PUBLICATIONS   137   CITATIONS   SEE PROFILE Ping YuUniversity of Wollongong 116   PUBLICATIONS   657   CITATIONS   SEE PROFILE David HaileyUniversity of Wollongong 216   PUBLICATIONS   3,377   CITATIONS   SEE PROFILE All content following this page was uploaded by Ping Yu on 11 November 2014. The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the srcinal documentand are linked to publications on ResearchGate, letting you access and read them immediately.  © Schattauer 2013 Methods Inf Med 4/2013 1 Caregivers’ Time Utilization before and after the Introduction of an Electronic Nursing Documentation System in a Residential Aged Care Facility E. N. Munyisia; P. Yu; D. Hailey University of Wollongong, School of Information Systems and Technology, Wollongong, NSW, Australia Keywords Electronic nursing documentation, electronic health record, impact, nurse, residential aged care, nursing home Summary Background:  Despite increasing research on caregivers’ interaction with technology, there has been no attempt to investigate how the introduction of an electronic system in a resi-dential aged care facility (RACF) may affect caregivers’ use of their time. Objective:  To assess how caregivers use their time before and after the introduction of an electronic documentation system in an RACF. Methods:  An observational work sampling study was undertaken with caregivers at two months before, and at 3, 6, 12 and 23 months after the implementation of an electronic documentation system. Results:  During the first 12 months after im-plementation, the proportion of time spent by personal carers on documentation in-creased, that on direct care reduced, and the proportion on communication remained un-changed. At 23 months, the proportion on documentation and direct care had returned to pre-implementation levels. The percentage of time spent on these activities by recrea -tional activity officers remained unchanged at most measurement periods after imple-mentation. Changes in proportions of time on other activities were not directly associ-ated with the introduction of the electronic system. Conclusion:  It may take over a year for some caregivers in an RACF to integrate the use of a newly introduced electronic documentation system into their daily work. Organisations implementing such systems should develop strategies that support and accelerate the caregivers’ integration of the new documen-tation practice into their routine activities. The electronic documentation system may not however, replace the role of verbal com-munication between caregivers in aged care service. Correspondence to: Ping Yu School of Information Systems and Technology University of Wollongong Wollongong NSW 2522 Australia E-mail: ping@uow.edu.au Methods Inf Med 2013; 52: ■–■ doi: 10.3414/ME12-01-0024 received: March 26, 2012accepted: March 27, 2013prepublished: May 23, 2013 1. Introduction Electronic systems are increasingly being introduced into Australia’s residential aged care facilities (RACFs). These facilities care for older people, who because of frailty and other age-related conditions, are unable to live independently in their own homes and require care from others in an institution. The care provided to the older people ranges from personal care to nursing care [1].The use of electronic systems in RACFs could significantly improve quality, safety and efficiency of care service delivery. In a recent study, we found that a computerized documentation system reduced repetitions in data entry and enhanced accessibility, accuracy, and legibility of nursing records [2]. Another study found that an electronic system improved management decision-making by facilitating quick access to resi-dents’ records [3]. Despite growing evidence and mandates to implement health information technol-ogy (health IT), computer use in RACFs to support delivery of quality care and im-prove management of residents’ records is still uncommon [4]. Most aged care man-agers are reluctant to introduce computers into caregivers’ daily work. Reasons range from high cost of implementation to uncer-tainty of how this technology will impact on caregivers’ practice [5, 6]. Some leaders in aged care fear that caregivers may take a long time to learn the new workflow in an electronic system, a situation that may im-pact resident care. Others believe the new system may improve caregivers’ efficiency and accuracy of documentation [6]. This demonstrates the need for a clear under-standing of the changes in caregivers’ work following the introduction of an electronic system in an RACF.This goal could be achieved by explor-ing caregivers’ time on activities [7, 8]. Pre- vious investigations of time spent on activ-ities after the introduction of an electronic system in nursing practice have mainly been undertaken in hospitals [9 –11]. For example, seven months after the imple-mentation of an electronic system in the Original Articles For personal or educational use only. No other uses without permission. All rights reserved.Note: Uncorrected proof, prepublished onlineDownloaded from www.methods-online.com on 2013-07-15 | ID: 1000369434 | IP: 