Assessing Nursing Students' Attitude Toward Nursing Process Software

Background: The nursing process is the core and the standard of practice in nursing profession. Nowadays, the use of information technology in the eld of nursing processes, education and practice has been emphasized. Since nurse’s attitudes towards clinical information systems are considered as an indicator of the success rate of information systems, and nurse’s attitudes about the nursing process can effect their execution of the process. So the purpose of this study was to evaluate nursing students' attitudes in the eld of the nursing process software. Methods: In this quasi-experimental study, 160 undergraduate nursing students (terms 4-8) in Tabriz University of Medical Sciences were selected by convenience sampling. To evaluate the effectiveness of nursing process software in this study, Mazlom and rajabpoor (2014) questionnaire consisted of 21 components based on a ve-point Likert scale was completed by students after using the software. Data were then analyzed by SPSS 19 software. Results: The mean score of students' attitude toward nursing process software was good (80.70 ± 5.58). The highest student satisfaction with the software was respectively in the elds of "Effectiveness of software in prioritizing patient care and problems", "Completeness of electronic patient information compared to handwritten mode" and "Software effectiveness in saving your time". Also, the lowest level of students' satisfaction with the software was respectively related to the "sense of fairness in the work-division based on the software", "the effectiveness of the software in determining your workload" and "the sense of satisfaction in the work-division based on the software". There was a statistically signicant relationship between gender and age and students' attitude toward nursing process software. Conclusions: Nursing students had a positive attitude about nursing process software. Therefore, in order to make the most use of the nursing process it is recommended to use this software in educational, research and clinical elds, which require a substructure of the nursing process software in universities and clinics.

implementing information systems [28]. Among these methods, surveying information systems users' attitudes is still considered as an effective and e cient way of obtaining feedback from nurses about the effectiveness of information systems [29]. Studies have shown that nurses` attitudes and satisfaction with clinical information systems are considered as an indicator of the success rate of information systems [30][31][32] and nurses' attitudes towards the nursing process can effect the implementation of the process [33]. However, considering the undeniable bene ts of the nursing process [34] and the lack of its application in clinical care [12] together with the in uence of nursing professionals' attitude on using nursing process [18], and nally the importance of using information technology on Nursing Process teaching and practice [25]. The purpose of this study was to evaluate attitudes of nursing students towards using nursing process software.

Methods
This study is a quasi-experimental study that was done to determine the attitudes of nursing students regarding the nursing process software. We used the nursing students of Tabriz University of Medical Sciences in 2018. The study population consisted of all undergraduate nursing students in terms 4-8. The total number in our sample was 160 people selected by the convenience sampling method. Criteria for participation in the study included; willingness to participate in all stages of study, undergraduate terms 4-8 students at Tabriz University of Medical Sciences, basic knowledge of computer use, and two weeks of continuous use of the nursing process software (with a minimum of 4 patients).
In this study, a two-part questionnaire was used. The rst part consisted of socio-demographic characteristics of the participants and consisted of 11 questions. And the second part was Mazlom and rajabpoors(2014)questio ∩ airewhichassessedνrsingstudents attitudes towards nursing process software [35]. This questionnaire consisted of 21 items based on a ve-point Likert scale (1: very low, 2: low, 3: average, 4: good, and 5: very good). The validity and reliability of the primary instruments in the study by Mazlom and rajabpoor (2014) were investigated in Iran. The content validity of the questionnaire was con rmed by 10 experts and the reliability of the tool was assessed by retesting method (0.81) [35]. The questionnaire's score is calculated based on the sum of the total scores.
