Lucy Wanjuki Kivuti BSc N, MSc. HSM and
Angeline Chepchirchir BScN, MSc Medical Microbiology
Kivuti, L. and Chepchirchir, A. (February 2011). Computerization readiness. Online Journal of Nursing Informatics (OJNI), 15, (1), Available at http://ojni.org/issues/?p=178
This cross-sectional descriptive study was conducted among middle and functional level nurse managers at a National Referral Hospital with the aim of establishing their preparedness for computerization of nursing services, their attitudes towards computerization, their training needs, and their preferred mode of study. A purposive sample of all 112 nurse managers was obtained for this study. The response rate was 95.5 % (n=107). Data was collected using structured, self-administered questionnaires. The study revealed that nurse managers had positive attitudes toward use of computers. Their attitudes toward use of computers were not significantly influenced by accessibility to computers or competence in computer use, but nursing experience and the age of the respondents had a negative influence on attitudes toward computerization of nursing services (p=0.05).
Eighty-five percent of the respondents (n=91) did not have computer studies during their training in basic nursing; 51% (n=55) had sought training in computers after their basic training; 98% (n=105) desired to be trained in computer applications; and 69.1% (n=73) preferred in-house training in computers. The hospital would benefit by inculcating positive attitudes toward computer use through training and upgrading of skills among nurses managers.
KEY WORDS: computerization; nurse managers; attitudes; knowledge; practices.
Information communication and technology (ICT) knowledge enables nurses to enhance patient care delivery, as well as the practice and safety of care (Newbold and Douglas, 2005). Nurses all over the world are expected to keep pace with ICT developments in order to help them make informed decisions regarding patient care and management (Newbold & Douglas, 2005; Gerdin, Tallberg and Wainwright, 1997). Because a user’s attitude toward the whole phenomenon of ICT affects his/her willingness to use computers – and hence an organization’s ability to move toward a paperless system – it’s important to establish the existing attitude of nurse managers in order to determine how computerization will be achieved (Burger and Blignaut, 2004). Knowing the skill levels of the nurse managers would establish the competency levels and hence form a basis for developing the desired skills (Newbold & Douglas, 2005; Ngin and Simms, 1996).
In Kenya, nursing management is organized into three levels: The top-level nursing management is responsible for policy formulation; the middle-level nurse managers act as leaders and liaisons who are responsible for policy implementation; and the lower-level is the functional or supervisory nurse managers who are in charge of smaller teams within the wards or clinic. This structure of nursing administration can be compared to that of Taiwan and South Africa (Lin, Wu, Huang, Tseng, & Lawler, 1996; Jooste, 2000). This structure is based on the roles and responsibilities of the nurse managers. Nurse managers at different levels influence hospital strategy and plan nursing activities in order to provide a competitive environment (Gerdin et al, 1997). This study sought to find out the skills, attitudes, and beliefs of nurses toward computer use.
According to MacBride & Nagle (1996), it is of essence that positive attitudes towards computers be promoted among nurses if they are to use computers at optimal levels in both educational and practical settings. Research studies on factors that may affect nurses’ attitude toward computer technology such as age, educational preparation, and computer use experience have been done. However, overall results have been inconclusive. Even though few if any studies have specifically targeted nurse managers, most refer to a whole group of nurses and hence it is assumed that their views included those of nurse managers. Studies done in the past indicated that age affects the attitude of nurses toward computerization (Shoham & Gonen, 2008; Krampf & Robinson, 1984). Younger nurses had a more positive attitude toward computer use. However, more recent studies have indicated that the age of the nurses did not affect their attitude toward computer use (Brodt & Stronge, 1986; Dillon, McDowell, Saimian, and Conklin, 1998; Parker & Abbot, 2000).
