Factors Influencing Nursing Students’ Acceptance of Electronic Health Records for Nursing Education (EHRNE) Software Program Yanika Kowitlawakul, Sally Wai Chi Chan, Joyce Pulcini, Wenru Wang PII: DOI: Reference:
S0260-6917(14)00194-4 doi: 10.1016/j.nedt.2014.05.010 YNEDT 2740
To appear in:
Nurse Education Today
Received date: Revised date: Accepted date:
13 January 2014 12 May 2014 19 May 2014
Please cite this article as: Kowitlawakul, Yanika, Chan, Sally Wai Chi, Pulcini, Joyce, Wang, Wenru, Factors Influencing Nursing Students’ Acceptance of Electronic Health Records for Nursing Education (EHRNE) Software Program, Nurse Education Today (2014), doi: 10.1016/j.nedt.2014.05.010
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Factors Influencing Nursing Students’ Acceptance of Electronic Health Records for Nursing Education (EHRNE) Software Program
PT
Yanika Kowitlawakul*, PhD, RN; Sally Wai Chi Chan, PhD, RN,FAAN; Joyce Pulcini, PhD, PNP-BC,FAAN,FAANP; and Wenru Wang, PhD, RN
RI
Authors
NU
SC
Yanika Kowitlawakul, PhD, RN (Corresponding author) Assistant Professor Alice Lee Centre for Nursing Studies/Yong Loo Lin School of Medicine National University of Singapore, Block MD 11, Level 2, 10 Medical Drive, Singapore 117597 Phone: +65-6601-1766, Fax: 65-6776-7135, Email: [email protected]
D
MA
Sally Wai Chi Chan, PhD, RN, FAAN Professor and Head School of Nursing and Midwifery, University of Newcastle Callaghan, Newcastle Phone: +61 2 4921 6770, Fax: +61 2 4921 6981, Email: [email protected]
AC CE P
TE
Joyce Pulcini, PhD, PNP-BC, FAAN, FAANP Professor The George Washington University, School of Nursing 2030 M St, NW, Suite 300, Washington, DC, 20036 Phone: +1-202-994-9536, Fax: 202-994-2777, Email: [email protected] Wenru Wang, PhD, RN Assistant Professor Alice Lee Centre for Nursing Studies/Yong Loo Lin School of Medicine National University of Singapore, Block MD 11, Level 2, 10 Medical Drive, Singapore 117597 Phone: +65-6516-5088, Fax: 65-6776-7135, Email: [email protected] Acknowledgements This study was funded by the Alice Lee Centre for Nursing Studies, Start- up Grant, at the National University of Singapore. We would like to thank the participants and faculty members who have been very supportive for the study. Word count Abstract = 201 Manuscript = 3,517 Total = 4,547 (including abstract, main manuscript, and references)
ACCEPTED MANUSCRIPT 2
Abstract
PT
The Institute of Medicine (IOM) and the Health Information Technology Act (2009) in America
RI
had recommended that electronic health records (EHRs) should be fully adopted by 2014. This has urged educational institutions to prepare healthcare professionals to be competent in using
SC
electronic health records (EHRs) while they are in schools. To equip nursing students with
NU
competency in using EHRs, an electronic health record for nursing education (EHRNE) has been developed and integrated it into nursing curricula. The purposes of the study were to investigate
MA
the factors influencing nursing students’ acceptance of the EHRs in nursing education using the extended Technology Acceptance Model with self-efficacy as a conceptual framework. The
TE
D
study is a descriptive study design using self-reported questionnaires with 212 student participants. The IBM SPSS and AMOS 22.0 were used to analyse the data. The results showed
AC CE P
that attitude toward using the EHRNE was the most influential factor on students’ acceptance. The preliminary findings suggested that to enhance the students’ acceptance of the EHRNE, cultivation of a positive attitude toward using this EHR as well as increasing the perceived usefulness is very important. Also, the study’s framework could be used in guiding learning health informatics and be applied to nursing students.
