Raymund John Ang, RN, MAN
Open Nursing Information System Project
and Tailored Healthcare Staffing

John Robert Bautista RN MPH PhD
Open Nursing Information System Project
School of Information, The University of Texas at Austin, TX, USA
Center for Health Communication, Moody School of Communication,
The University of Texas at Austin, TX, USA

Joaquin Sapul Jr, RN, MAN
Open Nursing Information System Project
West Visayas State University Medical Center – Iloilo City, Philippines

Citation: Ang, R. J., Bautista, J.R. & Sapul, J. (2021). Development, testing and evaluation of an electronic nursing kardex based on a content management system. Canadian Journal of Nursing Informatics, 16(1). https://cjni.net/journal/?p=8579

ABSTRACT

Objective: This study presents the development and user testing of an electronic nursing kardex (hereafter electronic kardex) prototype. It also identifies the mechanism by which usability factors (perceived usefulness and perceived ease of use) mediate the association between system characteristics (perceptions of key functionalities and intuitiveness of user interface) and attitude towards the electronic kardex – a crucial step towards its acceptance and adoption.

Methods: The electronic kardex was developed using WordPress, a content management system, based on the Open Standards for WordPress in Healthcare. A user testing followed by a web survey was conducted among 143 registered nurses working in a private hospital in Iloilo City, Philippines. Mediation analysis was used to determine direct and indirect associations of key variables with attitude towards the electronic kardex.

Results: The users had positive reception of the electronic kardex as evidenced by mean scores of >3 in perceptions of the key functionalities, intuitiveness of the user interface, perceived usefulness, perceived ease of use, and attitude towards the electronic kardex. Next, perceptions of key functionalities and intuitiveness of the user interface were positively associated with attitude towards the electronic kardex. Perceived usefulness and perceived ease of use mediated the association between perceived key functionalities and attitude towards the electronic kardex. Only perceived usefulness mediated the association between intuitiveness of user interface and attitude towards the electronic kardex.

Conclusion: The findings suggest that improving the system characteristics of the electronic kardex to suit nurses’ needs (i.e., making it more useful) is a key pathway for having a positive attitude towards the electronic nursing kardex.

Introduction

Nurses should have the necessary knowledge about their patients before they can safely and efficiently provide nursing care. The nursing kardex or patient care summary has been instrumental on how nurses manage information – both during change-of-shift reports and in the actual provision of patient care. It serves as a reference tool and is one of the forms of communication where patient information is documented, such as patient identity, attending physicians, code status, diet and allergies, diagnostic results, and level of activity. The kardex can also be used as a guide for making nursing assignments and estimating nurse-to-patient ratio needs on a particular unit (Timby, 2009).

With the advent of electronic medical records (EMR), the workflow of healthcare professionals has shifted from paper to computer-based systems. Even with this shift in workflow, the nursing kardex can still be an indispensable mechanism for nurses to organize patient information. Following the Data-Information-Knowledge-Wisdom (DIKW) model, the kardex can be thought of as a repository of data where data input from nurses, physicians and other healthcare providers are stored. These data would be of no use if nurses are not able to put meaning into them, and apply the information and knowledge generated from processing these data into wisdom to plan and execute nursing interventions (McGonigle & Mastrian, 2017).

The need for a quick reference of patient and care information brought the integration of the nursing kardex into the clinical setting. It is important to note that the content of the nursing kardex is not static, but changes frequently based on alterations in patient condition or updates in diagnosis or treatment regimen. It is also important to point out that the nursing kardex is not part of the permanent patient record and should be treated as a nursing tool (Timby, 2009; Hager & Munden, 2008; Perry, Potter & Ostendorf, 2016). Considering how useful the nursing kardex is in clinical practice, there is a need to develop an electronic kardex, particularly in hospitals from developing countries where EMRs are less adopted. Likewise, it is also equally important to identify mechanisms by which nurses develop a positive attitude towards such technology – a critical step before technology acceptance adoption.

Open-NIS Electronic Nurse Kardex

The Open Nursing Information System (Open-NIS) Project is an open collaboration project with the aim of enhancing the field of nursing informatics and improving patient care through open and innovative collaborations, particularly among nurses. In developing the electronic kardex, the Open-NIS Project used WordPress as a web-based content management system (CMS) application. A CMS is an application whose main feature is to manage content using a defined content type or logical unit of content. For blogs and websites, this content type or logical unit of content can be in the form of “posts”. For healthcare or nursing-related applications, the content type can be in the form of “patients” or any other logical unit of content related to patient care. Nonetheless, CMS’s are not competing or alternative solutions for EMR’s. A workflow system can be designed such that the electronic medical record can be thought of as a data repository, while the content management system can be considered the repository of processed data in the form of information, knowledge or wisdom. The input provided in the electronic kardex is a combination of the DIKW elements. Processing of raw data from the electronic medical record may be dependent on how the processor – the nurse or other healthcare provider – deems the data or information relevant to his or her field of practice.

