i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 0 ( 2 0 1 1 ) 782–792

journa l h o mepage: www.i jmi journa l .com

Does the introduction of an electronic nursingdocumentation system in a nursing home reducetime on documentation for the nursing staff?

Esther N. Munyisia, Ping Yu ∗, David HaileySchool of Information Systems and Technology, The University of Wollongong, NSW 2522, Australia

a r t i c l e i n f o

Article history:

Received 16 January 2011

Received in revised form

9 August 2011

Accepted 24 August 2011

Keywords:

Documentation

Efficiency

Electronic nursing documentation

Electronic health record

Long-term care

Nursing home

Nurse

Observation

Longitudinal study

a b s t r a c t

Purpose: To determine whether the introduction of an electronic nursing documentation

system in a nursing home reduces the proportion of time nursing staff spend on documen-

tation, and to use this information in evaluating the usefulness of the system in improving

the work of nursing staff.

Methods: An observational work sampling study was conducted in 2009 and 2010, 2 months

before, and 3, 6 and 12 months after the introduction of an electronic nursing documentation

system. An observer (ENM) used a work classification tool to record documentation activities

being performed using paper and with a computer by nursing staff at particular times for

periods of 5 days.

Results: Three hundred and eighty three (383) activities were recorded before implementation

of the electronic system, 472 activities at 3 months, 502 at 6 months, and 338 at 12 months

after implementation. There was no significant difference between the proportion of time

nursing staff spent on documentation 2 months before and 3 months after the implemen-

tation of the electronic system. Six months after implementation, the proportion of time on

documentation increased significantly and after 12 months, settled back to original levels

that were recorded in the paper-based system. Over half of the proportion of time on doc-

umentation at 6 and 12 months after implementation was spent on paper documentation

tasks.

Conclusion: Introduction of an electronic nursing documentation system did not reduce the

proportion of time nursing staff spent on documentation. This may in part have been a

result of the practice of documenting some information items on paper and others on a

computer. To reduce the use of paper documentation or to achieve a paper-free documenta-

tion environment in this setting, an in-depth understanding of nursing staff’s information

needs, and documentation workflow is necessary.

munication technology (ICT) holds promise for addressing

1. Introduction

The healthcare sector in various countries is today facedwith issues surrounding quality, safety, efficiency, cost, and

∗ Corresponding author. Tel.: +61 242215412; fax: +61 242214045.E-mail address: ping@uow.edu.au (P. Yu).

1386-5056/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights resdoi:10.1016/j.ijmedinf.2011.08.009

© 2011 Elsevier Ireland Ltd. All rights reserved.

access to health and aged care services. Information and com-

these challenges [1,2]. The use of modern ICT in healthcareprovides a tremendous opportunity for improved deliv-ery of services through increased efficiency, reduced costs,

erved.

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Phase 2 followed 1 month later with the introduction of chartsand forms, such as blood glucose chart and restraint chart.Phase 3 was the introduction of the nursing care plan in July2009.

i n t e r n a t i o n a l j o u r n a l o f m e d i c

quitable health, and better care outcomes [3,4]. Hopes foruch positive outcomes have motivated the development andmplementation of electronic systems into healthcare settings5,6].

In recent years in Australia, aged care organizations haventroduced electronic documentation systems into nursingomes in an effort to reduce documentation load for the nurs-

ng staff [7,8], and allow them more time to care for seniors.hese initiatives are also aimed at improving the quality ofesidents’ records in terms of legibility, completeness, andccuracy. Although there is evidence to suggest that electronicursing documentation systems can improve quality of theesidents’ records [9,10], there is a lack of evidence that suchystems can reduce documentation efforts and time for theursing staff in aged care facilities.

Several studies evaluating the relationship between thentroduction of an electronic system and documentationfficiency have been undertaken in hospitals and theirndings have varied. Some studies [11,12] have found aeduction in time, for example, an observation of nursingtaff using either paper or electronic documentation sys-em in the intensive care unit (ICU) of a surgical wardound a significant reduction in charting time, 6 months aftermplementation of the electronic system [11]. In the sameear (2003) and setting, Bosman et al. [12] found a signifi-ant reduction in documentation time for the nursing stafffter 7 months of using a computerized system to registeratients.

However, some studies [13,14] have found an increase inocumentation time. Saarinen and Aho [13] found nurses took

onger to document care using an electronic system than with paper-based system, 2 years after implementation of thelectronic system. In a randomized evaluation of a comput-rized system in a psychiatric ward, Ammenwerth et al. [14]ound a significant increase in time on report writing andocumentation of tasks, 7 weeks after implementation of theutomated system.

Other studies [15,16] have found no changes in documen-ation time for the nursing staff. For example, Menke et al.15] found no significant difference between manual and elec-ronic documentation time, after the electronic system hadeen in use for 3 months in the ICU of a paediatric ward.n observation of nursing staff using either manual or elec-

ronic documentation systems in a surgical ward also foundo significant difference in time on admission and routineocumentation of care, 1 year after the introduction of thelectronic system [16].