ACCEPTED MANUSCRIPT 3
INTRODUCTION The Institute of Medicine (IOM) and the Health Information Technology Act (2009) in
PT
the United States of America (U.S.A) had recommended that a nationwide mandatory reporting
RI
system should be established and electronic health records (EHRs) should be fully adopted by 2014 (Meyer et al., 2011). Since then, EHRs have extensively been implemented in healthcare
SC
delivery systems not only in the U.S.A, but also worldwide. The assumptions are that EHRs
NU
adoption would help to improve patient safety, increase health care quality, and reduce the health care costs (Bate, 2010; Cherry et al., 2010; Murphy, 2011). Several recent studies reported that
MA
healthcare professionals use the EHRs to share patients’ information to provide clinical advice and improve clinical practice (Matheson et al., 2012; Perera et al., 2011). In addition, electronic
TE
D
health data can be used by healthcare providers for research and evidence-based practice. Therefore, EHRs are becoming an essential system for documentation of health care information
AC CE P
around the world.
In Singapore, the Ministry of Health has decided that all public hospitals would implement the EHRs. Most hospitals in Singapore have adopted EHRs in their practice and health care professionals need to be competent in using this health information technology. It is therefore important to equip nursing students with such competency. Most nursing students studying for a nursing degree program learn their clinical skills in simulation centre before they embark on learning at clinical settings. In this study, paper-based documentation, such as documentation of health history, physical health assessment, and nursing interventions was used in the simulation centre. To equip the students with competency in using EHRs, an electronic health record for nursing education (EHRNE) software has been developed to allow the students to learn and use the EHRs. The purposes of integrating EHRNE into nursing education program
ACCEPTED MANUSCRIPT 4
are to cultivate students’ awareness of utilizing the EHRs, and to promote students’ understanding of the importance of documentation before they start their clinical practice.
PT
Furthermore, this learning process would enhance students’ perceptions on how to improve
RI
patient safety outcomes with the EHRs.
A review of literature found that EHRs had been implemented in some nursing curricula
SC
and the available studies focused mainly on the barriers and attitudes toward using the
NU
technology, but not on the users’ acceptance (Bembridge et al., 2010; Jones and Donelle, 2011; Meyer et al., 2011). We could not use advanced technology to improve organizational outcomes
MA
and performance if this technology is not accepted or not being used by the end users (Davis et al., 1989). In this study, nursing students are the end users of the EHRNE. If nursing students
TE
D
do not accept and do not have intention to use the EHRNE software program in their learning activities, the expected outcomes of integrating the EHRNE into nursing curriculum would not
AC CE P
be achieved. The main purpose of the study was therefore to investigate the factors influencing nursing students’ acceptance of the EHRNE in nursing education. The applicability of the extended Technology Acceptance Model (TAM) with self-efficacy used in the study was also examined.
CONCEPTUAL FRAMEWORK AND AIMS The extended Technology Acceptance Model (TAM) was used as a conceptual framework to guide the study. The TAM was primarily developed by Fred Davis in 1986 for his dissertation, and it was published in 1989 (David et al., 1989). The TAM has been widely used as a theoretical framework in many empirical studies with various population and technologies. The original TAM (Figure 1) consists of five constructs: perceived usefulness (PU), perceived
ACCEPTED MANUSCRIPT 5
ease of use (PEOU), attitude toward using (ATU), intention to use (ITU), and actual system use (David et al., 1989). TAM attempts to describe, identify, and predict the factors that influence
PT
the intention of people to use the particular computer system. The key determinants in
RI
acceptance of computer systems are the belief that the computer system will help to enhance the performance (PU) and the belief that the computer system is easy to use (David et al., 1989).
SC
Those two key determinants impact the user’s attitude toward the computer system, as well as
NU
their intentions to use the system. The intention to use the system then leads to the end-user actual behaviour.
