A Scoping Review of Research Involving Nurses and Electronic Health Records in Middle Eastern Countries

C l i n M e d International Library Citation: Strudwick G, Tanimizu A, Saraswathy SN, Yousef S, Nickerson V (2015) A Scoping Review of Research Involving Nurses and Electronic Health Records in Middle Eastern Countries. Int Arch Nurs Health Care 1:012 Received: August 23, 2015: Accepted: October 28, 2015: Published: November 02, 2015 Copyright: © 2015 Strudwick G. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Strudwick et al. Int Arch Nurs Health Care 2015, 1:2

Nurses represent the largest group of healthcare professionals in Middle Eastern countries expected to use EHRs when implemented in a particular care setting [5]. The quality of nurses' usage in the region is therefore important as organizations strive to meet their health information technology goals. However, implementation of EHRs can be challenging for nurses, as they are required to learn the intricacies of a new system, while maintaining a high quality of care delivery. In some situations, nurses may initially be required to 'double chart' (record the same observation electronically and on paper) while the system is being implemented in phases.
The context in which the EHR is implemented plays an important role in ensuring that the conditions facilitate the nurses' use of the technology. Additionally, nurses have varying comfort levels with the use of a computer, have different experiences using a computer at work, and may or may not utilize a computer in their personal lives. Within the region, the nursing workforce is comprised of a number of internationally educated nurses who may or may not have used EHRs in their professional training. These differences can influence nurses' attitudes toward [6,7], and ability to use an EHR both efficiently and effectively [8].

Introduction
Public and private healthcare organizations in Middle Eastern countries are investing in electronic health records (EHRs) to support the management of data and to improve the quality and efficiency of care delivery [1,2]. Some countries such as Saudi Arabia [2], Turkey [3], and Kuwait [4] have committed to adopting Abstract Aim: Nurses effective and efficient use of electronic health records (EHRs) is essential for the successful adoption of the technology. In recent years, countries within the Middle East have experienced an increase in the installation and implementation of such technologies, with nurses representing the largest user group. As such, the aim of this literature review is to understand the scope of research containing nurse participants related to the technology and its use in the region.
Methods: A scoping review methodology was utilized to conduct a literature review with 5 online databases searched. Two researchers reviewed all of the studies and applied inclusion and exclusion criteria. Any discrepancies related to inclusion were discussed and agreed upon.

Methods
A scoping review methodological framework [9,10] adopting the Arksey and O'Malley [11] approach was utilized. One of the goals of this approach is to "examine the extent, range and nature of research activity" [11] in a given field. As the aim of the review is to understand the landscape of research within a specific population (nurses) and topic area (EHR use), a scoping review is an appropriate methodology.
Arksey and O'Malley outline five stages to conducting a scoping review. In the first stage, the aim of the literature review is clearly identified, as the specific search strategy is developed based on this aim. A wide approach using broad terminology is encouraged at this time to be able to ensure breadth of coverage. In the second stage, studies are identified through a variety of different methods to ensure that all relevant studies have been included. In this review, studies were identified through searching several online databases and scanning reference lists. Databases searched included PubMed, Cochrane, Embase, Ovid (Medline) and the Cumulative Index for Nursing and Allied Health Literature (CINAHL).
The purpose of the third stage of conducting a scoping review is to select the appropriate studies to be included in the review [11]. Inclusion and exclusion criteria were determined and then applied to the discovered articles. For articles to be included in the review, the study setting needed to be within a Middle Eastern country. Countries that were considered to be Middle Eastern included Saudi Arabia, Yemen, Oman, Egypt, Iraq, Turkey, Iran, Syria, Jordan, Lebanon, Israel, Kuwait, Qatar, United Arab Emirates and Bahrain. Additionally for studies to be included in the review, they needed to have nurses as the participants and focus on electronic health record use in some capacity. Initially only English articles were to be included, however since none were found in other languages, no articles were eliminated and thus this inclusion criteria was deemed unnecessary. The process for article discovery is shown in figure 1.
In the fourth stage, charting of the data occurs where researchers sort through the findings and identify key themes . In this review,  a table was created to identify key information from each study  inclusive of the authors, year of publication, country of study, study  type, participant group, study aims, methodology, findings and  important results. This can be seen in table 1. Finally, during the fifth stage, the literature is collated, summarized and the results are reported. The Kuwait Cancer Control Center-University Health Network research team then met to determine important findings, and to discuss the implications of the studies. The results of these discussions are summarized in the discussion section.

