Health Info Libraries J - 2008 - Ward - The Attitudes of Health Care Staff To Information Technology A Comprehensive

DOI: 10.1111/j.1471-1842.2008.00777.
The attitudes of health care staff to information

Blackwell Publishing Ltd
technology: a comprehensive review of the

research literature
Rod Ward*, Christine Stevens*, Philip Brentnall† & Jason Briddon‡, *Faculty of Health and Social Care,
University of the West of England, Bristol, †Healthcare Software Systems, Mansfield Woodhouse and
‡Library Services, University of the West of England, Bristol, UK
Abstract
Objectives: What does the publicly available literature tell us about the
attitudes of health care staff to the development of information technology in
practice, including the factors which influence them and the factors which may
be used to change these attitudes?
Methods: Twelve databases were searched for literature published between
2000 and 2005 that identified research related to information technology (IT),
health professionals and attitude. English language studies were included
which described primary research relating to the attitudes of one or more
health care staff groups towards IT. Letters, personal viewpoints, reflections
and opinion pieces were not included.
Results: Complex factors contribute to the formation of attitudes towards IT.
Many of the issues identified were around the flexibility of the systems and
whether they were ‘fit for purpose’, along with the confidence and experience
of the IT users. The literature suggests that attitudes of practitioners are a
significant factor in the acceptance and efficiency of use of IT in practice. The
literature also suggested that education and training was a factor for encour-
aging the use of IT systems.
Conclusions: A range of key issues, such as the need for flexibility and usability,
appropriate education and training and the need for the software to be ‘fit for
purpose’, showed that organizations need to plan carefully when proposing the
introduction of IT-based systems into work practices. The studies reviewed did
suggest that attitudes of health care professionals can be a significant factor in
the acceptance and efficiency of use of IT in practice. Further qualitative and
quantitative research is needed into the approaches that have most effect on the
attitudes of health care staff towards IT.
‘National Programme for IT’ (NPfIT), computer

Background
applications within the NHS have been increasing.2
The use of information technology (IT) in the In Wales related developments have been undertaken
UK’s National Health Service (NHS) has a long by Informing Healthcare3 and in Scotland by
history. Since the publication of the Information eHealth for NHS Scotland.4 These developments
for Health Strategy1 and more recently England’s are not limited to the UK but have international
significance. Around the world similar developments
Correspondence: Rod Ward, Faculty of Health and Social Care,
University of the West of England, Glenside Campus, Blackberry Hill, in IT use are taking place with increased
Stapleton, Bristol BS16 1 DD, UK. E-mail: [email protected] employment of electronic health records (EHRs),
© 2008 The authors

Journal compilation © 2008 Health Libraries Group. Health Information and Libraries Journal, 25, pp.81–97 81
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82 Attitudes of health care staff to IT, Rod Ward et al.
automated administration and increased electronic Table 1 Databases included in the review
sharing of patient information. The importance of
Allied and Complementary Medicine Database (AMED)*
IT in the NHS modernization agenda has been
British Nursing Index (BNI)*
underpinned by several reports (such as those led Cumulative Index to Nursing and Allied Health Literature (CINAHL)*
by Derek Wanless in 20025 and 20076) and its role EMBASE*
in increasing patient safety and reducing errors Health Management Information Consortium (HMIC)*
made clear.7 Index to theses
There is also a large and growing body of liter- ISI proceedings
Maternity and Infant Care (MIDIRS)*
ature about aspects of health informatics related
MEDLINE*
to policy, hardware, software and implementation. NHS National Research Register
One of the factors identified as significant in the PSYCINFO*
introduction of information technology into health SPORTDISCUS*
care practice is the attitude of staff that will be ZETOC conference search
required to use it. In the UK surveys undertaken
*Databases searched via Ovid interface.
by Medix (a market research company in the health
sector) found that the attitudes of doctors and nurses
have shown increasingly negative attitudes.8,9 predilection of journals to publish research with
The Technology Acceptance Model (TAM)10,11 (statistically) significant findings; for example,
may provide a context to study the acceptance, medline bias for excluding papers not indexed in
or otherwise, of IT in the NHS. It has also been medline and ‘language bias’ from exclusion of
extended by Dixon and Dixon into the Informa- non-English publications.21 In our review, the
tion Technology Adoption Model (ITAM),12,13 selection of appropriate sources and the
which may provide a more comprehensive theoretical development of the search strategy was a dynamic,
model for this study. iterative process balancing the expertise and
Over twenty years ago, Stronge and Brodt14 neutrality of the librarian with the knowledge and
were studying this area in the USA with their experience of the researchers. The key principle in
Nurses’ Attitudes Towards Computers (NATC) our selection was to be as inclusive as possible
questionnaire and others have continued this within the resources and timescales for the project
work, using similar instruments with different whilst being open to the possibility of bias. In
findings. Sultana15 and McBride and Nagle16 developing our search strategy, we continually traded
found more positive attitudes than Stronge and sensitivity (recall) against specificity (precision).
Brodt.14 Schumacher et al.17 found that students Thirteen databases (see Table 1) were identified
showed more positive attitudes than qualified as covering relevant material for this review. These
staff, but Scarpa and Smeltzer 18 found no dif- databases were explored in a series of discussions
ferences in attitude with nursing experience or between the researchers and librarian, which
educational level, but had found that experience balanced the knowledge of the librarian on their
with computers was significant. In addition, Schwirian characteristics (for example, accessibility, currency
et al.19 had shown gender differences in attitude. and potential relevance) and the researchers’
A recent review of the literature on eHealth has knowledge of the subject area. Potential search
been carried out,20 but little was included on the terms were applied across all these databases,
attitudes of staff and students towards these enabling us to explore the suitability and function-
emerging technologies. ality of their search interface and the significance
of their output to our review.
Methods
Developing the search strategy
Literature search
In tandem with our exploration of databases, a
In developing a search strategy, bias may arise cyclic, iterative approach to identifying appropriate
from a number of factors, including the search terms was undertaken. Search terms were
© 2008 The authors