MA
Inserted Figure 1 here
TE
D
TAM was extended in many studies with various constructs, such as self-efficacy (Chow et al., 2013; Park, 2009), perceived enjoyment (Liao et al., 2008), self-efficacy and
AC CE P
innovativeness (Hong et al., 2013), and technology anxiety and self-efficacy (Chuo et al., 2011). The literature suggested that the computer self-efficacy construct seemed to be more recognized and adopted in previous studies to gain better understanding of user acceptance behavior, and enhanced the power of the extended TAM (Shih, 2006). A meta-analysis by Karsten et al. (2012) found that computer self-efficacy was significantly correlated with perceived ease of use, perceived usefulness, attitudes, and other constructs. Extended TAM with computer self-efficacy constructed has been used as a conceptual framework extensively in public sector, education, and healthcare setting (Al-Haderi, 2013; Chow et al., 2013; Yi and Hwang, 2003; Chuo et al., 2011). Only a few studies used extended TAM with computer self-efficacy construct/domain in healthcare education, especially in nursing (Chow et al., 2012; Chow et al, 2013). In addition, it has been recommended that
ACCEPTED MANUSCRIPT 6
computer self-efficacy was an important area for educational research (Karsten et al., 2012; Irby and Strong, 2011).
PT
Aims of Study
RI
In this study, nursing students are identified as end users and their acceptance of the electronic health records in nursing education (EHRNE) is explored. The aims of the study were
SC
to investigate the factors influencing nursing students’ acceptance of the EHRNE software
(TAM) with self-efficacy in nursing education.
NU
application, and to examine the applicability of the extended Technology Acceptance Model
MA
The operational definition of EHRNE self-efficacy is consistent with the computer selfefficacy definition, which was defined as an individual’s perception of self-efficacy in using
TE
D
EHRNE in learning activities (Compeau and Higgins, 1995). The extended TAM with computer self-efficacy (Chow et al, 2013) was used as a conceptual model for the study, and
AC CE P
seven hypotheses were proposed:
1. The computer self-efficacy of nursing students significantly influences perceived usefulness of EHRNE software application. 2. The computer self-efficacy of nursing students significantly influences perceived ease of use of EHRNE software application. 3. Nursing students’ perception of EHRNE’s ease of use significantly influences perceived usefulness of EHRNE software application. 4. Nursing students’ perception of EHRNE’s ease of use significantly influences the students’ attitude toward using EHRNE software application. 5. Nursing students’ perception of EHRNE’s usefulness significantly influences the students’ attitude toward using EHRNE software application.
ACCEPTED MANUSCRIPT 7
6. Nursing students’ perception of EHRNE’s usefulness significantly influences the students’ intention to use the EHRNE software application.
RI
intention to use the EHRNE software application.
PT
7. Nursing students’ attitudes toward using significantly influences the students’
SC
IMPLEMENTATION OF EHRNE
NU
The EHRNE software was recently developed by the research team to enhance students’ learning and awareness of health information technology and has been integrated into the nursing
MA
curriculum (Kowitlawakul et al., 2013). This software program is a standalone program without a server and the students easily download the program to their own computer from the
D
department web-link. The contents in the EHRNE software were customized to fit the
TE
undergraduate courses and mainly focus on nursing documentation. The students can enter the
AC CE P
clinical data and save as a pdf.file to their computer. There are several case scenarios that can be retrieved and viewed by the students and academic staff. The feature is broken down into different blocks/menus, for example, nursing assessment tab menu contains sub-tab menus, such as neurological and nervous system, cardiovascular system, and respiratory system (Kowitlawakul et al., 2013). A user handbook was developed and provided to the students before the semester started. An introduction of the software e application was also provided to the students on the first week of the semester. The EHRNE software application was used in four core nursing modules, and each module chose the menu contents that fit to weekly session lectures and laboratory activities. Table 1 presents the use of EHRNE software for documentation in each module. Inserted Table 1 here
ACCEPTED MANUSCRIPT 8
METHODS Design and Sample
PT
A cross-sectional, descriptive study design using self-directed questionnaires was
RI
adopted for the study. A convenience sample was used and the undergraduate nursing students were recruited from a university in Singapore. The inclusion criteria were undergraduate nursing
SC
students who were studying in year 1 to year 3, and used the EHRNE software application in the
NU
nursing laboratory. A total of 264 nursing students were eligible and the questionnaires were administered to the eligible students. Two hundred and twelve participants completed
MA
questionnaires which were returned in January 2013. The overall response rate was 80.3%, which is considered satisfactory. This sample size was adequate to achieve a moderate effect
analysis.
