VOL. 2, NO.

2, APRIL-JUNI 2021

Journal of Muslim Community Health (JMCH)

ISSN 2774-4590
Published by Postgraduate Program in Public health, Muslim University of Indonesia
Original Research Open Access

EFFECTIVENESS OF COMPUTER-BASED NURSING DOCUMENTATION

IN NURSING CARE IN HOSPITAL – A LITERATURE REVIEW

Brajakson Siokal
Bagian Keperawatan FKM Universitas Muslim Indonesia

Email: brajaksonsiokal1@gmail.com

Abstract

Background: Nurse Population in hospitals has a greater proportion than other health workers.
Nearly 60-70% of the total human resources available, occupied by nurses. In fact, 90% of the
health services provided are a form of nursing service. Therefore, nursing service is a form of
professional service that is the biggest indicator in realizing the quality of hospital services. One
of the duties of nurses in providing nursing services in accordance with standards is to document
all nursing care provided. Objective: To review journals about documenting computer-based
nursing care in hospitals for the effectiveness of the preparation of nursing care. Methods:
Quantitative, mixed-methods, and qualitative reviews that aim to evaluate the influence of
computerized nursing documentation (eg, management, computerized decision support systems
and information systems) on nursing care were included. We used the nursing care performance
framework as an extraction grid and analytical tool. This model illustrates how the interplay
between nursing resources and nursing services can produce changes in patient conditions. The
primary outcomes included nurses' practice environment, nursing processes, professional
satisfaction, and nursing-sensitive outcomes. The secondary outcomes included satisfaction or
dissatisfaction with computerized nursing documentation according to nurses 'and patients'
perspectives. Reviews published in English, French, or Spanish from January 1, 2000 to
December 15, 2019, were considered. Results: A total of 5515 titles or abstracts were assessed
for eligibility and full-text papers of 72 articles were retrieved for detailed evaluation. It was
found that 22 reviews published between 2002 and 2015 met the eligibility criteria. Many nursing
care themes (ie, indicators) were influenced by the use of computerized nursing documentation,
including time management; time spent on patient care; documentation time; information quality
and access; quality of documentation; knowledge updating and utilization; nurse autonomy; intra
and interprofessional collaboration; nurses' competencies and skills; nurse-patient relationship;
assessment, care planning, and evaluation; teaching of patients and families; communication and
care coordination; perspectives of the quality of care provided; nurses and patients satisfaction or
dissatisfaction with computerized nursing documentation; patient comfort and quality of life
related to care; empowerment; and functional status.

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Keywords: Nursing Documentation, Computerized Nursing Documentation, Effectiveness of
Nursing Care Documentation

Introduction documentation format creates a sense of

Documentation of nursing care is the act boredom in nurses. In addition notes in
of recording any data obtained by nurses written form are sometimes difficult to
in a systematic document. The process read, can be misinterpreted, and can only
of recording does not only write data in be used for one person at a time (3).
the available formats. Nursing From the discussion above, it can be
documentation focuses on the process concluded that manual nursing care
and results of recording (13). Nurse documentation takes a lot of time
population in hospitals has a greater required in addition to lack of data
proportion than other health workers. validity and incomplete documentation
Nearly 60-70% of the total human of nursing care. In addition it costs more
resources available, occupied by nurses. to buy documentation paper that will be
In fact, 90% of the health services recorded in nursing care (9). The
provided are a form of nursing service. existence of this phenomenon if not
Therefore, nursing service is a form of treated will be difficult to explain and
professional service that is the biggest measure the contribution of nurses. To
indicator in realizing the quality of overcome these problems, one of them is
hospital services. One of the duties of to implement a nursing care information
nurses in providing nursing services system that can help nurses in
(14)
according to standards is to document all documenting nursing care .
nursing care provided (7). Nurses have Utilization of nursing care information
the responsibility of carrying out their systems helps nurses to reduce the time
duties in accordance with nursing needed in the documentation process so
standards regardless of where they work that the time to care for patients becomes
and what their specialization is. At more, improve communication, reduce
present documentation of nursing actions errors in documentation and evaluation
performed by nurses is still manually (15). of the results of nursing actions and
One obstacle that is often the complaint reduce hospital efficiency in terms of
for most nurses when writing nursing paper use thereby increasing
(17)
actions is their limited time in recording effectiveness costs . With the
and documenting nursing care. As a advancement of information and
result, what nurses have done directly to communication technology, it is very
patients is often not well documented, possible for nurses to have a more
resulting in less effective evaluation of sophisticated documentation system of
the progress of care in patients. care by utilizing the development of
Furthermore, the long and complex information technology. Nursing