Journal compilation © 2008 Health Libraries Group. Health Information and Libraries Journal, 25, pp.81–97
Attitudes of health care staff to IT, Rod Ward et al. 83
Table 2 Search strategy for database searches
Word group 2 Word group 3 Word group 4 Word group 5

Word group 1 (IT) (health professional) (attitude) (research) (patient/public attitude)
information tech* nurs* attitud* research* patient attitud*

communication tech* doctor* study patients attitud*
ICT physician* studies patient information*
comput* professional* evaluat* consumer attitud*
e health practitioner* consumers attitud*
Ehealth clinician* consumer information*
Informatics staff public attitud*
e learn* health care worker* publics attitud*
elearn* personnel public information*
technology in health care therap*
midwi*
dietician*
dietitian*
nutritionist*
radiograph*
radiotherap*
radiolog*
surgeon*
scientist*
health visitor*
dentist*
dental
physiotherap*
GP
medic*
All terms within groups combined with OR; word groups 1–4 combined with AND; group 5 relating to patient/public attitude
combined with groups 1–4 with NOT (to exclude studies which focused on patient/public and not health professionals).
*Indicates truncation.
ICT, information and communications technology.
identified through discussion between the research On exploring the references retrieved using the
team, including the faculty librarian, and by four initial concepts, a fifth concept was added—
scanning background material. The search Public/Patient attitudes. This was combined with a
strategy is detailed in Table 2. NOT in order to exclude items that related to the
Search terms were developed using what were public’s attitude to IT in health care.
considered to be the richest sources of data for this Overall, a sensitive approach was taken to the
review; amed, BNI, cinhal, embase, medline, development of the strategy, by searching for our
Sportdiscus and PsycInfo (‘core databases’ terms using the default keyword search in the Ovid
accessed on the Ovid interface). interface. This maps search terms to a range of
The initial search was built on four concepts fields including titles, subject headings, heading
that were to be present in all retrieved references as words and abstracts. Finding the appropriate
they were seen as being key to the research questions: balance between sensitivity (recall) and specificity
1 IT; (precision) was achieved through the iterative
2 health professionals; process of refining and testing the search terms
3 attitude; and strategy across the seven ‘core databases’.
4 research. Thesauri for the databases included in the review
The concepts were combined together with were checked to identify any further potential search
AND in the search strategy. terms and to ensure that all relevant subject
© 2008 The authors

Table 3 Search strategy and results
Database Search strategy used n
AMED Full search strategy as detailed in Table 2. 1895

BNI
CINAHL
EMBASE
HMIC
MEDLINE
PSYCINFO
SPORTDISCUS (all on
Ovid interface)
Index to theses† Limitations in search interface. Used search strategy of IT concepts combined with 20
‘health’. Gave n = 20
ISI Proceedings Full search strategy as detailed in Table 2 70
MIDIRS Full search strategy as detailed in Table 2 retrieved nothing—so reduced search to 12
cover just IT concepts combined with attitude*
Zetoc Limitations in search interface—can only use one term for each of our concepts—ran 17
several of these through to ensure coverage of appropriate material—
Effectively search strategy was ... (information tech* or communication tech* or ICT or
comput* or e health or ehealth or technology in health care or informatics or e learn*
or elearn*) AND (attitud*)
†Index to theses records (n = 20) were handled separately as they could not be transferred to RefWorks™.
headings were extracted to be included in the list

Article selection
of search terms. Encapsulating all relevant subject
headings as search terms negated the need to per- A data extraction sheet (Appendix 1) was devel-
form exploded subject heading searches alongside oped to standardize the collection of information
mapping keywords to titles, subject headings and and enable rapid comparison between them.
abstracts. The standard keyword search in the The bibliographic details in the computerized
Ovid interface was used when searching, mapping database search including abstracts, where available,
the search terms to a default range of fields which were either printed out or examined on the computer
included titles, subject headings, heading words screen in a sifting exercise. For the sifting exercise,
and abstracts. This approach meant that it was inclusion criteria focusing on research material
unnecessary to develop separate search strategies examining health care personnel attitudes were agreed
for each of the ‘core databases’ built around their by the research team through ongoing discussions
unique subject heading structure. A single, based on their experience and initial reviews of the
all-encompassing search strategy could be devel- literature. At this point, it appeared that there was
oped and applied across all of the databases in the thematic analysis being performed to further narrow
Ovid interface. Pragmatically, this allowed for a down the material. A comparison of the selections
single set of results to be generated from which made by the reviewers (1 : 20) was therefore under-
duplicates could be removed by the Ovid ‘remove taken independently to reduce selection bias.
duplicates’ tool. Logistically, having a single final Full papers were acquired if they fulfilled the
search strategy that could be used across the ‘core criteria; however, even after this stage some items
databases’ was a real bonus for this review, reducing were excluded using the criteria shown in Table 4,
the complexity of having multiple strategies that as they were ambiguous, either containing limited
would need to be run individually. relevance to the review or insufficient detail to
Table 3 details the search strategy used on the meet all the criteria.
various databases included in the review and the Even when explicit inclusion criteria have been
number of papers (n) retrieved on each database. specified, decisions concerning the inclusion of
© 2008 The authors

