Implementation and evaluation of a nursing process support system for long-term care: a Taiwanese study.
OBJECTIVE
To (1) develop and implement a Nursing Process Support System in Chinese (NPSSC) enabling computerised documentation for nursing home residents, (2) evaluate the efficiency of NPSSC, (3) assess obstacles to the use of the NPSSC and (4) assess nurse users' satisfaction with the NPSSC.


BACKGROUND
Long-term care facilities in Taiwan have been slow to computerise resident's medical records. The development and implementation of a computerised documentation system provides a way to enhance nursing documentation in long-term care settings and can prevent hazards that result from documentation errors.


METHODS
Quasi-experimental.


METHODS
This study used one group pre/post-test. Five nursing homes in Taiwan were included in the study. Twenty-seven nurses used the NPSSC to computerise 396 residents' medical records. Using the NPSSC allowed nurses to enter health assessment data into the computer system, which automatically triggered appropriate nursing diagnoses. The NPSSC included geriatric nursing interventions and the use of alternative Chinese therapies.


RESULTS
Obstacles that hindered nurses' use of the NPSSC were identified and possible solutions to overcome these hindering factors were discussed. The use of the NPSSC significantly improved nursing documentation in that resident's records were organised and consistent and nurses were able to complete a comprehensive care plan within 48 hours. Nurses reported a higher satisfaction in nursing documentation after the implementation of the NPSSC than previously.


CONCLUSIONS
This study suggested a pathway to develop and implement a computer-based, user-friendly nursing documentation system for nursing homes. This study may be used as a template for implementing computerised documentation worldwide. Relevance to clinical practice. Nursing home providers may consider implementing the NPSSC to replace the traditional hand-written documentation system. An effective use of in-service programs within the workplace helped ease the transition from hand-written documentation to the computer-based NPSSC.
Yeh
Shu-Hui
SH
Department of Nursing, Chang Gung Institute of Technology, Chang Gung Memorial Hospital at Kaohsiung, #123 Ta-Pei Road, Niao-Sung, Kaohsiung, Taiwan. yangkd.yeh@msa.hinet.net
Jeng
Bingchiang
B
Lin
Li-Wei
LW
Ho
Tien-Hui
TH
Hsiao
Chiu-Yueh
CY
Lee
Li-Na
LN
Chen
Shu-Li
SL
D000328:Adult; D005260:Female; D006801:Humans; D008134:Long-Term Care; D008875:Middle Aged; D009736:Nursing Process; D011795:Surveys and Questionnaires; D013624:Taiwan