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documentation using a computer is outcomes, an organizational model was
expected to help improve quality nursing used. The nursing care performance
documentation (3). The world of nursing framework represents a synthesis of the
in Indonesia continues to grow, along most recent developments in the field
with the increasing strata of nursing and is part of leading initiatives aiming
education in Indonesia, in addition to to conceptualize nursing care
(6)
very fast access to information performance . Conceptualization of
throughout the world (18). It has an effect nursing care performance is based on a
on significant progress in nursing, system perspective that builds on system
including in the documentation of the theory, Donabedian’s earlier works on
nursing process. From the previous health care organization, and Parsons’
manual, shifted towards computerization theory of social action. 1) This model,
(8)
. Even in its development, computers illustrated is composed of 14 dimensions
not only help in the documentation of and 51 indicators and shows how the
the nursing process, but their use reaches interplay of three nursing subsystems
the interests of hospital management, (resources, processes or services, and
where treatment activities can be patients’ outcomes) can operate to
monitored in a hospital database (5). achieve three key functions: acquiring,
Thus, the use of nursing care deploying, and maintaining nursing
information systems for the resources; 2) transforming nursing
implementation of nursing care is an resources into nursing services; and 3)
innovative method of documentation that producing changes in patients’
is able to provide time efficiency and conditions in response to the nursing
improve the quality of nursing care services provided (“nursing-sensitive
outcomes”).
documentation (2).
The first function refers to the human
and material resources needed to provide
Objectives
effective nursing care, such as nursing
We conducted an overview of systematic
staff supply, working conditions, staff
reviews to systematically summarize the
maintenance, and economic
evidence that comes from qualitative,
sustainability. The second function
quantitative, and mixed-method
encompasses nurses’ practice
systematic reviews regarding the effects
environments (eg, nurse autonomy;
of computerized nursing documentation
collaboration), nursing processes (eg,
on nursing care.
assessment, care planning, and
evaluation; problems and symptom
Nursing Care Performance Framework
management), nurses’ professional
satisfaction, and patient experience. The
In order to illustrate how computerized
desirable end result of the interactions
nursing documentation interventions
between nursing staff and nursing
influence nursing care and impact health

17
processes is to improve patients’ evaluate the influence of computerized
conditions. The third function is then nursing documentation used by nurses
described as the positive changes that on nursing care were eligible. The
can be detected among patients (also inclusion of reviews using multiple
called “nursing-sensitive outcomes”). methodological approaches is justified
by the possibility of broadening the
Methods understanding of the impact of
Overview and Eligibility Criteria computerized nursing documentation on
nursing care. The interventions targeted
Quantitative, mixed-methods, and were the use of computerized nursing
qualitative reviews that aim to evaluate documentation by Mair et al: (1)
the influence of computerized nursing management systems; (2)
documentation (eg, management, communication systems; (3) CDSSs; and
computerized decision support systems (4) information systems. The following
and information systems) on nursing ICTs were excluded: (1) nurse
care were included. We used the nursing management systems, which are purely
care performance framework as an administrative and designed for the
extraction grid and analytical tool. This management of human resources and
model illustrates how the interplay working conditions (eg, scheduling) and
between nursing resources and nursing nursing staff maintenance (such as
services can produce changes in patient retention); (2) educational systems,for
conditions. The primary outcomes example, e-learning initiatives used for
included nurses' practice environment, the training of nursing students, unless
nursing processes, professional they are applied to direct patient care;
satisfaction, and nursing-sensitive and (3) telephone systems, because
outcomes. The secondary outcomes according to most definitions of ICTs,
included satisfaction or dissatisfaction they are not digital technologies and
with computerized nursing cannot support the electronic capture,
documentation according to nurses 'and storage, processing, and exchange of
patients' perspectives. Reviews information. Further details of the
published in English, French, or Spanish inclusion criteria for the selection of
from January 1, 2000 to December 15, systematic reviews are described in:
2019, were considered.