Table 4 Inclusion and exclusion criteria used and the findings. The team then met and each
contributed the ideas for themes which they had
Inclusion criteria
identified from the papers they had reviewed. An
English language
2000–2005
iterative process was undertaken to refine the themes
Primary research and explore the overlaps and gaps between them.
Included measures of attitude related to IT Each team member then identified which of the
Exclusion criteria papers they had reviewed applied to one or more
Not in English of the themes. A sample of the papers was then
Not relevant to search aims
reviewed by a second member of the team to
Before 2000
Not relevant to ‘health professions’ ensure consistency of allocation to themes.
Not research (any form of original data collection)
Does not consider a concept related to attitudes
Case studies involving only one person/case
Results
Single page or less
No author identified Literature review
Letters/personal viewpoints/reflective articles/opinion pieces/
commentaries on papers unless clearly relevant and ‘evidence- A wide range of papers were reviewed, covering a
based’ or collected as part of a properly designed study variety of research methods and examining different
Not pre- and post-registration/graduate education/ aspects of the domain. The majority of the papers
continuing professional development (CPD) reflected quantitative and qualitative studies, mostly
surveys, although there were several interview
studies and a few observational studies with
sample sizes reflecting the variations in methods.
The papers had collected data in 16 countries
with 52% of those from the USA. Several studies
were conducted before and after computerization
of systems (e.g. Derup24), although the majority of
studies were developed by the individual researchers,
often with little evidence of piloting or checking
the validity and reliability of the instrument.
Studies were often conducted in conjunction with
the introduction of new hardware or software
systems into the areas in which respondents
worked (e.g. Junger25).
The primary focus of the studies was the
attitudes of staff to IT in general, but often they
had a more specific or different focus and the data
about staff attitudes were supplemental or tangential
Figure 1 Results of the literature search
to the main study.
Information systems can be seen as an organized
and coordinated approach by individuals to
individual studies remain relatively subjective, as process and share information with each other.
has been described in other studies.23 A number of Therefore, an information system contains
papers that provided general analyses, literature interfacing components, some of which are
reviews and other works were used to inform the people, objects and procedures. The technical
review but were not included for detailed data system is viewed as embedded in a social system—
extraction. the human activity system includes the use of
Each paper was read by one of the research team computer-based systems.26
and the data extraction sheet completed, high- The themes that emerged as affecting attitudes
lighting the setting of the study, the methodology towards IT, ranged from the social system aspects
© 2008 The authors