Although nurses’ attitudes toward computer use has become increasingly positive, resistance to use and negative attitudes toward computers have often been attributed to lack of knowledge about computers, the nature of the nurses’ work, and the practical application of computers today and in the future (MacBride & Nagle, 1996; Simpson & Kendrick, 1997; Sullivan & Decker, 1997). Studies on the effect of educational preparation on nurses’ attitudes toward computers have been inconclusive. One study found that the higher the educational preparation of nurses, the more the positive their attitude toward computerization. It was also found that nursing administrators had a higher educational level, which indicated a plausible rationale for their more positive attitudes toward computers (Estabrooks, O’leary, Ricker, and Humphrey, 2003). The results on the relationship between the length of nursing experience and attitude toward computer use have also been inconsistent. According to Dillon et al (1998), nurses with more than 21 years of nursing experience were more likely to have positive attitude toward computer use than nurses with fewer than 10 years of experience, while Raja et al (2004) found that computer attitude was not influenced by the years of nursing service.
A study done earlier by Chang (1984) found that nurses who have had a shorter period of practice as trained personnel had a more positive attitude toward computer usage. Area of work may influence nurses’ attitudes toward computer use (Dillon et al,1998, Sullivan & Decker,1997). Nurses, who work in rehabilitation, pediatrics, elderly care units, medicine, specialist units, and nursing administration, approved of computer use more than nurses who work in the medical surgical units (Dillon et al, 1998; Sullivan & Decker, 1997). Studies done on the relationship between attitudes of nurses and the amount of time of interaction with computers have also yielded contradicting results (Parker & Abbott, 2000; Miller & Jeffcote, 1997; Russell & Alpay, 2000). According to studies reported by Getty, Ryan, and Ekins (1999), nurses who did not use computers regularly had a more favorable attitude toward computer use. However, several other studies found that familiarity and previous experience with computers led to more positive attitudes (Sullivan& Decker, 1997; Ball,200; Njin, Simms and Erbin-Reesemann,1996; Chan,2009).
Nurses’ attitudes have been identified as a key variable for successful implementation of clinical information systems (Dillon, 1998). An investigation into the relationship between work excitement and level of self-perceived computer skills found that computer users were more positive than non-users (Brumini, Kovic, Zombori, Lulic & Petroveck, 2005). In general studies on nurses’ attitude toward computer use in the last 30 years have demonstrated contradictory findings. Most of the studies were done in developed countries in settings with developed information technology infrastructure. It is therefore necessary to carry out studies in developed countries such as Kenya, where the infrastructure is less advanced, or completely lacking, in order to establish the attitude of nurses and nurse managers toward computers in those regions.
1) To establish computer literacy level of functional- and middle-level nurse managers at Kenyatta National Hospital (KNH).
2) To assess the practices of computer skills by functional- and middle-level level nurse managers.
3) To establish attitudes of functional- and middle-level nurse managers toward use of computers in provision of nursing care.
4) To identify factors affecting functional- and middle-level nurse managers’ attitudes toward computer use in provision of nursing care.
This cross-sectional descriptive survey was done at KNH among functional- and middle-level nurse managers, with the aim of establishing the knowledge, attitudes, and practices of computer applications in provision of patient care. Data were collected between August 2008 and September 2008.
KNH is the biggest referral hospital in Eastern and Central Africa. It is the main medical training institution in Kenya and accommodates both undergraduate and graduate students from different mid-level colleges and universities. Current in-patient bed capacity stands at 1,800. On any given day, KNH caters to more than 2,000 in-patients. Average bed occupancy rate is 94%, but in medical, orthopedic, and pediatric wards, the rate goes as high as 210%. The hospital has a staff strength capacity of 6,000, of which 35% (1,800) are nurses.
The population of interest in this study was functional- and middle-level nurse managers at Kenyatta National Hospital. The mid-level managers in this study refer to assistant chief nurses (ACNs), who are charged with the responsibility of managing specific departments. The functional-level managers are comprised of a Senior Nursing Officer (SNO), Nursing Officer One (NO1), Nursing Officer Two (NO2), and Nursing Officer Three (NO3). They are referred to as functional-level nurse managers and are in charge of wards, clinics, and theatres, and are involved in the day-to-day running of the wards or clinics. First-level nurse managers have been the focus of the study because they are the main link between the middle-level nurse managers and the staff-level nurses. They also carry out both direct patient care, as well as managerial functions within their units. It is therefore assumed that their views would be more representative of the training needs of nurse practitioners both at management levels and for direct care providers.
A purposive sample of all (112) the middle-level nurse managers and functional-level nurse managers was performed. The response rate was 95.5 % (N=107).