130.130.37.85  Methods Inf Med 4/2013 © Schattauer 2013 2 Intensive Care Unit (ICU) of a surgical ward, Bosman et al. [9] found that care-givers took much less time on registration of patients (documentation) and more time on patient care (direct care) compared with the time associated with paper-based documentation practice. These authors found no difference between paper-based and electronic documentation systems in time spent on personal (i.e., meal breaks) and unit-related (i.e., ordering supplies) ac-tivities. To our knowledge, there are no studies providing this kind of information in the setting of an RACF.Understanding how time on activities may change after the introduction of an elec-tronic system is essential in both promoting acceptance of the systems by caregivers and in motivating the aged care providers to in- vest in innovative health IT applications to optimize care services. In addition, the infor-mation can be used to re-design caregivers’ activities and work flow to enhance produc-tivity. This paper presents the results of a 25-month longitudinal study on caregivers’ time utilization before and after the introduc-tion of an electronic documentation system in a low care section of an RACF. In the Aus-tralian aged care system, residents in a low care aged care setting require minimal per-sonal care and support for their activities of everyday living [1]. 2. Objective The objective of this study is to assess how caregivers use their time before and after the introduction of an electronic nursing documentation system in an RACF. The study specifically explores changes in pro-portion of time spent on activities by per-sonal carers (PCs) and recreational activity officers (RAOs) before and after the intro-duction of the electronic system. 3. Methods 3.1 Design An observational work sampling technique was used in this study. Details of this tech-nique have been reported by Munyisia et al. [12]. 3.2 Study Setting This work is part of a larger project on changes in caregivers’ work following the introduction of an electronic system in an RACF in Australia. This study was specifi-cally conducted in a low care section of the RACF. This section has 64 beds. On a typi-cal morning shift, care of the residents is provided by four PCs and one RAOPrior to the implementation of the elec-tronic system, residents’ information was handwritten as free-text or entered into standardized nursing forms provided by the facility’s management. In 2009, after implementation, residents’ demographics, incident and accident reports, forms and charts, progress notes and assessments were entered and maintained on a com-puter. The electronic system was also used to prepare care plans, shift handover re-ports and the funding of care.During the electronic documentation period, information on continence was documented either on paper or on a com-puter. Information on blood pressure, weight and blood sugar level was docu-mented on paper and on a computer from six months after implementation. Infor -mation on medication management and recreational activities was recorded and maintained on paper throughout the study.In preparation for implementation, the electronic system was installed on a laptop and four desk top computers. Each care-giver received a 30-minute one-on-one training session. Newly employed care-givers learned to use the electronic system from the facility’s IT support officer or from colleagues with experience in work-ing with the new system. 3.3 Participants Participants in the study were PCs and RAOs working on a morning shift (6.45 am to 3.15 pm). The caregivers working on afternoon or night shifts, allied healthcare staff, and registered nurses (RNs) assigned to administrative tasks or supervision of the PCs were excluded from the investi-gation. Figure 1 The five periods of work activity measurement E. N. Munyisia et al.: Changes in Caregivers’ Time Utilization with the Introduction of Electronic Documentation For personal or educational use only. No other uses without permission. All rights reserved.Note: Uncorrected proof, prepublished onlineDownloaded from www.methods-online.com on 2013-07-15 | ID: 1000369434 | IP: 130.130.37.85  © Schattauer 2013 Methods Inf Med 4/2013 33.7 Caregivers’ Activities The work sampling tool was designed to include all possible activities performed by the PCs and the RAOs on a morning shift. A detailed account of the procedures fol-lowed in identifying the activities, valida -tion of these activities and assessment of inter-rater reliability are presented by Munyisia et al. [16]. The final instrument contained 48 activities grouped into eight categories ( ▶ Table 1). 3.8 Ethical Considerations The study was approved by the Human Re-search Ethics Committee of the University of Wollongong, Australia. The purpose and method of the study were explained to the caregivers. Caregivers were given informa-tion sheets about the study to read, under-stand and ask any questions before signing informed consent forms. Each participant was assigned a code number to ensure ano-nymity of the records. 