of management—power, education and training, Table 5 Themes from the literature

to the user-specific attributes of age, gender,
Clinical records (EMR) Education and training
professional groups and previous experience and
also the design of the system. These themes are Gohlinghorst et al.27 Derup24
summarized in Table 5. Chiasson & Lovato28 Lee35
Junger25 Fischer et al.36
Weir et al.29 Polhamus et al.61
Management/workload/efficiency Adams et al.30 Chan et al.55
Trivedi et al.31 Embi et al.62
Two types of barriers to the implementation of IT Beuscart-Zephir32 Westerlund et al.63
Collins et al.33 Haluck et al.64
systems were identified by Leung et al.50 These
Pagliari et al.20 Sery-Ble et al.65
were cost related (both financial and time/effort) Design of software/hardware Power and decision-
and the knowledge/attitude of end-users. Incentives making ability
for the introduction of IT-based systems were Carroll & Christakis34 Stricklin et al.66
Lee35 Doolan et al.67
either economical or driven through new Fischer et al.36 Pare68
legislation and regulatory requirements. One McAlearney et al.37 Chismar & Wiley-Patton69
finding was that computer systems enable greater Ammenwerth et al.38 Beuscart-Zephir32
Chiasson & Lovato28 Loomis et al.42
accountability and evaluation, giving managers Beuscart-Zephir32 Timmons70
more control over health care services. Johnston et al.71
Both Rodriguez et al.46 and Urkin et al.45 found Lai et al.72
Previous experience Moffat et al.73
that physicians highlighted the potential of com-
Liu et al.39 Araujo et al.74
puterized charts with office work, preventing the Dixon & Stewart40 Temple et al.75
loss of information and facilitating communica- Moody et al.41
tion. However, they had concerns about how Ammenwerth et al.38 Telemedicine/imaging/
pathology systems
patients’ records were displayed and anticipated Loomis et al.42 Yousem & Beauchamp76
an increase in workload and the time taken for Balter43 Mast et al.77
data entry. Kleiner et al.49 also detected concern Chan et al.55
Management/workload/efficiency Lehoux et al.78
about workload issues in their study looking at Rosenbloom et al.44 Demartines et al.79
e-mail consultations. In addition to being con- Urkin et al.45 Bartoloni80
cerned with confidentiality issues, 80% felt that Rodriguez et al.46 Gattas et al.81
Apkon & Singhaviranon47 Crowley et al.82
using e-mail would increase their workload. This
Moody et al.41 Rydmark et al.83
was also supported by Gadd and Penrod,48 who Gadd & Penrod48
found the time taken for documentation was Kleiner et al.49 Professional issues
increased by a computerized system. Contrary to Leung et al.50 Krall & Sittig84
May et al.85
this, Moody et al.41 found that more than one-third Professional groups Seckman et al.86
of nurses (36%) perceived that EHRs had resulted Lee51 Ammenwerth et al.38
in a decreased workload. Porteus et al.52 Anderson87
Ammenwerth et al.38 Darr et al.56
Other impacts in addition to workload were Hersh et al.53 Campbell et al.88
identified by Moody et al.,41 who found that Ash et al.54 Larcher et al.89
respondents believed that electronic charting Chan et al.55 Travers & Downs90
Darr et al.56 Lee et al.91
would lead to improved safety and patient care,
Jacko et al.57 Liederman & Morefield92
whilst another study found improved efficiency.44 Schubart & Einbinder93
Electronic documents contained 50% more Confidence in system privacy Walter et al.94
descriptors than handwritten documents.47 Lee35
Kouri et al.58 Age and gender
Colleagues derived benefits from increased legibility, Darr et al.56
more detailed content and the ability to generate Decision support systems Loomis et al.42
administrative and patient-care reports. Bauer et al.59 Chan et al.55
Rosseau et al.60 Lai et al.72
The majority of nurses (64%) preferred bedside Araujo et al.74
documentation, but also found that environmental
and system barriers often prevented EHR charting EMR, electronic medical record.
© 2008 The authors

at the bedside. EHRs are seen to improve the quality The success of implementation of clinical
of documentation.41 information systems was studied by Doolan
et al.67 The presence of high-level leadership was
considered the single most important factor con-
Power and decision-making ability
tributing to successful implementation. Each site
Stricklin et al.66 found that nurses’ work and the had the aim of improving quality of care through
barriers they perceived to making changes each implementation of electronic records, with emphasis
appear to explain more variance in nurses’ placed on the clinical processes being supported
attitudes toward computers than security issues; by the system and not driven by them. The study
and that it is vital for the industry and its providers also identified that it is important to build on the
to be prepared for the myriad ways point-of-care momentum of earlier successes to achieve wide-
(POC) technology will affect the practice of spread implementation and use of a new system.
nurses, the end-users. The ultimate satisfaction This is also supported by Johnston et al.,71 in that
and use of the technology of home-care nurses negative attitudes towards computerization were
will greatly affect not only the business success of only displayed by physicians that do not have an
the organization but also the structure, process and existing IT system. The majority of negative
outcomes of care to patients and their families. attitudes are related to the cost of computerization.
The various methods that staff use to challenge Organizationally successful implementation
the implementation of IT systems was studied by was about identifying champions and getting the
Timmons,70 who found that resistance took a wide right people on board (see Ash et al.54). The
variety of forms, including attempts to minimize selection of the implementation strategy depended
use of the systems and extensive criticism of the on the experience, skills, beliefs and motivation of
systems, although outright refusal to use them was the key actors involved. Pare68 concluded that
rare. Resistance was as much about the ideas and health care IT projects are always characterized by
ways of working that the systems embodied as it some vagueness and projects can never be per-
was about the technology being used. The patterns fectly controlled or predicted.
of resistance can best be summed up by the phrase
‘resistive compliance’. Another aspect of non-
Education and training
compliance was discussed by Beuscart-Zephir,32
who found that, whilst novice anaesthetists The potential of IT in facilitating training has been
followed the system, experienced anaesthetists explored in a number of studies. Haluck et al.64
jumped around the questions, underlining and suggest that programme directors believe this type
setting alerts, etc., surrendering the system useless of technology would be beneficial but lack
or depersonalized. adequate information regarding virtual environment
Chismar and Wiley-Patton69 used the Extended simulators. This was supported by Polhamus
Technology Acceptance Model (TAM2) to examine et al.,61 who examined the potential for the use of
paediatricians and showed perceived usefulness technology in distance education and concluded
was a strong determinant of intention to use, that, to make effective use of web-based resources,
whereas perceived ease of use and subjective norm both technology skills and confidence in using
did not significantly affect intention to use IT. those skills are essential. It should not be assumed
Further analysis identified job relevance and that those enrolling in distance learning have the
results demonstrability as factors determining necessary technical skills to complete training
perceived usefulness. Physicians are willing to successfully.
adopt beneficial applications in IT, even if they are In the study by Sery-Ble et al.,65 nurses believed
not easy to use; the tool used (TAM2) did not take that the computerized presentation was an effec-
into account the higher level of competence, tive way to learn new material, even though only
intellectual and cognitive capacity that physicians 57.1% considered themselves proficient with
generally have, also the ability to adapt to new computers. They suggested future studies should
technologies. also examine the types of medically related skills
© 2008 The authors