A self-administered questionnaire was developed using items from published questionnaires that were modified and developed specifically for the purpose of this study. The questionnaire contained the following areas: demographic variables, computer use, and attitudes about computer use in the provision of nursing care. A multi-trait five point Likert scale was used to measure attitudes towards computer use in provision of patient care.
Approval to conduct the study was obtained from Kenyatta National Hospital administration, Joint University of Nairobi, and Kenyatta National Hospital Ethics Committee. Full disclosure of information to respondents was made, and study subjects’ anonymity was ensured through the absence of names on the questionnaires. Finally, consent was obtained in writing from the respondents. The respondents were informed of their right to participate or withdraw from the study without any repercussions whatsoever. No compensation was given to the respondents as research was conducted during their normal working hours. There were no competing interests, and the study was self-sponsored and aimed at improving nursing care.
In order to ensure feasibility, reliability, and validity, the tool was pretested among five functional-level and three middle-level nurse managers working on the ground-floor level of the hospital. These nurse managers were not included as study subjects during the main study.
Trained research assistants hand-delivered the questionnaire to the nurse managers’ offices and collected the questionnaires within 48 hours of administration.
One hundred and seven completed questionnaires were entered and analyzed using SPSSTm version 11.0. This represented a 95.5% response rate. Descriptive statistics (mean, standard deviation, percentages, and range) as well as inferential statistics (correlation) between biographical characteristics, knowledge, attitudes, and practices were calculated. P values of ?0.05 were considered statistically significant.
Biographical data were as stipulated in Table One. The distribution of managerial levels was in expectation of the vertical/triangular structure of the nursing department. Therefore, computer training was not an integral part of basic nursing training programs in most nursing schools in Kenya. Fifty-one percent (n=55) of the nurse managers had trained in computers through their own initiative.
The nurse managers who had access to a computer constituted 57.9% (n=62), while 42.1 % (n=45) of the respondents did not have access to computers. The nurse managers accessed computers at different points, with 59.7 % (n=37) accessing the computer at cyber cafés, 33.9 % ( n=21) at home, only 1.6 % ( n=1) at the work place, and 4.8% (n=3) elsewhere. The nurse managers utilized the computers for various activities. A majority (38.7%, n=24) of those who had access to the computer used the computer to send and receive e-mails, while 38.7 % (n=24) typed personal work, 12.9% (n=8) searched for information on the internet, and 9.7 % (n=6) utilized the computers for other activities. However, the research did not detail what kind of information the nurse managers sought, as that was beyond the scope of this research.
The nurse managers reported their experience in different skills. A majority reported experience in both e-mailing (69.2 %, n=74) and general internet experience (65.4 %, n=70). Those who had experience in data entry constituted 63.6 % (n=68), while 61.7 % ( n=66) had experience in word processing, and 57.9 % ( n=62) had computer-assisted learning experience. Other computer experiences were reported by 1.9% (n=2) of the respondents (Table 2). Overall, a majority of the nurses reported moderate (mean=3) computer experience in various skills. Computer experience was not significantly influenced by sex, date of promotion, or computer access point (p=.05). However, computer experience was positively influenced by level of education (p=0.01), previous computer training as a nurse (p=0.05), and access to a computer (p=0.05). The same computer experience was negatively affected by length of practice as a nurse (p=0.05) and age of the respondent (p=0.05).
The nurse managers’ attitudes toward the use of computers in nursing were analyzed and ranked, and the results are stipulated in Table 3. Linear correlation showed that the years of practice were positively correlated with age and designation (p=0.05). Pearson’s correlation was calculated to show the correlations between different variables. A p< value of 0.05 was considered significant. A majority of the nurse managers (98% N=105) had a positive attitude toward use of computers in nursing care provision. The attitudes were not significantly influenced by age, sex, marital status, and access to a computer, designation of the nurse, or access to a computer. The attitudes were positively influenced by level of education (p=0.01) and computer experience (p=0.05). A majority (98.1%, n=105) of the nurse managers expressed a desire to be trained in computer skills, with 68.6% (n=72) of them preferring in-house/on job training and 31.4 % (n=32) preferring full-time study outside of the workplace. A majority of nurse managers (95.3 %, n=102) also felt that the hospital was not doing enough to equip nurses with computer skills, while only 1.9 % (n=2) felt that the hospital was. However, 2.8 % (n=3) of the nurse managers had no comment on the issue.