The scope was formulated using PICOS

(participants, interventions,
comparisons, outcomes, study design).
All types of qualitative, mixed-method,
and quantitative reviews, published from
January 1, 2010 and that aimed to

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Criteria Description of inclusion criteria

Type of reviews All types of qualitative, mixed-method, and

quantitative reviews that aimed to evaluate the
influence of ICTsa(four eHealth domains) used by
nurses on nursing care, which stated a methodology (a
“Methods” section) with explicit eligibility criteria,
had systematic researchstrategies to identify selected
reviews and provided a systematic presentation and
summary of the characteristics and outcomes of the
included reviews

Publication type Reviews published in French, English, or Spanish

from January 1, 2015.

Population RN, nurses in training, nursing students, or patients

receiving care from qualified RN through the medium
of ICTs.

Intervention: ICTs covered by Four eHealth domains were considered in the

four eHealth domains overview: management systems, communication
systems, computerized decision support systems, and
information systems. ICTs embody all digital
technologies that support the electronic capture,
storage, processing, and exchange of information, in
order to promote health, prevent illness, treat disease,
manage chronic illness, and so on

Management systems Management systems are computer-based systems

used for acquiring, storing, transmitting, and
displaying patient administrative or health information
from different sources. They can support
administrative or clinical activities. Electronic health
records (EHRs) and personal health records (PHRs)
are examples of management systems.

Computerized decision support Refer to an automated computer-based system that

systems aims to support health professionals in practicing
within clinical guidelines and care pathways. These
systems are usually operated in real-time and involve
decision support that comes from artificial intelligence

19
 (eg, a software program).

Outcomes The primary outcomes included nursing resources,

nurses’ practice environment, nursing processes or
scope of practice, professional satisfaction, and
nursing-sensitive outcomes (eg, patient outcomes,
such as risk outcomes and safety, patient comfort, and
quality of life related to care). The secondary
outcomes included nurses’ and patients’ satisfaction or
dissatisfaction with ICTs.

Search Strategy
A medical librarian developed and 2014); PubMed (until December 8,
conducted the search strategies, drawing 2014); Embase (until January 7, 2015);
on other reviews of similar topics and Web of Science (until January 9, 2015);
using well-established search filters and Cumulative Index to Nursing and
where appropriate. We searched Allied Health Literature (CINAHL)
publications in English, French, or (until December 14, 2019). The
Spanish in the following electronic preferred reporting items for systematic
databases from January 1, 2000: reviews and meta-analyses (PRISMA)
Cochrane Database of Systematic study flow diagram. ICT: information
Reviews (until January 15, 2015); and communication technology
Epistemonikos (until December 25,

20
Result Practice, 1(1), 25–31.
https://doi.org/10.5430/jnep.v1n1p25
The results of this study indicate that
nurses agree on the ease of computer 2. Baysari, M. T., Gigante, J. Del, Moran,
M., Sandaradura, I., Li, L., Richardson,
programs to document nursing care
K. L., … Day, R. O. (2017). Redesign
(Perceived Ease of Use). They agreed
of computerized decision support to
because they believed that a computer improve antimicrobial prescribing.
program to document nursing care was Applied Clinical Informatics, 8(3),
easy to learn, easy to control, easy to 949–963.
use, clearer to understand, and made it https://doi.org/10.4338/ACI201704006
easier for nurses to do nursing care. In 9
addition, nurses also agree that the
achievement of nursing performance can 3. Bennett, P., & Hardiker, N. R. (2017).
increase if using a computer program to The use of computerized clinical
document nursing care (Perceived decision support systems in emergency
Usefulness). The statement became their care: A substantive review of the
literature. Journal of the American
belief that using a computer program
Medical Informatics Association, 24(3),
would speed things up, performance
655–668.
would be better, productivity would https://doi.org/10.1093/jamia/ocw151
increase, it would be more effective to
document nursing care, and work would 4. Clínica, D. E. L. a E., Resultados, I. Y.,
be easier. The computer-based nursing Teresinha, G., Dal, M., Couto, D.,
care documentation system that was Barra, C., … Debétio, M. G. (2013).
built including nursing assessment, Computerized nursing process : 47(1),
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plan. There is a difference in the length 5. Donsa, K., Beck, P., Höll, B., Mader, J.
K., Schaupp, L., Plank, J., … Pieber, T.
of time, cost and quality of the
R. (2016). Impact of errors in paper-
preparation of documentation of nursing
based and computerized diabetes
care that is prepared using a computer- management with decision support for
based nursing care documentation hospitalized patients with type 2
system with that manually. diabetes. A post-hoc analysis of a
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