The use of WordPress as the CMS of choice was based on its ease of use, feature extensibility, and availability of themes and plugins. Besides, it is easy to use because of its intuitive user interface for both administrators and end users. WordPress uses PHP as its backend programming and templating language (Barker, 2016; Shivakumar, 2017). With the availability of themes and plugins, it is possible to extend application functionalities beyond blogging, which was what WordPress was initially designed for. Knowledge in computer programming is necessary to allow a greater degree of flexibility in application design. But with the availability of plugins, the same functionalities may be achieved, although it may be limited by the scope of the particular plugin (Ang, 2018; Ang, 2019).

To appropriate WordPress for use as an electronic kardex, the Open Standards for WordPress in Healthcare was used as a basis to integrate the content management system as a health information system application platform (Open-NIS Project, 2018).The open standards became the blueprint or guide on which the electronic kardex was developed. First, patient data was defined as custom post type with custom fields treated as meta fields using the default WordPress database schema. Next, a third-party theme and plugins were also utilized in building the prototype for this study. Themes enhance presentation layout of the web application, while plugins extend application features and functionalities. Finally, the application was deployed using a cloud service provider, which was accessible through the Internet (see Figures 1 and 2).

Predicting Attitude Towards Electronic Kardex

To obtain user feedback on the electronic kardex, this study examines user perceptions that predict attitude towards electronic kardex. Specifically, it investigates whether system characteristics (i.e., perceptions of key functionalities and intuitiveness of user interface) and usability factors (i.e., perceived usefulness and perceived ease of use) are associated with attitude towards the electronic kardex. The following paragraphs discuss the key constructs of this study.

System characteristics

In this study, the authors focused on two facets of the electronic kardex’s characteristics: perceptions of key functionalities and intuitiveness of user interface.

Like the paper-based kardex, the electronic kardex was developed to have several key functionalities. These include support for decision making, prevention of medical errors and provision of a patient care summary. Aside from improving the efficiency of nurses’ clinical work, these functionalities also aim to improve health outcomes by keeping nurses informed of the patient’s situation. By asking nurses to try and experience functionalities offered by the electronic kardex, the authors could determine nurses’ attitude towards it.

Aside from offering several functionalities, the electronic kardex was also designed to have an intuitive user interface. An intuitive user interface can be characterized by quick response to inputs, sensible arrangement of on-screen fields, appropriate feedback during task performance and clarity of presented terminologies (Viitanen et al., 2011). Viitanen and colleagues argued that these should be assessed since intuitiveness of user interfaces reflect the success of user interface design. Following this, it can be argued that the intuitiveness of the electronic kardex’s user interface would determine nurses’ attitude towards it.

Usability factors

Following the Technology Acceptance Model (TAM), attitude towards technology is predicted by two fundamental usability factors: perceived usefulness and perceived ease of use. The former refers to “the degree to which a person believes that using a particular system would enhance his or her job performance” while the latter refers to “the degree to which a person believes that using a particular system would be free of effort” (Davis, 1989, p.320). Aside from theoretical assumptions, recent empirical studies support such association in the context of attitude towards EMR use (Mijin, 2019; Sayyah Gilani, 2017). Hence, those who find the electronic kardex useful and easy to use will develop a more positive attitude towards it.

Despite the abundance of studies showing the association between usability factors and attitude towards healthcare technologies, it is unclear whether such factors act as significant mediators between the association of system characteristics and attitude. While it is possible for the electronic kardex’s system characteristics to positively influence attitude, it is uncertain how much perceived usefulness and perceived ease of use would account in the association when these are treated as mediators. From a technology development perspective, understanding their mediating effect would guide electronic kardex development. For instance, given the limited time and resources for its development, the researchers can determine whether focusing on the electronic kardex’s usefulness or ease of use would be the most effective route in obtaining a more positive attitude towards electronic kardex. Focusing on improving users’ attitude towards electronic kardex is crucial since it can cascade to intention to use and, ultimately, usage behavior (Venkatesh & Davis, 2000).

Research Questions

In general, this study examines the mechanism by which system characteristics (i.e., perceptions of key functionalities and intuitiveness of user interface) and usability factors (i.e., perceived usefulness and perceived ease of use) are associated with attitude towards Open-NIS’s electronic kardex prototype. Specifically, the authors propose the following research questions (RQs):

RQ1: Are system characteristics, such as perceptions of key functionalities and intuitiveness of user interface, associated with attitude towards the electronic kardex?

