JOURNAL OF MEDICAL INTERNET RESEARCH Rouleau et al

Original Paper

Impact of Information and Communication Technologies on

Nursing Care: Results of an Overview of Systematic Reviews

Geneviève Rouleau1,2, RN, PhD(c); Marie-Pierre Gagnon1,3, PhD; José Côté2,4, RN, PhD; Julie Payne-Gagnon3, MA;
Emilie Hudson5, RN, BSc; Carl-Ardy Dubois4, PhD
1
Faculty of Nursing Sciences, Université Laval, Quebec, QC, Canada
2
Research Center of the Centre Hospitalier de l’Université de Montréal, Research Chair in Innovative Nursing Practices, Montreal, QC, Canada
3
Research Centre of the Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC, Canada
4
Faculty of Nursing Sciences, Université de Montréal, Montreal, QC, Canada
5
School of Nursing, McGill University, Montreal, QC, Canada

Corresponding Author:
Marie-Pierre Gagnon, PhD
Faculty of Nursing Sciences
Université Laval
Pavillon Ferdinand-Vandry
1050 Avenue de la Médecine
Quebec, QC, G1V 0A6
Canada
Phone: 1 418 525 4444 ext 53169
Fax: 1 418 525 4194
Email: [email protected]

Abstract
Background: Information and communication technologies (ICTs) are becoming an impetus for quality health care delivery
by nurses. The use of ICTs by nurses can impact their practice, modifying the ways in which they plan, provide, document, and
review clinical care.
Objective: An overview of systematic reviews was conducted to develop a broad picture of the dimensions and indicators of
nursing care that have the potential to be influenced by the use of ICTs.
Methods: Quantitative, mixed-method, and qualitative reviews that aimed to evaluate the influence of four eHealth domains
(eg, management, computerized decision support systems [CDSSs], communication, and information systems) on nursing care
were included. We used the nursing care performance framework (NCPF) as an extraction grid and analytical tool. This model
illustrates how the interplay between nursing resources and the nursing services can produce changes in patient conditions. The
primary outcomes included nurses’ practice environment, nursing processes, professional satisfaction, and nursing-sensitive
outcomes. The secondary outcomes included satisfaction or dissatisfaction with ICTs according to nurses’ and patients’ perspectives.
Reviews published in English, French, or Spanish from January 1, 1995 to January 15, 2015, were considered.
Results: A total of 5515 titles or abstracts were assessed for eligibility and full-text papers of 72 articles were retrieved for
detailed evaluation. It was found that 22 reviews published between 2002 and 2015 met the eligibility criteria. Many nursing care
themes (ie, indicators) were influenced by the use of ICTs, including time management; time spent on patient care; documentation
time; information quality and access; quality of documentation; knowledge updating and utilization; nurse autonomy; intra and
interprofessional collaboration; nurses’ competencies and skills; nurse-patient relationship; assessment, care planning, and
evaluation; teaching of patients and families; communication and care coordination; perspectives of the quality of care provided;
nurses and patients satisfaction or dissatisfaction with ICTs; patient comfort and quality of life related to care; empowerment;
and functional status.
Conclusions: The findings led to the identification of 19 indicators related to nursing care that are impacted by the use of ICTs.
To the best of our knowledge, this was the first attempt to apply NCPF in the ICTs’ context. This broad representation could be
kept in mind when it will be the time to plan and to implement emerging ICTs in health care settings.

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Trial Registration: PROSPERO International Prospective Register of Systematic Reviews: CRD42014014762;

http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014014762 (Archived by WebCite at
http://www.webcitation.org/6pIhMLBZh)

(J Med Internet Res 2017;19(4):e122) doi: 10.2196/jmir.6686

KEYWORDS
information and communication technology; eHealth; telehealth; nursing care; review, overview of systematic review

