Barriers and facilitators influencing the implementation of an interactive Internet-portal application for patient education in psychiatric hospitals
Introduction
The introduction of information technology (IT) can radically affect the health care organisation, the nurses’ daily work processes [1], health care delivery and outcome [2], [3]. Internet applications, for example, have been seen as a potential support for patients’ needs for information and empowerment [4], [5], [6], [7]. IT can also increase nurses’ job satisfaction, if the application used makes work flexible [8]. However, not all IT applications in health care are successful. The use of IT has also increased staff's responsibilities [9], or stress level and work strain during implementation process [10], [11]. Overall a systematic review showed that the use computer-generated patient education material had hardly any effect on professional practice [12].
Various interconnected factors seems to exist to improve or impede the implementation of technology in clinical practice, among them staff's attitudes and understanding of the meaning and benefits of IT for clinical practice [10], [13], adequate education and training of staff [14], technological issues such as usability of the technological application [15], [16], [17], [18], and Internet access [19] or reliable and feasible technology solutions [13], [20]. Moreover, organisational factors, such as staff resources [21] and the effects of IT on the work environment [22], may be significant factors which improve implementation in practice. Implementation may be restricted by a low level of education among the personnel [23], lack of opportunities and time to practice IT use [14], [24], user friendliness of the new technology [23], [25], or a lack of technical support [11], [18], [25].
In general, nursing professionals often have negative perceptions of technology [26]. The perceptions may become even more negative over time as system glitches and the reality of system limitations become clear [10], [11]. If IT causes anxiety in users, they will quickly avoid using it. This was found in a randomized controlled trial where Internet-based intervention programmes failed due to a lack of support [27]. Nurses are also concerned that IT will have negative consequences for patient care [25]. Particularly in the field of psychiatric nursing, nurses may be worried that technology will replace face-to-face contacts with mental patients [28], [29], [30]. On the other hand, there is still a professional ambivalence among nursing staff working in psychiatric services about giving information to patients although the role of the patient is shifting from that of passive recipient to active consumer of health information [31].
Despite a large amount of research evidence of the effects on IT systems in health care in general, there is only limited knowledge about the impacts of IT in daily psychiatric care, where interaction between patient and nurse and patient education are central issues [32], [33]. Patients have expressed their dissatisfaction with information provision [4], [34], [35], [36]. Systematic patient education is lacking in many psychiatric services [37], and there is a lack of resources and knowledge of how to implement patient education in nursing [38], [39]. In general, deficiencies in staff's communication skills related to information dissemination to patients have also been found [40], [41].
New methods are needed to increase effectiveness in the process of patient education [6], [12], [42] IT may be one way forward [43], [44]; however, previous data demonstrate that implementation of IT in daily clinical nursing activities is problematic, especially in those areas where personal interaction between client and staff is an essential element in nursing [34], [35], [44], [45]. In order to address these problems, we joined the FITT (fit between individuals, task and technology) framework. The FITT framework is based on the idea that IT adoption in a clinical environment depends on the fit between the attributes of the individual users (e.g. computer anxiety, motivation to use computer), attributes of the technology (e.g. usability, functionality) and attributes of the clinical tasks and processes (e.g. organisational factors). The model helps to analyse the socio-organisational technical factors that influence IT adoption in a health care setting [46], [47], [48]. Ammenwerth et al. [46] pointed out that the fit between the attributes is more important than the individual attributes themselves. They described some attributes that affect the various fit dimensions. On the individual level IT knowledge, motivation and interest are factors which interact with new ways of working, team culture and organisational context. On task level organisational activities and the interdependence and the complexity of tasks affect IT implementation. On the technology level usability and functionality of an application, costs of a tool and available technical infrastructure are factors which have impacts on the implementation process. These attributes interact with each other when a new IT application is implemented clinical practice in health care [46].
In this paper we identify the barriers and facilitators of the implementation process of the Internet-portal application to be used on a daily basis as part of patient education in two psychiatric hospitals in Finland. The explorative study we report here is part of a multi-center study where an interactive Internet-portal application (Mieli.Net; Engl. Mental.Net) was developed together with a patient association and experts for use in psychiatric hospitals. The overall goal of this wider study is to generate information on clinical outcomes and of IT use in mental health care. The objectives are to evaluate the impacts of IT on mental patients’ well-being and self-management of mental illness, and to describe the impacts of IT on staff knowledge, skills and attitudes, and organisational performance.
Section snippets
Methods
The study is the part of the Mieli.Net (Engl. Mental.Net) project, which aims to evaluate the effects of information technology used in patient education on psychiatric wards in two hospitals. In the trial, nursing staff working on nine acute psychiatric wards were randomized into two groups. In Group X, the portal was used as part of standardised patient education sessions. Group Y carried out standard patient education sessions with written material.
Results
Four main categories were formed to describe barriers or facilitators of portal implementation on psychiatric wards. These categories were (1) organisational resources, (2) nurses’ individual characteristics, (3) patient-related factors and (4) portal-related factors (Table 1).
Discussion
In our study, various interconnected factors seemed to influence the success or failure of the implementation process of IT applications in daily care in psychiatric hospitals. The same portal was also seen as a success by one nurse but as a failure or at least as problematic by another person [47]. Nurses’ different individual characteristics, such as IT skills, motivational factors and attitudes [14], [26], may relate to nurses experiences in the implementation process of the portal. Although
Acknowledgments
This study was partly funded by Pirkanmaa Hospital District (9E084), The Academy of Finland (213440), The Finnish Cultural Foundation and The Finnish Konkordia Fund.
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