Health Care Workforce Report

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PREPARED BY DR. PING YU

PREPARED FOR: UNITINGCARE AGEING SOUTH EASTERN REGION

JULY 2005

Capacity and Willingness of Residential Aged Care Workers to Use IT to Manage Care Information

UnitingCare Ageing South Eastern Region University of Wollongong i

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Acknowledgements_______________________________________________________________ vi

1. Executive Summary ________________________________________________________________ 1

1.1 Introduction ________________________________________________________________ 1

1.2 Research aim _______________________________________________________________ 1

1.3 Sample size ________________________________________________________________ 1

1.4 Key findings ________________________________________________________________ 2 1.4.1 Participants’ demographic profile_______________________________________________________ 2

1.4.2 Aged care workers’ general computer experience ___________________________________________ 2

1.4.3 Have you received any kind of formal computer training before? _________________________________ 2

1.4.4 The current nursing documentation practice in the residential aged care facilities investigated______________ 3

1.4.5 The major problems with the current nursing documentation practice ______________________________ 3

1.4.6 Aged care workers’ level of job satisfaction and satisfaction with the current nursing documentation practice____ 3

1.4.7 Aged care workers’ attitudes toward the introduction of information systems into their facilities for managing care

information _____________________________________________________________________ 4

1.4.8 Aged care workers’ attitudes towards sharing resident information internally in the same management group and

with external service providers________________________________________________________ 4

1.4.9 Aged care workers’ attitudes toward computer skill training _____________________________________ 4

1.4.10 The perceived benefits of introducing computer-based nursing documentation practice ___________________ 4

1.4.11 The perceived benefits for care service delivery from introducing an electronic nursing documentation system into

work practice ___________________________________________________________________ 5

1.4.12 The main reasons against the introduction of electronic documentation system into aged care facility__________ 5

1.4.13 The perceived areas of practice that could be improved by adopting innovative IT solutions ________________ 6

1.4.14 What factors lead aged care workers to believe an information system is ‘easy to use’?___________________ 6

1.4.15 What factors lead aged care workers to consider an information system to be useful_____________________ 7

1.4.16 Challenges for implementing IT solutions to manage care information_______________________________ 7

1.5 Summary of main data _________________________________________________________ 7

2. Background _______________________________________________________________________ 9

3. Research aim _____________________________________________________________________ 10

4. Research methods and approach ____________________________________________________ 11

4.1 Quantitative research _________________________________________________________ 11

4.2 Qualitative research __________________________________________________________ 11


UnitingCare Ageing South Eastern Region University of Wollongong ii

4.3 Data modelling aged care workers’ acceptance of using information system to manage nursing care information

_______________________________________________________________________ 12

5. Detailed findings __________________________________________________________________ 13

5.1 The major characteristics of aged care workers in UnitingCare Ageing South Eastern Region ___________ 13 5.1.1 The occupation of aged care workers and the type of facilities they work for_________________________ 13

5.1.2 Age groups of the participants________________________________________________________ 14

5.1.3 The participants’ aged care work experience______________________________________________ 16

5.1.4 Gender of the participants___________________________________________________________ 17

5.2 Aged care workers’ general computer experience _______________________________________ 17 5.2.1 How would you rate your current ability to use computers in general? _____________________________ 18

5.2.2 What best describes your pattern of computer use? _________________________________________ 18

5.2.3 Can you type? __________________________________________________________________ 19

5.2.4 What is the approximate number of words per minute (wpm) that you can type? _____________________ 20

5.2.5 Have you received any kind of formal computer training before? ________________________________ 20

5.2.6 Have you used any online help system? Do you like the idea of using an online help system to learn to use a

particular software package?________________________________________________________ 21

5.3 The current nursing documentation practice in the facilities investigated_________________________ 21 5.3.1 Unanderra Nursing Home __________________________________________________________ 21

5.3.2 UnitingCare-Mirinjani Canberra_______________________________________________________ 21

5.3.3 UnitingCare Mayflower Nursing Home __________________________________________________ 22

5.3.4 Georges River Presbytery Aged Care __________________________________________________ 22

5.3.5 Banks Lodge ___________________________________________________________________ 23

5.3.6 Roberts Lodge __________________________________________________________________ 23

5.3.7 Bankstown Uniting Centre __________________________________________________________ 23

5.3.8 Problems with the current nursing documentation practice_____________________________________ 23

5.4 Aged care workers’ levels of job satisfaction and satisfaction with the current nursing documentation practice____

_______________________________________________________________________ 24 5.4.1 Are you happy with working in your facility?_______________________________________________ 24

5.4.2 How important is staff satisfaction valued at your facility?______________________________________ 25

5.4.3 Are you happy with the current nursing documentation practice? ________________________________ 25

5.4.4 Does management encourage the collection and sharing of information about best practice?_____________ 26

5.4.5 Is it necessary to create formal procedures to ensure that lessons learned in work practice are passed on to others

doing similar tasks in the facility? _____________________________________________________ 26

5.5 Aged care workers’ attitudes towards the introduction of an information system into aged care facility for

managing care practice _______________________________________________________ 26 5.5.1 To what degree do you trust the reliability of computer systems? ________________________________ 26

5.5.2 Would you like information technology to be introduced into your facility to manage care? _______________ 27

5.5.3 If your workplace introduced an electronic nursing documentation system, would you use it? _____________ 27


UnitingCare Ageing South Eastern Region University of Wollongong iii

5.6 Aged care workers’ attitudes toward sharing resident information internally in the same management group and

with external service providers___________________________________________________ 28 5.6.1 Electronically sharing resident information internally between aged care facilities in the same management group

and with outside service providers ____________________________________________________ 28

5.6.2 Which outside healthcare service providers should aged care facilities share information with?____________ 29

5.6.3 Is developing an electronic resident management system to capture and circulate information amongst facilities in

one management group beneficial? ___________________________________________________ 29

5.7 Aged care workers’ attitudes towards computer skill training ________________________________ 30 5.7.1 Is it important to receive adequate training in computer usage, such as typing skills, word processing etc. before you

would like to learn to use a particular electronic nursing documentation system?_____________________ 30

5.7.2 If an electronic nursing documentation system was introduced into your workplace that requires you to be retrained

for that task, would you be willing to do so? ______________________________________________ 30

5.8 Aged care workers’ perceived benefits of computer-based nursing documentation system ____________ 31 5.8.2 The perceived benefits for care service delivery if introducing an electronic nursing documentation system into work

practice ______________________________________________________________________ 32

5.9 The main reasons against the introduction of electronic documentation system into a facility ___________ 33

5.10 The perceived nursing care practice that might be improved through introducing an information system____ 35

5.11 The suggested technologies having potential to be introduced in nursing care practice as perceived by aged care

workers _________________________________________________________________ 37

5.12 Aged care workers’ acceptance of using an information system to manage nursing documentation _________ 37 5.12.1 What attributes lead an aged care worker to believe that an information system is easy to use? ____________ 38

5.12.2 What are the factors that lead an aged care worker to consider an information system as useful? ___________ 38

5.12.3 Aged care workers’ intention to use an information system______________________________________ 39

5.12.4 Factors determining aged care workers’ acceptance of information systems _________________________ 39

5.13 The challenges for the implementation of IT systems into aged care facilities ______________________ 40 5.13.1 The cultural resistance to change_______________________________________________________ 41

5.13.2 Technical issues __________________________________________________________________ 41

5.13.3 Cost considerations ________________________________________________________________ 41

5.13.4 The aged work force _______________________________________________________________ 42

6. Conclusions and recommendations __________________________________________________ 43

7. Limitations of the study ____________________________________________________________ 45

9. References _______________________________________________________________________ 46


UnitingCare Ageing South Eastern Region University of Wollongong iv

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Table 1. The participants’ occupation and type of facility they work for_____________________________ 13

Table 2. A comparison of the percentage of aged care workers by occupation in our survey and the data collected by Richardson (2004) from residential aged care facilities _________________________ 14

Table 3. The age group of the participants in both high-care and low-care facilities ____________________ 15

Table 4. The age group of participants in different occupations ___________________________________ 15

Table 5. Work experience of aged care workers in two types of facilities ____________________________ 16

Table 6. Work experience of aged care workers in different occupations ____________________________ 17

Table 7. The answers to the question, and number and percentage of respondents ___________________ 18

Table 8. The number and percentage of participants that can, cannot type and did not answer the question 19

Table 9. The number and percentage of respondents who can type at a certain speed _________________ 20

Table 10. The percentage of respondents and their rating of the problems for the current resident record management system. ____________________________________________________________ 24

Table 11. Aged care workers’ perception on how importantly staff satisfaction is valued at their facility______ 25

Table 12. Aged care workers’ happiness with the current nursing documentation practice________________ 25

Table 13. The answers to the question, the number and percentage of respondents who answered the question______________________________________________________________________________ 28

Table 14. The respondents’ answers to sharing resident information internally and externally, the number and percentage of respondents who give the answer _______________________________________ 28

Table 15. The number and percentage of respondents that agreed with sharing resident information with outside healthcare service providers: GP, pharmacy, hospital, specialist, allied health, pathology and radiology______________________________________________________________________________ 29

Table 16. The number and percentage of respondents who believe that using an electronic resident management system to capture and circulate information amongst facilities in one management group is beneficial ____________________________________________________________________ 29

Table 17. The content of the answer, number and percentage of participants that responded _____________ 30

Table 18. Responses to, ‘What is the perceived impact of introducing a computer-based nursing documentation system into your facility’ and the percentage of respondents that gave the answer _____________ 32

Table 19. The six major categories of obstacles for the introduction of computer-based nursing documentation system identified in focus group discussions and interviews, along with the subcategories of obstacles (the numbers in brackets refer to the number of times the issue was mentioned)_______________ 35

Table 20. The major areas of care practice that could be improved by the introduction of an information system, and the number of times the issue was mentioned by the survey participants _________________ 36

Table 21. The number and percentage of respondents in different occupations who identified the area of care practice that could be improved by IT ________________________________________________ 37


UnitingCare Ageing South Eastern Region University of Wollongong v

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Figure 1. The initial research model to measure aged care workers’ acceptance of using an information system to manage nursing care information. _________________________________________________ 12

Figure 2. The respondents’ pattern of usage of computers. The number on the histogram represents the number of respondents who selected the answer._______________________________________ 19

Figure 3. The percentage of respondents that selected different level of trust for computer-based information systems. The legend on the upper right corner of the diagram describes the meaning of the numbers on ‘X’ axis _____________________________________________________________________ 27

Figure 4. The number of times a benefit is mentioned by participant in interviews and focus group discussions31

Figure 5. The major opportunities for care service delivery if introducing computer-based nursing documentation as identified in the interviews and focus group discussions________________________________ 33

Figure 6. Percentage of respondents and their answers to the main reasons against the introduction of computer-based nursing documentation system ________________________________________ 34

Figure 7. The final verified quantitative model to predict aged care workers’ acceptance of an information system for managing care before any system is introduced _______________________________ 40

Figure 8. The participants’ major concerns about implementing computer-based nursing documentation identified in interviews and focus group discussions _____________________________________ 40


UnitingCare Ageing South Eastern Region University of Wollongong vi

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The author would like to acknowledge the contributions to the project by:

The University of Wollongong Research Council and UnitingCare Ageing for joint funding support.

Ms Margaret McMillan for her effort to establish linkages between UnitingCare Ageing and the University of Wollongong.

Ms Marisa Mastroianni, Regional Director and Ms Barbara Schuetrim, Executive Director Care, UnitingCare Ageing South Eastern Region for their contribution to the refinement of research objectives, survey instrument validation and facilitating research team access to the aged care facilities in the region.