of data from the system (eg, vital signs, symptoms) and then
Introduction use clinical decision skills to respond properly to each patient’s
Background condition [10]. In order to discern cues within the interactions
via technological modalities, specific communication skills
The use of information and communication technologies (ICTs) remain essential, that is, active listening, facilitating
for health, referred to as eHealth [1,2] represent a means to conversation, questioning, redirecting, and verifying [11-13].
support health care delivery [3]. These technologies change
how nurses plan, deliver, document, and review clinical care; ICTs are becoming an impetus for quality health care delivery
this will only continue as technology advances. The processes by nurses. It is thus relevant to study the role of nurses in the
whereby nurses receive and review diagnostic information, clinical use of ICTs [3] as well as the impact of ICTs on nursing
make clinical decisions, communicate and socialize with patients practices [14]. The use of any type of ICT to provide direct or
and their relatives, and implement clinical interventions will be indirect care to patients may transform nurses’ day-to-day
fundamentally modified with further integration of ICTs into practice [3]. In some systematic reviews, different types of ICTs
nursing practice [4,5]. have been reviewed, for instance, EHRs [15], nursing
computerized records systems [16], or CDSSs [17]. In general,
There is a wide range of ICTs used for supporting and providing nursing practice or nursing care was not well-defined in those
health care. Mair et al [6] suggested four general domains of reviews, and there was no conceptual framework enabling
eHealth that include a variety of ICTs: management systems, reflection on the way ICTs could influence indicators of nursing
communication systems, computerized decision support systems care. To overcome this gap, we used a broad and comprehensive
(CDSSs), and information systems. Management systems allow conceptualization of nursing care based on the nursing care
for the acquisition, storage, transmission, and display of performance framework (NCPF) [18] to embrace a
administrative or clinical activities related to patients, such as multidimensional perspective of nursing care. The NCPF is
electronic health records (EHRs) or electronic medical records composed of three distinct but interrelated subsystems: nursing
(EMRs). Communication systems can be used for diagnostic, resources, nursing services, and patients’ conditions. It is defined
management, counseling, educational, or support purposes. as “the capacity demonstrated by an organization or an
They can be implemented to facilitate communication between organizational unit to acquire the needed nursing resources and
health professionals or between health professionals and use them in a sustainable manner to produce nursing services
patients. There are a wide range of communication systems, that effectively improve patients’ conditions ([18], p.6).”
varying from email and mobile phones to telemedicine and
telecare systems. CDSSs are automated systems accessible from However, an integrated body of knowledge was lacking with
various devices, such as computer, mobile phone, or personal respect to the effects of ICTs on nursing care, because of the
digital assistants (PDAs). They support decision-making for heterogeneity of ICTs used in the literature as well as the poor
health professionals and assist them in practicing within clinical conceptualization of nursing care. We conducted an overview
guidelines and care pathways. Information systems, such as of systematic reviews to develop a broad picture of the indicators
Web-based resources and eHealth portals, refer to the use of of nursing care that have the potential to be enhanced or
Internet technology to access health-related information sources. constrained by the use of ICTs. The use of an overview is an
interesting starting point from which to compare and contrast
To support complex and diversified practices and interventions outcomes of separate reviews [19] regarding the positive,
in nursing, myriad ICTs can be adopted, though not without negative, and neutral effects of ICTs on nursing care.
challenges. Some ICTs, such as EHRs and computerized nursing
care plans, facilitate access to patient information and help to Objectives
document and plan nursing care [7]. However, with the use of We conducted an overview of systematic reviews to
these technologies, nurses are expected to change the way they systematically summarize the evidence that comes from
document patient care by shifting from paper-based records to qualitative, quantitative, and mixed-method systematic reviews
electronic systems. The features (eg, copy and paste, electronic regarding the effects of ICTs on nursing care.
interface, drop-down menus) of electronic nursing
documentation may affect critical thinking and accuracy of Nursing Care Performance Framework
documentation [8]. Telehealth technologies are another example, In order to illustrate how ICTs interventions influence nursing
which include a wide range of ICTs such as remote patient care and impact health outcomes, an organizational model was
monitoring, videoconferencing, and computer-mediated used [18]. The NCPF represents a synthesis of the most recent
communications [9]. In the case of remote patient monitoring developments in the field and is part of leading initiatives aiming
(telemonitoring), nurses must be able to process a large quantity
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to conceptualize nursing care performance. Conceptualization The 51 indicators capture the content currently supported by
of nursing care performance is based on a system perspective the scientific literature and cover all major areas of nursing care
that builds on system theory [20], Donabedian’s earlier works performance. More than a simple list of indicators, the NCPF
on health care organization [21], and Parsons’ theory of social provides an integrative and systemic framework that has been
action [22]. used in recent studies to analyze various dimensions of nursing
care [23,24]. The NCPF has been used, for example, to structure
This model, illustrated in Figure 1, is composed of 14
a scoping review undertaken to identify indicators that are
dimensions and 51 indicators and shows how the interplay of
sensitive to ambulatory nursing [23]. The results showed the
three nursing subsystems (resources, processes or services, and
capacity of NCPF to be extended and applied to ambulatory
patients’ outcomes) can operate to achieve three key functions:
nursing care and furthermore, five new indicators have been
(1) acquiring, deploying, and maintaining nursing resources;
added to the framework. The authors of the NCPF have
(2) transforming nursing resources into nursing services; and
suggested that further studies should be conducted to assess the
(3) producing changes in patients’ conditions in response to the
implementation of the framework in different contexts of nursing
nursing services provided (“nursing-sensitive outcomes”). The
care [18]. This overview constitutes a first attempt to use and
first function refers to the human and material resources needed
apply the NCPF to structure and analyze the indicators of
to provide effective nursing care, such as nursing staff supply,
nursing care that are influenced by ICTs. We expect that using
working conditions, staff maintenance, and economic
the NCPF will confirm existing indicators, add new indicators
sustainability. The second function encompasses nurses’ practice
specific to the context of ICTs, and eventually modify existing
environments (eg, nurse autonomy; collaboration), nursing
indicators.
processes (eg, assessment, care planning, and evaluation;
problems and symptom management), nurses’ professional In this overview, our main interest was to extract data related
satisfaction, and patient experience. The desirable end result of to nurses. For instance, if results of a systematic review were
the interactions between nursing staff and nursing processes is exclusively on patient outcomes without describing nursing
to improve patients’ conditions. The third function is then resources, services, or processes, the review was excluded.
described as the positive changes that can be detected among However, we considered nursing sensitive outcomes (ie,
patients (also called “nursing-sensitive outcomes”). patients’ outcomes) as long as they could be related to ICTs use
by nurses.