AC CE P
Instrument
TE
D
size (0.13) with α = 0.05 and power level = 0.80 for structural equation modeling (SEM)
The Electronic Health Records Acceptance Survey (EHRAS) was used in this study. The EHRAS was modified from two validated surveys; the eICU Acceptance Survey (Kowitlawakul, 2011) and a survey by Seeman and Gibson (2006). The EHRAS consists of 17 items with 5Likert scale range from 1 (strongly dissatisfy) to 5 (strongly satisfy). The instrument consists of five domains: EHRNE self-efficacy; perceived usefulness; perceived ease of use; attitude toward using; and intention to use. The content validity of the EHRAS was examined by six experts. The experts were asked to comment on the appropriateness, clarity, and the relationship among the items in each construct, and the content validity were satisfied. In this study, the internal consistency for each subscale and total scale was acceptable with Cronbach’s alpha ranging from 0.76 to 0.92 for the subscales and 0.92 for the total. The principal component analysis showed
ACCEPTED MANUSCRIPT 9
that the cumulative variance explained for 17 items account for 80.9% (using Eigen value > 1). Therefore, psychometric properties of the EHRAS had adequate reliability and construct validity.
PT
Data Collection and Ethical Considerations
RI
The study was approved by the Institutional Review Board (IRB) of the university in Singapore. The informed consent has included three ethical principles: human dignity,
SC
beneficence, and justice. Full disclosure of the study purposes and the participants’ rights as
NU
human subjects was provided to the participants. Participation in this study was voluntary and the participants could withdraw from the study at any time without any penalty. The information
MA
sheet, consent form, and questionnaires were provided to the students after the purposes of the research study were explained and confidentiality was reassured. The students were asked to
put in a collection box.
AC CE P
Data analysis
TE
D
place the answered questionnaires and signed informed consent in the sealed envelopes, and then
The IBM SPSS and AMOS version 21.0 (IBM corp, Armonk, New York) were used to analyze the data. . Statistical significance for all of the analysis was defined as p ≤ 0.05. Data screening was performed for missing data and outliers. Missing data varied from 1 to 6 and they were replaced by a series of means. Descriptive statistics were used to summarize the demographic profile of the participants, and independent t-test for two samples and one-way Analysis of variance (ANOVA) were used to compare the differences of intentions to use the electronic health records scores within the demographic characteristics. Structural equation modeling (SEM) was used to test the hypotheses and examine the applicability of the model (Kelloway, 1996).
ACCEPTED MANUSCRIPT 10
RESULTS Characteristics of Participants
PT
The age of the participants ranged from 18-29 years old with an average age of 20.89
RI
years old (SD=1.67). Majority of the participants were female (83.8%). The number of year 2 students who participated in the study (36.7%) was higher than students in years 1 and 3 (30.5%
SC
and 32.9% respectively). Most of the participants had practiced in clinical sites/hospitals less
NU
than 11 weeks (72%), and neither attended any electronic health records (EHRs) class (94.3%) nor trained to use the EHRs at the clinical sites (81.8%). No statistical significance was found in
MA
intention to use EHRNE within gender, practice time in clinical setting, years of experience in using computer, and experience in training using EHRNE. There was statistical significance
TE
D
among year 1, year 2, and year 3 students, in intention to use EHRNE scores (p=0.002). Those in year 3 had the highest intentions to use with a mean score of3.79 ± 0.52, and those in year 1
AC CE P
had the lowest mean score (3.38 ± 0.48). Table 2 presents the demographic data and differences in intention to use EHRNE scores accounting for the participants’ demographic characteristics.