All of the facility managers, DONs and DDONs in the facilities surveyed for distribution and collection of questionnaires, accepting interviews and organising focus group discussions. Registered Nurses, ENs, AINs and PCWs who participated in the questionnaire survey, interviews and focus group discussions. Without the above peoples’ active participation and generous contribution of time and information, this project would not have succeeded.

My former students Nicolas Comensoli, Myra Scheeringa and Kylie Hose for their preliminary investigation into information management issues in residential aged care. Without their contribution, it would have been impossible for the research team to accurately identify the information management issues in residential aged care or to construct a coded survey instrument with reasonable relevance and accuracy.

Dr. Pam Davy for her advice on statistical data analysis.

Project co-investigator Prof. Patrick Crookes for his contribution to project coordination and research idea generation.

Korravich Tangyudamrogul for contributing to the quantitative questionnaire design and data collection.

Sunaina Sharon Lobo for interviewing aged care workers and subsequent transcription of audio records.

Yiyu Qiu for participating in interviews and focus group discussions; audio records transcription and concepts elicitation from qualitative data; quantitative data entry and validation.

My husband, Dr Chao Deng, for his advice on statistical data analysis and generous support.


UnitingCare Ageing South Eastern Region University of Wollongong 1

1. Executive Summary

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In order to inform strategic information technology planning and workforce education, the management in UnitingCare Ageing South Eastern Region wished to understand the basic computer skill sets and willingness of residential aged care workers in the region towards adopting a computer-based nursing documentation practice. The researchers in the Health Informatics Research Centre, the School of IT and Computer Science and the Department of Nursing at the University of Wollongong agreed to conduct a systematic, scientific investigation of the issue through qualitative and quantitative research.

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To conduct a comprehensive investigation of residential aged care workers’ basic computer skill sets, and willingness towards the introduction of information technology (IT) to manage care information in UnitingCare Ageing South Eastern Region.

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Two hundred and ninety questionnaires were mailed to the residential aged care homes belonging to UnitingCare Ageing South Eastern Region, or distributed to the aged care workers on site visits by the researchers. In order to encourage response, approximately three weeks after the distribution, reminder calls were made to the manager of each home. Questionnaires were collected during site visits by the researchers or mailed back to the chief investigator. There were 116 questionnaires returned, with a response rate of 40%.

Nine interviews were conducted with regional and facility managers. Six focus group discussions were conducted with a relatively homogeneous group of participants in terms of occupation during site visits by the researchers. A SWOT (strength, weakness, opportunities and threats) analysis was conducted during the interview and focus group discussions.

Responses to the questionnaire, interviews and focus group discussions are the sources of data for this report. The main findings and conclusions are outlined below. Please refer to the body of the report for detailed analysis.



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1.4.1 Participants’ demographic profile

There is a significant age difference between occupations. All the registered nurses and people in management positions are above 30 years of age. Enrolled Nurses (ENs) are above 25 years of age, whereas the age profile of Personal Care Workers (PCW) /Assistants in Nursing (AIN) is younger. The major component of the aged care work force that participated in this survey was between 40 and 59 years of age (58.9%). 71% of people at management level are in the age group of 30 to 49 years. There is no statistically significant difference in the age profile of participants from high-care and low-care facilities.

38% of respondents have more than ten years work experience and 5% have recently joined the industry and have less than one year experience. No significant difference in aged care work experience was found between respondents from high-care and low-care facilities. However, there is a significant difference between respondents in different occupations (p<0.001).

The managers appear to have the longest aged care work experience in all occupational groups, followed by that of RNs, then ENs. The aged care work experience for the managers, RNs and ENs is about seven to ten years or more. PCWs/AIN’s have significantly less aged care work experience (four to six years or more) than the other occupational groups.

91% of respondents were female, which is close to the national figure of 94% given by Richardson (2004).

1.4.2 Aged care workers’ general computer experience

� The self-estimated computer ability of 58.5% of aged care workers (n = 116) is average, above average or excellent.

� The three most commonly used software packages are e-mail software (93.3% of users), Microsoft Word (91.1%) and Microsoft Excel (71.1%) (n = 45).

� 78.9% of respondents use Web browsers, 48.9% play games and 46.7% use Microsoft PowerPoint software.

� 70% of respondents can type, 13% have no typing experience and 17% did not answer this question.

� 60% of respondents can type more than twenty-one words per minute.

1.4.3 Have you received any kind of formal computer training before?

Only 29% of 116 respondents had received formal computer training. 46% of respondents under 30 years of age had received formal computer training (n=22). However, only 26.3% of respondents above 30 years of age had received formal computer training (n=94).



89% of clerks, 14% of managers, 15% of RNs and 15% of ENs, and 32% of PCWs/AINs had received formal computer training. Apart from clerks, PCWs/AINs appear to be the occupational group that has received the highest level of formal computer training. There is no significant difference in training received by RNs, ENs or managers.

Of the thirty-four respondents who had received formal computer training, all had received training in using Microsoft Word, 68% had received training in using PowerPoint, 56% in using a Web browser, and 50% in using e-mail. Only 38% had received training in using Excel.

1.4.4 The current nursing documentation practice in the residential aged care facilities investigated

The five high-care and five low-care facilities investigated all utilise computer-based care plans to a certain extent. Facilities belonging to Georges River Presbytery Aged Care use an in-house developed care plan and assessment template in Microsoft Excel. The other high-care facilities used Care Plan III. It is mainly used by the Director of Nursing (DON) or the facility manager to generate a care plan. The paper-based care plan is updated manually by RNs and then typed into the computer by a dedicated RN (or manager) if time allows. ENs and AINs all write progress notes on a daily basis.

1.4.5 The major problems with the current nursing documentation practice

71% of respondents (n = 95) considered the time-consuming nature of a paper-based record system to be the major problem, followed by the large storage space required (51%), lack of legibility (40%), difficulty of retrieving the previous records (31%), difficulty of updating resident information (29%) and misuse of resident information (11%).

1.4.6 Aged care workers’ level of job satisfaction and satisfaction with the current nursing documentation practice

� A very high level of staff satisfaction (91.4%) was recorded in the survey (n = 116).

� The majority of aged care workers surveyed, perceived that staff satisfaction was valued highly at their facility (67.2%), or as a mid-level priority (23.3%).

� 80.1% of respondents (n = 93) agreed that their management encouraged the collection and sharing of information about best practice.

� 84.5% of respondents (n = 99) considered it necessary to create formal procedures to ensure that lessons learned in work practice were passed along to others doing similar tasks in the facility.

� Although 16.4% of respondents (n = 116) were unhappy, or extremely unhappy with the current paper-based documentation practice, 50.9% were neutral, that is they neither approve nor disapprove of the practice. 26% of respondents were happy or extremely happy with the current practice.



1.4.7 Aged care workers’ attitudes toward the introduction of information systems into their facilities for managing care information

87% of respondents (n = 116) support the strategy of introducing IT to manage care information in residential facilities. The majority of aged care workers (80%) trust the reliability of computer-based systems.

More than 90% of respondents (n = 116) will use the introduced system. Half of the respondents will use the introduced system without condition. 36% of them regard the easy to learn nature of the system as a priority for use and 30% regard ‘significantly reduce the time taken for documentation’ as an important factor to consider for adopting a system.

1.4.8 Aged care workers’ attitudes towards sharing resident information internally in the same management group and with external service providers

53.4% of respondents (n = 116) believe that sharing information between aged care facilities and outside service providers is a good idea, whereas 17.2% disagree. 29.4% of respondents did not answer this question.

64% of respondents (n = 116) believe that developing an electronic resident management system to capture and circulate information amongst facilities in one management group would be beneficial. Only three respondents disagree with the idea. However, 38% respondents did not answer the question.

1.4.9 Aged care workers’ attitudes toward computer skill training

48% of respondents (n = 116) believe that it is important to receive adequate training in computer usage, such as typing skills, word processing etc. before they learn to use a particular electronic nursing documentation system. 16% believe that they could learn computer skills in the process of learning a particular electronic nursing documentation system and 36% did not answer this question.

87% of respondents are willing to be trained to use an electronic nursing documentation system if it would ultimately be beneficial (n = 116). Reducing the time taken to complete a task is the second most mentioned motivation (26%), followed by reducing repetition in the job (22%).

1.4.10 The perceived benefits of introducing computer-based nursing documentation practice

The respondents’ perceived benefits of introducing computer-based nursing documentation practice include: time saving (76%); legibility (72%); reducing storage space and easy retrieval of information (64%); ease of use (60%); reducing duplication, and is useful (50%); facilitating statistical analysis (45%); operational convenience (43%) and management decision support (33%) (n = 116).



1.4.11 The perceived benefits for care service delivery from introducing an electronic nursing documentation system into work practice

� More time spent on direct care of resident (70%)

� Improving resident information management (55%)

� Saving time on documentation (53%)

� Improving work process (49%)

The major opportunities of computer-based nursing documentation identified in SWOT analysis during interview and focus group discussions are listed in the diagram below:

1.4.12 The main reasons against the introduction of electronic documentation system into aged care facility

‘Not enough computers in the work place’ is the obstacle identified by the biggest percentage of respondents to this question (32%); followed by: the computer skill deficiency of the work force (28%); no technical person to provide support when problems encountered (23%); difficult to learn (15%); lack of funding to support implementation practice (14%); privacy considerations for electronically handled personal information, not easy to use and difficult to guarantee security of personal information (13%); not user friendly (11%) and time-consuming operation (9%).

The six major categories of obstacles for the introduction of a computer-based nursing documentation system identified in focus group discussions and interviews are listed in the table below, along with subcategories of obstacles (the numbers in brackets refer to the number of times the issue was mentioned by participants in focus group discussions and interviews).

0 2 4 6 8 10 12 14

Improving work efficiency

Improving information management

Improving efficiency in data entry

Benchmark statistics

Frequency of occurrence

Standardising forms and data

Improving communication

Decision support

0 2 4 6 8 10 12 14








Decision support



Lack of qualified

employees (70)

Management issues (60)

Limited resources

(45)

Training (39)

Negative attitudes of nurses (19)

Limitation of IT solutions

(11)

Nurses’ basic computer skills

(41)

Legislation requirements

(30)

No computer (18) Age (21)

Failure to perceive benefits

of IT (10)

Technical problems (5)

Limited usage of computer (11)

Business priority (23) Time (18) Need

training (7) Against

introduction (9) Not nursing specific (4)

Qualified IT support staff

(11)

Attitudes of management

(7) Funding (9) Support

(6) Limitation of information (2)

Limited exposure to

computers (7)

Language problems

(5)

1.4.13 The perceived areas of practice that could be improved by adopting innovative IT solutions

There are forty-one areas of work identified by participants that could be improved by IT and cover the entire business process of caring for a resident. The five major areas of practice that can be improved by IT solutions are (1) care plan; (2) progress notes; (3) general nursing documentation; (4) medication; (5) assessment.

1.4.14 What factors lead aged care workers to believe an information system is ‘easy to use’?

Aged care workers tend to consider that it is easy to use a new information system if:

� they had better IT skill sets

� they received managers’ and colleagues’ encouragement

� formal guidance was available to them, a specific group was available for assistance and they had a solid ‘network of support’

� their organisation had an IT strategy for improving staff’s IT knowledge

� aged care workers were convinced that the system could facilitate their care decision-making

� their organisation had an IT policy that protected confidentiality of resident information

Aged care workers tend to consider that it is difficult to use a new information system if:

� they were older

� they believed that using the system would increase their documentation load

� the introduced system would replace their job



1.4.15 What factors lead aged care workers to consider an information system to be useful

The intention of aged care workers to use IT is positively related to their perceived usefulness and perceived ease of use of the system.