Results
After duplicates were removed and the remaining articles screened for the inclusion and exclusion criteria at the title, abstract, and full article stage by two researchers, twelve articles remained ( Figure 1). The countries in which these articles were published included Saudi Arabia, Iran, Oman, Kuwait, Israel and Turkey  In 2014, a study examining the association between computer literacy and training, on the clinical productivity and user satisfaction of health professionals using an Electronic Medical Record (EMR) was conducted in Saudi Arabia [2]. In this study, surveys were distributed at a family health centre in Prince Sultan Medical Military City amongst nurses and physicians as these health professionals were deemed to represent the largest group of users of the technology. Results of the study showed that nurses with higher levels of computer literacy, and who were younger in age were more satisfied with their use of the system. However, in general nurses were positive about using the EMR in their practice and believed that using the system did not require advanced computer skills. Nurses and physicians reported making fewer mistakes related to transcription, and that missing information was less frequent in patient charts with the EMR present. Another study that took place in Saudi Arabia explored nurses' attitudes toward a computerized physician order entry (CPOE) and whether the electronic system could improve nurse-physician communication in the medication ordering process [12]. Surveys were distributed to 174 nurses, of which 146 were completed and returned. The majority of nurses perceived the CPOE to support their workflow and that the system allowed easier access to patient's medical information. Nurses who were employed for a longer duration and who worked in surgical departments had more negative views toward nurse-physician communication utilizing a CPOE. Some nurses felt that the system was not sufficient and that follow-up was required with physicians using phone calls or written notes to clarify orders.
In a study of nurses' perceptions of a health information system (HIS) in Riyadh, Saudi Arabia, nurses reported spending more time charting on the electronic record than they did on paper charts [5]. In this study, nurses were asked via a survey to communicate their satisfaction with using the system. Both level of education and years of experience were found to be significant predictors of their satisfaction with the HIS.
In a study of a Family Medicine Information System (FMIS) in Turkey, respondents reported that improved access to training, enhanced documentation practices for nurses and software upgrades would improve their perception of the system [3]. In this study of the attitudes of health professionals toward an EHR in a primary care setting, nurses reported that the FMIS saved them time, decreased their use of paper, provided better access to data, supported their clinical decision making and made it easier for data transfer. Despite nurses reporting saving time specifically with documentation, nurses still felt the FMIS took more time to utilize than paper-based records, and that their workload was increased. Nurses also worried about the impact the FMIS had on their interaction with other health professionals and patients, as well as the frequent downtimes of the system. Another Turkish study was conducted to understand in-patient nurses' views and satisfaction with an EMR in Ministry of Health, private and university teaching hospitals in Kocaeli [13]. Survey responses showed that a large number of nurses had never been formally trained on how to use the system, and that results of the study may have been different if all nurses had received training. 59% of nurses reported that the EMR was not well integrated into their workflow, and that use only occurred occasionally such as when lab results needed to be found. Nurses who used the system more were more satisfied with their interaction with the EMR, and felt the quality of the information was better. Nurses also reported that the system improved the legibility of patient information and improved patient safety.
Walston and colleagues (2010) investigated potential relationships between information technology (IT) and the visibility of patient care errors in five hospitals in Saudi Arabia [14]. The authors expected to find that the more nurses used the IT system, the lesser the number of patient care errors would be present. A total of 566 nurses responded to the survey and the results supported the authors' hypothesis. It was discussed that hospitals need to encourage staff to report incidents and facilitate a blame-free climate in addition to implementing IT systems to focus on patient safety, and to support quality improvement.
In an Iranian study evaluating the compatibility of an electronic patient record (EPR) system with nurses' management needs, a survey was distributed to head nurses and nursing supervisors [1]. Responses to the survey indicated that over half (57.6%) of head nurses and nursing supervisors used a computer at home, and that those with more experience using a computer had better perceptions of the EPR system in their workplace. Additionally, respondents reported that at the time the information contained within the EPR was not sufficient to meet the information gathering requirements of their roles, and that they were required to seek out other sources of information. In another study conducted in Iran aimed at evaluating the effectiveness of training courses for HIS, doctors, nurses, and medical personnel provided feedback on their use of the system [15]. Respondents feedback was then categorized into the following themes: software problems, hardware problems e.g. slow computer processing speed, personnel related issues such as users not familiar with using computers, problems related to the management and supervision, and training problems. The results showed that users of the HIS found the system to have many basic problems, and that continued support e.g. further training, and system improvements may enhance their use of it. The participants ISSN: 2469-5823 also requested a separate system for management functions, and requested clinical decision support functions to be incorporated into the EPR.
One of the studies discovered was a dissertation conducted at the Royal Hospital in Muscat, Oman [16]. Although this study had several aims, one specifically assessed the usefulness and ease of use of an EHR system called 'Al-Shifa' to support the transition of care during nursing handoff. In this study, the doctoral student utilized a mixed methodology inclusive of a survey, interviews, participant observations and artifact analysis. Findings of the study showed that age had a significant relationship on the 'ease of use' of the system. Specifically, older nurses found the 'Al-Shifa' system to be more difficult to use. Additionally, nurses who found the system useful, and easy to use, used the system more frequently.
A study by Darr et al (2003) investigated important features required in an EMR system from the perceptions of physicians and nurses [17]. Eleven senior specialists, seven junior doctors, and eight nurses from five Israeli hospitals were included in the study which was conducted via interviews. The authors learned that nurses' reactions to the EMR were similar to that of senior physicians rather than to junior doctors. Nurses found that EMRs provided easier access to patient information. Interestingly, as nurses were involved in the implementation of the EMR, they believed that the system supported their workflow and therefore their attitudes toward it were positive. A Kuwaiti study looked at nurses' attitudes towards the use of HIS in government hospitals [4]. 530 out of 574 surveys were completed and returned. Results showed that nurses working in Kuwait had positive attitudes towards computerized health information systems. Higher education, female gender, duration of computer-use, and nationality, influenced more positive attitudes towards HIS for patient care.
Lastly, Agharezaei et al. (2014) investigated attitudes toward a computerized clinical decision support system (CDSS) that aimed to reduce the incidence of pulmonary embolism and venous thrombotic embolisms [18]. Interviews were conducted with software users including nurses and were followed by standardized questionnaires. Users found it helpful to have the electronic system and saw benefits of applying it in their practice to improve patient care. Specifically, nurses found that the prompts provided by the CDSS were helpful to ensure that they provided patients with evidenced based care.