Thus, it is unknown whether investment in an electronicocumentation system in a nursing home will reduce the pro-ortion of time nursing staff spend on documentation, andllow them to spend more time on residents’ care [17]. Thisnformation is important in evaluating the usefulness of suchystems in the work of nursing staff. In addition, the infor-ation is necessary in motivating nursing staff to adopt ICT

olutions, and in encouraging the aged care sector to investn ICT innovations. Therefore, the motivation of this studyas to measure the effect of the introduction of an electronicursing documentation system in a nursing home, on theroportion of time spend on documentation by the nursingtaff.

f o r m a t i c s 8 0 ( 2 0 1 1 ) 782–792 783

2. Study context

2.1. Organizational setting

This work was carried out at an Australian nursing homebetween March 2009 and November 2010. The study is partof a larger investigation of the impact of an electronic docu-mentation system on nursing staff activities in a residentialaged care facility.

2.2. System details

A commercial Web-based electronic documentation systemwas implemented in May 2009. The system is used forresidents’ demographic information, assessments, progressnotes, and residents’ forms and charts. It is also used forincident and accident reports, care plans, funding of care,administrative and 24-h shift handover reports. Use of the 24-h report was introduced at the facility from 6 months afterthe implementation of the electronic system. The system isdesigned to automatically integrate information entered onforms, charts and progress notes into nursing care plans, cal-culation of funding and management reports.

The approach taken by the nursing home was to continueto use paper documentation for some types of informa-tion after implementation of the electronic system. Theseincluded information on medication, activities of daily living(ADL), summary shift handover report, and recreational activ-ities. Memory aid notation, scheduled tasks, and awarenessinformation were also captured on paper (Table 1). Conti-nence information was documented and stored on paperfor 3 months after the introduction of the electronic sys-tem, after which such information was entered and storedelectronically.

2.3. Training of staff and system setup

Training sessions were held 3 months before the introductionof the electronic system. Each nursing staff member received a30 min one-on-one training session. Subsequently, the newlyemployed nursing staff learned how to use the system fromtheir peers with experience.

The system was installed in six desk-top computers. Ausername and password was assigned to each nursing staffmember. Data entry into the system was through a combi-nation of text using a keyboard, and ‘drop and click’ methodusing a structured drop-down menu.

2.4. Implementation of the system

The electronic system was implemented in three phases.Phase I was the introduction of progress notes in May 2009.

784 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 0 ( 2 0 1 1 ) 782–792

Table 1 – The types of information documented in computer or on paper after implementation of the electronic system.

Type of information 3 Months afterimplementation

6 Months afterimplementation

12 Months afterimplementation

Resident demographic details Computer Computer ComputerAssessments Computer Computer ComputerProgress notes Computer Computer ComputerResident forms and charts (excluding continence chart) Computer Computer ComputerIncident and accident reports Computer Computer ComputerCare plan Computer Computer ComputerFunding of care Computer Computer ComputerAdministrative shift handover report Computer Computer Computer24-h shift handover report a Computer ComputerMedication Paper Paper PaperActivities of daily living (ADL) Paper Paper PaperSummary shift handover report Paper Paper PaperRecreational activities Paper Paper PaperMemory aid notation Paper Paper PaperScheduled tasks and awareness Paper Paper Paper

aper

staff

Continence P

a The report was not part of the information documented by nursing

2.5. Nursing staff and their role in documentationduties

2.5.1. Registered Nurses and Endorsed Enrolled NursesRegistered Nurses (RNs) and Endorsed Enrolled Nurses (EENs)are professional nursing staff in Australia’s healthcare sys-tem [18,19]. These staff members have differing training andresponsibilities. The RNs need to complete a 3 year baccalau-reate program in a university, whereas EENs undertake an18 months program conducted in a vocational training centresuch as College of Technical and Further Education and thencomplete additional training on medication management. TheRNs are the team leaders in a work shift, and the EENs workunder RNs’ direction and supervision.

The RNs and the EENs were responsible for medication doc-umentation, preparing shift handover reports, developing andupdating residents’ care plans, and completing information onfunding of care. However, administration and documentationof drugs of addiction was fully the responsibility of RNs. Withthe introduction of the electronic system, most documenta-tion was automatically performed as indicated in Section 2.2(system details).

2.5.2. Personal CarersPersonal Carers (PCs) in Australian nursing homes providebasic care to the residents, for example, showering. They workunder the direction and supervision of a registered or enrollednurse. The PCs were responsible for writing progress notesand completing charts and forms using the electronic system.They completed most of this documentation as they providemost direct care services in a nursing home [20].

2.5.3. Recreational activity officersRecreational activity officers (RAOs) are responsible of plan-ning, implementing and evaluating leisure and recreational

programs for individual residents [21]. They work under super-vision of a residential service manager. The RAOs manuallycharted the involvement of each resident in recreational activ-ities. However, they documented in the electronic system

Computer Computer

at this period of study.

whenever they were involved in direct care of residents, suchas feeding.