Insert Table 2 here
Structural Equation Modeling (SEM) Results Structural equation modeling was performed to test the hypotheses and determine the casual effects among variables and goodness-of-fit of the model. The model consisted of five constructs; EHRNE self-efficacy, perceived usefulness, perceived ease of use, attitude toward using, and intention to use. All the hypotheses were accepted and supported by the significance of the path coefficients (p < 0.01). EHRNE self-efficacy had a significant influence on perceived
ACCEPTED MANUSCRIPT 11
usefulness and perceived ease of use (β=0.26, 0.55 respectively, and p
S0260-6917(14)00194-4 doi: 10.1016/j.nedt.2014.05.010 YNEDT 2740
To appear in:
Nurse Education Today
Received date: Revised date: Accepted date:
13 January 2014 12 May 2014 19 May 2014
Please cite this article as: Kowitlawakul, Yanika, Chan, Sally Wai Chi, Pulcini, Joyce, Wang, Wenru, Factors Influencing Nursing Students’ Acceptance of Electronic Health Records for Nursing Education (EHRNE) Software Program, Nurse Education Today (2014), doi: 10.1016/j.nedt.2014.05.010
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Factors Influencing Nursing Students’ Acceptance of Electronic Health Records for Nursing Education (EHRNE) Software Program
PT
Yanika Kowitlawakul*, PhD, RN; Sally Wai Chi Chan, PhD, RN,FAAN; Joyce Pulcini, PhD, PNP-BC,FAAN,FAANP; and Wenru Wang, PhD, RN
RI
Authors
NU
SC
Yanika Kowitlawakul, PhD, RN (Corresponding author) Assistant Professor Alice Lee Centre for Nursing Studies/Yong Loo Lin School of Medicine National University of Singapore, Block MD 11, Level 2, 10 Medical Drive, Singapore 117597 Phone: +65-6601-1766, Fax: 65-6776-7135, Email: [email protected]
D
MA
Sally Wai Chi Chan, PhD, RN, FAAN Professor and Head School of Nursing and Midwifery, University of Newcastle Callaghan, Newcastle Phone: +61 2 4921 6770, Fax: +61 2 4921 6981, Email: [email protected]
AC CE P
TE
Joyce Pulcini, PhD, PNP-BC, FAAN, FAANP Professor The George Washington University, School of Nursing 2030 M St, NW, Suite 300, Washington, DC, 20036 Phone: +1-202-994-9536, Fax: 202-994-2777, Email: [email protected] Wenru Wang, PhD, RN Assistant Professor Alice Lee Centre for Nursing Studies/Yong Loo Lin School of Medicine National University of Singapore, Block MD 11, Level 2, 10 Medical Drive, Singapore 117597 Phone: +65-6516-5088, Fax: 65-6776-7135, Email: [email protected] Acknowledgements This study was funded by the Alice Lee Centre for Nursing Studies, Start- up Grant, at the National University of Singapore. We would like to thank the participants and faculty members who have been very supportive for the study. Word count Abstract = 201 Manuscript = 3,517 Total = 4,547 (including abstract, main manuscript, and references)
ACCEPTED MANUSCRIPT 2
Abstract
PT
The Institute of Medicine (IOM) and the Health Information Technology Act (2009) in America
RI
had recommended that electronic health records (EHRs) should be fully adopted by 2014. This has urged educational institutions to prepare healthcare professionals to be competent in using
SC
electronic health records (EHRs) while they are in schools. To equip nursing students with
NU
competency in using EHRs, an electronic health record for nursing education (EHRNE) has been developed and integrated it into nursing curricula. The purposes of the study were to investigate
MA
the factors influencing nursing students’ acceptance of the EHRs in nursing education using the extended Technology Acceptance Model with self-efficacy as a conceptual framework. The
TE
D
study is a descriptive study design using self-reported questionnaires with 212 student participants. The IBM SPSS and AMOS 22.0 were used to analyse the data. The results showed
AC CE P
that attitude toward using the EHRNE was the most influential factor on students’ acceptance. The preliminary findings suggested that to enhance the students’ acceptance of the EHRNE, cultivation of a positive attitude toward using this EHR as well as increasing the perceived usefulness is very important. Also, the study’s framework could be used in guiding learning health informatics and be applied to nursing students.