Aged care workers tend to consider an IT system to be useful if:

� they perceive that using IT could enhance their effectiveness and quality of work

� using IT may make it easier to do their work and increase their productivity

� using IT is relevant to the delivery of residential care

� their managers believe in the value of introducing an IT system

� they receive colleagues’ encouragement

� the organisation’s IT policy facilitates them to improve their IT knowledge

� the system that is introduced can facilitate their care decision making

� the IT policy of the organization ensures confidentiality of resident and staff information

1.4.16 Challenges for implementing IT solutions to manage care information

The major challenges for implementing computer-based nursing documentation practice identified in interviews and focus group discussions are: resistance to change; technical issues; cost of implementation and the senior age of the work force.

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The aged care workforce in UnitingCare South Eastern Region is a happy workforce. The majority of facility-level managers have significant experience and are within an age group that is able to form a strong and sustainable management team for the next ten years. The organisational culture is optimistic, cohesive, and centred at the quality of care for residents.

Although used to the paper-based nursing documentation practice, the majority of aged care workers fully understand the weakness of the current practice as well as the opportunities and benefits of electronic nursing documentation. More than half of the survey participants have basic computer skill sets. They see the automation of nursing documentation as their highest preference for the introduction of an IT system and are willing to embrace the new practice if the organisation introduces a computer-based nursing documentation system.

Although PCWs/AINs are less experienced in aged care service delivery, their computer skills are significantly better than the other occupational groups. Standardizing nursing documentation practice through the introduction of an electronic documentation system might be an effective strategy to improve technical efficiency because this effectively leverages the variety of IT skills and care experience among care staff.



The above evidence suggests that the workforce is ready for the introduction of IT to manage care information in UnitingCare Ageing South Eastern Region.

The survey results suggest that the critical factors for the successful introduction of an electronic nursing documentation system in UnitingCare South East Region include: (1) a strong training program and on-going technical support to ensure that the IT learning needs of care workers with various levels of computer skills are satisfied; (2) the implementation of a strong change management strategy; (3) the allocation of sufficient funding for improving hardware and network infrastructure and (4) a strong championship and advocacy for innovation.



2. Background

Like many aged care management groups, UnitingCare Ageing NSW is in the early stage of business case analysis to identify the needs, costs and benefits of introducing innovative new IT solutions in order to improve care operation and satisfy accreditation and funding requirements effectively and efficiently. The management in UnitingCare Ageing South Eastern Region understands that the enabling role of IT can only be realised when the workforce accept, adopt and integrate the technology into daily work practices. Therefore, it is important to understand the attitudes of the workforce towards computer-based nursing documentation practice before resources are directed into introducing them. So far, no systematic investigation has been conducted regarding aged care workers’ capacity and attitudes towards using a computer-based information system in the organisation.

To assist with strategic planning, the Management in UnitingCare Ageing South Eastern Region considered it essential to conduct a systematic, scientific investigation to fully understand the attitudes of aged care workers in the organisation towards computer-based nursing documentation practice and the capacity of the workforce to harness the new practice. After discussion, UnitingCare Ageing South Eastern Region Management and researchers at University of Wollongong (UOW) agreed to change the direction of the jointly funded UOW - UnitingCare Ageing NSW Industry Linkage Project: ‘The impact of introducing a resident information management system into aged care’ towards assessing the capacity and willingness of aged care workers to adopt a computer-based nursing documentation system.

This report covers the main findings of the investigation. The data are collected in both high-care and low-care facilities belonging to UnitingCare Ageing South Eastern Region. This includes:

High-Care Facilities Low-Care Facilities

Unanderra Nursing Home Roberts Lodge

Mayflower Nursing Home Bankstown Uniting Centre

UnitingCare-Mirinjani Canberra Nursing Home Bruce Sharpe Lodge UnitingCare-Shoalhaven Banks Lodge

Leisure World Nursing Home UnitingCare-Mirinjani Canberra - Hostel



3. Research Aim

The aim of the research is to conduct a comprehensive investigation to examine aged care workers’ IT capacity and their willingness to adopt computer-based nursing documentation practice. This was achieved by investigating the following issues:

� The major characteristics of aged care workers in UnitingCare Ageing South Eastern Region and their general computer experience.

� The current nursing documentation practice in the facilities investigated.

� Aged care workers’ level of job satisfaction and satisfaction with the current nursing documentation practice.

� Aged care workers’ attitudes towards adopting a computer-based nursing documentation system and sharing resident information internally in the same management group and with external service providers.

� Aged care workers’ perceived benefits and challenges resulting from the introduction of computer-based nursing documentation practice.

� Aged care workers’ perceived area of work practice that could be improved by adopting innovative IT solutions.

� Aged care workers’ attitudes toward computer skill training.

� Technologies perceived by aged care workers that might be introduced into nursing care practice.

� Factors determining aged care workers’ acceptance of information systems.

� Challenges for implementation practice.



4. Research Methods and Approach

Both quantitative and qualitative research was taken in this study. Quantitative study was conducted through a self-administered questionnaire. Qualitative study took the form of key informant interviews and focus group discussions.

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The self-administered questionnaire was designed in consultation with the CEO of UnitingCare Ageing South Eastern Region, Ms Marisa Mastroianni, and Executive Director Care, Ms Barbara Schuetrim, and three registered nurses. The questionnaire is composed of four parts: basic demographic information; questions to investigate; satisfaction survey; and a technology acceptance survey (adopted from Venkatesh and Davis, 2000). The questionnaire starts with a brief introduction providing background information for the research, contact details of researchers and seeks explicit consent for participation. It details channels for complaints about research ethics.

Two hundred and ninety questionnaires were mailed to the aged care homes mentioned above, or distributed to the aged care workers on site visits by the researchers. Personal distribution of questionnaires was conducted between September 27 and October 3, 2004 in Mayflower Nursing Home, UnitingCare-Shoalhaven and Leisure World Nursing Home. Questionnaires were mailed to UnitingCare-Mirinjani Canberra and Georges River Presbytery Aged Care in November, 2004. Reminder calls were made to the managers for the collection of questionnaires. Questionnaires distributed to UnitingCare-Mirinjani Canberra were sent back to the chief investigator by the manager of the facility. The researchers collected the questionnaires from the facilities belonging to Georges River Presbytery Aged Care during site visits in early December. The final cut-off date was December 10, 2004. There were 116 questionnaires returned, with a response rate of 40%.

Quantitative data analysis was conducted using statistical software SPSS (Copyright © 2005, SPSS Inc. Headquarters, 233 S. Wacker Drive, 11th floor Chicago, Illinois 60606).

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Interviews were conducted with regional and facility managers. A total of nine staff at management level, including CEOs in the region, Care Service Manager, Directors of Nursing, Deputy Directors of Nursing and Facility Manager, were interviewed. A convenience sample of aged care workers was invited for focus group discussions during site visits by the researchers. The people that participated in focus group discussions included:

� Unanderra Nursing Home: 5 Registered Nurses

� UnitingCare Mirinjani Hostel: 2 Personal Care Workers

� Mayflower Nursing Home: 3 Enrolled Nurses and 3 Assistants in Nursing



� Leisure World Nursing Home: 2 Assistants in Nursing

� Roberts Lodge Hostel: 5 Personal Care Workers

� Banks Lodge: 3 Personal Care Workers, one kitchen hand and one cleaner

Interviews and focus group discussions were audio-taped and transcribed into a Word document. Concepts presented in the discussion were extracted using NVIVO software for every transcript.

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The Technology Acceptance Model (TAM) developed by Davis (1989) to explain and predict user acceptance of information technology at work was modified to model aged care workers’ acceptance of introducing an IT system to manage nursing care information. Technology Acceptance Model is a well-established, robust, powerful and highly accepted model for predicting user acceptance of information systems. A substantial amount of information system research has been focused on end-user acceptance study applying, validating or extending the TAM model. In response to the criticism that TAM does not address social influences on user acceptance of information technology, Venkatesh and Davis (2000) proposed TAM2 to incorporate additional theoretical constructs including social influence (subject norm, voluntariness and image) and psychological cognitive process (job relevance, output quality, result demonstrability and perceived ease of use). The research model for the current study is adopted from TAM2, incorporating the possible social influence factors unique to the residential aged care environment such as the aged care workers’ work experience, type of facilities (high-care or low-care), occupation (Personal Care Worker/Assistant in Nursing, Enrolled Nurse, Registered Nurse, Facility Manager and Clerk), age, support and IT policy (Figure 1).

Figure 1. The initial research model to measure aged care workers’ acceptance of using an information system to manage nursing care information.

PerceivedUsefulness

PerceivedEase of use

Intention to Use(user acceptance)

SubjectiveNorm

Type of Facility

Image

WorkExperienceWorkExperience

Age

ComputerExperienceComputerExperience

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VoluntarinessVoluntariness

Support

IT Policy

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ComputerExperienceComputerExperience

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VoluntarinessVoluntarinessVoluntarinessVoluntariness

SupportSupport

IT PolicyIT Policy

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5. Detailed findings

In this section we present the major findings from the quantitative and qualitative data analysis and data modelling. Firstly, we describe the major characteristics of aged care workers, their general computer experience and the current nursing documentation practice in the facilities investigated. We then discuss aged care workers’ level of satisfaction with their job and current nursing documentation practice. Their attitudes toward introducing a computer-based nursing documentation system and sharing resident information internally in the same management group and with external service providers are addressed. This is followed by an investigation of their perceived benefits of computer-based nursing documentation practice, their perceived challenges resulting from the introduction of such a system and their attitudes towards computer skills training. A brief discussion follows to ascertain their opinions on which current work practices should be computerised. Factors determining aged care workers’ acceptance of IT are also discussed. The section concludes with a discussion on the issues surrounding the implementation of an IT system.

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The major characteristics of aged care workers in UnitingCare Ageing South Eastern Region are expressed in terms of occupation, type of facility worked (high-care or low-care), age group, aged care work experience, and gender.

5.1.1 The occupation of aged care workers and the type of facilities they work for

A total of 116 aged care workers responded in the self-administered questionnaire survey, including 64 PCWs/AINs, 13 ENs, 13 RNs, 17 managers (DONs or DDONs) and nine clerks from both high-care and low-care facilities.

Table 1 lists the number of participants grouped by occupation and the type of facilities in which they are employed.

Table 1. The participants’ occupation and type of facility they work for

High-Care Low-Care Total

Number Percent Number Percent Number Percent PCW and AIN 35 50.0% 29 63.0 64 55.2% EN 13 18.6% 0.0 11.2% RN 9 12.9% 4 8.7 13 11.2% Manager (DON, DDON) 8 11.4% 9 19.6 17 14.7%

Clerk 5 7.1% 4 8.7 9 7.8% Total 70 100.0% 46 100.0 116 100.0%



Slightly more Personal Care Workers (PCWs) from low-care facilities (60.4%) participated in the survey than the equivalently qualified Assistants in Nursing in high-care facilities (50.0%). This reflects the fact that, apart from facility managers and possibly one or two part-time Registered Nurses (RNs), the care workers employed in low-care facilities are all PCWs. There is a significant difference in the number of participants from high-care (70 people) and low-care facilities (46 people). This may be because there are more aged care workers employed in high-care facilities than in the low-care facilities. This may also indicate that the opinion of aged care workers in high-care facilities might be over-represented compared with that of aged care workers in hostels.