Satisfaction and attitude
Many of the studies included in the review focused on nurses' satisfaction or attitude toward using the particular EHR system [1][2][3][4][5][6]11]. Since nurses are required to use the technology by their organization, the salience of studying satisfaction and attitude of nurses toward EHRs may be questioned. However, authors of the studies assessing these concepts argue that there are "diverse effects of nursing satisfaction with the use of HIS in their daily practice" [5], and that nursing satisfaction may be an indicator of how well the system supports nursing work, and has been adopted generally. It is therefore suggested that nurses' satisfaction and attitude toward an EHR system may be a good proxy for its adoption into an organization.
In the reviewed studies, a number of factors that have been shown to influence nurses' satisfaction toward an EHR include a nurses' computer literacy level [2], computer experience [5], level of education [5] and use of the EHR itself [13]. The reviewed studies also show that nurses' attitude toward an EHR may be affected by their gender [4], nationality [4], level of education [4], duration of computer use [1,4] and their knowledge of computers overall [1]. Research conducted in non-Middle Eastern settings has also found similar results [6,[19][20][21]. Additional factors that have been shown in non-Middle Eastern studies to influences nurses' satisfaction or attitudes toward EHRs include age [22], experience as a nurse [21,23] specialty in nursing [19], access to computers [7] and system factors such as its design [24], speed [7] and frequency of downtimes (Weber). Ensuring that nurses are part of the team responsible for a system implementation has also been suggested to improve adoption [25].