that can be effectively taught by computerized potential users of the ambulatory care EMR had
training programmes. This is supported by generally positive or neutral attitudes toward the
Zdanuk et al.95 who showed that computer-based system, physician groups had less positive feelings
learning is beneficial for the confidence of clinicians. than the other professional groups.
Searching skills and access to adequate technology
was highlighted by Moffat et al.73 as areas
Professional issues
stopping clinicians using online information effec-
tively. Despite general positivity, Hancock et al.96 Social network analysis can be used to analyse
also found a need for more computer literacy, relationships between health care providers and to
information literacy and research education. identify influential individuals who are critical to
the successful implementation of IT systems.87
Identifying barriers to successful implementation
Professional groups
was the focus of some studies. Campbell et al.88
Comparisons between professional groups were concluded that implementation strategies should
often difficult. Darr et al.56 found nurses were the be tailored to the environmental conditions of the
most enthusiastic about IT implementation, while practice sites. In further detail, Darr et al.56
junior doctors were the least. The junior doctors identified six main domains of concern expressed
resented the system as they had to enter most of by physicians: managerial implications of EMR;
the data, whereas nurses stressed the positive limits on professional autonomy; its impact on
impact of the electronic medical record (EMR) on communication with colleagues; facilitation of
improving patient care. Porteous et al.52 found research; legal defence; and influence on the
that, whilst general practitioners (GPs) had professional hierarchy within the hospital.
concerns about technical issues, pharmacists were Campbell et al.88 also found six similar and related
more worried about workload issues. themes examining care providers’ receptivity to
In another study, hospital physicians felt the technological change: turf; efficacy; practice
system to be technically cumbersome and time- context; apprehension; time to learn; and
consuming, and in the teaching hospitals resented ownership. Care providers and administrators
using the ‘physician order entry’ (POE) system. consider a range of factors, including economic
However, in a community hospital setting, staff ramifications, efficacy, social pressure and
had been involved in developing clinical pathways, apprehension, when deciding whether and how
resulting in a system which had a positive organi- fast to adopt telemedicine. Travers and Downs90
zational impact as it was multi-disciplinary. also found five main themes. These were:
In a study of a range of health professions, usefulness; organizational culture; relationships
Jacko et al.57 showed significant results as a result and partnerships; and the challenge of
of the occupation of the participant. The nature of implementing a system developed for an academic
the occupations influenced the need for a more centre environment into private practice settings.
comprehensive list of possible search subjects and Once implemented, user commitment and atti-
topics and different search tools. Nurses need tude change; Krall and Sittig84 identified five main
access to more sites than pharmacists and specialists, topics in their focus groups—efficiency, usefulness,
although nursing students were the most likely to information content, user interface and workflow
be non-users of the Internet. being key issues. The focus groups held generated
The fact that the requirements of the different some innovative suggestions and surprised the
professional groups vary was also documented by researchers with the level of emotional engagement.
Ammenwerth et al.38 Medics welcomed speedier Lee et al.91 found that intensive care unit (ICU)
access to information, recording data at the nurses were ambivalent towards a new system as
patients bedside and the ability to communicate some shortcomings of the manual processes were
anywhere—leading to health care professionals not addressed by implementing the system. How-
working together to provide better and improved ever, major themes were: system saves resources;
patient care. However, Lee51 found that, whilst individualizes care plans; waiting for printouts
© 2008 The authors

from system; routine based; and there was no up study,38 years of computer experience is
consensus on nursing diagnostics, concluding that positively correlated to initial acceptance of
there was a shift for nurses from being patient computer use and it was concluded that the fit
centric to information systems centric. between the task and the selected technology is
Although physician productivity increased important for user acceptance. Poor fitness for use
significantly after introduction of the system, can have a negative effect on quality of patient care
Liederman and Morefield92 identified speed of the provision.
computers and extra workload as reasons for a A study by Balter43 found attitudes to com-
negative attitude towards the system. Seckman puters and e-mail became more positive over the
et al.86 found a strong correlation was detected years, especially amongst the employees. The
between adoption of technology and perceived majority of managers were positive at the start of
usefulness, as well as significant differences IT implementation and remained positive.
between specialities being identified about ‘per- Location has been demonstrated to impact on
ceived usefulness’ and ‘impact’, but no differences attitude to IT; Loomis et al.42 found EMR non-
were found in relation to perceived ‘ease of use’. users were more likely to practice in a suburban or
Schubart & Einbinder93 identified the importance rural location. Non-users were significantly less
of organizational culture and the need for data likely than users to believe that (i) physicians
was illuminated by the executive management should computerize their medical records; (ii)
interviews. Their study also found that com- current EMRs are useful; (iii) EMRs will reduce
patibility with an individual’s work style and their risk of making medical errors; and (iv) EMRs
skills was associated strongly with satisfaction will improve health care quality in their office.
and continued use of the system. Improvement in Liu et al.39 found that nurses’ computer skills
care and communication was also documented by were significantly and positively correlated with
Walter et al.94 both computer knowledge and computer attitudes;
however, no significant correlation was found
between computer knowledge and computer
Previous experience
attitudes.
Findings by Dixon and Stewart40 showed that,
amongst primary care physicians, usage of IT
Age and gender
showed significant differences among groups for
intent, interest, perceived usefulness, perceived Although it was anticipated from other literature
ease of use, finesse and knowledge. This was also that age and gender were significant factors in
supported by Moody et al.41 who found that, attitudes to IT, with female and older users being
amongst nurses with expertise in computer use, less positive, papers in this review generally did not
80% had a more favourable attitude toward EHRs find this to be the case (e.g. Chan et al.55).
than those with less expertise. Also, positive Lai et al.72 were unable to demonstrate any
correlation between acceptance of the system and influence of age and gender on the translation of
years of experience of computer systems was intention to actual implementation of a system.
demonstrated by Ammenwerth et al.38 Users with Loomis et al.42 found that there were no statisti-
less positive attitudes had previously worked in cally significant differences in age or gender
areas with less thorough documentation between users and non-users of EMR systems.
procedures prior to the implementation of the Although, in another study, Moffat et al.73 found
system, therefore, post-implementation, the nurses 41% of female GPs were non-users compared with
had experienced an increased workload in order to 28% of male GPs, Araujo et al.74 found that
supply complete documentation. Possible links computer use, age group and gender were not
between the number of motivated key users and significant in explaining the attitude. They had,
department-wide acceptance of the system was however, found evidence of a strong intention
also explored. Acceptance increases over time as towards utilization and these intentions are
users become familiar with the system. In a follow- conditioned by attitude.
© 2008 The authors