3. Methods

3.1. Study design

This study was carried out using work sampling with an obser-vational component. This technique was first developed byTippett in 1935 for use in industrial engineering and manage-ment [22]. It requires a trained observer or a team of observersto use a pre-defined classification of activities in recording thespecific activity being undertaken at a particular time, basedon pre-defined or randomly selected time intervals.

3.2. Study flow

Following approaches taken by other researchers [23,24], thecurrent investigation was conducted in four separate peri-ods. The first period was 2 months before the introduction ofan electronic documentation system. The second, third andfourth periods were at 3, 6 and 12 months after implementa-tion of the system, respectively (Fig. 1). These periods of studyrepresent the different stages of electronic system implemen-tation [25]: the learning stage (after 3 months), early use (after6 months) and when the system is fully integrated into routinepractice (after 12 months). Each period of data collection wasconducted in a day shift (6.45 am to 3.15 pm) and lasted 5 days(Monday, Tuesday, Wednesday, Saturday and Sunday).

3.3. Participants

All nursing staff working in a day shift including RNs, EENs,PCs and RAOs agreed to participate in the study. On a typical

day shift, staff on the floor comprised one RN, one EEN, 12PCs and one RAO. Nursing staff working on afternoon or nightshifts were excluded from the investigation as well as staff onorientation, those on stand-by assisting with activities on the

i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 0 ( 2 0 1 1 ) 782–792 785

1st period (March 2009 ) May -July 2009 2nd period (Augus t 2009 ) 3rd perio d (Nov ember 2009 )

• Intervention (Intr oductio n of the electronic nursing documen tati on system)

Data collection 3 mon ths af ter th e intro ducti on of the electronic system

4th period (May 2010 ) Time

Data collection 2 mon ths b efore the intro ducti on of the electronic system

Data collection 6 mon ths af ter th e introd ucti on of the electronic system

Data collection 12 mon ths af ter the introd ucti on of the electronic system

riods

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3

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Fig. 1 – The four pe

oor, temporary employees from an employment agency andNs assigned to administrative tasks.

.4. Documentation activities

ll possible documentation activities for the nursing staff,ncluding paper-based and computer-based activities weredentified from previously published instruments [12,26,27].etails of procedures followed in validating these activities,

ncluding assessment of inter-rater reliability, are describedy Munyisia et al. [28]. The resulting activities included takingecords from the storage place, flipping through to identify theorrect page, reviewing resident information/reading notes,riting progress notes/charts and forms, putting records back

o the filing area, medication documentation, admission docu-entation, documentation to transport a resident to hospital,

ocating the correct window, inputting a username and pass-ord, typing progress notes/charts and forms, and closing the

lectronic system.

.5. Observer

bservations were made by a Ph.D. candidate (ENM) whos an experienced observer and with practical knowledge ofesidential aged care work. These characteristics helped thebserver to identify and record documentation activities.

.6. Study procedures

efore the first period of data collection, the observer visitedhe facility on two separate days and was introduced by theesidential service manager to the nursing staff in their han-over shift meeting. The observer talked to the nursing staffnd reassured them that the study was not meant to seekaults but to understand changes in the proportion of timehey spent on documentation before and after the introduc-

ion of an electronic documentation system. This meetingnabled the observer to familiarize with the nursing staff,nd also for them to become comfortable with the observer,hich could potentially minimize the ‘Hawthorne effect’ and

of data collection.

lead to an accurate recording of documentation activities forstaff. The observer also explained the purpose and method ofstudy to the nursing staff and invited them to participate inthe investigation. An information sheet about the study wasprovided to each nursing staff member to read, understandand ask questions, before consent to their participation wassought.

During data collection, observations were made at an inter-val of 9 min/h. The observer started making observations froma fixed location in the nursing home. Following the sameroute on each round of observation, all documentation activi-ties being undertaken by each staff member were recorded.Brief communication between the observer and a nursingstaff member to clarify a documentation activity being under-taken was allowed when necessary. The observed activitiesfor the nursing staff were recorded on a tabular data col-lection form using a unique code number allocated to eachtask. The tabular form contained information about the dayand date of observation, and whether a nursing staff memberunder observation was an RN, EEN, RAO or PC. A dash (–) wasused to denote a nursing staff member who was not observedduring a given round of observation. The study methods andprocedures remained the same for the four periods of datacollection.

3.7. Analysis

Data were entered into MS Excel 2003 spreadsheet andexported to a Statistical Package for Social Sciences (SPSS) 17.0for analysis. Any items with less than five data entries at aspecific measurement period were excluded from the analy-sis. Unlike in time motion studies, where the exact time onan activity is measured, in this study occurrences of docu-mentation activities were recorded. For ease of reporting thisdata, activity occurrences were converted into a percentage,and the main outcome variable of time reported as ‘percent-

age of time’. This format of reporting work sampling data hasbeen validated by the previous studies [29,30].