RQ2:  Do usability factors, such as perceived usefulness and perceived ease of use, mediate the association between perceptions of key functionalities and attitude towards the electronic kardex?

RQ3: Do usability factors, such as perceived usefulness and perceived ease of use, mediate the association between intuitiveness of user interface and attitude towards the electronic kardex?

By answering these RQs, the authors hope to provide insights on the mechanisms by which users obtain a more positive attitude towards the electronic kardex. Such insights will be useful in improving the design of the electronic kardex for subsequent deployment in hospitals, particularly those situated in the Philippines where health information technologies are currently poorly adopted (Bautista & Lin, 2016; Bautista, Lin & Theng, 2020).

METHODS

Research Design and Ethics Approval

This user study used a cross-sectional and descriptive correlational design. Prior to data collection, the institutional and ethics review board of the hospital where the study was conducted approved the study (Approval code: 2018-04).

Data Collection

A web survey was completed by Registered Nurses employed in a 108-bed, privately-owned, tertiary-level (level II) general hospital in Iloilo City, Philippines. As of February 2019 (first month of data collection), the hospital has 171 registered nurses who were eligible for the study. After securing ethics approval, the researchers invited all potential nurse respondents to participate in the study. Only those present and employed full-time during data collection were eligible to take the web survey.

Data were collected between February and April 2019. During this period, the hospital was in the process of rolling-out system customization and digitalization of documentation for paperless documentation. After obtaining informed consent, the respondents were asked to test the electronic patient care summary prototype using a research laptop for this study. Note that the prototype did not contain actual patient data and the information shown were fictitious for the purposes of demonstration. The link was sent to a research assistant and was further cascaded to four laptops in the hospital’s Nursing Service Office. A research assistant was available throughout the testing session for any queries.

After a few minutes of testing, the research assistant asked the participants to answer a web survey using the same study research laptop. The web survey was divided into two parts. The first part asked for the respondents’ demographics (i.e., gender, age, and highest educational level) and work background (i.e., years of experience, position, area, and average number of patients handled). The second part consisted of items related to the study’s main variables (i.e., attitude towards electronic kardex, perceptions of key functionalities, intuitiveness of user interface, perceived ease of use and perceived usefulness,). The questions in the web survey were in English since it is the language used in nursing education in the Philippines (Kinderman, 2006).

Measures

Attitude towards electronic kardex

Attitude towards electronic kardex (M = 3.74, SD = .68) was measured using items from Morton and Wiedenbeck (2010). The items were slightly modified to fit the context of the study.

Respondents were asked to indicate their response using a five-point Likert scale ranging from “1” (strongly disagree) to “5” (strongly agree). The items had excellent internal consistency, with a Cronbach’s alpha = .93. A higher mean score indicates a more positive attitude towards electronic kardex.

Perceptions of key functionalities

Perceptions of key functionalities (M = 3.65, SD = .73) was measured using items from Viitanen et al. (2011). The items were slightly modified to fit the context of the study. Respondents were asked to indicate their response using a five-point Likert scale ranging from “1” (strongly disagree) to “5” (strongly agree). The items had excellent internal consistency, with a Cronbach’s alpha= .90. A higher mean score indicated a more positive perception of the electronic kardex’s functionalities.

Intuitiveness of user interface

Intuitiveness of user interface (M = 3.70, SD = .66) was measured using items from Viitanen et al. (2011) The items were slightly modified to fit the context of the study. Respondents were asked to indicate their response using a five-point Likert scale ranging from “1” (strongly disagree) to “5” (strongly agree). The items had good internal consistency, with a Cronbach’s alpha =.88. A higher mean score indicates a more positive experience of the electronic kardex’s user interface intuitiveness.

Perceived usefulness

Perceived usefulness (M = 3.67, SD = .75) was measured using items from Morton and Wiedenbeck (2010). The items were slightly modified to fit the context of the study. Respondents were asked to indicate their response using a five-point Likert scale ranging from “1” (strongly disagree) to “5” (strongly agree). The items had excellent internal consistency, with a Cronbach’s alpha= .96. A higher mean score indicates a high perceived usefulness.

Perceived ease of use

Perceived ease of use (M = 3.85, SD = .71) was measured using items from Morton and Wiedenbeck (2010).  The items were slightly modified to fit the context of the study. Respondents were asked to indicate their response using a five-point Likert scale ranging from “1” (strongly disagree) to “5” (strongly agree). The items had good internal consistency, with a Cronbach’s alpha =.89. A higher mean score indicates a high perceived ease of use.