ACCEPTED MANUSCRIPT 3
INTRODUCTION The Institute of Medicine (IOM) and the Health Information Technology Act (2009) in
PT
the United States of America (U.S.A) had recommended that a nationwide mandatory reporting
RI
system should be established and electronic health records (EHRs) should be fully adopted by 2014 (Meyer et al., 2011). Since then, EHRs have extensively been implemented in healthcare
SC
delivery systems not only in the U.S.A, but also worldwide. The assumptions are that EHRs
NU
adoption would help to improve patient safety, increase health care quality, and reduce the health care costs (Bate, 2010; Cherry et al., 2010; Murphy, 2011). Several recent studies reported that
MA
healthcare professionals use the EHRs to share patients’ information to provide clinical advice and improve clinical practice (Matheson et al., 2012; Perera et al., 2011). In addition, electronic
TE
D
health data can be used by healthcare providers for research and evidence-based practice. Therefore, EHRs are becoming an essential system for documentation of health care information
AC CE P
around the world.
In Singapore, the Ministry of Health has decided that all public hospitals would implement the EHRs. Most hospitals in Singapore have adopted EHRs in their practice and health care professionals need to be competent in using this health information technology. It is therefore important to equip nursing students with such competency. Most nursing students studying for a nursing degree program learn their clinical skills in simulation centre before they embark on learning at clinical settings. In this study, paper-based documentation, such as documentation of health history, physical health assessment, and nursing interventions was used in the simulation centre. To equip the students with competency in using EHRs, an electronic health record for nursing education (EHRNE) software has been developed to allow the students to learn and use the EHRs. The purposes of integrating EHRNE into nursing education program
ACCEPTED MANUSCRIPT 4
are to cultivate students’ awareness of utilizing the EHRs, and to promote students’ understanding of the importance of documentation before they start their clinical practice.
PT
Furthermore, this learning process would enhance students’ perceptions on how to improve
RI
patient safety outcomes with the EHRs.
A review of literature found that EHRs had been implemented in some nursing curricula
SC
and the available studies focused mainly on the barriers and attitudes toward using the
NU
technology, but not on the users’ acceptance (Bembridge et al., 2010; Jones and Donelle, 2011; Meyer et al., 2011). We could not use advanced technology to improve organizational outcomes
MA
and performance if this technology is not accepted or not being used by the end users (Davis et al., 1989). In this study, nursing students are the end users of the EHRNE. If nursing students
TE
D
do not accept and do not have intention to use the EHRNE software program in their learning activities, the expected outcomes of integrating the EHRNE into nursing curriculum would not
AC CE P
be achieved. The main purpose of the study was therefore to investigate the factors influencing nursing students’ acceptance of the EHRNE in nursing education. The applicability of the extended Technology Acceptance Model (TAM) with self-efficacy used in the study was also examined.
CONCEPTUAL FRAMEWORK AND AIMS The extended Technology Acceptance Model (TAM) was used as a conceptual framework to guide the study. The TAM was primarily developed by Fred Davis in 1986 for his dissertation, and it was published in 1989 (David et al., 1989). The TAM has been widely used as a theoretical framework in many empirical studies with various population and technologies. The original TAM (Figure 1) consists of five constructs: perceived usefulness (PU), perceived
ACCEPTED MANUSCRIPT 5
ease of use (PEOU), attitude toward using (ATU), intention to use (ITU), and actual system use (David et al., 1989). TAM attempts to describe, identify, and predict the factors that influence
PT
the intention of people to use the particular computer system. The key determinants in
RI
acceptance of computer systems are the belief that the computer system will help to enhance the performance (PU) and the belief that the computer system is easy to use (David et al., 1989).
SC
Those two key determinants impact the user’s attitude toward the computer system, as well as
NU
their intentions to use the system. The intention to use the system then leads to the end-user actual behaviour.