The percentage of time spent on each documentationactivity was calculated using descriptive statistics with 90%

i c a l

786 i n t e r n a t i o n a l j o u r n a l o f m e d

confidence intervals (CI). We chose to use this CI because ofour limited resources; a single observer (ENM) made obser-vations for this study, unlike previous work sampling studies[12,31] with two or more observers. This situation might havereduced our sample size. Other researchers in healthcare havealso used this CI in reporting their results [32].

Any significant differences in proportions of time acrossthe four data points were identified using Pearson’s chi-squaretest. Statistical significance was assumed when the p-valuewas less than 0.10. If a significant difference was identified,post hoc comparison of proportions of time between any twoof the four periods of study was conducted using Pearson’schi-square test.

We also used Pearson’s chi-square test to analyse the pro-portion of time spent on paper-based and on computer-baseddocumentation tasks after the introduction of the electronicsystem. The proportions of time spent on paper or on com-puter documentation tasks across the three data points werecompared. If any significant difference was identified, posthoc comparison of proportions of time between any two ofthe three data points was conducted. The proportions of timespent on paper-based and computer-based documentationtasks at the same data point were also compared to determineany differences amongst them.

4. Results

A total of 1695 documentation activities were recorded. Threehundred and eighty three (383) activities were recorded beforethe introduction of the electronic system, 472 at 3 months, 502at 6 months, and 338 at 12 months after implementation of thesystem. Forty seven (47) nursing staff were observed before theintroduction of the electronic system, 53 after 3 months, and54, after both 6 and 12 months of using the electronic system(Table 2). Most of the observed nursing staff were PCs (73.1%).There was no significant variation amongst the four data col-lection periods in the number of observed nursing staff indifferent job roles.

The recorded numbers of documentation activities for theRAOs were too few for analysis at all measurement periods.Thus, they were excluded from the analysis by level of nursingstaff, but are included where the proportion of documentationfor entire nursing staff is reported.

4.1. The proportion of time spent on documentationactivities by nursing staff before and after theintroduction of electronic nursing documentation

Table 3 shows the overall results of the changes in propor-tion of time on documentation activities before and after theintroduction of the electronic system. In general, there was nosignificant variation in the proportion of time spent on docu-mentation using the paper-based system and the proportionof time spent 3 months after implementation of the electronic

system. Six months after implementation, the proportionof time on documentation increased significantly comparedwith the proportion recorded when the paper-based systemwas used (p = 0.02). The proportion of time on documentation

i n f o r m a t i c s 8 0 ( 2 0 1 1 ) 782–792

returned to a level similar to that for the paper-based system12 months after implementation of the electronic system.

We compared nursing staff’s proportion of time spent ondocumentation after the implementation of the electronicsystem and the proportion of time spent on documentationin the paper-based system. At 3 months after implementa-tion of the electronic system, RNs’ and EENs’ proportionsof time spent on documentation reduced significantly fromthose recorded when they were using the paper-based system(p = 0.08 and p = 0.02, respectively). In contrast, the PCs’ pro-portion of time spent on documentation in this period greatlyincreased (p < 0.01).

At 6 months after the introduction of the electronic sys-tem, the RNs’ proportion of time on documentation increasedconsiderably compared with the proportion when the paper-based system was used (p = 0.04). The EENs’ proportion of timeon documentation rose to a level similar to the proportion inthe paper-based system. Personal Carers’ proportion of timeon documentation remained significantly higher than the pro-portion recorded when using paper-based methods (p < 0.01).

At 12 months into electronic documentation, RNs’ andEENs’ proportions of time spent on documentation reducedsignificantly compared with the proportions of time at6 months after implementation. The RNs’ proportion of timewas not significantly different to the proportion recorded inthe period prior to the introduction of the electronic system.The PCs’ proportion of time on documentation continued toremain significantly higher than the proportion of time spentusing the paper-based system (p < 0.01); however, this propor-tion was lower than that at three and at 6 months after theimplementation of the electronic system (Table 3).

4.2. The proportion of time spent by nursing staff ondocumentation activities performed using paper and withcomputer

Analysis of the proportions of time spent by nursing staffon documentation activities performed using paper and withcomputer is presented in Table 4. Overall, slightly over half ofthe proportion of time on documentation at 6 and 12 monthsafter implementation was spent on paper documentationactivities. A majority of the proportion of time spent on docu-mentation by both RNs’ and EENs’ involved use of paper-basedrecords at each measurement period after the introduction ofthe electronic system (p < 0.01). The PCs spent a greater pro-portion of their documentation time working with computerthan with paper across all the measurement periods after theimplementation of electronic documentation (p < 0.01).

