Female Student Nurses Attitudes towards Electronic Medical Records in Riyadh City*

International Conference on Electrical, Electronics, and Optimization Techniques (ICEEOT) - 2016 Female Student Nurses Attitudes towards Electronic Medical Records in Riyadh City* Afrah Almutairi (Corresponding Author) School of Systems Engineering University of Reading Whiteknights, Reading, Berkshire, RG6 6AY, UK a.almutairi@pgr.reading.ac.uk Professor Rachel McCrindle School of Systems Engineering University of Reading Whiteknights, Reading, Berkshire, RG6 6AY, UK r.j.mccrindle@reading.ac.uk Abstract The aim of this study was to investigate the attitudes of female student nurses studying at the Technical Institute for Health Training in Riyadh City to the use of Electronic Medical Records. The findings of the study, which involved 56 female student nurses show that there is no significant relation between years of prior computer experience and knowledge or attitude toward EMR, although there is a significant relationship between age and the readiness to use EMR with student nurses over 23 years of age being more prepared to use the EMR than those who are under 23 years. Keywords E-Health; Electronic Medical Records; Student Nurse; Health Informatics; Information Management; Saudi Arabia; Hospital. I. INTRODUCTION Health care in the Kingdom of Saudi Arabia has been developing since 1949, with one such development being the move from handwritten records as the method used to store medical information to the use of electronic health systems in many hospitals and organizations in Saudi Arabia. Health care and medical service in Saudi Arabia are divided into three major sectors (1) Ministry of Health, (2) Other Governmental agencies such as Teaching Hospitals, University Hospitals, Military Hospitals and (3) the private Health Care Sector [1]. The Saudi government and the private sector in Saudi Arabia have invested heavily to build the essential infrastructure required to ensure adequate health care is provides for all people [2, 3, 4, 5]. In doing so, they have established a high level of health care infrastructure and other resources analogous with health care levels in many developed countries [6, 7]. However, the use of EMR is often not centralized or standardized across hospitals and private health organizations, and harmonization between the different health care providers and other associated sectors is required [8]. Research by Gallagher highlights gaps that require further study such as improvements to learning systems and efforts made by hospitals to improve the readiness of staff to use EMR [5]. Al Sheifi suggests that in order to implement successful EMR, the Ministry of Health should give strong support to female nurses receiving computer training including search techniques and data entry skills, in preparation for their use of medical records [9]. II. OBJECTIVE OF THE STUDY The objective of the study was to ascertain the perception, knowledge, and attitudes of female nurse students at the Technical Institute for Health Training in Riyadh towards the use of electronic medical records (EMR) as well as to investigate if there were any correlations between age, computer experience and level of study and their perceptions towards EMR. The study was conducted at the female branch of the Technical Institute for Health Training (TIHT) in Riyadh City. TIHT is a private institute, opened in 2001, that offers Diploma level courses in a number of applied health specialties to both male and female students. TIHT has two female branches one in Riyadh city (the capital of Saudi Arabia) and the other in Abha (located in the south region of Saudi Arabia). Both branches offer a Diploma in Nursing that lasts two years after Secondary school. Female nursing graduates work in Government or private hospitals, companies operating in the private medical sector, specialized medical centers, and government health centers. Questionnaires were used as the primary research methodology in this study. The questionnaire was written in Arabic (the mother language of the students) and then translated to English for the purpose of reporting the results. Statistical analysis was applied using SPSS software, and multi-variance analysis was used to assess group differences across different variables. Participants female student nurses at the TIHT in Riyadh were asked closed questions about EMRs as well as being encouraged to write about their knowledge, perceptions and attitudes towards the use of EMR through two open-ended questions. The questionnaire was distributed to 70 female nursing students of whom 56 (80%) responded. The questionnaire was divided into four sections: Section 1 included questions related to general information about the female student nurses, such as their age and level of education. Section 2 contained questions about their knowledge of computers, using a five-point Likert scale with responses 978-1-4673-9939-5/16/$31.00 2016 IEEE