Data Analysis

The authors used IBM SPSS Statistics 23 (i.e., SPSS) for data management and analysis. Since the study used a web survey, there was no missing data in the data set. After exporting the data from Microsoft Excel to SPSS, the authors performed descriptive analyses to obtain an overview of the data.

The researchers ran two regression models to answer the research questions. These regression models were performed using Hayes’ (2019) PROCESS macro version 3.4 (model 4) for SPSS. Both models were performed to answer RQ1. Model 1 answered RQ2 by testing whether perceived usefulness and perceived ease of use mediate the relationship between perceptions of key functionalities and attitude towards electronic kardex. On the other hand, model 2 answered RQ3 by testing whether perceived usefulness and perceived ease of use mediate the relationship between intuitiveness of user interface and attitude towards electronic kardex. Direct and indirect effects (expressed as unstandardized regression coefficients) were derived from 10,000 bootstrap samples. Demographic and work background were used as control variables during analysis.

Statistical significance was based on p <.05 for direct effects while indirect effects that had confidence intervals that did not cross zero were considered statistically significant.

Results

Respondent’s Profile

A total of 143 respondents answered the survey which translates to a response rate of 83.6%. Table 1 shows a summary of the respondents’ profiles. Most were female (67.1%) and their average age was 27.75 years old. Most had a bachelor’s degree in nursing (91.6%) as the highest educational attainment, while some were taking or had completed a master’s degree (8.4%). On average, the respondents had been working in the study site for 2.56 years with a majority holding a staff nurse position (83.9%) and assigned in specialty areas (49.0%). On average, the respondents reported that they usually handle 7.20 patients.

Descriptive Results

Table 2 provides an overview of the descriptive results of the main variables at the construct and item level. For ease of interpretation the authors also included the percentage of responses that strongly agree/agree and strongly disagree/disagree. In general, the results suggest that the respondents had a positive outlook of the electronic kardex as evidenced by a mean score of > 3 for perceived ease of use, perceived usefulness, attitude towards electronic kardex, perceptions of key functionalities, and intuitiveness of user interface.

For perceived ease of use, most of the respondents (81.8%) agreed that they expect to become skilled using the electronic kardex. However, a few (8.4%) noted that it is not user-friendly. As for perceived usefulness, a majority 76.2% agreed that it is a useful tool for nursing practice while a small portion of the respondents (11.9%) thought that it will not allow them to accomplish tasks more quickly. In terms of attitude towards electronic kardex, a majority (82.5%) believed that all nurses should learn how to use it while some (8.4%) thought that they do not need it to provide effective patient care. As for perceptions of key functionalities, most of the respondents (72.0%) agreed that the electronic kardex provided a proper summary of the patient’s situation. However, a few (11.2%) did not think that it can help to prevent medication errors. Finally, as for intuitiveness of user interface, most agreed (70.6%) that the electronic kardex’s terms and concepts are clear and unambiguous. On the contrary, some respondents disagreed that the arrangements of the fields on-screen were sensible for the work nurses do (7.7%) and that it responds quickly enough to inputs (7.7%).

Research Question 1

RQ1 asked whether system characteristics, such as perceptions of key functionalities and intuitiveness of user interface, were associated with attitude towards the electronic kardex. Model 1 (see Figure 3) shows that perceptions of key functionalities (B = .20, p < .001) was positively associated with attitude towards the electronic kardex. Likewise, model 2 (see Figure 4) shows that intuitiveness of user interface (B = .30, p < .001) was positively associated with attitude towards electronic kardex.

Research Question 2

RQ2 asked whether usability factors, such as perceived usefulness and perceived ease of use, mediate the association between perceptions of key functionalities and attitude towards electronic kardex. Results shown in Figure 3 indicate that there are significant indirect effects as evidenced by confidence intervals that did not reach zero in two paths. However, the researchers noticed that the strength of mediation varies between these paths. Specifically, the indirect effect of perceived key functionalities on attitude towards electronic kardex via perceived usefulness (B = .40 [95% CI: .22, .60]) is greater than that of perceived ease of use (B = .12 [95% CI: .01, .27]). Simply, the effect of key functionalities to attitude towards electronic kardex is more of a function of perceived usefulness than perceived ease of use.

Nonetheless, given that the total indirect effect (B = .52 [95% CI: .37, .70]) of perceptions of key functionalities on attitude towards electronic kardex (via perceived usefulness and perceived ease of use) is greater than the direct effect between them (B = .20, p < .001), the results indicate that perceived usefulness and perceived ease of use were significant mediators.