Few studies, if any, have assessed the preparation and attitudes of nurses prior to the use of computerized systems, and this study accomplishes that objective at KNH.
This study showed that a majority of the nurse managers did not receive computer training as part of their basic nursing programs. The results of this study contrast those done in Taiwan, which has a similar nursing management structure as Kenya, including a top-, middle- and, functional-level structure (Lin et al, 2007; Jooste, 2000). The results of the Taiwan study showed that 70% of nurse executives received ICT education in their in-service education, and 32% of them had information education in their pre-service education programs (Ginn et al, 1997). Most nurses had been trained in medical informatics during their basic training programs (Brumini et al, 2005).
Kenyatta National Hospital has not yet computerized the nursing department, and the middle- and functional-level nurse managers do not have a computer in their offices or at their desks. The results of this study contradicted a study done in developed countries that showed that both nurses and their managers had access to a computer in the workplace (Eley et al, 2009; Estabrooks et al, 2003). Other studies have shown that nurse managers had significantly greater access to computers and technical support compared to staff nurses (Njin et al, 1996). Nurse Managers at KNH used computers primarily for emails and internet searches. This finding supported a study done by Estabrooks et al (2003) but contradicted Eley et al (2009), who found that nurses frequently used the computers for managing patients’ records and continuing professional education.
Data analysis showed that the overall computer knowledge and skills of nurses were at moderate levels (57.9% to 69.2%), which was consistent with the results of studies done elsewhere (Estabrooks et al, 2003; Liu et al, 2000). However, Eley (2009) reported a higher computer experience among Australian Nurses which ranged between 64% and 90%. Computer experience was not significantly influenced by sex, date of promotion, or computer access point, and this supported one of the study’s findings (Liu, 2000). However, computer experience was positively influenced by level of education (p=0.01). This supported the finding that showed that higher levels of education positively influenced experience with computers (Chan, 2009). Previous computer training as a nurse (p=0.05) and access to a computer at work (p=0.05) were also found to positively influence nurses’ computer skills. These results supported studies done elsewhere (Brumini et al, 2005); however, this study contradicted the argument that older age and senior ranking are factors that improve nurses’ computer skills (Chan, 2009).
A positive attitude toward computers is essential, as it would enhance use of ICT skills among nurses, not only in their own practice but also in supporting their clients in making better use of ICT skills. In some countries however, nurses as a group of care providers have been found to resist computerization, seeing computerized health information systems as dehumanizing, confusing and uncaring (Raja, 2004; Alquraini, 2007). Nurses’ beliefs are influenced by their use of information technology (IT) and their perception of IT benefits and satisfaction (Abdra et al, 2006). However this study revealed that 98% of the nurse managers had a positive attitude toward use of computers in health care provision.
The study results are consistent with those of others studies that suggested nurses in general have a positive attitude toward use of computerized systems (Getty & Ekins, 1999; Gordana et al, 2005; Eley et al, 2009; Liu et al, 2000; Raja et al, 2004; Alquraini et al, 2007; Abdra et al, 2006; Andrus & Mullins, 2006). However, the results contradicted studies such as Estabrooks et al (2003) that showed nurses have negative or neutral attitudes toward computers. There was no significant correlation between computer knowledge and attitudes. The results supported a study done in India (Raja et al, 2004) but contradicted studies done elsewhere that revealed that the level of computer competency and experience was an indicator of positive attitudes toward computerization (Chan et al, 2009; Alquraini et al, 2007). Length of practice as a nurse (p=0.05) and age of the respondent (p=0.05) negatively influenced the attitudes of the nurse manager toward computer use. The results of this study contradicted findings of a research done in China that showed that older age, higher educational levels and attitude scores are factors that significantly improve nurses’ knowledge (Chan et al, 2009) while supporting Brumini et al(2005) who proposed that younger nurses were more likely to have positive attitudes toward computer use.