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Figure 1. Nursing care performance framework.

interest were registered nurses (RN), nurses in training, nursing

Methods students, or patients receiving care from qualified RN through
Overview and Eligibility Criteria the medium of ICTs. The interventions targeted were the use
of ICTs covered in the four eHealth domains suggested by Mair
The protocol of this overview has been registered on et al [6]: (1) management systems; (2) communication systems;
PROSPERO (CRD42014014762) and published elsewhere [25]. (3) CDSSs; and (4) information systems. The following ICTs
We followed the Cochrane Collaboration methodology [26] were excluded: (1) nurse management systems, which are purely
and other relevant works in this domain [19,27] to develop the administrative and designed for the management of human
overview. The scope was formulated using PICOS (participants, resources and working conditions (eg, scheduling) and nursing
interventions, comparisons, outcomes, study design) [28,29]. staff maintenance (such as retention); (2) educational systems,
All types of qualitative, mixed-method, and quantitative reviews, for example, e-learning initiatives used for the training of
published in French, English, or Spanish from January 1, 1995 nursing students, unless they are applied to direct patient care;
and that aimed to evaluate the influence of ICTs (four eHealth and (3) telephone systems, because according to most definitions
domains) used by nurses on nursing care were eligible. The of ICTs [30,31], they are not digital technologies and cannot
inclusion of reviews using multiple methodological approaches support the electronic capture, storage, processing, and exchange
is justified by the possibility of broadening the understanding of information. Further details of the inclusion criteria for the
of the impact of ICTs on nursing care. The populations of selection of systematic reviews are described in Table 1.

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Table 1. Inclusion criteria for the selection of systematic reviews.

Criteria Description of inclusion criteria
Type of reviews All types of qualitative, mixed-method, and quantitative reviews that aimed to evaluate the in-
fluence of ICTsa(four eHealth domains) used by nurses on nursing care, which stated a
methodology (a “Methods” section) with explicit eligibility criteria, had systematic research
strategies to identify selected reviews and provided a systematic presentation and summary of
the characteristics and outcomes of the included reviews [28].
Publication type Reviews published in French, English, or Spanish from January 1, 1995.
Population RNb, nurses in training, nursing students, or patients receiving care from qualified RN through
the medium of ICTs.
Intervention: ICTs covered by four eHealth domains Four eHealth domains were considered in the overview [6]: management systems, communication
systems, computerized decision support systems, and information systems. ICTs embody all
digital technologies that support the electronic capture, storage, processing, and exchange of
information, in order to promote health, prevent illness, treat disease, manage chronic illness,
and so on [30,31].
Management systems Management systems are computer-based systems used for acquiring, storing, transmitting,
and displaying patient administrative or health information from different sources. They can
support administrative or clinical activities. Electronic health records (EHRs) and personal
health records (PHRs) are examples of management systems.
Communication systems Telecommunication systems are employed when users are distant in space and/or time. This
kind of communication takes place in a synchronous or an asynchronous way, between health
professionals, or between health professionals and patients or caregivers. It involves a targeted
sharing of information between specific individuals, or individuals who play distinct roles for
diagnostic, management, counseling, educational, or support purposes. There are a wide range
of communication systems, from email and mobile phones to telemedicine and telecare systems.
Computerized decision support systems (CDSSs) Refer to an automated computer-based system that aims to support health professionals in
practicing within clinical guidelines and care pathways. These systems are usually operated in
real-time and involve decision support that comes from artificial intelligence (eg, a software
program).
Information systems Are defined by the use of Internet technology to attain access to different information resources,
such as health and lifestyle information. The information remains general, and it is not tailored
to specific individual needs. Web-based resources and eHealth portals for retrieving information
are some types of information systems.
Comparisons Usual care, any other ICT, and other types of interventions.
Outcomes The primary outcomes included nursing resources, nurses’ practice environment, nursing pro-
cesses or scope of practice, professional satisfaction, and nursing-sensitive outcomes (eg, patient
outcomes, such as risk outcomes and safety, patient comfort, and quality of life related to care).
The secondary outcomes included nurses’ and patients’ satisfaction or dissatisfaction with ICTs.