In a survey of the aged care workforce, Richardson (2004) conducted a detailed breakdown of the occupations within it. The results, based on data collected from facilities are as follows: 21% RN, 14% EN and 57% Personal Carer. She did not include manager and clerk in her category of occupations.

If we include facility managers involved in the current survey because they were RNs, the occupational profile of the participants in the current survey is not much different from that detailed by Richardson (2004) (Table 2). This indicates that the demographic coverage of our survey is close to the national profile. Although no significant difference in occupations between participants from high-care or low-care facilities was found, Table 2 suggests that PCW (or AIN, the equivalent in high-care in terms of qualification) is slightly under-represented in high-care but over-represented in low-care facilities in our study compared with that of Richardson’s; the same applies for RNs. The percentage of ENs in our survey is slightly higher than that reported by Richardson (19% vs. 14%). The difference in percentage of participants by occupation in these two surveys may be attributed to the slight difference of occupational profile in the two surveys. ‘Clerk’ was included in our survey, but not ‘allied health’, whereas in Richardson’s survey, ‘clerk’ was excluded and ‘allied health’ was included.

Table 2. A comparison of the percentage of aged care workers by occupation in our survey and the data collected by Richardson (2004) from residential aged care facilities

High-Care

Low-Care

Richardson’s data collected from facilities

Clerk 7% 9% 8% (Allied Health)

Personal Care Worker (or AIN) 50% 63% 57%

Registered Nurse 24% 28% 21%

Enrolled Nurse 19% 14%

Total 100% 100% 100%

5.1.2 Age groups of the participants

34.5% of aged care workers that participated in the survey were in the age group of 40 to 49 years; 25% were 50 to 59 years of age, and 14.7% were in the age group of 30 to 39 years. However, there is no statistically significant difference in the age profile of participants from high-care or low-care facilities.



Table 3 shows the age groups of the participants in the self-administered questionnaire survey. There is a significant difference in the number of aged care workers belonging to various age groups (p < 0.001). However, there is not a significant difference between the age profiles found in high-care and low-care facilities.

Table 3. The age group of the participants in both high-care and low-care facilities

High-Care Low-Care Total

Number Percentage Number Percentage Number Percentage

Under 20 4 5.70% 1 2.20% 5 4.30%

20 to 24 4 5.70% 4 8.70% 8 6.90%

25 to 29 5 7.10% 4 8.70% 9 7.80%

30 to 39 11 15.70% 9 19.60% 20 17.20%

40 to 49 25 35.70% 15 32.60% 40 34.50%

50 to 59 18 25.70% 10 21.70% 28 24.10%

60 and over

3 4.30% 3 6.50% 6 5.20%

Total 70 100.00% 46 100.00% 116 100.00%

The biggest group of aged care workers (31.3%) are in their 40s, followed by 22.9% in their 50s, then 20.8% in their 30s. Our results fit with the age profile of care workers suggested by Richardson (2004). This indicates that the age profile of participants in the current study is close to the national figure.

There is a significant age difference between occupations (p<0.05). All the RNs and people at management position are above 30 years of age. ENs are above 25 years of age, whereas the age profile of PCWs/AINs is slightly younger (Table 4). The majority of the aged care workforce that participated in this survey is represented by the group aged 40 to 59 years (58.9%).

Table 4. The age group of participants in different occupations

PCW/AIN EN RN Manager (DON, DDON) Clerk Total

No. Percent No. Percent No. Percent No. Percent No. Percent No. Percent

Under 20 4 6.3% 0 0 0 0 0 0 1 11.11% 5 4.3%

20 to 24 7 10.9% 0 0 0 0 0 0 1 11.11% 8 6.9%

25 to 29 7 10.9% 2 15.4% 0 0 0 0 0 0.00 9 7.8%

30 to 39 9 14.1% 1 7.7% 2 15.4% 5 29.4% 3 33.33% 20 17.2%

40 to 49 24 37.5% 5 38.5% 4 30.8% 7 41.2% 0 0.00 40 34.5%

50 to 59 11 17.2% 5 38.5% 6 46.2% 3 17.6% 3 33.33% 28 24.1%

60 and over

2 3.1% 0 1 7.7% 2 11.8% 1 11.11% 6 5.2%

Total 64 100% 13 100.0% 13 100% 17 100% 9 100% 116 100%



The age profile of Enrolled Nurses in our survey is similar to the national profile (Richardson 2004). In accordance with Richardson’s finding, 46% of RNs are aged 50 years or over and they are older than people in other occupations. The age profile of PCWs/AINs appears to be younger than the national profile given by Richardson (2004). It is encouraging to see that 71% of people at management level, such as facility managers, Directors of Nursing or Deputy Directors of Nursing, are in the age group 30 to 49 years because this might suggest that the management team is sustainable in the next 10 or 15 years.

5.1.3 The participants’ aged care work experience

Until now, no information about care experience of aged care workforce has been reported. This is the first time this information has been collected.

38% of the aged care workers that responded have more than ten years experience in aged care. The aged care work experience of 57% of respondents spreads evenly from one year to ten years. 5% of the workforce has recently joined the industry and has less than one year experience in the area (Table 5).

Table 5. Work experience of aged care workers in two types of facilities

Aged-care Work Experience

High-care (n = 67) Low-care (n = 48) Total (n = 115)

3 months to 1 year 3% 8% 5%

1 to 3 (+) years 18% 21% 19%

4 to 6 (+) years 16% 23% 19%

7 to 10 (+) years 21% 15% 18%

10 (+) years 42% 33% 38%

Total 100% 100% 99%

No significant difference in aged care work experience was found between participants from high-care and low-care facilities.

There is a significant difference in aged care work experience between participants in different occupations (p<0.001). Managers, RNs and ENs have a similar amount of aged care work experience, about seven to ten years or more. Personal care workers have significantly less aged care work experience (four to six years or more) than the other occupational groups (p<0.05). Managers appear to have the longest aged care work experience in all occupational groups, followed by that of RNs, then ENs (Table 6). However, this difference is not statistically significant.



Table 6. Work experience of aged care workers in different occupations

PCW/AIN EN RN Manager (DON, DDON) Clerk Total

3 month to 1 year 5 0 0 0 1 6

1 to 3 (+) years 17 2 1 0 2 22

4 to 6 (+) years 16 1 1 2 2 22

7 to 10 (+) years 9 3 4 3 2 21

10 (+) years 16 7 7 12 2 44

Total 63 13 13 17 9 115

Richardson found that only 5% of the aged care workforce in Australia is aged between 16 and 24 years, whereas 11% of the workforce in this age group is recorded in our study. Our data suggest that only 5% of the workforce has three months to one year aged care work experience (Table 5). The majority of aged-care workers (38%) in this study have 10 years or more aged care work experience. This indicates that the aged care workforce in the South Eastern Region might be relatively younger and more stable than the average within the industry.

5.1.4 Gender of the participants

Only eleven participants are male, accounting for 9% of the population surveyed. 105 (91%) of the respondents are female, which is close to Richardson’s finding that 94% of aged care workers are women (2004). Eight of eleven male participants are Personal Care Workers in hostels (4) and Assistants in Nursing in nursing homes (4). One male participant is a clerk. One is a facility manager in a hostel and one is a Deputy Director of Nursing in a nursing home. The gender ratio is equal between high-care and low-care facilities. The aged care work experience of the male participants is similar to that of their female counterparts, ranging from ’3 months to one year‘ to more than 10 years. As the sample size of this population group is too small to conduct reliable statistical analysis, no gender comparison was conducted in the current study.

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Information on aged care workers’ general computer experience was gathered through collecting the following information:

� Participants’ self-reported current ability to use computers in general.

� Investigating participants’ pattern of computer usage.

� Asking participants whether they could type and what their typing speed was.

� Enquiring whether participants had received any formal computer training. If the answer was yes, the participants were further probed about which software packages they had been trained to use.



� Enquiring whether participants had used any online help system or if they would like to use an online help system to solve computer usage problems.

Sections 5.2.1 to 5.2.6 provide answers to the issues listed above.

5.2.1 How would you rate your current ability to use computers in general?

14.7% of respondents ranked their ability to use a computer as ‘poor’ and 11.2% as ‘below average’; therefore, 26% of respondents’ self-estimation of their computer ability was below average or poor. The highest proportion of respondents saw their current ability as average (28.4%), followed by 23.2% who ranked their ability as above average. 6.9% ranked their computer ability as excellent and 16% did not answer this question (see Table 7). If we take the responses of ‘average’, ‘above average’ or ‘excellent’ as being close to, or satisfying the basic skills needed for the daily use of a particular software system, then 58.5% of aged care workers participating in this survey are capable of using an information system in daily work practice providing that a strong training program is in place.

Table 7. The answers to the question, and number and percentage of respondents

Self-assessed computer ability

Poor Below Average

Average Above Average

Excellent No Answer

Total

No. of Respondents

17 13 33 26 8 19 116

Percent of Respondents

14.7% 11.2% 28.4% 23.2% 6.9% 16% 100%

5.2.2 What best describes your pattern of computer use?

Responses to this question provide a clear picture of which software is used by whom. Only 45 out of 116 participants (38.8%) answered this question. Figure 2 shows the percentage of respondents that gave answers to the six commonly used software packages.

The three most commonly used software packages by respondents are e-mail (93.3%), Word (91.1%) and Excel (71.1%). 68.9% of respondents use Web browsers and 48.9% play games. This is closely followed by 46.7% of that use PowerPoint (Figure 2).

Of the forty-five respondents who had experience with the software packages mentioned, 46.7% of them had experience with three to six types of software. 5.1% of respondents did not specify which software they frequently used.



Figure 2. The respondents’ pattern of usage of computers. The number on the histogram represents the number of respondents who selected the answer

The respondents were asked to rank the usage numerically from the most used to the least used. 48.9% of respondents selected Microsoft Word, 26.7% selected e-mail and 13.3% selected Microsoft Excel as the most frequently used software. 33.3% of respondents selected Web browsing, 22.2% selected Word or Email and 17.8% selected Excel as the second most frequently used software. 37.8% of respondents selected e-mail, 20% selected Excel and 15.9% selected Word as the third most frequently used software. PowerPoint is the least used software in the six types of software mentioned. Therefore, Word, e-mail, Excel and Web browsers are the software packages most frequently used by the respondents.

No significant difference in self-estimated IT ability was found for respondents in different age groups, facilities, occupations or aged-care work experience.

5.2.3 Can you type?

70% of the respondents can type, 12% have no typing experience and 18% did not answer this question (Table 8).

Table 8. The number and percentage of participants that can, cannot type and did not answer the question

Yes No No Answer

Can you type 81 14 21

Percentage 70% 12% 18%

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5.2.4 What is the approximate number of words per minute (wpm) that you can type?

The typing skills of the eighty-one respondents who claimed that they could type varied substantially. About 30% of respondents claimed to type 21 to 30 words per minute (wpm); 12% of respondents up to 10wpm, or 31-40 wpm, or 50+ wpm; 17% of the respondents did not know their typing speed. Consequently, if we take a typing speed of 21-30 wpm as the minimum typing speed required for using software on a daily basis, then 59% of respondents can use software without additional training in typing. If the implementation of an IT system started on a voluntary basis, the workforce should have enough people with adequate typing skills to interact with the computers.

Table 9. The number and percentage of respondents who can type at a certain speed

1-10wpm

11-20wpm

21-30wpm

31-40wpm

41-50wpm 50+wpm Don’t

know

No. of responses 10 9 24 10 4 10 14

Percentage 12% 11% 30% 12% 5% 12% 17%

5.2.5 Have you received any kind of formal computer training before?

There is no significant difference in response to this question between respondents with various degrees of experience in aged care and in different facility types. However, there is a significant difference between respondents in different occupations (p < 0.01) and age groups (p < 0.05).