ranging from excellent to poor. Questions also covered: whether they had a PC or laptop, using yes and no options; how many hours per week they used computers and the internet, ranging from none to nine or more hours ; how often they wrote or read emails, using a four-point Likert scale ranging from never to always ; their comfort when reading text on the screen; and whether they had taken any training courses in using office software, using yes and no options. Section 3 included questions about their knowledge and perceptions of EMR, such as whether they had heard about EMR and if they had taken any EMR-related courses in their studies, using yes and no options. This section also contained a table to gauge their perceptions to EMR through a series of statements about EMR, using a five-point Likert scale ranging from strongly agree to strongly disagree, as well as a don t know option. Statements included whether: EMR helps finish work faster than paper medical records; EMR decreases patient waiting time; EMR makes their job easier to do; EMR helps with writing and entering patient data; EMR helps to access medical records from different places in a hospital; EMR decreases the risk of human error; EMR helps in taking the right decisions about patient care; EMR improves the communications between health professionals in the hospitals; EMR increases the cost of medical care; confidentiality and privacy of patient information are more secure with EMR than with paper medical records; patient information may be lost due to technical problems when using EMR; EMR improves the quality of medical care; and EMR will help to build a national healthcare database. Finally, Section 4 of the questionnaire contained questions about the female student nurses readiness to use EMR, such as whether they thought they had the ability to use EMR effectively, using yes and no options, and having them rank in order of importance factors that might help them to adapt to a new EMR in a hospital. These factors were training courses outside the hospital, training courses inside the hospital, colleagues at the hospitals, personal experience and other, using a score of 1 5, where 1 meant most important and 5 least important. The final two questions were open-ended inviting a written response about the barriers for applying effective EMR in hospitals and any issues that the female nurse students felt were not adequately addressed by the questionnaire. TABLE.1 SAMPLE FREQUENCIES BY AGE Age Less than 23 years More than 23 years Frequency Percent Cumulative Percent Figure 1 shows that 23 of the study s population (41%) were in the first level of a 2 years nurse diploma course which is the highest group among the female nurse student cohort. 11 students (19.6%) and 12 students (21.4 %) were at the second and third levels, and 10 students (17 %) were at the highest level of their studies. Fig..1 Frequencies among level of education 33 58.9 58.9 23 41.1 100.0 The second part of the questionnaire focused on the respondents current usage of computers. The results in Table 2 show that 25 students which constitute the highest percentage of the population have very good knowledge about the use of computers (44.6%). Only 5 students rate their knowledge of computers fair and poor. TABLE.2 FREQUENCIES AMONG KNOWLEDGE OF COMPUTERS Knowledge of Computers Frequency Percent Excellent 15 26.8 Very good 25 44.6 Good 11 19.6 Fair 4 7.1 Poor 1 1.8 Most of students have their own personal computer or laptop (89%) while only 10.7% do not (Fig.2). III. RESULTS The results of the first part of the questionnaire, which investigate the characteristics of the population, show that 33 of the respondents (58% of respondents) were less than 23 years, while 23 students (41.1%) were older than 23 years. Fig. 2 Percentages of students who have or do not have computers: The results show that the highest frequency group is those who students who spend 3 to 6 hours a week on the computer and internet (15 students, 26.8% of the whole population). 13

students (23.2%) spend more than 9 hours per week using the computer, and 6 spend 6 to 9 hours a week on the computer. Only 8 students out of the sample (14.3 %) do not use the computer or the internet (Table 3). TABLE.3 HOURS SPENT USING A COMPUTER AND INTERNET Hours Frequency Percent None 8 14.3 1-3 14 25.0 3-6 15 26.8 6-9 6 10.7 9 or more 13 23.2 Fig.3 show that biggest group (15 students; 28,8%) of the study population do not write or read emails while 14 and 13 students respectively usually and always use emails. 25% of the students sometimes use email. Even though the bigger frequency is positive 33 (58.9%), a significant number (41%) had not heard of EMR (Table 5). TABLE.5 FREQUENCIES OF STUDENTS WHO HAVE OR HAVE NOT HEARD OF EMR Heard of EMR Frequency Percent Yes 33 58.9 NO 23 41.1 Results showed that most students had not been taught about EMR during their Diploma or high school with 44 of the population (79%) answering No to the question Have you had any courses regarding EMR in your studies while only 12 (21.4 %) answered positively this question (Fig.5) Fig.5 Having previous learning about EMR Fig. 3: Frequencies among using emails Table 4 shows that the majority of students feel comfortable in reading from a screen (80%) compared to only 20 % who do not. TABLE.4 COMFORT IN READING TEXTS FROM SCREEN Comfort Frequency Percent Yes 45 80.4 NO 11 19.6 To investigate knowledge, attitude, behaviour of the female nurse students toward the use of EMR in hospitals, different statements about EMR implications and trends were used. The statements were derived from the literature review and used to measure the level of knowledge students have about EMR and to predict their attitudes toward using EMR when they work at hospitals. The fourth part of the questionnaire discussed how prepared students felt for using EMR. Results in Fig. 6 show that 46 students (82.1%) think they are able to deal with EMR while 10 students (17.9%) think they are not prepared well to deal with EMR. In response to the question which asked if respondents had received any training courses in the use of office software, 75% of the students replied that they had received training. (Fig.4). Fig. 6 Frequencies among the ability to use effectively EMR Fig.4 the percentage of students who have previous training in office software applications. The third part of the questionnaire investigated the knowledge, attitudes, and behaviors of female nurse students toward the use of EMR in hospitals. The first question in this section asked whether the students had heard of EMR records. Students were asked to rank the factors that might help them adapt to using EMR in a hospital according importance to them (Table 6). Results show that students felt being given training inside the hospital was the most important factor followed by training outside the hospital. Personal experience came before colleagues in the importance according to the students preferences. TABLE.6 THE ARRANGEMENT OF POSSIBLE FACTORS THAT HELP TO ADAPT WITH NEW EMR