3.9 Data Analysis The main outcome of analysis was the pro-portion of time spent in each activity cat-egory before and after the introduction of the electronic documentation system. To Observations were made every five minutes. Starting from a fixed location in the house and following the same route on each round of observation, the ob -server recorded all activities being per-formed by each caregiver on a tabular data collection tool. When a caregiver was not found on a given round of obser- vation, a dash (–) was recorded to denote missing. But if another caregiver on the floor indicated that his or her colleague, for instance was on break, then this activ-ity was recorded accordingly. These pro-cedures were followed at all measurement periods of the study. At 6 months and 12 months after imple-mentation, structured interviews were held with the caregivers to assess their experi-ences with the electronic system. The cri-terion for participating in the interviews was that caregivers had to have some ex-perience using the electronic documen-tation system in their daily work and were willing to discuss this. It was assumed that with this experience, a caregiver under-stood the operations related to the use of the electronic system and would have formed some opinions about using it. In total, six PCs and two RAOs participated during the two interview periods. Each in-terview was audio-taped and then tran-scribed verbatim. 3.4 Roles of the PCs and RAOs Personal carers in Australian RACFs pro- vide basic care to the residents, for example, showering and toileting. They also re-stock supplies and aid residents in their mobility. They are responsible for per-forming documentation duties for their ac-tivities in a work-shift. The PCs in this study were also involved in the activity of medication administration [13, 14]. Recreational activity officers have the responsibility of planning, implementing and evaluating leisure and recreational programs for individual residents in an RACF [15]. The RAOs at the RACF were also involved in direct care of the residents, for example, feeding. They also docu-mented on all their work activities. 3.5 Data Collection Data collection was carried out between 2009 and 2011 on a morning shift at five separate measurement periods ( ▶ Figure 1). Each period lasted for five days (Mon-day, Tuesday, Wednesday, Saturday and Sunday). 3.6 Procedures Two weeks prior to the first period of data collection, the observer (ENM) was intro-duced by the residential service manager to the caregivers in their shift handover meet-ings. The observer talked to the caregivers and reassured them that the investigation was not meant to identify flaws in their work, but to understand any changes in their time expenditure following the introduction of an electronic documentation system. At the end of each meeting, the observer invited caregivers to participate in the study. They all accepted by signing consent forms.Before the start of observations on each morning shift, the observer (ENM) ob-tained a list of the caregivers scheduled to work during that shift, re-arranged the list by replacing caregivers’ names with code numbers, and noted names of new care-givers in the study. During observations, when the observer met the new caregiver, she introduced herself, explained the purpose and method of the study, and re-quested the caregiver to participate. Table 1 Caregivers’ activities Categories Direct care activitiesMedication managementCommunication activitiesDocumentation activitiesIndirect care activitiesPersonal activitiesIn-transitOthers Work activities and definitions All nursing activities performed in the presence of a resident and/or relative, for example, hygiene/oral care/bathing/toileting/shaving, nutrition/feeding.All medication related tasks including preparation/administration and documentationAll activities related to oral communication such as sharing information about a resident/de-briefing, discussion with allied healthcare workers, staff orientation, and coordination of care.All activities related to paper-based and computer-based documentation such as taking records from the storage place, flipping through to identify the correct page, inputting a username and password, and typing progress notes/charts and forms.All activities that are not resident specific such as identifying correct supplies, packing supplies to trolley, and equipment set up/sling set-up/shower chair set-up.All activities unrelated to residents, for example personal errands, meal breaks and making telephone calls.Time between tasks, such as time spent walking in corridor.Tasks not classified anywhere above. E. N. Munyisia et al.: Changes in Caregivers’ Time Utilization with the Introduction of Electronic Documentation For personal or educational use only. No other uses without permission. All rights reserved.Note: Uncorrected proof, prepublished onlineDownloaded from www.methods-online.com on 2013-07-15 | ID: 1000369434 | IP: 130.130.37.85  Methods Inf Med 4/2013 © Schattauer 2013 4 obtain the proportion of time, the total number of snapshots in a category was divided by the total number of snapshots recorded during the entire work sampling