a
ICTs: information and communication technologies.
b
RN: registered nurse.

in a single reference database, and duplicate citations were

Search Strategy removed. The specific search strategies for databases are
A medical librarian developed and conducted the search presented in Multimedia Appendix 1.
strategies, drawing on other reviews of similar topics and using
well-established search filters where appropriate. We searched Selection of Reviews
publications in English, French, or Spanish in the following Two reviewers (GR, JPG) independently screened the title and
electronic databases from January 1, 1995: Cochrane Database abstract of the papers in order to assess their eligibility.
of Systematic Reviews (until January 15, 2015); Epistemonikos References that did not meet the preestablished inclusion criteria
(until December 25, 2014); PubMed (until December 8, 2014); were excluded. Full-text copies of publications were retrieved
Embase (until January 7, 2015); Web of Science (until January and were assessed by the same two reviewers. Any discrepancies
9, 2015); and Cumulative Index to Nursing and Allied Health were resolved through discussion. A third reviewer was available
Literature (CINAHL) (until December 25, 2014). for arbitration when consensus was not reached.
Structured search strategies were developed using the thesaurus Data Extraction and Management
terms of each database (eg, Medical subject heading (MeSH) Three reviewers (GR, JPG, and EH) were involved in the data
for PubMed) and using free text, targeting the “title” and extraction and management process. Information on each review
“abstract” fields. The strategies were then adapted to the other was independently extracted by two of the reviewers. Any
databases. The results of each database search were collected disagreement arising during the data extraction process was
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discussed among the two reviewers. The third reviewer was of summarizing and explaining outcomes from multiple studies
involved in case of disagreement. by employing the use of words and text [39]. The core
characteristic of a narrative synthesis is the adoption of a
Characteristics of included reviews were extracted and
“textual approach to the process of synthesis to ‘tell the story’
summarized: objectives, type of review, number of included
of the outcomes from the included studies” [39]. We categorized
studies, search dates, population, setting, eHealth domain, types
the reviews into subgroups according to the type of intervention
of general and specific ICTs, examples of included interventions,
and their effects (positive, negative, or no effect) on a specific
comparisons, primary and secondary outcomes, review
dimension of nursing care (eg, practice environment, nursing
limitations, and authors’ conclusions. A data extraction form
processes, professional satisfaction, and nursing-sensitive
was developed based on the NCPF [18] and the dimensions of
outcomes).
the actual scope of nursing practice [32]. The data extraction
grid was modified during the extraction process by adding
dimensions or categories of results. To facilitate teamwork
Results
between the three reviewers (GR, JPG, and EH) in performing Description of the Reviews
the data extraction, we used a shared file in Google Sheets.
Reviewers communicated with each other through Google A total of 6187 titles or abstracts were identified. After removing
Sheets and added comments on the extraction when needed. duplicate references, 5515 titles or abstracts were assessed for
The three reviewers reviewed the completed data extraction eligibility. Full-text papers of 72 articles were retrieved for
grid to eliminate discrepancies and errors. detailed evaluation. It was found that 22 reviews published
between 2002 and 2015 met the eligibility criteria. The list of
Methodological Quality Assessment of Included these included reviews is presented in Multimedia Appendix 2.
Reviews Twelve reviews used a mixed-method synthesis approach, nine
The three reviewers (GR, JPG, and EH) were involved in the used a quantitative approach, and one used a qualitative
methodological quality assessment of the reviews that met the approach (meta-ethnography). Fifty reviews were mainly
eligibility criteria, using the assessment of multiple systematic excluded because they did not present primary outcomes related
reviews (AMSTAR) tool [33,34]. Two reviewers assessed each to nursing care (n=24), or because outcomes related to nurses
review independently, and disagreements were discussed. The were indistinguishable from other populations (n=13). In
third reviewer was available for arbitration when needed. Multimedia Appendix 3, details are provided regarding the
AMSTAR is an 11-item checklist from which reviewers assign primary reasons for exclusion and the full references of the
one point when the criterion is met. AMSTAR items provide excluded articles. The preferred reporting items for systematic
an assessment of methodological criteria such as the reviews and meta-analyses (PRISMA) study flow diagram [40]
comprehensiveness of the search strategy and whether the are illustrated in Figure 2 to show the overall process of review
quality of included studies was evaluated and accounted for selection.
[35]. AMSTAR characterizes quality at three levels: 8-11 is The general characteristics (ie, type of reviews, search dates,
high quality (ie, minor or no methodological limitations), 4-7 target population, and health care settings) of the included
is medium quality (ie, moderate methodological limitations), reviews are presented in Multimedia Appendix 4. The review
and 0-3 is low quality (ie, major methodological limitations) objectives, limitations, and main conclusions are synthetized
[36]. in Multimedia Appendix 5. The eHealth domains covered were
In this overview, we included different types of systematic management systems (n=14), communication systems (n=7),
reviews, that is, quantitative reviews (randomized and and CDSSs (n=10). No reviews dealt with information systems.
nonrandomized designs), mixed-method synthesis reviews, and Five reviews included more than one eHealth domain [3,41-44].
qualitative reviews. AMSTAR is used primarily for quantitative Articles reviewing management systems included the following
reviews using randomized controlled trial (RCT) design. When ICTs: electronic medical or health or patient records,
undertaking an overview, challenges encountered are the computer-based nursing records or computerized nursing care
assessment of limitations (risk of bias) as well as the quality of planning, and regional health care information system. The ICTs
evidence in systematic reviews [37,38]. There were no reporting covered in the communication systems were email, mobile
guidelines on assessing methodological quality of mixed-method phone, bedside communication tool or bedside terminals, iPod
and qualitative reviews at the time of the overview. We decided technology to assist in educational conferences, and telemedicine
to apply AMSTAR to all reviews in order to use the same or telehealth with the use of videophone or videoconferencing.
criteria for quality assessment, although this had limitations (ie, The CDSSs covered were medication management
inappropriateness of applying some criteria to mixed-method technology—e-prescribing, electronic medication administration
and qualitative reviews). record systems, computerized provider order entry (CPOE),
bar-code medication administration (BCMA) —and PDAs.
Data Synthesis These eHealth services can be categorized as belonging to more
A statistical meta-analysis of outcomes was not possible because than one domain [6], depending on their components. Details
the included studies were too heterogeneous. We therefore about eHealth domains, examples of included interventions,
conducted a narrative synthesis, which is defined as an approach and comparisons are presented in Multimedia Appendix 6.