Only 29% of respondents (n = 116) had received formal computer training; 46% of respondents under 30 years of age had received formal computer training (n = 22). However, only 26.3% of respondents above 30 years of age had received formal computer training (n = 94).

89% of clerks, 32% of PCWs/AINs, 15% of ENs, 15% of RNs and 14% of managers had received formal computer training. Apart from clerks, PCWs/AINs appear to have received considerably more formal computer training than other occupational groups. There is no significant difference in training received by ENs, RNs or managers.

Of the thirty-four people who received formal computer training, all received training in using Microsoft Word; 68% of them had received training in using PowerPoint; 56% had received training in using a Web browser; and 50% had received training in using e-mail. Only 38% had received training in using Microsoft Excel.

Eight respondents had received training in all of the software packages mentioned: Word, Excel, PowerPoint, Web browser and e-mail. Five of them are PCWs/AINs, one is a facility manager, one is an EN and one is a clerk. It is obvious that apart from clerks, PCWs/AINs are the group that received much more computer training than the rest of the groups. This may be attributed to the fact that PCWs/AINs are significantly younger than the other occupational groups. It is interesting to notice that only one RN and one EN mentioned that they had received formal computer training.



5.2.6 Have you used any online help system? Do you like the idea of using an online help system to learn to use a particular software package?

Only twenty-five respondents had experience using an online help system. Considering that forty-three respondents used one of the five software packages specified in the questionnaire, the ratio of computer users who consulted online help is 58%. When asked if ‘you like the idea of using an online help system to learn to use a particular software application’, obviously some respondents that had not used computer software previously also answered ‘yes’ to this question, because 53% of respondents (n = 116) answered ‘yes’, they would use online help.

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The five high-care and five low-care facilities investigated all utilise a computer-based care plan to a certain extent. At the time of the site visits in November and December, 2004, the facilities were undergoing the process of installing Intranet and Internet connections. They had all received new computers allocated by the South Eastern Region Office. A pager system for communication between staff was in place in all of the facilities.

Four high-care facilities, Unanderra Nursing Home, Mirinjani Nursing Home, Mayflower Nursing Home and Uniting Care-Shoalhaven (no direct visit was made to this nursing home due to the Director of Nursing being fully occupied and not agreeing to a visit), use the same commercial care plan package, Care Plan III.

The following sections describe in detail the current nursing documentation practice in each facility at the time of the visit by the researchers.

5.3.1 Unanderra Nursing Home

The RNs in Unanderra Nursing Home update the care plan daily on one computer that is designated for writing the care plan. This practice has been in place for more than three years. The task of data entry is performed by two RNs who have better computer skills than the others. The RNs regularly update the care plan at 4.00 pm each day. However, all the RNs are given read and write access to the program. This facility has the highest rate of usage of computers by RNs. During focus group discussions, the RNs all agreed that they would rather use an electronic care plan than handwriting, although some of them mentioned that the software still needed to be improved. Some functions are not relevant to their work practice. More functions need to be built into the software.

Unanderra Care Services has participated in a Commonwealth funded Aged Care Product Trial namely, ‘Electronic Prescribing’.

5.3.2 UnitingCare-Mirinjani Canberra

This facility is also a participant in a Commonwealth funded Aged Care Product Trial namely, ‘Clinical Monitoring’. At the time of the visit, there were a total of eighteen computers (including the recently allocated ones) in the facility. Computers are used for administration, rostering and



documentation purposes. An electronic care plan has been in use in the facility for two years. The Care Manager generates the care plan and prints it out as hard copy. All of the care staff is given access to documentation.

As the legislative requirements for nursing documentation in the ACT is different from that in NSW, the nursing documentation practice in Mirinjani is quite different from that of the facilities in NSW. The care plan is evaluated every two months, or whenever there is a turnover of residents. After the care plan is generated on the computer, changes are made on hard copy. Care workers write progress notes by hand two or three times in each shift. Registered Nurses need to spend at least one hour per day to complete documentation. Personal Care Workers spend at least one hour each day on progress notes. The time spent on documentation in Mirinjani appears to be less than that in the majority of facilities in NSW.

The researchers are very impressed by the computerised medication system (MPS) used in the high-care and low-care facilities in Mirinjani. The resident’s name and time for the administration of medication is printed on the packaged plastic bag that holds the medication. The nurse checks the name labelled on the bag against the patient’s name, tears off the bag and gives the medication to the relevant patient. It saves time on dosage checks and decreases the chance of medication error.

5.3.3 UnitingCare Mayflower Nursing Home

There are two computers used by management and a receptionist in UnitingCare Mayflower Nursing Home. The care plan is generated by the Deputy Director of Nursing (DDON) with help from one RN, then printed and updated by RNs on paper. The care plan should be reviewed by the RNs every day, but in practice this is not feasible. Normally it is done once a week or fortnightly. The DDON then enters the revised care plan into the computer when time allows. Enrolled Nurses and AINs update progress notes daily, normally before each shift. This typically takes half an hour. At the time of the visit, five nursing staff were enrolled in a Computer Program Certificate Level II training course. The facility is in the process of installing Intranet and there will be two computers located at the nursing station.

5.3.4 Georges River Presbytery Aged Care

There is one high-care facility (Leisure World Nursing Home) and four hostels in Georges River Presbytery Aged Care. The Manager of Care Services designed a Microsoft Excel-based care plan. The Director of Nursing or facility manager generates an electronic care plan based on this template, which is then printed and updated by RNs in the high-care facility. The care plan is evaluated and updated very two months.

Enrolled Nurses will spend probably three or four hours per day on documentation. Personal Care Workers are involved in care plans in some hostels. Assessment forms were also developed in-house. Progress notes are paper-based. Only RNs and ENs write progress notes at the end of shifts in Leisure World Nursing Home.



5.3.5 Banks Lodge

There are three computers in this hostel. One is used by the manager; one by the receptionist and the third one is located in the office. It is worth mentioning that every care worker has access to the third computer and obviously PCWs have tried to write care plans and progress notes using this one. Care plans are evaluated every two months. The evaluation is conducted by the Facility Manager, who is the only full-time RN working in the hostel. There is an allocated rotating RN who works at each facility approximately sixteen hours per week. The Facility Manager needs to spend 16-17 hours per week on the care plan. Personal Care Workers do care plan evaluations in the morning and after lunch they write progress notes. One PCW mentioned that she compiled rosters on the computer.

5.3.6 Roberts Lodge

There are two computers in this hostel. Personal Care Workers write progress notes and assessment, but not care plans. They spend two hours per day on writing progress notes. The Facility Manager and one part-time RN are responsible for the care plan.

5.3.7 Bankstown Uniting Centre

This hostel also has two computers. Care plans are drawn up by the Facility Manager and a support RN, who comes twice a week on average. Personal Care Workers are involved in updating care plans, writing progress notes and assessment results. It normally takes a PCW between forty-five minutes and one hour each day to complete nursing documentation. Sometimes this may take two hours.

5.3.8 Problems with the current nursing documentation practice

Of the ninety-five people who responded to this question, 71% of them considered the time consuming nature of a paper-based record system to be the major problem, followed by the large storage space required (51%), lack of legibility (40%), difficulty in retrieving the previous records (31%), difficulty in updating resident information (29%) and misuse of resident information (11%) (Table 10).

During focus group discussions, aged care workers all complained that nursing documentation had taken away a significant proportion of their work time, resulting in less time for direct care of the residents.



Table 10. The percentage of respondents and their rating of the problems for the current resident record management system

Problems listed Percentage of respondents (n = 95)

Time consuming 71

Requires large storage space 51

Not legible 40

Difficult to retrieve the previous records 31

Difficult to update resident information 29

Misuse of resident information 11

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A need-satisfaction theoretical model (Salancik & Pfeffer 1977) suggests that when the characteristics of a job are compatible with the needs of the person responsible for the job, the person is satisfied. The level of satisfaction has an important influence on attitudes, motivation and behaviour towards the job. Herzberg et al. (1969) commented that identifying and meeting employees’ needs is critical to individual and organisational performance. The employers who identify and meet employees’ needs tend to experience high job satisfaction and low turnover. Therefore, the importance employees’ attitudes, motivation and behaviour towards their jobs necessitates an investigation of this issue before assessing aged care workers’ attitudes towards the introduction of an innovation such as computer-based nursing documentation practice.

Sections 5.4.1 to 5.4.5 describe in detail answers to the questions in the original questionnaire. These responses suggest that the aged care workers that participated in the survey are happy with their job. They are used to the way nursing documentation is conducted in the current practice and happy with management. An alternative explanation might be that they are reluctant to change without knowing the impact of a new practice. Our survey results agree with the conclusion made by Richardson (2004) that ’staff express quite high levels of job satisfaction’.

5.4.1 Are you happy with working in your facility?

A very high level of staff satisfaction was found: 56.9% respondents (n = 112) are happy, 34.5% are very happy and 2.6% are somewhat happy with their facility. None of the respondents selected the answer ‘Not at all’. Four people did not answer this question. There is no significant difference in answer to this question among respondents from different facilities, occupations or age groups. This suggests that there is a consistent and high level of job satisfaction across the population groups surveyed.



5.4.2 How important is staff satisfaction valued at your facility?

90.4% of respondents are happy with the way staff satisfaction is valued at their facility. There is no significant difference in answers to this question between respondents from different facilities, occupations, age groups or aged care work experience. Only 2.6% of respondents (n = 116) answered ‘It is a low priority’ and 23.3% thought ‘It is a mid-level priority’. The majority (67.2%) perceived ‘It is a high priority’; 2.6% of respondents selected ‘Don’t know’, and 4.3% did not answer this question (Table 11).

Table 11. Aged care workers’ perception on how importantly staff satisfaction is valued at their facility

Frequency Percentage (%)

It’s a low priority 3 2.6

It’s a mid-level priority 27 23.3

It’s a high priority 78 67.2

Do not know 3 2.6

Did not answer 5 4.3

Total 116 100.0

5.4.3 Are you happy with the current nursing documentation practice?

There was no significant difference in answers to this question among age groups, occupations, aged care work experience and facility type. The average answer is close to ‘neutral’. 1.7% of respondents selected ‘extremely unhappy’, 14.7% selected ‘unhappy’, 50.9% selected ‘neutral’, 25% selected ‘happy’, 1.7% selected ‘extremely happy’ and 6% of people did not answer this question (n = 116, Table 12). It appears that although not fully satisfied with the current nursing documentation practice, the respondents are used to it and see it as the way things are. They may not see much need for change, or they are uncertain what change will bring and whether it will be beneficial to them. Therefore, their answer to this question is neutral.

Table 12. Aged care workers’ happiness with the current nursing documentation practice

Frequency Percentage (%)

Extremely unhappy 2 1.7

Unhappy 17 14.7

Neutral 59 50.9

Happy 29 25

Extremely happy 2 1.7

Did not answer 7 6

Total 116 100.0



5.4.4 Does management encourage the collection and sharing of information about best practice?

80.1% of respondents answered ‘yes’, 0.9% answered ‘no’ and 19% did not answer this question (n = 116). Although there were some reservations in answering this question, the majority of respondents are happy with their managements’ attitude towards collecting and sharing information about best practice.

5.4.5 Is it necessary to create formal procedures to ensure that lessons learned in work practice are passed on to others doing similar tasks in the facility?