After obtaining consent to conduct research from the University Research Council and ethical permit from the relevant eld, (IR. TBZMED.REC.1393.214), rstly some information about the research and assurance regarding the con dentiality of the information obtained, and the privacy and of the participants was provided. Participants were also assured that participation was optional. After containing written consent from participants and explaining goals of the study, undergraduate nursing students from terms 4-8 of Tabriz University of Medical Sciences who were undergoing internship in medical surgical wards were selected using random sampling. To design the nursing process software, extensive text review and also the latest international standards relating to the American nursing association, NANDA were consulted. In addition, nursing diagnosis list (2018-2020) and also reference care books in Nursing such as Ulrich and …. were used. The software consisted of six steps of 1. Assessment 2. Nursing diagnosis 3. Determining goals and expected outcomes 4. Planning 5. Implementation and 6. Evaluation. The software was designed in CD and web-based forms. This way, students could use this software through their cell phones using their network connection. Nursing students were able to access the different steps of the nursing process by simply entering the patient's characteristics and information related to the surveys carried out. Initially, students were taught how to use the designed software. Nursing process software was provided to students for two weeks of working with patients. Then the attitude-test questionnaire about nursing process software was completed by students using self-report method. The data were collected from May to June of 2019.
After data collection, data were analyzed by SPSS (Statistical Package for Social Sciences) software version 19 using descriptive statistics test (mean and standard deviation) and analytical statistics (independent t-test and one-way ANOVA).

Results
In the present study, the total number of participants was 160 people. The mean age of the participants was 23.02 ± 3.13. Also the mean score of students was 16.1 ± 36.18. Nursing interest based on the 10-point scale in the experimental group was 5.19 ± 1.65. Other socio-demographic characteristics of the students participating in the study are presented in Table 1.  Table 2 presents the mean scores of nursing students based on the Likert scale and frequency (percentage) in each item of assessing students` attitude to the nursing process software's questionnaire. The highest students , satisfaction with the software was respectively related to "Effectiveness of software in prioritizing patient care and problems", "Completeness of patient's electronic information compared to handwritten mode" and "Software's effectiveness in saving your time". Also, the lowest level of students' satisfaction with the software was respectively related to the "feeling of fairness in labor division based on the software", "the effectiveness of the software in determining your workload" and "the feeling of satisfaction in labor division based on the software".
The mean score of students' attitude toward nursing process software was 80.70 ± 5.58. Based on the three-part score range, scores of lower one-third were identi ed (poor) 21-49, middle one-third (medium) 50-77, and higher one-third (desirable) 78-105, so students` attitude scores were considered desirable. When examining the relationship between demographic characteristics and the mean scores of students aitudes, Ma ∩ -Whit ≠ ytestshowedasign if icantd ⇔ erencebetween ≥ nder and themeansc or esofstudents′ aitude(P -Value = 0.02), w attitude scores were signi cantly higher. There was no signi cant relationship between other demographic variables and students' mean attitude scores (p > 0.05). Discussion: The purpose of this study was to determine the attitudes of nursing students towards the nursing process software. The mean score of students' attitudes toward the nursing process software was 80.70 ± 5.58. Based on the three-part range, scores of lower one-third were poor , middle one-third were medium (50-77), and higher one-third were desirable (78-105), so students` attitude scores were considered desirable.
According to the study by Liaskos and Mantas (2004), nurses in most areas had a positive attitude about using software to execute the nursing process and found them to be creative, interesting, useful and easy to use [36] which is similar to the results of this study. Based on the study of Mazlom and rajabpoor (2014), 81.3% of the participants rated the software as good or very good. E ciency of software in patient care was very high, so that the mean score of students' opinions was 84.3 ± 5.83 and for nurses was 73.2 ± 1.13 from total score of 100 and the use of the nursing process software was cited as a facilitator of clinical practice [35].
According to some studies, students were satis ed with the use of nursing process software in clinical practice and its e ciency in promoting clinical care [13,35]. According to the students' attitudes in the study by Sayadi and Rokhafroz (2013), their knowledge and skills about the nursing process improved after using the software, and 86% of the students said their satisfaction from using software was high or very high [13].