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Figure 2. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) study flow diagram. ICT: information and communication
technology.

the inappropriateness of pooling data (eg, highlighted issues

Assessment of Review Quality about heterogeneity or variability between the studies), that is,
The AMSTAR tool was used to assess the methodological the authors summarized and synthesized the available evidence
quality of all reviews. Four reviews, mostly quantitative ones, narratively according to a defined analysis plan and/or using
were high quality (scores: 8-9); nine were medium quality appropriate qualitative methods and techniques (eg, construction
(scores between 4 and 7), and nine scored low quality (between of common rubrics, content analysis, tabulation, groupings, and
0 and 3). AMSTAR scoring for each review is presented in clustering).” Regarding criteria 10, about the assessment of
Table 2. We adapted the interpretation of two criteria (#7 and publication bias, it seems that empirical evidence on this topic
#9) of the AMSTAR tool to assess the quality of mixed-method in qualitative research is very limited [46]. We presume that
and qualitative reviews. For the criteria 7—reporting and this is the same reality regarding the mixed-method reviews.
assessment of scientific quality of the included reviews—we
answered “yes” if authors mentioned having assessed and Dimensions of Nursing Care That Are Influenced by
documented quality of quantitative reviews, and if they Information and Communication Technologies
acknowledged clearly the difficulty of assessing qualitative or The results (see Figure 3) will be presented in association with
mixed-methods reviews. For criteria 9, entailing the the NCPF: the function, the dimension, and the theme (which
inappropriateness of methods used to combine findings, we correspond or not to a particular indicator in the framework).
answered “yes,” based on the decision rules developed by Table 3 presents the frequency of extracted data per dimensions,
Kitsiou et al [45]: “reviews’ authors made a statement regarding themes, and ICTs.