5. Discussion

This study examined the effect of introducing an electronicnursing documentation system in a nursing home on the pro-portion of time nursing staff spend on documentation. Toour knowledge, this investigation is the first of its kind to

be undertaken in the setting of a nursing home. Moreover,longitudinal measurement with four data collection pointsspanning 14 months is unique amongst studies conductedwith a similar aim in other settings [11–13,15,16,33]. This

i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 0 ( 2 0 1 1 ) 782–792 787

Table 2 – The number of nursing staff at different measurement periods.a

Type of nursing staff 2 Months beforeimplementationn (%)

3 Months afterimplementationn (%)

6 Months afterimplementationn (%)

12 Months afterimplementationn (%)

Number of RNs 5 (10.6) 6 (11.3) 5 (9.3) 7 (13.0)Number of EENs 5 (10.6) 4 (7.5) 5 (9.3) 3 (5.6)Number of PCs 34 (72.3) 40 (75.5) 40 (74.0) 38 (70.4)Number of RAOs 3 (6.4) 3 (5.7) 4 (7.4) 6 (11.1)Total 47 (100.0) 53 (100.0) 54 (100.0) 54 (100.0)

in theys.

aomfa

ddotTatidpsaw

toe

a Numbers include double counts of some nursing staff. For example,

on a morning shift, one was on duty for 3 days and another for 2 da

pproach has led to findings that enrich our understandingf the dynamics in nursing staff’s proportion of time on docu-entation after the introduction of an electronic system; right

rom the learning period to when the system is more stablend integrated into routine practice [34].

It is widely anticipated that the introduction of electronicocumentation in nursing practice will reduce time spent onocumentation of care by nursing staff, through eliminationf repetitive data entry processes in the paper-based sys-em [2]. This expectation was not supported by this study.he proportion of time spent on documentation 3 monthsfter implementation of the electronic system was similar tohat when using the paper-based system. Six months aftermplementation, a greater proportion of time was spent onocumentation compared with the initial proportion in theaper-based system. After 12 months of using the electronicystem, the proportion of time on documentation dropped to

level similar to the proportion when the paper-based systemas used.

One possible reason for the non-reduction in the propor-

ion of time spent on documentation is nursing staff’s practicef documenting some information items on paper and oth-rs on a computer. Over half of the proportion of time on

Table 3 – The proportion of time nursing staff spent on documeelectronic nursing documentation system.

Nursing staff Percentage of nursing staff time in documenta(90% confidence interval)

2 Monthsbefore imple-mentation

3 Months afterimplementa-tion

6 Monthsimplemetion

Nursing staff ingeneral

10.7%(9.8–11.5)†ac

n = 383

11.7%(10.9–12.6)ab

n = 472

12.5% (11.n = 502

RNs 20% (16.8–23.2)a

n = 8615.6% (12.9–18.3)b

n = 7526.2% (22.n = 92

EENs 32.3% (28.1–36.6)a

n = 10723.8% (19.5–28.2)b

n = 6230.1% (26.n = 109

PCs 6.5% (5.7–7.3)a

n = 17710.3% (9.4–11.2)b

n = 3299.2% (8.4–1n = 298

n = number of observed recordings.† The same superscript letter between measurement periods represents no

tion. Different superscript letters between measurement periods denote‡ Chi-square score across the four measurement periods.§ Significance difference in proportions of time on documentation across

study period 2 months before implementation, only two RNs worked

documentation at 6 and 12 months after implementation wasspent on paper documentation tasks. There may be severalreasons for the relatively high proportion of time spent onpaper documentation. First, nursing staff not only charted cer-tain information on paper (Table 1), but also used paper whenit was more convenient and practical to do so because theinformation could not be captured on computer. For instance,they preferred documenting on paper in real time at the pointof care to aid their memory. Nursing staff would note conti-nence information on a piece of paper at the time when theydelivered care, then at some point, particularly at the end of awork-shift, enter the information into a computer. This actionreveals the limitations of some computer systems.

In addition, nursing staff used paper to alert, notify orprompt their colleagues to take action based on new infor-mation. They used a diary or ‘communication book’ to passessential information to their colleagues working on a dif-ferent work shift. Such information included the need forearly preparation of a resident to accompany his or her fam-ily members. Although this information could be recorded in

a resident’s progress notes in the electronic system, it wascharted on paper instead. The electronic system had no alertsignal for new information, thus, paper was seen as a more

ntation activities before and after the introduction of the

tion activity Chi square‡ p-Value§

afternta-

12 Monthsafter imple-mentation

6–13.3)b 9.5% (8.7–10.3)c

n = 33818.410 <0.001

4–30.1)c 16.2%(13.4–19.0)ab

n = 76

18.144 <0.001

1–34.1)a 22.5% (17.5–27.5)b

n = 438.937 0.030

0.1)b 7.8% (7.0–8.7)c

n = 21830.990 <0.001

significant difference in the proportion of time spent on documenta- a significant difference in the proportion of time on documentation.

the four measurement periods.

788 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 0 ( 2 0 1 1 ) 782–792

Table 4 – The proportion of time nursing staff spent on documentation activities performed using paper and withcomputer.