The study supported findings that despite positive feelings about computerization, practice nurses appear to be getting insufficient or inadequate training and support to fully utilize the technology (Brodt & Stronge, 1986). At the same time, nurses have been found to be in need of appropriate educational training to enable them to use IT adequately (Getty & Ekins, 1999). The results of this study revealed that 95.3% of the nurse managers felt that the hospital was not doing enough to equip nurses with computer skills. This results of this study supports a study done in Taiwan revealed that only 44% of the respondents felt that the hospital put emphasis on development of nurses in computers. A further analysis showed that only 14% of the investigated hospitals had a program in nursing information education with 24% of them offering information education to executive levels (Brumini et al (2005). Hence supports the argument that nurses are not being adequately trained in computers.
Abdra (2006) and Mohamad (1996) suggested that providing a training program to increase nurses’ computer self-efficacy can improve their perceptions about computer use. At the same time “planned teaching strategies must be adopted to support staff in becoming confident using the computer, and the importance of computer training should not be underestimated”(Getty et al, 1999, pg 438). The majority of the nurse managers at KNH who wished to be trained in computer applications preferred in-house training as part of continuing education as opposed to full time study. The results supported a study done by Getty & Ekins (1999) that found that nurses preferred being trained by technical staff in the clinical area as opposed to self-directed learning with written instructions
The results from this study cannot be generalized, as it might not be representative of the needs and views of the nurses’ fraternity in Kenya in regards to computerization of nursing care.
The nurse managers have a positive attitude toward use of computers in nursing. However, an environment characterized by a lack of computers at work stations may create barriers to computer utilization and affect the nurse managers’ attitude toward the same. A majority of the nurse managers did not receive computer training during their basic nursing training program; however, they would like to be trained in computer skills. Most IT competence was self-acquired as most of the nurse managers have trained in computer use of their own volition, usually as self development initiatives. This phenomenon may explain the correlation between a higher level of education and increased computer use.
Further research is required to determine this phenomenon. The positive attitudes and the motivation of nurses to train on computers of their own initiative is an asset and a platform that can be tapped by KNH management to enhance the quality of health care through computerization of nursing care services. The KNH management should consider facilitating low-cost, in-house training for its nursing staff since part of its strategic plan is to be ICT compliant and computerize its services, including in the nursing department. The results of this research could allow KNH management to plan appropriately for education and training of nurse managers in effective use of ICT.
Acknowledgment is given to all the nurse managers who took time of their busy schedules to participate in this study.
Abdrbo, A. A., Hudak, C.A., Anthony, M.K., & Douglas, A.L. (2006). Moderating and mediating roles of nurses’ beliefs: Information systems use among Ohio nurses. American Medical Informatics Association. 13, 668-675.
Alquraini, H., Alhashem A. M., Shah, M.A., & Chowdhury, R.I. (2007). Factors influencing nurses’ attitudes toward the use of computerized health information systems in Kuwaiti hospitals. Journal of Advanced Nursing. 57(4), 375–381.
Andrus, L. C. & Mullins, C. (2006). Assessing Attitudes and Competencies of Clinical Staff toward Electronic Health Records. Journal of Emergency Nursing. 32(4), 273-274.
Ball, J. (2000). Nursing Informatics of Tomorrow. Health care informatics: (Feb) Retrieved from http://www.providersedge.com/ehdocs/ehr_articles/Nursing_informatics of tomorrow.pdf.
Brodt, A. & Stronge, J. (1986). Nurses’ attitudes toward computerization in Midwestern Community Hospital. Computers in Nursing. 4, 82-86.
Brumini, G., Kovic, I., Zombori, D., Lulic, I., & Petroveck, M. (2005). Nurses’ attitudes toward computers: Cross Sectional questionnaire study. Croatia Medical Journal. 46(1), 101-104.
Burger, A. & Blignaut, P., (2004). A computer literacy course may initially be detrimental to students’ attitudes toward computers. ACM International Conference Proceeding Series. 75.
Chan, M. F. (2009). Factors affecting knowledge, attitudes, and skills levels for nursing staff toward the clinical management system in Hong Kong. Computers, Informatics Nursing. 27(1), 57-65.