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Table 2. Assessment of multiple systematic reviews (AMSTAR) scoring.

References Type of reviews or designs AMSTAR score
Free [42] Quantitative (RCTa) 9 (high)

Mador [47] Quantitative (various designs) 9 (high)

Urquhart [16] Cochrane review—quantitative (RCT+1 other design) 8 (high)
McKibbon [43] Mixed 8 (high)
Nieuwlaat [48] Quantitative (RCT) 7 (medium)
Mickan [49] Quantitative (RCT) 6 (medium)
Finkelstein [41] Mixed 6 (medium)
Randell [50] Quantitative (RCT) 5 (medium)
Georgiou [51] Quantitative (various designs) 5 (medium)
Dowding [52] Quantitative (various designs) 5 (medium)
Poissant [53] Quantitative (various designs) 4 (medium)
Husebo [54] Mixed (integrative) 4 (medium)
Jones [55] Mixed (integrative) 4 (medium)
Meißner [56] Qualitative (meta-ethnography) 3 (low)
Bowles [44] Mixed 3 (low)
Anderson [17] Mixed 3 (low)
Maeenpa [57] Mixed 2 (low)
NGuyen [58] Mixed 2 (low)
Stevenson [15] Mixed 2 (low)
Bartoli [59] Mixed 1 (low)
Carrington [3] Mixed 1 (low)
Kelley [60] Mixed (integrative) 0 (low)

a
RCT: randomized controlled trial.

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Figure 3. Presentation of results.

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Table 3. Frequency extracted data.

Dimension Themes (Number of reviews) (Types of eHealth domain) Positive effects Negative effects No effect Total
of ICTsa of ICTs

Time and efficiency 20 17 7 44

Time management (4) (MSb, CSc, CDSSd) 2 1 1 4

Time spent for patient care (7) (MS, CS, CDSS) 4 5 3 12

Documentation time (7) (MSe) 14 11 3 28

Nurses’ practice environment 19 5 1 25

Knowledge updating and utilization (3) (CS, CDSS) 3 0 1 4

Information quality and access (5) (MSf, CDSS) 11 2 0 13

Nurse autonomy (1) (CSe) 1 0 0 1

Intra and interprofessional collaboration (6) (MSf, CS, CDSS) 4 3 0 7

Nursing processes 30 12 3 45
Nurses competencies-skills (4) (MS, CDSS) 9 1 1 11

Nurse-patient relationship (3) (CSe) 4 0 0 4

Quality of documentation (7) (MSf, CS) 6 4 1 11

Assessment, care planning, and evaluation (10) (MS, CS, CDSS) 13 8 2 23

Teaching of patients and families (4) (CSf, CDSS) 5 0 0 5

Communication and care coordination (2) (CS, MS) 2 0 0 2

Professional satisfaction 29 18 1 48
Nurses’ perspectives of the quality of care provided (6) (MS, CS, CDSS) 15 2 0 17
Satisfaction or dissatisfaction of nurses using ICTs (10) MS, CS, CDSS) 14 16 1 31
Nursing sensitive outcomes 28 5 5 38
Patient comfort and quality of life related to care (7) (CS, CDSS) 7 0 1 8

Empowerment (4) (CSf, MS) 6 0 1 7

Functional status (3) (CSe) 3 0 1 4

Satisfaction or dissatisfaction of patients using ICTs (5) (CS, MS) 12 5 2 19

a
ICTs: information and communication technologies.
b
MS: management systems.
c
CS: communications systems.
d
CDSSs: computerized decision support systems.
e
One eHealth domain covered exclusively a particular theme.
f
Majority of one eHealth domain covered a particular theme.

showed negative effects [43], and two reported positive effects

Function 1: Acquiring, Deploying, and Maintaining [44,53]. In Nieuwlaat et al’s [48] review, results demonstrated
Resources that nurses perceived that conventional care compared with
Time and Efficiency CDSSs were equally time-consuming (no effect). The other
review reported that reminder systems were “time-consuming”
Overall, 11 reviews [15,16,43,44,47,48,51,53,56,58,60] had
[43]. The results in the Poissant et al [53] review revealed that
results related to time: time management (time consumed or
the use of EHRs has been shown to reduce the time devoted to
time saved resulting the use of ICTs); time spent for patient
the verbal transmission of information at the end-of-shift.
care; and documentation time.
Consequently, this caused a change in the workflow, which may
Time Management have been a strong incentive for nurses to become efficient users
Four reviews [43,44,48,53] targeting CDSSs, communication, of the system. In the Bowles and Baugh [44] review, the effect
and management systems had findings on “time management” of telehomecare was also reported positively in terms on “saving
in a general way: one review showed no effect [48], another time.”