MA
Inserted Figure 1 here
TE
D
TAM was extended in many studies with various constructs, such as self-efficacy (Chow et al., 2013; Park, 2009), perceived enjoyment (Liao et al., 2008), self-efficacy and
AC CE P
innovativeness (Hong et al., 2013), and technology anxiety and self-efficacy (Chuo et al., 2011). The literature suggested that the computer self-efficacy construct seemed to be more recognized and adopted in previous studies to gain better understanding of user acceptance behavior, and enhanced the power of the extended TAM (Shih, 2006). A meta-analysis by Karsten et al. (2012) found that computer self-efficacy was significantly correlated with perceived ease of use, perceived usefulness, attitudes, and other constructs. Extended TAM with computer self-efficacy constructed has been used as a conceptual framework extensively in public sector, education, and healthcare setting (Al-Haderi, 2013; Chow et al., 2013; Yi and Hwang, 2003; Chuo et al., 2011). Only a few studies used extended TAM with computer self-efficacy construct/domain in healthcare education, especially in nursing (Chow et al., 2012; Chow et al, 2013). In addition, it has been recommended that
ACCEPTED MANUSCRIPT 6
computer self-efficacy was an important area for educational research (Karsten et al., 2012; Irby and Strong, 2011).
PT
Aims of Study
RI
In this study, nursing students are identified as end users and their acceptance of the electronic health records in nursing education (EHRNE) is explored. The aims of the study were
SC
to investigate the factors influencing nursing students’ acceptance of the EHRNE software
(TAM) with self-efficacy in nursing education.
NU
application, and to examine the applicability of the extended Technology Acceptance Model
MA
The operational definition of EHRNE self-efficacy is consistent with the computer selfefficacy definition, which was defined as an individual’s perception of self-efficacy in using
TE
D
EHRNE in learning activities (Compeau and Higgins, 1995). The extended TAM with computer self-efficacy (Chow et al, 2013) was used as a conceptual model for the study, and
AC CE P
seven hypotheses were proposed:
1. The computer self-efficacy of nursing students significantly influences perceived usefulness of EHRNE software application. 2. The computer self-efficacy of nursing students significantly influences perceived ease of use of EHRNE software application. 3. Nursing students’ perception of EHRNE’s ease of use significantly influences perceived usefulness of EHRNE software application. 4. Nursing students’ perception of EHRNE’s ease of use significantly influences the students’ attitude toward using EHRNE software application. 5. Nursing students’ perception of EHRNE’s usefulness significantly influences the students’ attitude toward using EHRNE software application.
ACCEPTED MANUSCRIPT 7
6. Nursing students’ perception of EHRNE’s usefulness significantly influences the students’ intention to use the EHRNE software application.
RI
intention to use the EHRNE software application.
PT
7. Nursing students’ attitudes toward using significantly influences the students’
SC
IMPLEMENTATION OF EHRNE
NU
The EHRNE software was recently developed by the research team to enhance students’ learning and awareness of health information technology and has been integrated into the nursing
MA
curriculum (Kowitlawakul et al., 2013). This software program is a standalone program without a server and the students easily download the program to their own computer from the
D
department web-link. The contents in the EHRNE software were customized to fit the
TE
undergraduate courses and mainly focus on nursing documentation. The students can enter the
AC CE P
clinical data and save as a pdf.file to their computer. There are several case scenarios that can be retrieved and viewed by the students and academic staff. The feature is broken down into different blocks/menus, for example, nursing assessment tab menu contains sub-tab menus, such as neurological and nervous system, cardiovascular system, and respiratory system (Kowitlawakul et al., 2013). A user handbook was developed and provided to the students before the semester started. An introduction of the software e application was also provided to the students on the first week of the semester. The EHRNE software application was used in four core nursing modules, and each module chose the menu contents that fit to weekly session lectures and laboratory activities. Table 1 presents the use of EHRNE software for documentation in each module. Inserted Table 1 here
ACCEPTED MANUSCRIPT 8
METHODS Design and Sample
PT
A cross-sectional, descriptive study design using self-directed questionnaires was
RI
adopted for the study. A convenience sample was used and the undergraduate nursing students were recruited from a university in Singapore. The inclusion criteria were undergraduate nursing
SC
students who were studying in year 1 to year 3, and used the EHRNE software application in the
NU
nursing laboratory. A total of 264 nursing students were eligible and the questionnaires were administered to the eligible students. Two hundred and twelve participants completed
MA
questionnaires which were returned in January 2013. The overall response rate was 80.3%, which is considered satisfactory. This sample size was adequate to achieve a moderate effect
analysis.