Chang B.L. (1984). Adoption of innovations: Nursing and computer use. Computers in Nursing. 2(6), 229-235.
Dillon, T. W., McDowell, D., Saimian, F., & Conklin, D. (1998). Perceived ease of use and usefulness of bedside computer systems. Computers in nursing. 16(3), 151- 156.
Eley, R., Soar, J., Buikstra, E., Fallon, T., & Hegney, D. (2009). Attitudes of Australian nurses to information technology in the workplace: A national survey. Computers Informatics, Nursing. 27 (2), 114-121.
Estabrooks, C. A., O’Leary, K. A., Ricker, K. L., & Humphrey, C.K. (2003). The Internet and access to evidence: How are nurses positioned? Journal of Advanced Nursing. 42(1), 73-81.
Getty, M., Ryan, A., & Ekins, M. L. (1999). A comparative study of the attitudes of users and non-users toward computerized care planning. Journal of Clinical Nursing. 8(4), 431-9.
Gerdin, U., Tallberg, M., & Wainwright, M. (1997) The impact of nursing knowledge on health care informatics. Nursing informatics: Netherlands, Amsterdam: IOS Press.
Ginn, J., McLean, T., & Balloch, S. (1997). Work histories of social services staff, London. Ageing and Society. 16, 27-55.
Jooste K. (2000). A comparison of the viewpoint of different levels of nurse managers on empowerment in their workplace. Health SA Gesondheid. 5(3).
Krampf, S. & Robinson, S. (1984). Managing nurses’ attitudes toward computers. Nursing Management. 15, 29-34.
Lin Li-Min, Wu Jen-Her, Huang I, Tseng,K. and Lawler, John . (2007). Management development: A study of nurse managerial activities and skills. Journal of healthcare Management. May-June.
McBride, S.H., & Nagle, L.M. (1996). Attitudes toward computers: A test of construct validity. Computers in Nursing. 3, 164-170.
Newbold, S., Klein, J.O., & Douglas J. V. (2005). Nursing informatics education: Past, present and future. In: K. J. Hannah, M. J. Ball, & M. J. A. Edwards (Eds). Introduction to Nursing Informatics. US: Springer.
Ngin, P.M. & Simms, L. M. (1996). Computer use for work accomplishment: A comparison between nurse managers and staff nurses. The Journal of Nursing Administration. 26(3), 47-55.
Parker, J. L. & Abbott, P.A. (2000). The new millennium brings nursing informatics. AORN Journal. 72, 1011-1017.
Raja E., Evangel J., Mahal R., & Masih, V., Barkat. (2004). An exploratory study to assess the computer knowledge, attitude and skill among nurses in health care setting of a selected hospital. Ludhiana, Punjab, India.
Russell, A. & Alpay, L. (2000). Practice nurses’ training in information technology: Report on an empirical investigation. Health Informatics Journal. 6(3), 142-146.
Shoham, S. & Gonen, A. (2008). Intentions of hospital nurses to work with computers: Based on the theory of planned behavior. Computer Informatics in Nursing. 26(2), 106-16.
Simpson, G. & Kendrick, M. (1997). Nurses’ attitudes toward computerization in clinical practice in British General Hospital. Computer Nursing Journal. 15(1), 37-42. Sullivan, E.J. & Decker, P.J. (1997). Effective leadership and management in nursing. Addison Wesley Longman Inc. Canada.
Ms Kivuti is a lecturer at the School of Nursing Sciences, University of Nairobi, Kenya. She is currently pursuing PhD at the University of Nairobi in Health systems engineering with a concentration on e-health. Her PhD project is titled: Dynamic Simulation Model for Assessing Clinical and Socio-Economic Impact of the Use of e-Health Tools in Cervical Cancer Management in Kenya. Her research main interests are Health informatics, Impact of internet technologies in provision of patient care, Simulation and modelling in health systems, HIV/AIDS and cancer of reproductive system.
She is also an adjunct lecturer at the Kenya Methodist University where she lectures Health Information Management systems.
Ms Chepchirchir is a lecturer at School of Nursing Sciences, University of Nairobi, Kenya. Her research main interests include infectious diseases and HIV/AIDS as well as use of technology in communication and health promotion of the same.