Nursing staff Documentationactivities

Percentage of nursing staff time in documentationactivity (90% confidence interval)

Chi-square‡ p-Value§

3 Months afterimplementation

6 Months afterimplementation

12 Months afterimplementation

Nursing staff ingeneral

Performed usingpaper

42.6%(38.8–46.3)†a

n = 201

56.6% (52.9–60.2)b

n = 28450.6% (46.1–55.1)c

n = 17119.106 <0.001

Performed withcomputer

57.4% (53.7–61.2)a

n = 27143.4% (39.8–47.1)b

n = 21849.4% (44.9–53.9)c

n = 167RNs Performed using

paper68.0%(59.1–76.9%)n = 51

78.3% (71.2–85.3)n = 72

75.0% (66.8–83.2)n = 57

2.315 0.314

Performed withcomputer

32.0% (23.1–40.9)n = 24

21.7% (14.7–28.8)n = 20

25.0% (16.8–33.2)n = 19

EENs Performed usingpaper

72.6%%(63.3–81.9)n = 45

79.8% (73.5–86.1)n = 87

67.4% (55.7–79.2)n = 29

2.864 0.239

Performed withcomputer

27.4% (18.1–36.7)n = 17

20.2% (13.9–26.5)n = 22

32.6% (20.8–44.3)n = 14

PCs Performed usingpaper

31.9% (27.7–36.1)a

n = 10541.3% (36.6–46.0)b

n = 12338.5%(33.1–44.0)ab

n = 84

6.209 0.045

Performed withcomputer

68.1% (63.9–73.3)a

n = 22458.7% (54.0–63.4)b

n = 17561.5%(56.1–66.9)ab

n = 134

n = number of observed recordings.† The same superscript letter between measurement periods represents no significant difference in the proportion of time spent on docu-

mentation. Different superscript letters between measurement periods denote a significant difference in the proportion of time spent ondocumentation, and no superscript letters amongst the measurement periods denotes no significant difference in the proportion of time ondocumentation.

‡ Chi-square score across the three measurement periods. A single chi-square score represents documentation activities performed using paperand with computer as their analysis datasets were inverse of each other.

crosstheir

§ Significance difference in proportions of time on documentation amentation activities performed using paper and with computer as

effective channel for passing this information than computer.The use of paper in this case provides useful information forimprovement of the electronic system.

There was no difference in the proportion of time spent ondocumentation before and 3 months after the introduction ofthe electronic system. At this period, nursing staff were stilllearning how to use the electronic system in their work andtheir speed in data entry and searching the correct modulewas slow. This is evident from the relatively high proportionof time spent on computer-based documentation at this mea-surement period (57.4%, Table 4). Similar results were reachedin an investigation undertaken 3 months after the introduc-tion of an electronic documentation system in a hospital’spaediatric ward [15].

The proportion of time spent on documentation at6 months after implementation was higher than the propor-tion recorded in the paper-based system. This finding may beattributed to increased documentation requirements at thismeasurement period. Nursing staff were required to completea 24-h shift handover report and continence information using

the electronic system. This task appeared to take longer oncomputer than on paper. Our finding is contrary to those ofprevious studies [11,12] which reported a reduction in time atthe similar period after electronic system introduction. The

the three measurement periods. A single p-value represents docu-analysis datasets were inverse of each other.

difference may be due to variations in study settings, the mixof study participants, study design, and documentation activ-ities under investigation.

The proportion of time spent on documentation at12 months after implementation was not different from theproportion when the paper-based system was used. Our find-ing at this measurement period is similar to results reportedby Hakes and Whittington [16]. However, their finding wasonly for the activities of admission and routine documenta-tion procedures in a surgical ward. A specific explanation forour current finding may be that after 1 year of using the elec-tronic system, nursing staff had familiarized with the system,including documentation of continence information and shifthandover report. Therefore, they could complete their docu-mentation at a reasonable speed.

Despite the lack of a reduction in time on documentationafter the implementation of the electronic system, care staffmembers seem positive toward the system because of its otherbenefits in their work. In our recent survey of the percep-tions of the nursing staff members in the same facility about

quality of information and benefits of electronic nursing docu-mentation, nursing staff perceived this system had increasedthe accessibility, accuracy and legibility of the residents’records. Repetitions in data entry were also reduced [9]. Such

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enefits appear to motivate nursing staff to continue usinghis electronic system.

To improve efficiency of documentation, management ofhe nursing home is using the feedback from the study todentify strategies to improve management and usage of thelectronic system. They are exploring the possibility of mov-ng all paper forms on computer; for instance, computerizing

edication documentation forms through the introductionf an electronic medication management system. They arelso looking into the possibility of introducing mobile comput-ng technology at the point of care to support documentationfforts of the nursing staff.

.1. The proportion of time spent on documentationctivities by nursing staff in different job-roles before andfter the introduction of electronic documentation

.1.1. Registered Nurses and Endorsed Enrolled Nursesn electronic system is not only expected to support nursingtaff in delivery of care, but also to free them from documen-ation duties and enable them to spend more time on directare work [17]. Apparently, there was no conclusive evidencebout a reduction in proportion of time on documentation forhe RNs and the EENs in this study. The RNs’ proportion of timeeduced only in the period after using the electronic systemor 3 months, but not after 6 and 12 months. The EENs’ propor-ion of time reduced only after 3 and 12 months of using thelectronic system, and not after 6 months.