Nurses' time
One of the benefits of an EHR to patients may be that more of a nurse's time is spent interacting and providing patients with care, rather than administrative tasks or documentation, as is found in a paper based system [5]. The results of the reviewed studies suggest that when efficiencies in documentation time are gained, nurses may be asked to complete a more enhanced or detailed level of documentation which may then lead to nurses spending even more time documenting than they did with the paper based record [3,5]. Additionally, nurses may be required to double document (on paper and in the EHR), when a system is initially implemented.
A systematic review of the impact of an EHR on time efficiencies of nurses found that bedside terminals rather than centrally located computers allowed nurses to use their time more effectively and efficiently when documenting [26]. Although not examined in the studies included in this review, point-of-care devices such as workstations on wheels that are being implemented in health settings globally may also influence the amount of time nurses spend documenting as they don't have to recall information when entering information into a computer at a fixed location [27]. In the reviewed studies, computers were located in central locations. The opportunity to utilize more portable systems for EHR use and access should be considered in future implementations.

System and setting variability
Seven different terms were utilized for EHR in the studies reviewed. These included Family Medicine Information System [3], Electronic Medical Record [2,13,17], Al-Shifa e-health application [16], Hospital Information System [4,5], Electronic Patient Record [1], Computerized Physician Order Entry [12] and Information Technology [14]. Not only is different terminology used, the systems in themselves may vary considerably. Some of the systems may serve several different functions e.g. Laboratory results viewing and nursing documentation, whereas others may offer only one function e.g. computerized physician order entry. Given that a broad search was conducted, these findings are not surprising. However, given the heterogeneity of the EHR configurations, how nurses interacted with these systems is unknown. It therefore remains unclear if nurses are expected to document and contribute information to all of these systems, or to utilize some of the systems to simply extract information. This lack of clarity renders the findings of the studies less generalizable, and perhaps less valuable to other organizations within Middle Eastern countries who may wish to apply the lessons learned from the studies to their particular situation.

Further Research
Although nurses have used computers in the Middle East for many years, nursing research with a focus on EHRs in this region is relatively new. Thus, it was not surprising to find only twelve studies focusing on this topic. However, there are many EHR systems that have been implemented, or are currently being implemented in the region, and therefore nursing research that aims to evaluate how best these systems can be implemented to support nursing practice would be valuable. Although nurses' satisfaction with and attitudes towards EHRs may be an important indicator of how well the technology supports nurses, a more comprehensive evaluation of system implementations is encouraged. As past literature has also suggested, organizations wishing to adopt such technology may want to understand barriers to successful adoption, and how these barriers may be best addressed [25]. The middle-east is a unique region in which language, infrastructure, a large expatriate population in some countries, and other important factors may influence nurses' use of the technology. As such, research that seeks to identify the unique barriers and facilitators to EHR use by nurses, as well as interventions or support mechanisms integral to a successful implementation may be valuable.

Conclusion
In conclusion, this literature review showed that despite the large number of technology implementations in the region, little research has been conducted to understand the intricacies of adoption unique to the region. Saudi Arabia had the most publications whereas countries such as Qatar or the United Arab Emirates had no publications. Findings from the twelve studies that were completed showed there is great variability in the systems and settings in which EHRs are implemented. Further training was the most common suggestion to support nurses' use of EHRs. Although nurses' attitudes towards the systems are generally positive, further research may identify more effective and efficient ways to enhance nurses' adoption of the technology.