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Time Spent for Patient Care technology [43]. The negative impact were pointed out in two
Almost one-third of the reviews (7/23) [16,43,47,51,56,58,60] reviews [58,60] that cited the results of the same primary study
outlined positive [16,47,56,58] and negative effects [61], that is, nurses could not retrieve the information perceived
[43,51,56,60], as well as no effect [43,51,58] of CDSSs, as essential for patient care within the electronic nursing
management systems, and communication systems on time documentation system.
spent for patient care. Nurses are sometimes concerned that Nurse Autonomy
using electronic nursing documentation or the BCMA for Only one review mentioned nurse autonomy as a positive effect.
documenting and for administering medication might take away In this review [59], nurses were expected to handle most cases
or reduce time for patient care [43,56]. Conversely, other autonomously and to refer to doctors only in exceptional cases
reviews including communication systems (eg, telehomecare) when using the tele-triage system designed to monitor chronic
and management systems (eg, EHRs) found that time spent for heart failure patients remotely.
patient care has significantly improved [16,47,56,58] and
particularly, nurses using EHRs spent more time with patients Intra- and Interprofessional Collaboration
in assessment, education, and communication [58]. Four reviews highlighted positive [17,42,52,59] effects regarding
intra- and interprofessional collaboration, one showed negative
Documentation Time
effect [43] and one reported no effect [60] with the use of
Nurse documentation time was reported in seven reviews CDSSs [17], communications [42,59], and management systems
[15,16,43,47,53,56,60] touching on management systems, such [43,52,60]. Reviews including CDSSs reported improved
as EHRs, e-prescribing system, and critical care information communication between members of the interdisciplinary team
system (CCIS). Effects of these ICTs on documentation time [17], such as between nurses and surgeons [42], better and more
were mixed within and across the reviews: six reviews trustworthy relationships between nurses and doctors by using
demonstrated positive effects [15,16,47,53,56,60], six telehomecare systems [59], and more frequent collaboration
demonstrated negative effects [15,16,43,47,53,60], and three between members of the health care team when using
demonstrated no effect [43,47,60]. Negative results showed that management systems (ie, clinical dashboards) [52]. In one
nurses spent more time documenting when they used review, results showed that electronic nursing documentation
management systems and the positive results showed the systems negatively affected collaborative working relationships
contrary: documentation time diminished with ICTs. The time between nurses and physicians [60].
saved for documenting was sometimes reallocated for patient
care and had positive outcome on the improvement of health Nursing Processes
care [15]. Otherwise, when the task of documenting took much Nurses’ Competencies and Skills
more time, nurses had less time to spend with patients [60].
Four reviews that encompassed CDSSs and management
Function 2: Transforming Resources into Services systems showed that they had a positive influence on these
domains of nurses’ competencies and skills: decision support
Nurses’ Practice Environment
or decision-making [17,43,56], observation skills [56], clinical
Knowledge Updating and Utilization judgment [17,56], and critical thinking [60]. Additionally, due
Three reviews found positive effects [17,44,54] of CDSSs and to some features of CDSSs and management systems (eg,
communication systems on knowledge updating and utilization, readability of data, remote accessibility of data, better quality
whereas one review found no effect [17]. CDSSs are useful of patients’ records, presence of reminders, or automatic alerts),
tools to increase knowledge and information use, and translate these ICTs supported clinical judgment and decision-making
outcomes from research into practice by improving nurses’ [43,56]. Conversely, some features of the ICTs not previously
compliance with established guidelines [17]. The potential of available on paper, such as copy and paste, drop-down menus,
communication systems (eg, telehomecare or telehealth) to and check boxes, affected the nurses’ capacity to employ critical
transfer nursing knowledge was also reported [44,54]. thinking regarding their patients [60]. Finally, the results
presented in Anderson and Willson [17] review showed no
Information Quality and Access effect of CDSSs on the knowledge or clinical decision-making
The eHealth domain that was the most covered in relation to of nurses associated with pressure ulcer prevention.
information quality and access was management systems,
Quality of Documentation
covered in four reviews [43,57,58,60], followed by CDSSs in
two reviews [17,43]. One review documented the improvement Positive effects on documentation quality were highlighted in
of information quality as perceived by doctors and nurses after six reviews [3,15,43,56,58,60]; five on these reviews
the implementation of EHRs [58], and the results of five reviews encompassed management systems. Negative effects were
highlighted information access [17,43,57,58,60]. Management reported in three reviews [15,56,60], and another review
systems and CDSSs had positive impact in three reviews documented no effect [41]. Results from the Stevenson et al
[43,57,60] on information access regarding patient issues, [15] review: nurses reported that EHRs did not reflect their
clinical data, medication information or profile, and other practice and reported that it was “incapable of capturing much
information (policies, guidelines, drug resources, patient files). of what they believed was crucial in nursing care.” With regards
Nurse practitioners felt that CDSSs could assist them with to psychological care, nurses also reported issues with fitting
patient care when data is easily accessible with the use of the complex caring practice into systems that are not intended to