However, the results of a descriptive study in Year 2008 showed that less than half of the nurses were relatively satis ed with the impact of a computerized hospital information system on patient care activities [37]. The results of the study by BabaMohamadi et al (2013) showed that more than half of the nurses did not understand the bene ts of the impact of the nursing computer program on the patient care process and from their point of view the computer program in uenced a limited number of patient care processes. According to the ndings of this study, computer programs prevalent in the clinical nursing environment didnthavecomp ≤ te ∩ ability ∵ theycod ̲ nt process information in all or most aspects of care [28]. In many studies, the nursing process has been de ned as a separate pathway that does not cover all stages and the most unconsidered stage was the evaluation stage [5,25,26]. Though the nursing process has been divided into parts, they do not occur in isolation but are interdependent and recurring [38,39]. Also in spite of the different bene ts of computer programs, traditionally some nurses have regarded information technology as an attack on routine patterns and practices and sometimes as a deviation from direct patient care [40,41]. And also some nurses may see this process of change as a challenge [42]. Based on recent text reviews, limited studies use computer systems in helping and managing aspects in the nursing process [43].
According to Amini et al. study (2017), lack of knowledge and attitude are the main barriers to the proper implementation of the nursing process, and nurses (49.7%) who are more familiar with the nursing process and use it in care giving have a more positive attitude (62.9%) to the nursing process [44]. In this regard, nursing education is a major part of improving the use of the nursing process and thus promoting the overall quality of nursing care [45]. The use of computer-based techniques and technologies at the bachelor level helps to make teaching more interactive and creative [46]. The use of technology and computer systems to gather, store, process and modify nursing-related data can facilitate the delivery of nursing services, enable nursing care, and support educational resources for educating nurses [47]. However, the lack of proper and correct training during college, short and inadequate training time, lack of retraining, lack of tools [48] and lack of some equipment such as computers [25] to facilitate and process implementation are sited among barriers to proper implementation of the nursing process. Other factors that may in uence nurses' attitudes toward computer software include the existence of a minimum set of nursing data and standard nursing terms in computer software [28]. Also in the current health care setting with the aim of cost control, many nursing wards have insu cient staff and have little time to train and adopt new technology, which can effect their attitudes [28]. Therefore, nursing managers and nursing education authorities should try to remove existing barriers and provide the appropriate facilities to enhance the implementation of the computerized nursing process and enhance the provision of quali ed services based on the nursing process.
In this study, the students' most satisfaction with the software was in the elds of "Effectiveness of software in prioritizing care and patient's problems "," Completeness of electronic patient information compared to handwritten mode" and "Software's effectiveness in saving your time". Also, the lowest level of students' satisfaction with the software was related to the "sense of fairness in the division of labor based on the software", "the effectiveness of the software in determining your workload" and "the feeling of satisfaction in the division of labor based on the software".
Consistent with the ndings of the current study and based on the study of Mazlom and rajabpoor (2014), the most important bene ts of software from 90% of nurses` attitudes were being effective in prioritizing diagnoses, accuracy of electronic information compared to handwriting, and helping to organize patient's problems [35]. Also, the least frequent measure of satisfaction among 10% of nurses and students participating in the study of Mazlom and rajabpoor (2014) was related to the accuracy of electronic information compared to handwriting and the effectiveness of the software in saving time [35] which are not consistent with the ndings of present study. This may be due to the different software and research community in these studies. Like the present study, Kim's study (2005) about the implementation of the Nursing Diagnostics computer program showed that this program would assist nurses in the correct nursing diagnoses for patients, and the implementation of this program would improve nurse's performance and ultimately improve quality of nursing care [49]. It seems that the Software's comprehensiveness and using NANDA International Nursing Diagnosis and up-to-date care content affect the high degree of student satisfaction with software in prioritizing care and dealing with patient problems. Use of paper tools is common to register and execute a systematic nursing process [50]. But the use of these tools has received some criticism. Large amount of notes and low quality of prepared documents were emphasized as negative aspects [33]. The existence of an electronic care record system will help expand the standardization of care [51] and will make nursing care components more visible [52]. However, based on the study by BabaMohamadi et al (2013), nurses participating in the study believed that all the information needed for patient care is not recorded in a computer program [28]. Also in Kahouei et al study (2008), most staff did not record data electronically and entered patient characteristics into their paper nursing reports, the main reason for this was inadequate time and a sense of rework. Nurses believed that the electronic system did not reduce paper use and thus leads to overwork [37]. It has been shown that despite the need to record the nursing process, interventions and outcomes, electronic nursing records may not be completely available [53]. The reasons for this seem to be insu cient training and performance support in the eld of electronic documentation as well as limited software content covering the steps of the nursing process or care practice that need special attention.