influencing use. Software should be evaluated for

Confidence in system privacy
its capability to induce change in work practices in
Poor content design, system function and system order to achieve both short- and long-term relative
integration, led to the nurses seeing the advantage.28
implementation as a policy requirement, rather
than enhancing care and they were further worried
Clinical records (EMR)
about privacy and legal issues. Lee35 found that
nurses’ interest in IT was limited because of Whilst Weir et al.29 found overall user satisfaction
concerns about inconvenient access to computers; was relatively low on all measures and the level of
reduced work efficiency; inability to individualize adoption was quite low, none of the users
patient care and nursing speciality deficiencies. interviewed would return to paper-based systems.
Gadd & Penrod48 found that partly as a result of The need for good communication in software
worries that they would have an even more detri- development was emphasized by Trivedi et al.31
mental effect on personal and professional privacy A well-designed EMR system can provide positive
than they had previously judged. Physicians felt benefits. Adams et al.30 found paper-based visit
disenchanted with the Electronic Medical Record records had more content, whereas computer-based
(EMR). However, Loomis et al.42 established that visit records covered more areas and provided
users consider EMRs as more secure and more improved risk assessment. Although, despite them
confidential than paper based records. Supporting liking the computer charting better than the paper
this, all participants in a study by Kouri et al.58 records, Gohlinghorst et al.27 found nurses wanted
considered adequate privacy protection as a a record of the patient condition over time.
prerequisite for development of a system. Notwithstanding this, Collins et al.33 found more
comprehensive information was stored per episode
than with paper-based systems. They also reported
Design of software/hardware
that patients found it easy to use, but health pro-
Ammenwerth et al.38 described how one project fessionals had a more complex interface and
was required to support ‘hot line’ initially, because found the system more difficult to use.
staff were handling new and complex hardware Despite positive attitudes to the system being
and software. Therefore they were unable to found by Junger,25 this study also raised some
demonstrate reduced costs related to the imple- questions about the hardware and software and
mentation of this new technology. recommended that users should be trained to cope
Carroll et al.34 were among many studies which with problems and computer ‘bugs’ inherently
either directly looked at the design of software and present in today’s highly complex software
hardware for use in health care settings or pro- environments.
duced comments from participants which related Chiasson and Lovato,28 in their study of users
to these areas. Lee,35 amongst others, found views about new software for health care practice,
hardware availability, content design and user obtained user comments which reflected all five of
training/education programmes are critical issues Rogers’97 perceived characteristics of an innovation,
that affect nurses’ use of computers in their daily i.e. relative advantage, compatibility, trialability,
practice. Effect of hardware availability was also complexity and observability. The software slowed
underlined by McAlearney et al.37 down project momentum and created a reflective
The importance of flexibility in software design planning group when an action-orientated group
and project implementation was also emphasized was needed.
by Beuscart-Zephir.32 Users demonstrated that High levels of computer familiarity, welcoming
they needed to customize the options that were attitudes and positive ratings of usability, format
available within the software, based on their pro- and utility were revealed in a study by Pagliari
fessional judgement. Software compatibility with et al.20 Content analysis of electronic feedback
factors related to implementation, user background revealed mainly technical queries and general
and characteristics of the setting are important in expressions of satisfaction.
© 2008 The authors