The answers given by respondents to this question are highly uniform. Of 101 respondents who answered this question, only 1.7% selected ‘no’ as the answer. 84.5% selected ‘yes’ and 13.8% did not answer this question. It appears that the majority of respondents fully understand the importance of a formal procedure to ensure that lessons learned in work practice are passed on to others doing similar tasks.

The results imply that it might be relatively easy for the introduction of an IT system if an effort was made to persuade aged care workers that the new practice could ultimately contribute to the creation of formal procedures to facilitate communication. Maybe e-mail, bulletin boards, newsletters and notice boards are effective and acceptable solutions for achieving this goal.

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The enabling role of IT can only be realised when the workforce accept, adopt and integrate the technology into their daily work practice. Therefore, it is important to understand the attitudes of the workforce towards computer-based nursing documentation practice before an effort is made to actually introduce the practice. Sections 5.5.1 to 5.7 describe in detail answers to the following questions:

� To what degree do aged care workers trust the reliability of a computer-based documentation system?

� Would they like information technology to be introduced into their facility?

� If a new computer-based documentation system is introduced into the workplace, will they use it?

5.5.1 To what degree do you trust the reliability of computer systems?

80% of respondents (n = 116) trust the reliability of computer-based systems. 4% fully trust computer systems, 44% trust the system strongly and 32% trust the system. This suggests that the majority of respondents (80%) trust the system to a reasonably strong level. Only 16% did not quite trust the system and 5% did not answer this question (Figure 3).



Figure 3. The percentage of respondents that selected different level of trust for computer-based information systems. The legend on the upper right corner of the diagram describes the meaning of

the numbers on ‘X’ axis

5.5.2 Would you like information technology to be introduced into your facility to manage care?

The majority of respondents support the strategy of introducing information technology to manage care information in residential facilities. 87% of respondents answered ‘yes’, 6.7%, answered ‘no’, and 6% did not answer the question. There is no significant difference in answer to this question among different age groups, occupations, facilities and aged care work experience.

5.5.3 If your workplace introduced an electronic nursing documentation system, would you use it?

A significant difference was found in the final selections of the six options provided. 52% of respondents answered ‘yes’ to this question, 36.2% considered ease of learning a system as a priority for use, 30% regard ‘significantly reduce the time taken’ as a prerequisite for their consideration to use, 8% saw ‘management insisted’ as a condition for using and 4.3% of respondents were either not sure about their decision or just simply said that they would not use the system (Table 13). There is no significant difference in answers to this question among respondents in different facility types, age groups, aged care work experience or occupations. As multiple choices are allowed, some respondents selected more than one answer for this question; therefore, the total percentage of answers may exceed 100%.

9

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1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

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32%

44%

3%5%

1 2 3 4 5 No Answer

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2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

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2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

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8% 8%

32%

44%

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4. 76 to 100%

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4. 76 to 100%

5. 100%

8% 8%

32%

44%

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1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

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1 2 3 4 5 No Answer

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5. 100%

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4. 76 to 100%

5. 100%

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32%

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1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

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2. 26 to 50%

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4. 76 to 100%

5. 100%

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4 6

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4. 76 to 100%

5. 100%

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1 2 3 4 5 No Answer

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2. 26 to 50%

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4. 76 to 100%

5. 100%

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4. 76 to 100%

5. 100%

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1 2 3 4 5 No Answer

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4. 76 to 100%

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1 2 3 4 5 No Answer

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5. 100%

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4 6

1 2 3 4 5 No Answer

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2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

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2. 26 to 50%

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4. 76 to 100%

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4 6

1 2 3 4 5 No Answer

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2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

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3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

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1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

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9

37

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4 6

1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

3%5%

1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

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4 6

1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

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1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

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37

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37

51

4 6

1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

3%5%

1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

3%5%

9 9

37

51

4 6

1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

3%5%

9 9

37

51

4

1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

3%5%

9 9

37

51

4 6

1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

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9 9

37

51

4 6

1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

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4 6

1 2 3 4 5 No Answer

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2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

3%5%

1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5.

6

1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

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4 6

1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

3%5%

1 2 3 4 5 No Answer

1. Less than 25%

2. 26 to 50%

3. 51 to 75%

4. 76 to 100%

5. 100%

8% 8%

32%

44%

3%5%



Table 13. The answers to the question, the number and percentage of respondents who answered the question

The answer No. of respondents that answered

Percentage of respondents

Yes 61 52.6%

Yes, if it is easy to learn 42 36.2%

Yes, if it would significantly reduce the time taken 35 30.1%

Yes, if management insisted 9 7.8%

No 5 4.3%

Not sure 5 4.3%

Total No. of respondents 116 100%

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It is commonly recognised that one of the main advantages of a computer-based nursing documentation system is that it facilitates the sharing of resident information amongst facilities inside one management group and with healthcare service providers externally. Three questions were asked to seek aged care workers’ opinions on standardising documentation practice and sharing resident information. Sections 5.6.1 to 5.6.3 details the answers to these questions.

5.6.1 Electronically sharing resident information internally between aged care facilities in the same management group and with outside service providers

Of the 116 respondents, 29.3% did not answer this question. 53.4% believed it was a good idea and 17.2% disagreed with sharing resident information between aged care facilities and outside service providers (Table 14).

Table 14. The respondents’ answers to sharing resident information internally and externally, the number and percentage of respondents who give the answer

Sharing resident information is a good idea

No. of respondents that answered


Yes 62 53.4

No 20 17.2

No Answer 34 29.3

Total 116 100.0



5.6.2 Which outside healthcare service providers should aged care facilities share information with?

The respondents were asked to select which outside health service providers aged care facilities should share information with. There are seven options for this question, namely: GP, Hospital, Pharmacy, Radiology, Pathology lab, Specialists and Allied Health. The respondents were given the option to select more than one answer. 81.9% of respondents selected the GP as the first choice, followed by the pharmacy (71.6%), then the hospital (65.8%), then the specialist (55.3%). 44% of respondents selected allied health and pathology. Only 32.8% believe that aged care facilities should share information with radiology (Table 15). There is no significant difference in answer to this question in respondents grouped by facility type, occupation, age or aged care work experience.

Table 15. The number and percentage of respondents that agreed with sharing resident information with outside healthcare service providers: GP, pharmacy, hospital, specialist, allied health, pathology

and radiology

Service providers to

share information

with

GP Pharmacy Hospital Specialist Allied Health Pathology Radiology

No. of respondents 95 83 76 64 51 51 38

Percentage of respondents (n = 116)

81.9% 71.6% 65.8% 55.3% 44% 44% 32.8%

5.6.3 Is developing an electronic resident management system to capture and circulate information amongst facilities in one management group beneficial?

64% of respondents selected ‘yes’ to this question and only 2.6% answered ‘no’. However, 32.8% of participants did not answer the question, which might indicate that they were either not really keen to adopt the practice, or had reservations about the practice (see Table 16).

Table 16. The number and percentage of respondents who believe that using an electronic resident management system to capture and circulate information amongst facilities in one

management group is beneficial

Capturing and circulating information electronically amongst facilities in one management group is beneficial

No. of respondents Percentage of respondents

Yes 75 64.7

No 3 2.6

No Answer 38 32.8

Total 116 100.0



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5.7.1 Is it important to receive adequate training in computer usage, such as typing skills, word processing etc. before you would like to learn to use a particular electronic nursing documentation system?

48% of respondents selected ‘yes’ to this question and 16% answered ‘no’. 36% of respondents did not answer this question, indicating that they were sceptical about the effect and benefit of computer training.

5.7.2 If an electronic nursing documentation system was introduced into your workplace that requires you to be retrained for that task, would you be willing to do so?

An overwhelmingly majority of respondents (87%) claims to be willing to be retrained to use an electronic nursing documentation system if ultimately it would be beneficial. The second most mentioned motivation is reducing time taken to complete a task (26%), followed by reducing repetition in the job (22%). Only a small number of respondents see mandatory requirement from management as an influencing factor and only one explicitly answered ‘no’ to this question. 3% of respondents were not sure and 4% did not answer the question (see Table 17). The respondents were allowed to select more than one answer for this question.

The significant difference in the number of respondents to the first answer and that of the rest of the answers suggests that the workforce really puts caring for residents and benefits for the organisation much higher than just convenience for doing the job. Again, the survey results reflect that the workforce has a highly responsible attitude towards their job.

Table 17. The content of the answer, number and percentage of participants that responded

The answer No. of respondents answered


Yes, if ultimately it would be beneficial 101 87%

Yes, if it greatly reduces time taken to complete a task 30 26%

Yes, if it helps to reduce repetition in my job 26 22%

Yes, only if I was required to do so by management 7 6%

No answer 5 4%

Not sure 4 3%

No 1 0.80%

Total participants 116 100%



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Apart from three respondents that did not answer this question, 113 selected one or more answers to the ten listed potential advantages of a computer-based nursing documentation system. Two respondents identified two extra benefits that are not on the list, namely: it would facilitate the implementation of educational programs and it would be environmentally friendly.

The major perceived benefits of introducing computer-based nursing documentation practice are (n = 116):

� Time saving - 76% of respondents

� Legibility - 72% of respondents

� Reducing storage space and easy information retrieval - 64% of respondents

� ‘Ease to use’ - 60% of respondents

� Reducing duplication and useful - 50% of respondents

� Facilitating statistical analysis – 45% of respondents

� Operational convenience thus derived - 43% of respondents

� Management decision support - 33% of participants

No significant difference in answers was found for the respondents in different age groups, occupations, work experience, facility types and current IT abilities.

Figure 5 presents the benefits of electronic nursing documentation identified by interviewees and focus group participants. Again, time saving is identified twenty-two times as the most important benefit. Legibility or sophisticated report functions available in an electronic documentation system was identified eleven times as an important advantage. Easy to edit and revise, reducing duplication, timely information, more secure and less paper are benefits each identified on four occasions. The benefit of reducing error was identified three times.

Figure 4. The number of times a benefit is mentioned by participant in interviews and focus group discussions

0 5 10 15 20 25

Legibility

Timely information

Less paper

Reducing error

0 5 10 15 20 25

Legibility

Timely information

0 5 10 15 20 25

Legibility

Sophisticated report functions

Timely information

0 5 10 15 20 25

Time saving

Easy to edit and revise

Reducing duplication

More secure

0 5 10 15 20 25

Legibility

Timely information

Less paper

Reducing error

0 5 10 15 20 25

Legibility

Timely information

0 5 10 15 20 25

Legibility

Sophisticated report functions

Timely information

0 5 10 15 20 25

Time saving

Easy to edit and revise

Reducing duplication

More secure



Both quantitative and qualitative data suggest that time saving is the most commonly recognised benefit, followed by legibility. The third commonly recognised benefit suggested by qualitative data is sophisticated reporting functions. This benefit might be considered as a combination of ‘easy information retrieval’, ‘statistical analysis’ and ‘decision support’ listed as options in the questionnaire. Reducing storage space was the third most commonly identified advantage in the questionnaire survey; however, it was somewhat ignored in interviews and focus group discussions. Therefore, the benefits of a computer-based nursing documentation system represents a perfect solution for the problems of the current nursing documentation practice that have been identified by aged care workers in Section 5.3, namely: time consuming, requiring large storage space and illegible, etc.