Research Question 3

RQ3 asked whether usability factors, such as perceived usefulness and perceived ease of use, mediate the association between intuitiveness of user interface and attitude towards the electronic kardex. Mediation analysis results shown in Figure 4 indicate that there was only one path that intuitiveness of user interface had an indirect effect on attitude towards an electronic kardex. Specifically, the indirect effect of intuitiveness of user interface to attitude towards the electronic kardex via perceived usefulness (B = .43 [95% CI: .26, .65]) was significant while it was not for perceived ease of use (B = .10 [95% CI: -.03, .26]). Simply, the effect of key functionalities to the attitude towards electronic kardex is a function of perceived usefulness and not of perceived ease of use.

Nonetheless, given that the indirect effect (B = .43 [95% CI: .26, .65]) of intuitiveness of user interface to attitude towards the electronic kardex via perceived usefulness is greater than its direct effect (B = .30, p < .001), the results indicate that only perceived usefulness is a significant mediator.

Discussion

This study presented the development and testing of a prototype electronic nursing kardex. Overall, the results indicate positive user attitude towards the electronic kardex and there are certain mechanisms that can facilitate positive attitudes. The following paragraphs discuss the key findings of the study.

The findings show that the respondents had a positive attitude towards the electronic kardex and they perceived it to be easy to use, useful, intuitive and functional. However, the results also highlighted that there is still room for improvement since none of these variables reached a mean score of four out of five. For instance, considering that the item “The electronic kardex can help to prevent medication errors” had the lowest item level mean score, the researchers think that improving the presentation of the medication details in the display can improve the future version’s mean score for this item.

Consistent with TAM, (Davis, 2011) the research findings show that attitude towards an electronic kardex is positively related to usability factors, such as perceived usefulness and perceived ease of use. Such findings support previous work on EMRs (Mijin, 2019; Sayyah Gilani, 2017) and electronic health records for nursing education (Kowitlawakul et al., 2015).  However, what is interesting is that authors found that perceived usefulness, instead of perceived ease of use, served as a significant mediator when estimating the relationship of system characteristics (i.e., perceptions of key functionalities and intuitiveness of user interface) and attitude toward the electronic kardex. A possible reason for this is that the respondents tend not to have any electronic forms available for such clinical routines. It is crucial to note that most hospitals in the Philippines lag behind the adoption of health information technologies (Bautista & Lin, 2016; Bautista, Lin & Theng, 2020). As such, although the electronic kardex’s functionalities and intuitiveness can have a positive effect on attitude, the mechanism is that these system characteristics contribute to its perceived usefulness, which then leads to a positive attitude towards it. The results contribute to extending TAM’s reach by having system characteristics as additional direct antecedents for perceived usefulness and perceived ease of use, and indirect antecedents for attitude towards the electronic kardex.

Limitations and Future Direction

Although the study provides key insights in further developing the Open-NIS electronic nursing kardex, there are several limitations that need to be acknowledged. First, it is crucial to note that the results were derived from a private hospital in the Philippines and might not be generalizable to public hospitals. As such, future versions of the electronic kardex will also be tested in public hospitals so that it can capture usability issues from both types of hospitals in the Philippines. Next, the study delimited on using attitude as the terminal construct of the study.

While some might argue that the researchers should have included other constructs, such as intention to use and actual usage, the authors argue that the electronic kardex was just a prototype (it only had hypothetical details) in which it would be unrealistic for nurses to indicate their intention to use it. Therefore, future work would include working with hospitals to deploy it and conduct another study that would include intention to use and actual usage as well as other usability factors (e.g., compatibility, security, accuracy, reliability, etc) (Mijin et al., 2019).

Conclusion

As one of the primary providers of healthcare, nurses are at the forefront of quality healthcare service. With this, nurses should be creative in coming up with practical and realistic solutions to problems in logistics and workflow. The nursing kardex is a tool that every nurse can claim as their own and be proud of. Hence, the creation of the nursing kardex hailed from the need of nurses to process data and information that could, otherwise, have been lost in separate sections and entries in the patient’s chart. Transforming the traditional concept and use of the nursing kardex into its electronic form means making the knowledge and wisdom needed to provide care for patients readily available in a digitized manner through electronic storage and retrieval.

In this study, the researchers developed and tested a prototype electronic nursing kardex. Results show that the users had a positive attitude towards it. This positive attitude was informed by its key functionalities and intuitiveness through perceived usefulness rather than its perceived ease of use. Future studies will be aimed at improving the electronic kardex and performing extensive usability testing.

Acknowledgements

The authors would like to thank the nurses who participated in the survey, and the assistance of Mr. Hussein Catanyag.

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