Factor Training courses outside the hospital Training courses inside the hospital Colleagues at the hospitals Personal Experience Mean 2.12 1.85 2.69 2.55 Rank 2 1 4 3 TABLE.8 READINESS TO USE EMR AMONG AGE GROUPS Age group Mean Less than 23 yrs 1.762 more than 23 yrs 2.579 24 out of the 56 respondents answered the open-ended questions. The first of these questions asked students what they believed would be the barriers for applying effective medical records in hospitals. In frequency order the answers were: lack of qualified information systems staff; technical and electrical problems; lack of knowledge, experience, and training; viruses and hackers; English language and translation; lack of technical infrastructure; work load on few employees which might lead to entry mistakes; expensive software and applications; lack of sufficient budget to adopt good EMR systems; poor maintenance; mistakes in data entry. Similarly in response to the question asking whether there were issues not covered by the questionnaire the following responses were given: English language and good experience of computers; privacy and security of patient information; increase training in EMR; securing the system; Hiring qualified employees to deal with the system. To determine the effect of age and level of study on the knowledge and attitudes toward the use of EMR and the readiness to deal with the EMR, a multivariate test was used to draw the relation between the variables. The results show that there is no significant relation (less than.05) between the age or the level of the study and the knowledge or attitude toward EMR (table 8). TABLE.7 MULTIVARIATE TESTS IV. CONCLUSION The findings show that there is no significant relation between ages or the level of the study, and the knowledge or attitude towards EMR, although there is a significant relationship between age and the readiness to use EMR. The results show that female nurse students who are more than 23 years of age are more prepared to use the EMR than those who are under 23 years. The reason behind the lack of a significant relationship between the level of study and knowledge or attitude towards EMR might be due to the lack of formal teaching or modules that focus on EMR to perform nurses tasks. This point highlights the need for improving the health education system to make it able to adapt to developments in medical records. Students in their responses to the open-ended questions indicated their concerns about their ability to work with EMR. Most of the views asked for better qualifications in the area of EMR and health information systems in general. These statements need to be considered in the national processes of change towards e-health. Other barriers or concerns in relation to EMRs were linked to technical, financial and workload issues. The results from this study have informed a larger study investigating the perceptions of EMR and barrier to its uptake in both male and female nurses at all stages in their careers. Acknowledgment We would like to thank the staff members and participants of the Technical Institute of Health Training where this study was conducted. To illustrate the effect of age on the ability to use EMR a comparison between the means was used in table 9 which shows that female nurse students who are more than 23 years are more prepared to use the EMR. References [1] Ministry of Health Kingdom of Saudi Arabia. World Health Statistics Report. 2013, Available at http://www.moh.gov.sa/en/ministry/statistics/book/documents/statistics- Book-1434.pdf Accessed on [8 December 2015] [2] Ministry of Foreign Affairs. Kingdom of Saudi Arabia, available at: http://www.mofa.gov.sa/sites/mofaen/eserv/visitingsaudiarabia/about KingDom/Pages/KingdomGeography46466.aspx]. Accessed on: [8 December 2015]. [3] A.Al-Shekh, Perceptions of hospital experiences in Riyadh City, Saudi Arabia: a comparison of service quality in public and private hospitals, University of Wales, Swansea, 2003. [4] M.Al-Yousuf, T. M. Akerelel, and Y.Al-Mazrou, "Organization of the Saudi Health System", Eastern Mediterranean Health Journal, 8(4-5):645-53, 2002. [5] Saudi Association for Health Informatics. National e-health Strategy 2015. [Online] Available from: http://www.moh.gov.sa/en/ministry/nehs/pages/default.aspx [Accessed 8 December 2015]

[6] G A.A. Alshammasi, The Influence of Economic, Political and Sociocultural Factors on the Development of Health Services in Saudi Arabia. University of Hull,1986. [7] M. Almalki, G.Fitzgerald,, M.Clark,. Health care system in Saudi Arabia: an overview. Eastern Mediterranean Health Journal. 17(10), 2011. [8] M.M.Altuwaijri, Electronic-health in Saudi Arabia. Just around the corner? Saudi medical journal, 29(2), pp. 171-178, 2008. [9] N. AlSheifi, Attitiude of physicians and nurses towards medical records. Graduation Project, Department of Community Health, College of Applied Medical Sciences, King Saud University, 2001.