Modeling factors explaining the acceptance, actual use and satisfaction of nurses using an Electronic Patient Record in acute care settings: An extension of the UTAUT

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Highlights

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    We tested a model to explain nurses’ acceptance of an Electronic Patient Record (EPR).

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    Performance expectancy is the strongest direct determinant of actual EPR use.

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    Compatibility of the EPR is the most important determinant of nurses’ satisfaction.

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    Social influence has the strongest total effect on actual EPR use.

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    Self-efficacy and social influence do not affect nurses’ satisfaction with an EPR.

Abstract

Background and purpose

End-user acceptance and satisfaction are considered critical factors for successful implementation of an Electronic Patient Record (EPR). The aim of this study was to explain the acceptance and actual use of an EPR and nurses’ satisfaction by testing a theoretical model adapted from the Unified Theory of Acceptance and Use of Technology (UTAUT).

Methods

A multicenter cross-sectional study was conducted in the medical–surgical wards of four hospitals ranked at different EPR adoption stages. A randomized stratified sampling approach was used to recruit 616 nurses. Structural equation modeling techniques were applied.

Results

Support was found for 13 of the model's 20 research hypotheses. The strongest effects are those between performance expectancy and actual use of the EPR (r = 0.55, p = 0.006), facilitating conditions and effort expectancy (r = 0.45, p = 0.009), compatibility and performance expectancy (r = 0.39, p = 0.002). The variables explained 33.6% of the variance of actual use, 54.9% of nurses’ satisfaction, 50.2% of performance expectancy and 52.9% of effort expectancy.

Conclusions

Many results of this study support the conclusions of prior research, but some take exception, such as the non-significant relationship between the effort expectancy construct and actual use of the EPR. The results highlight the importance of the mediating effects of the effort expectancy and performance expectancy constructs. Compatibility of the EPR with preferred work style, existing work practices and the values of nurses were the most important factors explaining nurses’ satisfaction. The results reveal the complexity of this change and suggest several avenues for future research and for the implementation of IT in healthcare.

Introduction

Increasingly, information technologies (IT) are being proposed as solutions to the challenges faced in health care systems, for addressing population health issues and encouraging the emergence of new modes of healthcare delivery [1]. Even though the benefits of implementing IT in healthcare have been well documented, too much variance remains in the rates of satisfaction expressed by health professionals [2]. The professional culture of nurses is generally favorable to adoption of innovations such as an Electronic Patient Record (EPR) [3], but affective response remains a critical factor that influences the decisions and behaviors of IT users [4]. The fundamental differences between the paper-based patient record and the EPR as well as significant transformations of clinical practices raise significant questions about IT's impact on the nursing workflow, care delivery and nurses’ satisfaction [5]. In principle, an EPR should facilitate access to relevant information, patient evaluation, health promotion, clinical interventions and the organization of services [6]. These functionalities play a key role for nurses, since they make a unique contribution to the health system [7] by integrating information [8] and serving as pivots in the health team [9]. Furthermore, the adoption of an EPR is a complex change that occurs slowly, in a series of stages. Widespread adoption appears to be a prerequisite to achieving the overall benefits for a health system [10]. However, the EPR adoption stage varies from one facility to another, which limits interoperability. It is therefore important to identify and make use of explanatory factors to facilitate this important transition.

The aim of this study was to investigate explanatory factors for nurses’ acceptance and actual use of an EPR in acute care settings as well as for their satisfaction. More specifically, the research objectives examined: (1) nurses’ perceptions of the compatibility of the EPR and their self-efficacy regarding acceptance of the EPR, (2) the actual use of the EPR, and (3) their satisfaction.

Section snippets

Acceptance models and theories

Over the last few decades, many models and theories have been developed and tested in order to identify variables affecting the acceptance and use of IT provided to end-users. Among them, the Technology Acceptance Model (TAM) [11] stimulated one of the most active streams of research to predict intention to use an IT and explain actual use of IT [12]. Based on the Theory of Reasoned Action (TRA) [13], TAM examined the impact of external factors on the cognitive response of individuals

Design and settings

The research design was based on a multicenter cross-sectional study. Four acute-care academic settings were selected for the study: two university-affiliated hospitals and two teaching hospitals, all located in Montreal, Canada. All the study sites were implementing an EPR developed by the same vendor (Oacis™, Telus). The sites were at various EPR adoption stages ranging from 1 to 4. These adoption stages were assessed using the Electronic Medical Record Adoption Model – EMRAM [40]. One

Demographic characteristics of the sample

A total of 656 questionnaires (75.0%) were returned. The data were inspected to correct outliers caused by data entry errors. Mean substitution of missing data was performed by creating composite scores [59] based on the average of 75% of the remaining items for each construct. It nevertheless proved impossible to replace some of the values missing from forty questionnaires, so they were removed from the sample. SEM analyses are sensitive to missing data when estimating parameters using the

Discussion

This study investigated explanatory factors for the acceptance and actual use of an EPR and nurses’ satisfaction with the EPR by testing a model based on UTAUT. The sample was comprised exclusively of nurses from comparable clinical environments, i.e. medical and surgical wards in acute care hospitals. The four settings used in this study were at different EPR adoption stages, which provided for more variation in the data. This decision was based on the fact that it can be difficult to capture

Conclusion

Drawing inspiration from a well-known research stream, this study was based on a robust theory and research instruments that have once again proved their value. They have allowed us to test a theoretical model comprised of eight constructs and explain the phenomenon of EPR acceptance in four settings, using a relatively large sample of nurses. The results of our study strongly suggest that professionals should be provided with an EPR that they consider useful for improving their performance and

Author contributions

All the authors contributed equally.

Conflicts of interest

None.

Summary points

What was already known on the topic?

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    Technology acceptance models and theories can be applied to health professionals to measure a diverse range of health IT, in varied care contexts.

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    Several independent variables have been tested, with most studies measuring intention to use the system as a dependent variable.

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    Often the studies left out the affective measure from the models they tested.

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    Integration problems related to EPR compatibility have sometimes affected nursing practice.

Acknowledgments

The first author is most grateful for scholarships received from the FERASI Center, the Ministère de l’éducation, du loisir et des sports of the Government of Quebec and the Quebec Nursing Intervention Research Network. He would also like to thank the many nurses who participated in the study, as well as the stakeholders in the various practice settings who supported the study.

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