Telemedicine/imaging/pathology systems Discussion

The implementation of a Picture Archiving and This review aimed to identify relevant literature,
Communication System (PACS) in imaging review and summarize the methodologies and
departments had the most specific quantitative findings and make recommendations for future
documentation,55 identifying 91% in productivity practice and research in the area.
gains; 70% of radiologists reported improved The process of identification, selection and
diagnostic capabilities. Allied health professionals review of the articles included in the study was
(AHPs) productivity gained by 50% on average. complex and time-consuming. The initial search
Despite this, Yousem and Beauchamp76 highlighted was carried out in late 2005 and therefore more
the importance of consulting ‘customers’, i.e. recent articles were not included. The keywords
surgeons rather than radiologists only. and databases used gave a wide coverage and,
Additionally, Mast et al.77 found utilization of while not guaranteed to be comprehensive, do give
the system appeared to be highly dependent on a reflection of the information which has been
the individual rather than speciality. Challenges published in this area. Data extraction and
included mapping procedural skills from one thematic analysis is a subjective process based on
medium to another and general confidence in the the knowledge and interests of the research team,
quality of the images and tools on the system. This but with a series of checks and protocols in place
is supported by the work of Crowley et al.,82 who to make this as systematic as possible.
studied the use of pathology images in the electronic A wide range of material was reviewed from
record and found that image quality and issues of around the world which revealed some high
access and interpretation needed further evaluation. degrees of consistency amongst the studies, but
Satisfactory quality of images and audio, even also findings that were unique to a particular
improvements to that which existing facilities country or health care system.24,50 This added
offered was documented by Rydmark et al.83 and some interesting ideas and views to the review. For
Gattas et al.81 Bartoloni80 evaluated the ease of example, the Dørup25 study of medical students in
setting up systems in remote locations, reflecting higher education institutes (HEIs) coping with IT
an important factor in system design. Another literacy and ownership of computers found that,
study found that analysis of existing structures will in the year 2000, 79.7% males and 67.5% females
improve uptake by system users. Lehoux et al.78 in Denmark, compared with 44% males and 37%
found that technology does not always reflect females in Edinburgh, had their own computers at
existing structures and use of technology reflects home. This identifies both gender differences and
fitness for purpose and concluded that software resources issues that are likely to impinge on
designers often impose structures on users. attitudes towards IT. Similarities between countries
were noted from the study of Leung et al.50 when
researching barriers and incentives to the use of
Decision support systems
clinical computing in Hong Kong identified that
Mixed responses were found with systems designed time costs, lack of technical support and capital
for decision support. Bauer et al.59 found that staff investment were barriers. Improved office efficiency
were generally satisfied with the system and had and patient care were also incentives amongst the
discovered that it was of some benefit to their practicing physicians. Major country differences
practice, whilst Rosseau et al.60 found negative could be seen in the ranking of software copyright
comments about the decision support system privacy regulations and patient, public and regula-
significantly outweighed the positive or neutral tory demands for computer systems were ranked
comments. Respondents did not believe that the as least barriers and as catalysts for action.
system fitted well within the general practice Physicians had differing priorities, from concerns
context, with concerns emerging in three main with cost to patient-related factors to personal/
themes—timing of the guideline trigger, ease of physician issues. Leung et al.50 pointed out that
use of the system and helpfulness of the content. some countries, for example, the UK, were
© 2008 The authors

governed by legislation, whilst countries such as Experienced IT users tended to have more
Canada required all physicians to electronically positive attitudes towards the introduction and
register fees for their services. It was suggested that use of IT in their work setting.38 A more significant
Hong Kong should also look to government factor in many of the studies was the relationship
regulations and financial assistance to improve the between the IT system and the user’s professional
situation in practice areas. roles and power relationships, with some individuals
Much of the literature reviewed used question- seeing challenges to their role and traditional
naires such as the data collection method, practice, as seen in the study of Timmons70 when
although interviews, focus groups and observation he refers to ‘resistive compliance’. Explanation of
were also represented. In very few cases49,92 were the value of IT systems is therefore a necessary
attempts made to measure the effects on patients, part of staff preparation when planning imple-
although this may sometimes be inferred by the mentation or change. In a survey by Dillon et al.98
views of the health care professionals involved. it showed that experienced and mature nurses were
This is an area that requires further research. becoming more compliant and eager to utilize IT
Overwhelmingly, the issues that affected health resources, thus reinforcing the research evidence.
care professionals’ use of computers in their Attitudes of some professionals have changed
daily practice were hardware availability, content greatly, but other professional groups have still to
design and user training/education pro- accept the changes.
grammes.28,35,39,41,55,71,94 The specific computer Some issues were frequently cited concerning
hardware and software programs varied in the the introduction and use of new IT systems and
papers, but, for the majority, there were consistent their effects on workload and efficiency and per-
issues about the fitness for purpose and usability. ceived issues around privacy and confidentiality.58
This suggests that there are still a large number Particular issues arose within the first 6 to
of places and health workers that are not ready 12 months of implementation when the change is
for IT. hardest and efficiency gains had yet to be
Many of the studies included in the review obtained. In 1995, Newton99 had highlighted that
related to the introduction of electronic patient nurses attitudes to IT systems, although negative
records,23,29,30,41 reflecting their increasing develop- at 6 months, were less negative after 1 year of use
ment and use during the time period, although in the practice setting, with a subsequent improve-
studies examining telemedicine, pathology and ment in quality-of-care planning. There still
radiography systems were also included.78,80,81 appears to be some continuation of efficiency and
Many users were willing to overcome some of the data security concerns as the literature shows (see
difficulties of implementation if they saw long- Moody et al.41). A more recent study in 2007 by
term benefits. This focus amongst the studies Lee100 in Taiwan states that, although the same
included in this review may reflect a particular concerns were present, the nurses’ attitudes were
point in systems life cycles and different views positive. The answer appears to emphasis adequate
about the use of IT may be found if more studies education before implementation.
were conducted at different stages in the process Some of the major issues identified related to
and if longitudinal studies were carried out over a the drivers for implementation, which were often
number of years. ‘top down’ and the implementation at lower levels
A variety of studies considered the education in the organization. Generally, those systems with
and training needed for successful use of health a clear design and which build-in education and
care IT systems64,65 whereas others looked at the training were conceived to be the most successful.
use of IT in more general education and training.61,62 The previous IT experience of the users was also
Comments included the needs expressed by users important in influencing implementation.
both for more education and training before the The wide variety of techniques used for data
implementation of IT-based work systems and for collection and analysis made comparisons
more on the use of e-learning approaches to find between the different studies and settings difficult
out about professional health care practice. and, in many cases, it was hard to assess the quality
© 2008 The authors