period. Data in MS Excel 2003 were con- verted to SPSS, version 18.0 (SPSS Inc., Chicago, IL, USA) for statistical analysis using descriptive statistics. The proportion of time spent in documentation category after implementation includes the time spent on paper-based and on computer-based documentation tasks. Differences in proportions of time spent in each category before and after the imple-mentation of the electronic system were identified using Pearson’s chi-square test. A significance level for each test was set to 0.05. However, given the multiple compari-sons in this study (32 independent com-parisons for the PCs and 16 for the RAOs), we used the Bonferroni correction to adjust for the multiplicity. Thus, results from these comparisons are presented as ad- justed  p -values. Hence, a  p -value less than 0.002 for the PCs and a  p -value less than 0.003 for the RAOs were considered to be statistically significant. 3.10 Interview Data Analysis Data were analysed using an inductive con-tent analysis method as described by Elo and Kyngas [17]. First, transcripts were open-coded, line-by-line. Each transcript was then thoroughly reviewed to identify terms or events that appeared frequently. Categories emerged from these terms and events. The categories from different tran-scripts were then compared and grouped into broader higher order categories. Fi -nally, the content of these categories was used to abstract major themes from which to draw conclusions on the caregivers’ ex-periences with the electronic system. 4. Results A total of 109 observations of caregivers were made, 92 (84%) of PCs and 17 (16%) of RAOs. In total, 10,947 activities were recorded for the PCs and 1,500 for the RAOs. 4.1 Changes in the PCs’ Proportion of Time on Activities ▶ Table 2 shows the proportion of time the PCs spent on each category of activities be-fore and after the implementation of the electronic documentation system. When compared to the proportion of time spent on activities at two months before the in-troduction of the system, the proportion of time on communication and indirect care activities remained unchanged during the study except at 6 months after implemen-tation where the proportion on communi-cation reduced ( P   < 0.001) and that on in-direct care activities increased ( P   < 0.001).The percentage of time spent on direct care work reduced significantly at three and six months into electronic documen-tation, but at 12 and 23 months, the per-centage had settled back to a level similar to the value recorded in the pre-implemen-tation period.The proportion of time on documen-tation at three months after the introduc-tion of the electronic system was not sig-nificantly different from that recorded prior to implementation of the system. A large increase in the proportion of time was Table 2 PCs’ proportion of time on activities before and after the implementation of the electronic system Activities CommunicationIndirect careDirect CareDocumentationPersonalMedication managementIn-transitOthers a  The five measurement periods of the study are denoted by the numbers 2, 3, 6, 12 and 23; 2 = 2 months before the implementation of the system; 3 = 3 months after implementation; 6 = 6 months after implementation; 12 = 12 months after implementation; and 23 = 23 months after implementation. b Comparison of the proportion of time spent on each category of activities before and after the implementation of the electronic system. For instance, a comparison of the proportion of time spent on activities 2 months before and 3 months after the implementation of the system is denoted by ‘2–3’. * Statistically significant outcome of chi-square test. A p–value less than 0.002 was considered statistically significant. For example, in the row for com-munication, there is a notable difference in proportion of time spent between 2 months before and 6 months after the implementation of the system (  p  = 0.001).n = total observations % (number of observations)Measurement periods a 2n = 2549 42.6 (1086) 6.3 (161)14.9 (381)11.8 (300) 5.3 (134) 9.3 (237) 9.4 (239) 0.4 (11) 3n = 2331 40.2 (937) 7.3 (169)10.9 (255)10.4 (243)12.4 (289) 5.4 (127)11.9 (278) 1.4 (33) 6n = 2364 37.2 (880) 8.8 (211) 9.4 (223)18.1 (428) 7.8 (184) 5.9 (139)12.3 (291) 0.3 (8) 12n = 1623 38.6 (627) 4.3 (70)12.1 (196)15.8 (257) 9.0 (146) 5.4 (88)11.6 (189 ) 3.1 (50) 23n = 2080 39.9 (830) 6.4 (134)14.4 (299)10.2 (212)12.2 (254) 4.1 (85)12.1 (254) 0.7 (14) Chi-square test between measurement periods ( α  = 0.002) b 2–3  0.088 0.194< 0.001* 0.136< 0.001*< 0.001* 0.004<0.001* 2–6  0.001* 0.001*< 0.001*< 0.001*< 0.001*< 0.001* 0.001* 0.599 2–12  0.011 0.006 0.009< 0.001*< 0.001*< 0.001* 0.019< 0.001* 2–23  0.063 0.861 0.584 0.089< 0.001*< 0.001* 0.002* 0.269 E. N. Munyisia et al.: Changes in Caregivers’ Time Utilization with the Introduction of Electronic Documentation For personal or educational use only. No other uses without permission. All rights reserved.Note: Uncorrected proof, prepublished onlineDownloaded from www.methods-online.com on 2013-07-15 | ID: 1000369434 | IP: 130.130.37.85
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