5.8.2 The perceived benefits for care service delivery if introducing an electronic nursing documentation system into work practice

All 116 respondents answered this question (Table 18). The top four advantages of introducing an electronic nursing documentation system into work practice for care service delivery are:

� More time spent on direct care of residents (70%)

� Improving resident information management (55%)

� Saving time on documentation (53%)

� Improving work process (49%)

Table 18. Responses to, ‘What is the perceived impact of introducing a computer-based nursing documentation system into your facility’ and the percentage of respondents that gave the answer

Answers to the question Percentage of respondents

More time spent on direct care of resident 70

Improving resident information management 55

Saving time on documentation 53

Improving work process 49

Data analysis 36

Trends analysis 23

A change in aged care facility's awareness about the importance of integrating resident information 22

Improving facility's public image 16

Saving money 10

Workforce retention 9



The major opportunities for improving care service delivery if introducing computer-based nursing documentation, as identified in the SWOT analysis in interviews and focus group discussions, are listed in Figure 6. The information gathered through the interviews and focus group discussions is similar to the results acquired through the questionnaire survey. More time spent on patient care is the direct consequence of improving the efficiency of nursing documentation. Both of these have the highest response rate. ‘Standardising forms and data’ was not listed as a potential answer on the questionnaire. This important outcome was identified on twelve occasions in interviews and focus group discussions. Respondents in both qualitative and quantitative studies identified the benefit of improving information management. The benefit of improving communication was identified on six occasions in interview and focus group discussions.

Figure 5. The major opportunities for care service delivery if introducing computer-based nursing documentation as identified in the interviews and focus group discussions

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Ten reasons were listed for respondents to select as answer to this question and multiple choice was allowed. Only 82% of respondents (n = 116) answered this question. ‘Not enough computers in the work place’ is the obstacle recognised by 32% of respondents. ‘Computer skill deficiency of workforce’ was identified by 28%, followed by ‘no technical person to provide support when problems occur’ (23%) (see Figure 7). One respondent wrote ‘not relevant to my job description’ as a reason for not using a computer-based system. However, one AIN commented that, ‘if the nurses received the training when it is introduced, I don't see any reasons against it’.

None of the listed reasons were supported by more than half of the respondents. No additional comments except the one mentioned was raised. This might indicate that the majority of respondents do not believe that the barriers to the introduction of an electronic documentation system are insurmountable. Although ‘not enough computers in the facility’ was a problem identified by the largest percentage of respondents, it was only identified by 32% of them. The alternative interpretation of the message might be that 68% of respondents do not see ‘not enough computers’ in the workplace as a problem. Thus, it could be concluded that aged care workers participating in the survey are quite positive about introducing a computer-based documentation system into aged care facilities.

0 2 4 6 8 10 12 14





Number of times mentioned



Decision support

0 2 4 6 8 10 12 14





Number of times mentioned



Decision support



Figure 6. Percentage of respondents and their answers to the main reasons against the introduction of computer-based nursing documentation system

The participants in interviews and focus group discussions gave detailed elaboration about the potential problems involved in introducing a computer-based nursing documentation system. The six major problems synthesised from discussions are: not enough qualified employees, management issues, limited resources, training issues, negative attitudes of nurses and limitation of IT solutions.

The problems related to the ‘lack of qualified employees’ include the lack of confidence that management have that aged care workers possess the basic computer skills required for using a computer-based system. This is again attributed to the phenomenon that aged care workers rarely use, or even have the opportunity to be exposed to computers in the work place. Another problem identified is the difficulty in getting qualified IT support staff as the number of IT support staff employed in the industry is limited.

The management issues that are identified include: the current legislation discouraging the use of computers, for example, electronic signatures are not yet accepted; the introduction of IT solutions for nursing care information management is often not treated as a high priority in aged care; the negative attitudes of management towards the introduction of IT solutions: and the lack of experience in handling the technical problems that might occur during the implementation of an information system.

Limited resources is embodied in: the insufficient number of computers which are currently available for satisfying the needs of nursing documentation by all of the care staff; the tight work schedule makes it difficult for aged care workers to get enough time to learn how to use an IT

5

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system; the general lack of funding to support the introduction of an IT system; and inadequate support overall.

The obstacles to training include: the older workers had not received any formal computer training; language problems for aged care workers whose English is a second language; the general IT skills and knowledge of the whole workforce need to be improved.

The negative attitudes of nurses are represented by a failure to perceive the benefits of IT and the general negative attitudes towards the introduction of IT solutions.

The limitation of IT solutions includes: technical problems that might occur in the software, hardware and communication network; the information system introduced may not comply with nurses’ workflow; it may not satisfy nurses’ needs for nursing information.

Table 19. The six major categories of obstacles for the introduction of computer-based nursing documentation system identified in focus group discussions and interviews, along with the

subcategories of obstacles (the numbers in brackets refer to the number of times the issue was mentioned)

Lack of qualified employees (70)

Management issues (60)

Limited resources

(45) Training

(39)

Negative attitudes of nurses (19)

Limitation of IT solutions

(11)

Nurses’ basic computer skills

(41)

Legislation requirements

(30) No computer

(18) Age (21)

Failure to perceive

benefits of IT (10)

Technical problems (5)

Limited use of computer (11)

Business priority (23) Time (18) Need

training (7) Against

introduction (9) Not nursing specific (4)

Qualified IT support staff (11)

Attitudes of management

(7) Funding (9) Support (6)

Limitation of information

(2)

Limited exposure to computers (7)

Language problems

(5)

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42% of respondents (n = 116) answered ‘yes’ to the question asking if there is any area of work that could be improved through introducing an electronic information system, 7% answered ‘no’ and 51% of respondents did not answer the question.

Forty-one areas of nursing work practice have been identified by participants as having potential to be improved through the introduction of an information system. These areas cover the entire business process of caring for a resident. Table 20 lists the areas that were identified by at least two respondents. The care plan is the commonly identified practice, followed by progress notes, general nursing documentation, medication management and assessments.



The management may need to pay close attention to the opinions of the workforce gained through answering this question. The workforce is interested in and motivated by the introduction of an information system to improve work practice that is directly related to caring for residents and nursing practice, instead of improving administrative functions. Aged care workers’ interest in IT solutions is obviously different from those at the top management level, who are more concerned about management issues rather than utilising technology to improve work conditions and practice of frontline workers. The difference in managers’ and aged care workers’ point of view for the introduction of IT solutions will be discussed in another paper. However, if the two are not properly harmonised, the success of introducing innovative IT solutions may be problematic.

Table 20. The major areas of care practice that could be improved by the introduction of an information system, and the number of times the issue was mentioned by the survey participants

Area that could be improved by IT No. of times mentioned

Care plan 17

Progress notes 15

Documentation 12

Medication 6

Assessments 4

Maintenance management 3

RCS preparation 3

Budgeting 2

Communication 2

Handover 2

Order process, inventory 2

Resident admission systems 2

Time management 2

Update of NCP 2

Decision support 2

The distribution of respondents who provided answers to the above question is shown in Table 21. It appears that RNs and respondents at facility management level are more actively considering the issue of work practice improvement followed by ENs. Personal Care Workers and clerks rarely considered issues about the benefits to improvements in work practice.



Table 21. The number and percentage of respondents in different occupations who identified the area of care practice that could be improved by IT

Clerk Personal

Care Worker

Enrolled Nurse

Registered Nurse Manager

Number of participants answered the question

3 21 7 13 16

Total No. participants 9 63 13 13 17

Percentage of participants 33% 33% 54% 100% 94%

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The answers given to this question indicate that only limited numbers of respondents have much experience about the possible IT solutions. Few aged care workers are aware of the technologies available and how they could benefit their work practice. 42% of respondents (n = 116) answered ‘yes’ to the question asking if there is any area of work practice that could be improved by IT solutions. 7% of respondents answered ‘no’ to this question and 51% of respondents did not answer the question.

The respondents were asked to select one of the three types of technologies: PDA, Tablet and Barcode that they would like to see introduced into aged care. Only seventeen people answered this question. Among them, 71% preferred the introduction of Barcode and 29% preferred PDA or Tablet technology to be introduced into care practice. One respondent mentioned Palm Pilot and notebook computer.

Of the seventeen people who answered this question, eight are staff at the management level, two are RNs and seven are PCWs/AINs. Again, it appears that the respondents at facility management level are more actively considering the potential of innovation than those in other roles. Seven PCWs/AINs answered the question, indicating that they are more open to new opportunities than ENs, none of whom answered this question.

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According to the Technology Acceptance Model (TAM) developed by Davis (1989), end users’ behavioural intentions to use an information system in a voluntary situation is determined by their perceived usefulness and perceived ease of use of the system. The modified TAM2 model incorporates the social and organisational impact on perceived usefulness, perceived ease of



use and behavioural intention to use. We tested the respondents’ acceptance of the idea of introducing an information system to manage nursing documentation using the initial model (Figure 1) modified from TAM2. Sections 5.12.1 to 5.12.4 present the results of this analysis.

5.12.1 What attributes lead an aged care worker to believe that an information system is easy to use?

Aged care workers’ perception about ease of use of an information system is significantly influenced by their IT ability, subjective norm, support and policy in the organisation, age and the perceived threat to their jobs if the system were introduced.

Aged care workers tend to think that it would be easy to use a new information system if:

� they had better IT skill sets

� they received managers’ and colleagues’ encouragement

� formal guidance was available to them, a specific group was available for assistance and they had a solid ‘network of support’

� the organisation had an IT policy for improving staff’s IT knowledge

� they were convinced that the IT system introduced could facilitate their care decision-making

� the organisation had an IT policy that ensures the confidentiality of resident information

Aged care workers tend to think that it would be difficult to use a new information system if:

� they were older

� they believed that using the system would increase their documentation load

� the introduced system would replace their jobs

5.12.2 What are the factors that lead an aged care worker to consider an information system as useful?

Aged care workers’ perceptions about the usefulness of an information system is significantly influenced by external factors such as subjective norm and organisational policy. Other factors, such as image, aged care work experience, type of facilities, occupation, age and support have no significant impact on the perceived usefulness of an information system by aged care workers.

The following factors determine aged care workers’ attitudes towards the usefulness of an information system:

� whether using an IT system could enhance their effectiveness and quality of work



� whether using an IT system may make it easier to do their work and increase their productivity

� whether using an IT system is relevant to the delivery of residential care

� their manager’s opinion on the benefits of a particular IT solution

� their colleagues’ encouragement for usage

� the organisation’s IT policy that facilitates their acquisition of IT knowledge and skills

� whether they are convinced that the system introduced can facilitate their care decision-making

� whether the organisation has an IT policy that ensures confidentiality of resident information

5.12.3 Aged care workers’ intention to use an information system

Aged care workers’ intention to use an information system is positively related to their perceived usefulness and perceived ease of use of the system (Figure 8). The respondents strongly disagreed with the statements, ’people at other aged care facilities who use IT solutions have more prestige than those that do not use IT solutions‘; ’people at other aged care facilities that use IT solutions have a high profile‘, and ’using IT solutions is a status symbol of my aged care facility‘. This suggests that aged care workers disagree, or are negative about the assertions made in the above coded answers. In other words, aged care workers do not believe that people at other aged care facilities that use IT solutions have more prestige or a higher profile than those that do not use IT.

5.12.4 Factors determining aged care workers’ acceptance of information systems

Figure 8 outlines the validated quantitative model for measuring aged care workers’ acceptance of an information system before any experience with a particular system is established. The model suggests 41% of aged care workers’ perception about ease of use is attributed to their IT ability, subjective norms and support in the organisation, their age, perceived threat to their jobs and organisational policy. Their perception about usefulness is influenced by subjective norm, IT policy in the organisation and their perceived ease of use.

For an aged care worker who does not have any experience with a particular clinical information system, that person’s intention to use an information system is partly determined by his/her perceived usefulness and perceived ease of use of the system. As explained in Section 5.12.3, the negative correlation between image and behavioural intention to use an information system suggests that status has nothing to do with aged care workers’ intention to use information systems.