The reduction in proportion of time on documentation at months after implementation of the electronic system maye attributed to RNs’ and EENs’ positive attitude and enthusi-sm to use a newly introduced system in their practice [35].uch positive characteristics might have enabled RNs andENs to quickly learn and apply the electronic system in theirocumentation practice. To aid their learning, the electronicystem was user-friendly, with most documentation responsi-ilities completed automatically (Sections 2.2 and 2.5.1), basedn data already entered into the electronic system by PCs

Section 2.5.2). This means that RNs and EENs did not haveo create their documentation in the electronic system fromcratch, as they were already recorded in the system. The pos-tive characteristics of the users and the system might haveontributed to the efficiency in documentation at this period.

The RNs’ and EENs’ proportion of time on documenta-ion increased at 6 months after implementation comparedith the proportion in the paper-based system. This increaseay partly be attributed to increased documentation require-ents. Apart from two handover reports completed on

ach work shift (summary report and administrative report,able 1), an additional handover report covering all shifts in4 h was introduced at this measurement period (Table 1).he 24-h report was comprehensive, with detailed descriptionf the care provided to residents. Although a comprehensiveursing report is necessary in facilitating continuity of care,he process involved in completing such a report might haveaken RNs and EENs longer time to learn and adapt in their

aily work [36].

Paper-based workarounds created by RNs and EENs in theourse of their duties may also account for the increase inhe proportion of time on documentation. The RNs and EENs

f o r m a t i c s 8 0 ( 2 0 1 1 ) 782–792 789

recorded and kept certain information on paper as well asin the electronic system, i.e., residents’ glucose levels. Thepaper-based copy was seen as easier to retrieve and sharewith other healthcare staff such as doctors. This copy alsofacilitated quick assessment and evaluation of a resident’shealthcare status because data were organized in a longitudi-nal format and thus, it was easier for viewing. The electronicsystem poorly supported this format of data; data were locatedin various sections in the system. Such information could beused to improve the electronic system, and potentially savenursing staff time on documentation [37].

The RNs’ and EENs’ proportion of time on documenta-tion reduced significantly 12 months after using the electronicsystem compared with the proportion at 6 months after imple-mentation. The RNs and EENs appear to have familiarizedwith both electronic and paper-based documentation systemat this measurement period. Their skills and knowledge ofapplying the complex documentation system including paperworkarounds seem to have increased at this period. AlthoughEENs managed to achieve a remarkable reduction in propor-tion of time on documentation at this period compared tothe proportion in the paper-based system, RNs’ proportion oftime on documentation only reduced to a level similar to thevalue recorded when the paper-based system was used. Vari-ations in RNs’ and EENs’ patterns of the proportion of timeon documentation may be attributed to their differences indocumentation practice as indicated in Section 2.5.1.

5.1.2. Personal CarersThe proportion of time PCs spent on documentation at allmeasurement periods after the introduction of the electronicsystem was significantly higher than the proportion in theperiod when the paper-based system was used. This increasemay be a result of the slow typing speed observed in a num-ber of these staff members. It is possible that they took longerto input a username, locate the correct module, and typeprogress notes, charts and forms, than writing on paper. Ina study exploring barriers to adoption of information technol-ogy in Australia’s aged care settings, Yu and Comensoli [38]found limited computer skills to be a problem amongst oldernursing staff. This group of staff members may have missedthe opportunity to learn how to use computers in their nursingeducation. Indeed, Lee et al. [39] found old age of nursing staffto be associated with increased time spent on documentationwhen using an electronic system.

The high proportion of time on documentation may also bea result of the workflow and speed of the electronic system.The workflow in the electronic system (the process followed toaccomplish a task) [40,41] may have contributed to increasedproportion of time on documentation. The process followedby a nursing staff member to record a resident’s continenceinformation provides an illustration. In the electronic system,a staff member is required to complete three structured drop-down menus by selecting appropriate continence informationfrom a list, then type a password before closing a window fora resident’s continence chart. This process was repeated to

complete another resident’s chart. The paper-based systemrequired a single input in a resident’s continence chart, anda flip-over to complete another resident’s chart. The PCs per-ceived the procedure in the electronic system as more time

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consuming compared with their previous workflow in thepaper-based system.

In addition, one had to transition through a minimum offour screens to access and complete the continence chart.The PCs perceived time taken to navigate from one screento another as slow. This situation is not only frustrating butalso increases the amount of time in-front of the screen [5].In an interview with nursing staff in a nursing home, Yu et al.[42] found nursing staff dissatisfied with the running speedof their electronic system. Another study in a hospital set-ting found similar results [6]. Thus, the speed of an electronicsystem is critical for users in healthcare and should never beundervalued [43].

5.2. Limitations of the study

This study was conducted in a single nursing home. It wasframed by the particular organizational structure, culture, taskallocation, work processes, and the electronic system used.This limits the generalisability of findings. The study was alsoconfined to a day shift. The effect of an electronic system ondocumentation time for the nursing staff working in the after-noon and night shifts may be different. Therefore, the changein proportion of time on documentation following the intro-duction of the electronic system in the day shift may not beapplicable to the proportion of time in the other two shifts.