and rigour of the studies. The use of single instru- towards IT, providing an overview of current
ments, which had not been piloted or tested for developments and identifying key factors which
validity and reliability, means that the reliance influence these attitudes.
which can be placed on them in the development A range of key issues, such as the need for
of policy and practice is limited. The implementation flexibility and usability, appropriate education
of IT systems into health care delivery organizations and training and the need for the software to be
is increasing and, if some of the individual and ‘fit for purpose’, showed that organizations need
cultural issues are to be addressed, there is there- to plan carefully when proposing the introduction
fore a need to commission high-quality research of IT-based systems into work practices. Also,
which uses validated instruments to examine the those organizations could benefit from involving
attitudes of staff. In particular, independent studies users with higher levels of previous experience of
which identify effective strategies to change or IT, as they tended to have more positive attitudes.
manage staff attitudes to IT are needed to underpin Education in the use of IT for health care profes-
future development and implementation. sionals at undergraduate and postgraduate or
There have been significant changes and invest- continuing education levels is therefore an impor-
ment in the UK’s NHS in relation to IT over the tant aspect. These findings need to be taken into
last 5 years and many of the issues found in this account in future programme development and
review may have already been addressed. However, implementation.
it is likely that, as issues around IT implementation The studies reviewed did suggest that attitudes
are becoming concerns for a range of managers at of health care professionals can be a significant
practice level, the factors identified could be argued factor in the acceptance and efficiency of use of IT
to be more relevant than ever. Those responsible in practice. However, there do not appear to be any
for implementation at national and local levels will consistent indicators of their likely attitude other
need to take the findings into account and invest time than experience and confidence in using IT.
and effort into strategies that are likely to produce The quality of the studies and the wide variety
more positive attitudes amongst the workforce. of methods employed mean that it is difficult to
The issues identified in this review are signifi- place great reliance on their findings or identify
cant for practitioners, researchers and students in commonalities or variations, whether based on
the library and health professions, as the increasing geography or context. Although the themes
use of IT for the identification and retrieval of the identified do seem to recur in many studies, and
evidence to support practice requires adaptation therefore may well be significant for practice,
of the processes and education of end-users, further qualitative and quantitative research is
taking into account the attitudes of those staff. needed into the approaches which have most effect
Educational programmes need to be adapted to on the attitudes of health care staff towards IT.
the individual traits of the users, but also to their These may well include quantitative approaches
role within the organization and professional such as attitude scales and estimations of time taken
status. IT system development needs to take into to achieve particular tasks, but also qualitative
account the flexibility required for use in a variety studies which try to explore in greater depth the
of clinical settings as well as in the library or home varied factors which form and influence attitudes.
environment. Extensive testing and user profiling Consideration can then be given to the strategies
at all stages of development and implementation is which are likely to be most effective. This may
needed to ensure that health care staff are able to include the use of the IT systems found in practice
quickly see the real benefits of IT-based systems settings in library and educational environments.
supporting evidence-based care. As ever greater financial and other resources are
allocated to IT systems in health care, the factors
which influence staff attitudes towards them
Conclusions
become increasingly significant if the investment is
This study provides a comprehensive review of the to be worthwhile. If information systems under-
literature related to health care staff attitudes pinned by new technologies are to play a significant
© 2008 The authors

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© 2008 The authors


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DOI: 10.1111/j.1471-1842.2008.00777.

The attitudes of health care staff to information

technology: a comprehensive review of the

‘National Programme for IT’ (NPfIT), computer

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© 2008 The authors

Table 2 Search strategy for database searches

Word group 2 Word group 3 Word group 4 Word group 5

information tech* nurs* attitud* research* patient attitud*

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Table 3 Search strategy and results

Database Search strategy used n

AMED Full search strategy as detailed in Table 2. 1895

headings were extracted to be included in the list

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© 2008 The authors

of management—power, education and training, Table 5 Themes from the literature

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© 2008 The authors

© 2008 The authors

© 2008 The authors

influencing use. Software should be evaluated for

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Telemedicine/imaging/pathology systems Discussion

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© 2008 The authors

© 2008 The authors

role in the expansion of evidence-based practice, References

© 2008 The authors

© 2008 The authors

© 2008 The authors

© 2008 The authors

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