AC CE P
Instrument
TE
D
size (0.13) with α = 0.05 and power level = 0.80 for structural equation modeling (SEM)
The Electronic Health Records Acceptance Survey (EHRAS) was used in this study. The EHRAS was modified from two validated surveys; the eICU Acceptance Survey (Kowitlawakul, 2011) and a survey by Seeman and Gibson (2006). The EHRAS consists of 17 items with 5Likert scale range from 1 (strongly dissatisfy) to 5 (strongly satisfy). The instrument consists of five domains: EHRNE self-efficacy; perceived usefulness; perceived ease of use; attitude toward using; and intention to use. The content validity of the EHRAS was examined by six experts. The experts were asked to comment on the appropriateness, clarity, and the relationship among the items in each construct, and the content validity were satisfied. In this study, the internal consistency for each subscale and total scale was acceptable with Cronbach’s alpha ranging from 0.76 to 0.92 for the subscales and 0.92 for the total. The principal component analysis showed
ACCEPTED MANUSCRIPT 9
that the cumulative variance explained for 17 items account for 80.9% (using Eigen value > 1). Therefore, psychometric properties of the EHRAS had adequate reliability and construct validity.
PT
Data Collection and Ethical Considerations
RI
The study was approved by the Institutional Review Board (IRB) of the university in Singapore. The informed consent has included three ethical principles: human dignity,
SC
beneficence, and justice. Full disclosure of the study purposes and the participants’ rights as
NU
human subjects was provided to the participants. Participation in this study was voluntary and the participants could withdraw from the study at any time without any penalty. The information
MA
sheet, consent form, and questionnaires were provided to the students after the purposes of the research study were explained and confidentiality was reassured. The students were asked to
put in a collection box.
AC CE P
Data analysis
TE
D
place the answered questionnaires and signed informed consent in the sealed envelopes, and then
The IBM SPSS and AMOS version 21.0 (IBM corp, Armonk, New York) were used to analyze the data. . Statistical significance for all of the analysis was defined as p ≤ 0.05. Data screening was performed for missing data and outliers. Missing data varied from 1 to 6 and they were replaced by a series of means. Descriptive statistics were used to summarize the demographic profile of the participants, and independent t-test for two samples and one-way Analysis of variance (ANOVA) were used to compare the differences of intentions to use the electronic health records scores within the demographic characteristics. Structural equation modeling (SEM) was used to test the hypotheses and examine the applicability of the model (Kelloway, 1996).
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RESULTS Characteristics of Participants
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The age of the participants ranged from 18-29 years old with an average age of 20.89
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years old (SD=1.67). Majority of the participants were female (83.8%). The number of year 2 students who participated in the study (36.7%) was higher than students in years 1 and 3 (30.5%
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and 32.9% respectively). Most of the participants had practiced in clinical sites/hospitals less
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than 11 weeks (72%), and neither attended any electronic health records (EHRs) class (94.3%) nor trained to use the EHRs at the clinical sites (81.8%). No statistical significance was found in
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intention to use EHRNE within gender, practice time in clinical setting, years of experience in using computer, and experience in training using EHRNE. There was statistical significance
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among year 1, year 2, and year 3 students, in intention to use EHRNE scores (p=0.002). Those in year 3 had the highest intentions to use with a mean score of3.79 ± 0.52, and those in year 1
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had the lowest mean score (3.38 ± 0.48). Table 2 presents the demographic data and differences in intention to use EHRNE scores accounting for the participants’ demographic characteristics.
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Structural Equation Modeling (SEM) Results Structural equation modeling was performed to test the hypotheses and determine the casual effects among variables and goodness-of-fit of the model. The model consisted of five constructs; EHRNE self-efficacy, perceived usefulness, perceived ease of use, attitude toward using, and intention to use. All the hypotheses were accepted and supported by the significance of the path coefficients (p < 0.01). EHRNE self-efficacy had a significant influence on perceived
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usefulness and perceived ease of use (β=0.26, 0.55 respectively, and p