Our investigation used a work sampling technique. Thismethod is useful in evaluating time on activities in health-care. For example, it allows many observations to be recordedin a short period, thus increasing the representativeness ofdata obtained. However, time obtained is an estimate and notthe exact time on a given activity. There was no measure-ment of the PCs’ typing speed before and after the introductionof the electronic documentation system. Such measurementwould provide useful data that increases our certainty aboutwhether PCs’ increased time on electronic documentation wasassociated with slow typing speed.

This investigation used a single observer to record obser-vations, which may incur personal bias. However, inter-raterreliability testing achieved a high score [28], suggesting theobserver’s recording is trustworthy.

This study was limited to measuring the proportion of timeon documentation up to 12 months after implementation.Measurements conducted after 12 months may have providedadditional information that clarifies the recorded pattern inthe proportion of time on documentation. Nevertheless, thisstudy has provided longitudinal data that has not been foundin the literature to date.

6. Conclusion

Findings of this study show that the introduction of the elec-tronic documentation system in the nursing home did notreduce the proportion of time nursing staff spent on docu-mentation. This could in part be a result of the nursing staff’s

practice of documenting some information items on paperand others on a computer. An in-depth understanding of nurs-ing staff‘s information needs and documentation workflow isimportant before an attempt is made to redesign or update

i n f o r m a t i c s 8 0 ( 2 0 1 1 ) 782–792

an electronic system to reduce use of paper or to achieve apaper-free documentation environment in a nursing home.

There was no conclusive evidence of reduction in pro-portion of time on documentation for the RNs’ and EENs’following the use of the electronic documentation system.Further research is required to clarify the efficiency of an elec-tronic system on the amount of time that RNs and EENs spendcharting care. The PCs’ proportion of time on documentationincreased during the electronic documentation period. Thismay suggest the need for continuous training on basic com-puter skills and use of the electronic system, as well as regularsystem updates.

Individuals planning to introduce an electronic system ina nursing home with the aim of reducing documentationtime should consider other factors that may influence theachievement of this goal. These include speed of the system,users’ familiarity with the system, and their speed of typing.Measurement of the PCs’ typing speed is necessary in monitor-ing their progress in achieving computer skills. Longitudinalresearch in other nursing homes is needed to validate findingsof this study.

Ethical considerations

All procedures used in this study were approved by theHuman Research Ethics Committee, University of Wollongong,Australia, and complied with the National Health and Medi-cal Research Council National Statement on Ethical Conductin Research Involving Humans, 1999.

Authors’ contribution

Esther Naliaka Munyisia contributed toward study design,development and validation of the work sampling instrument,acquisition of data, statistical data analysis, data interpreta-tion and manuscript preparation; Ping Yu was responsible forstudy conceptualization and design, validation of the worksampling instrument, statistical data analysis, data interpre-tation, revising the paper for important intellectual contentand final approval of the version to be submitted; David Hai-ley contributed toward data interpretation, revising the paperfor important intellectual content and final approval of theversion to be submitted.

Conflict of interest

The authors have no conflict of interest.

Acknowledgements

This project was funded by Australian Research Council Indus-try Linkage Grant Scheme, Project No. LP0882430. It is part ofa larger investigation of the introduction of computer-baseddocumentation to residential aged care. The authors would

like to thank all the nursing staff (RNs, EENs, RAOs and PCs)at the nursing home for having accepted to participate in thestudy. The manager of the nursing home is also acknowledgedfor having provided support necessary for completion of the

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Summary pointsWhat was already known on the topic?

• Previous studies investigating efficiency of electronicsystems on documentation time in hospital settingshave had inconsistent findings. Some studies havereported a reduction in time compared to that asso-ciated with paper-based systems, others an increase,while others have found no time difference.

• Time efficiency is one of the motivating factors for theimplementation of electronic documentation systemsinto nursing homes.

• Nursing homes are increasingly introducing electronicsystems into nursing practice, but there is no empiri-cal evidence about the efficiency of these systems ondocumentation time for the nursing staff.

What this study adds to our knowledge?

• The longitudinal data collected in this study increasedour understanding of the changes in the proportionof time on documentation at different periods afterelectronic system implementation.

• Continued use of paper-based documentation meth-ods after the introduction of an electronic documen-tation system in a nursing home presents a challengefor the achievement of desired outcomes in nursingpractice.

• Other factors that may influence nursing staff’sproportion of time on documentation after the intro-duction of an electronic system in a nursing homeinclude the speed of the system, users’ familiarity withthe system, and their speed of typing.

• To reduce use of paper or to achieve a paper-freedocumentation environment in a nursing home, anin-depth understanding of nursing staff’s informationneeds and documentation workflow is important.

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tudy. We are also grateful to Dr. Marijka Batterham for hertatistical support and guidance.

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