Most nurses have a positive idea on the use of the nursing process, but have little interest in using it because of it being time consuming [33]. Nurses spend a lot of time on paperwork activities while the volume of patient information in medical documentation has increased [43]. In the study of Amini et al. (2017), 82.6% strongly agree that there is not enough time to perform the nursing process using the conventional pen and paper method. In this context, nursing informatics is associated with the care and management of the work process and the search for systems overlap and minimizes the time spent on paperwork and maximizes the time spent on care [54]. Using available and designed programs for the nursing process leads to more e cient and faster planning and, it leads to clarity of the nursing process steps [33]. Using software programs is a time management strategy that facilitates and accelerates the implementation of the nursing process because software programs allow nurses to enter assessment information quickly [33].
Regarding the cases where nursing students were least satis ed with the software, it should be noted that based on a review of extensive texts, in any of the studies cases such as observing the fairness of software-based division of work, the effectiveness of the software in determining workload and nursing students' satisfaction with software based work division has not been studied. However, it seems that since the clinical education system of the students use a case study method and every student is responsible for all the care of a patient, the patients are transferred to the students considering the students' academic knowledge and ability related to their semesters. However, proper division of tasks or assignment of student workload by their clinical instructors using nursing process software has not been considered, so it is suggested that nursing instructors evaluate students correctly in terms of the amount of activities and clinical learning software data especially in the steps of diagnosis, nursing intervention and implementation.
In general, from the student's point of view, the implementation of the computerized nursing process allows improved diagnosis accuracy, systematic and complete care and documentation. Although the implementation of a computer system is expensive and requires a great deal of planning and training, such systems can signi cantly improve patient safety by enhancing the quality of appropriate care [55] and it seems that the nursing process software not only helps to improve communication and care performance among nurses but also leads to proper interaction and improved diagnosis, together with improved care and therapeutic performance among other members of the care team.
In this study, female students had a signi cantly better attitude toward the nursing process software than male students. Also, the attitude scores of the younger students were signi cantly higher. As in the current study, Guedes et al. (2012) showed in their study that female nurses had a more positive view of the nursing process than male students [19]. Also in two other studies, female nursing students had more positive attitude compared to male students in terms of the ability to use the nursing process in providing high quality care [56,57]. In the study of Amini et al (2017), no signi cant relationship was found between students' attitude score with gender [44]. It should be noted that in all of these studies nurses or nursing student's attitudes towards nursing process software have not been addressed while their attitudes towards the nursing process have been explicitly investigated so this needs to be investigated in future studies.
However, it appears that in most of the studies, including the current study, most of the study's participants were women, in uenced by the traditional and feminine nature of the nursing profession. Similar to this study, based on the study of Lee et al (2008) the younger age of nurses effects higher degrees of satisfaction from nursing information systems [58]. The ndings of the present study were consistent with the results of the study by Lee et al. However, the results of the study by Amini et al. (2017) showed that nurse's attitude towards the nursing process signi cantly increased with age [44]. Also in the study of BabaMohamadi et al. (2013), younger nurses had somewhat negative attitudes toward the impact of computerized nursing programs on patient care compared to older nurses [28]. It seems that nowadays younger students are more willing and satis ed using nursing process software than older students because of their familiarity with the world of technology and informatics and the greater attractiveness of such technologies. It is also likely that students who are more experienced in the professional and educational elds will be more aware of the challenges and disadvantages of establishing different care giving practices based on the nursing process or related software.
One of the limitations of the present study is the single-group method of conducting the present study. Therefore, further semi-experimental research should be done in this regard. Another limitation of the present study is its application on only undergraduate students in speci c wards (internal and surgical), and so it is suggested that it be repeated among students from other departments, and nurses and from various wards.
Ethics approval and consent to participate Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to patient con dentiality but are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.