Figure 7. The final verified quantitative model to predict aged care workers’ acceptance of an information system for managing care before any system is introduced

Facility type, occupation and aged care work experience has no impact on aged care workers’ intention to use a new information system.

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Interview and focus group discussions suggest that the major challenges for introducing an information system into aged care facilities are: firstly, resistance to change; and secondly, technical issues. The third commonly identified challenge is cost, followed by the senior age of the workforce (Figure 9).

Figure 8. The participants’ major concerns about implementing computer-based nursing documentation identified in interviews and focus group discussions

0 5 10 15 20 25 30 35

Technical issues

Change practice

Security concern

Care outcomes

Change of skill sets

Cost

Change of communication pattern

Privacy and confidentiality

Return on investment

Lack of incentives


30

24

11

11

8

5

5

5

4

3

31Resistance to change

Age 21

0 5 10 15 20 25 30 350 5 10 15 20 25 30 35

Technical issues

Change practice

Security concern

Care outcomes

Change of skill sets

Cost

Change of communication pattern

Privacy and confidentiality

Return on investment

Lack of incentives


30

24

11

11

8

5

5

5

4

3

31Resistance to change

Age 21

PerceivedUsefulness



Threat to Job

0.2*

-0.26***

0.33***

-0.19**

0.18*

0.21*

R2 = 0.41

0.21**

0.36***

0.28**R2 = 0.40(0.42)

0.22*

0.33***

R2 = 0.23IT Ability

Age

Policy

SubjectiveNorm

Support

Policy

SubjectiveNorm

Image

-0.24**PerceivedUsefulness



Threat to Job

0.2*

-0.26***

0.33***

-0.19**

0.18*

0.21*

R2 = 0.41

0.21**

0.36***

0.28**R2 = 0.40(0.42)

0.22*

0.33***

R2 = 0.23IT Ability

AgeAge

Policy

SubjectiveNorm

SupportSupport

Policy

SubjectiveNormSubjectiveNorm

Image

-0.24**



5.13.1 The cultural resistance to change

The negative attitude of the workforce towards IT usage is one of the biggest hurdles to IT adoption in the industry. In responding to cultural issues that affect the acceptance of IT within the aged care sector, it is mentioned several times that IT was not considered an important function of care delivery. All of the participants suggested that the industry viewed IT as too complex, too hard and not a core component of their business, or even viewed IT as an additional burden. It is observed that senior nursing staff had a psychological barrier regarding the adoption of new technology. Contrary to the survey data acquired from the questionnaire, which is quite positive, a lack of confidence is obvious in the interviewees regarding the capacity of the industry to effectively introduce an information system into work place.

5.13.2 Technical issues

Concerns about technology include the limitations of technology and the common fear of breaking the equipment. ’The other obstacle is when you have implemented it and it is not working properly from day one’. ’They could lose confidence and the other thing would be if there were bugs in the software then it would be an absolute disaster’.

Again, it was raised that there were not enough computers for documentation, as aged care workers tend to document all at the same time. One AIN raised the issue of ‘how many computers can you have because I am sure they would all want to use the computer at once.’ The speed of operation, virus infection, accidental deletion of information, network capacity, backup and disaster recovery, data migration, storage space versus cost, etc. were the issues raised. Information technology is seen as too hard or complex and an ‘additional burden’ by some aged care workers.

Interviewees commented that aged care workers are visual learners. Computer systems designed for them should be GUI based, in wizard style and intuitive. The lack of time for training to effectively use computers also contributes to aged care workers’ negative attitude towards IT.

5.13.3 Cost considerations

Cost is a big concern for the industry, especially under the situation of ’how strapped for cash the sector is‘. The sector is still sceptical about ’Will it actually produce a net saving?’ Cost is seen as ’being initial cost, and then cost by the extra burdens on staff’.

One of the major inhibitors for adopting an IT system in aged care is the cost of acquiring a system, hardware infrastructure, implementation and maintenance. Many facilities and institutions simply do not raise enough revenue nor receive sufficient funding from government sources, which, in turn, means the IT budget is often cut. All of the interviewees commented that cost is a big consideration when deciding whether or not an IT project should be given the go ahead.

Six respondents cited financial issues as being the most critical aspect. The cost of training, staff time and system maintenance were all considered hurdles. Barriers to the procurement of an information system were also raised in interviews. Decisions on whether an IT solution should be considered are usually determined by calculation of the perceived return on



investment (ROI) and whether the ROI could be realised in a given time frame, which is considered to be between eighteen months and five years. However, the ROI is often hard to quantify in a healthcare setting. So far no ROI for an information system has been properly justified in aged care. Consequently, the lack of convincing evidence to demonstrate the benefit of IT investment is a serious barrier to the adoption of IT in this sector.

For aged care managers, one big problem for the decision making regarding IT investment is the extreme difficulty in determining just exactly what level of expenditure is sufficient for the introduction of an IT system. When this is combined with the changing cost of IT, a decision on what to buy and at what price becomes an ongoing problem. Too much uncertainty presents a business risk. Resources in aged care are scarce. Therefore, if such risks are not properly justified, the only final decision that can be expected will be ’no-go’.

5.13.4 The aged work force

The average age of nurses working in aged care is 47 years compared to 41.8 in other clinical areas, which is a serious barrier to the adoption of information technology and this is mentioned twenty-one times in interviews and focus group discussions. It is also identified as a negative factor impacting on perceived ’ease of use‘. Some respondents do not believe that there are enough qualified people in the industry that can master the computer-based documentation practice. One AIN commented, ’I do not think they care. A lot of them are older. The younger ones probably are good with computers but have never had any need to use it here’. ’A lot of staff are old, technology is not what they learned in school, and the terminology is different. They feel excluded’.

A general lack of knowledge about IT and its usage and benefits has led to the prevailing fear or negative attitude of the aged care work force towards adopting IT. Some nurses believe that computers and a computerised documentation system will lead to the dehumanisation of work practice and nursing documentation, which is the most legitimate reason for them to oppose the introduction of IT. Interview results suggest that the lack of proper computer training has led some nurses to think that inputting data into a computer is tedious and wastes precious care delivery time.



6. Conclusions and Recommendations

There is a happy, positive and relatively stable work force in UnitingCare Ageing South Eastern Region. The majority of survey participants like their job, the people they care for and the organisation they work for. A typical worker in the South Eastern Region is between 40 to 59 years of age. Personal Care Workers/Assistants in Nursing are the youngest occupational group. Registered Nurses are the oldest; therefore, the organisation may need to consider strategies for attracting young RNs into the workforce. The organisation has a strong management team with 70% of middle-level managers in the age group of 30 to 50 years.

Although less experienced in care service delivery, PCWs/AINs are the occupational group with most computer training. Standardizing nursing documentation practice through adopting computerised documentation system might be an effective strategy to leverage the difference in computer skills and care experience among various levels of aged care workers to improve technical efficiency.

All of the facilities currently have a computer-based care plan in place. However, who generates the care plan and who enters data into the computer is dependent on the number of computers available and varies among facilities. Registered Nurses are the people entering data into the computer in Unanderra Nursing Home, which demonstrates that RNs are able to learn and use a computer-based nursing documentation system.

58.7% of respondents (n = 116) ranked their ability to use a computer as average, above average or excellent; 38.8% described in detail their pattern of computer usage; 70% can type. These facts suggest that more than half of the workforce have basic computer skill sets. Consequently, there will be an adequate number of early adopters if a new information system is introduced providing a systematically planned implementation, adequate training and effective support mechanism is in place.

Aged care workers’ attitude towards the introduction of an information system is mainly dependent on the benefits of the system for care service delivery and organisation, rather than just convenience of the job.

Although lacking the incentive to be innovators, aged care workers in the region fully understand the pros and cons of computer-based documentation compared with the current paper-based practice. They are willing to be retrained and adopt new practices if their organisation introduces a new information system and provides them with adequate support. The stability of the workforce makes planning for work process re-engineering and workforce training both valuable and relatively manageable.

The workforce recognises that the major obstacles for introducing a computer-based documentation practice are: lack of qualified employees, including lack of qualified IT support staff; management issues of implementation; limited resources; training; and the negative attitudes of nurses. Various strategies for overcoming the obstacles have to be developed to guarantee the success of implementation.

Given the benefit of such a happy, relatively experienced workforce and their positive attitude towards work process re-engineering, it is highly recommended that the board and management of UnitingCare Ageing South Eastern Region place on the agenda the



implementation of a computer-based nursing documentation practice. This will satisfy aged care workers’ willingness to adopt IT solutions to improve care information management and nursing documentation practice.

The business plan, product acquisition and implementation strategy for an IT implementation practice should be carefully designed and justified. The enthusiasm and positive attitude of the workforce should be appreciated and further nurtured during the transition into new computer-based practice. It is promising that IT solutions will deliver its benefit in improving work efficiency, communication, management decision-making and care standards in the organisation as envisaged by aged care workers that participated in this study.



7. Limitations of the Study

Limitations of the study are outlined below:

The pre-coded response choices in the questionnaire may limit the respondents’ replies and be confined by the choices given. The accuracy of the pre-coded response choices were justified by the similar results acquired in semi-structured interviews and focus group discussions. This suggests that the choices available for response given in the questionnaire are relatively well coded.

We must be aware that the validity of any survey is limited by sample size and errors. One hundred and sixteen people participated in this survey. Although Cronbach’s alpha shows satisfactory reliability (above 80%) and internal consistency, the KMO Test shows that sampling adequacy is achieved for the majority of Likert Scale Items, the external validity of the survey results need to be considered.

A total percentage of 99 or 101 may result from rounding off percentages.

The validity of our quantitative survey component is constrained by a lack of response from 60% of participants. The possible reasons for no responses are: (1) the information about the questionnaire survey was not disseminated to every potential survey participant due to shift work as there is a large proportion of part-time workers in the workforce, and only a proportion of them may have been present when facility managers distributed questionnaires to staff. (2) As aged care workers are always very busy during work time, the task of completing questionnaires might be assigned low priority, or even completely forgotten; (3) Aged care workers who do not believe that computer-based nursing documentation is of relevance to them or are completely against computerisation might simply not bother to complete the questionnaire.

As the total sample size is adequate, in order to minimise disturbance to the aged care work practice, no follow-up survey was attempted.

Without previous experience with a particular electronic nursing documentation system, some of the respondents did not answer many items in the Likert Scale questionnaire because they found question items difficult to answer. However, this test is specifically designed to answer the research question about aged care workers’ intention to use IT before they are influenced by any particular introduced information system. No responses to the Likert Scale items were treated as ‘neutral’ in value. However, ‘neutral’ does not help with drawing meaningful conclusions. Missing data leads to reduced accuracy and validity of results and conclusions.



9. References

Davis, FD, Bagozzi, RP & Warshaw, PP 1989, ‘User acceptance of computer technology: a comparison of two theoretical models’, Management Science, vol. 35, no. 8, pp. 982-1003.

Herzberg, F, Mausner, B & Snyderman, BB 1969, The motivation to work, Wiley, New York.

Richardson S 2004, The care of older Australians: a picture of the residential aged-care workforce, National Institute of Labour Studies, Flinders University.

Salancik, GR & Pfeffer, J 1977, ‘An examination of need-satisfaction models of job attitudes’, Administrative Science Quarterly, pp. 427-456.

Venkatesh, V & Davis, FD 2000, ’A theoretical extension of the technology acceptance model: Four longitudinal field studies’, Management Science, vol. 46, no. 2, pp. 186-204.

Documents

Health Care Workforce Report