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accommodate it, for example, when providing emotional and improvement of quality of care and patient safety; nurses’
psychological support. Since EPRs lack sensitivity, they cannot perceptions that BCMA reduce medication errors and improve
capture “the being there stuff,” for example, caring for a dying medication administration processes [43]; and the provision of
patient by sitting on their bedside and holding their hand. Two comprehensive and adaptive care related to the patients’ needs
reviews [15,56] stated that when the quality of documentation with the help of telehealth used with elders [55]. In four reviews
is improved, quality of care and patient safety can be fostered [15,43,56,58], negative results were discussed: EHRs do not
since it allows a complete overview of the patient’s situation improve patient care as perceived by nurses [58]; and patients
[56]. do not receive necessary care because the quality of residents’
records is lacking [56].
Nurse-Patient Relationship
In three reviews, use of communication systems (virtual visits Satisfaction or Dissatisfaction of Nurses Using ICTs
using videophones, telehomecare, telehealth) positively impacted The results in ten reviews, targeting the three eHealth domains,
nurse-patient relationship. Reviews mentioned the potential of found that nurse satisfaction was mixed: nine reviews reported
ICTs to provide a pathway for communication [55], create new positive effects [17,41,43,44,48,54,56,58,60], eight reported
types of bonds with patients [44], establish trust through the negative effects [15,43,44,48,54,56,58,60], and one reported
videoconference system, and create a sense of connection (from no effect [43]. Results pertained to overall acceptance of ICTs
the patients’ perspective)[54]. and their satisfaction was described in general ways, such as
“nurses were satisfied with ICTs.” There were also elements
Assessment, Care Planning, and Evaluation
associated with ICTs, such as system navigability (eg,
Impact of CDSSs, management, and communication systems complexity, ease of use, user-friendliness, and flexibility),
were mixed, that is, positive effects were mentioned in seven nurses’ attitudes, concerns about patients’ privacy, and perceived
reviews [15,17,41,44,49,55,56], negative effects were mentioned benefits or inconveniences. Some nurses found EHRs to be
in five reviews [15,16,41,42,54], and no effect was documented irrelevant for practice [58].
in two reviews [16,55]. For example, a handheld computer-based
support system for preference-based care planning led to a Function 3: Producing Changes in Patients’ Condition
higher consistency between patient preferences and nursing care
Nursing-Sensitive Outcomes
plan priorities [17]. An “email intervention” cited in the
Finkelstein et al [41] review led to a more comprehensive heart Patient Comfort and Quality of Life Related to Care
failure and medication adherence assessment by nurses being The positive effects of CDSSs and communication systems on
recorded. EHRs contain templates that guide nurses for comfort and quality of life related to care [3,17,41,44,50,54,55]
assessment and help them identify problems [56]. The mixed were described in terms of patient outcomes: fewer number of
review by Stevenson et al [15] revealed negative impact of wetting occurrences [17], reduction of malnourished patients
EHRs regarding poor care plans updates, the difficulty of [3,50], the reduction of pain and anxiety [44], better quality of
individualizing care plans within the systems, and the difficulty life [41], and lower burden related to care [55]. One review
of capturing a broad picture of the patient within the electronic reported little improvement on quality of care with the use of
personal record. Similarly, the Urquhart et al [16] review showed telehomecare [44].
that computerized nursing care planning compared with manual
planning led to (1) no effect between groups regarding planning; Empowerment
and (2) negative effects, because planned tasks were not carried Four reviews [16,41,44,54] highlighted empowerment as a
out as expected for nurses using ICTs. positive effect of communication systems. One management
system showed no effect [16]. Some examples of positive impact
Teaching of Patients and Families
include diabetic patients, who felt that the telehomecare
Four reviews reported teaching benefits: three with the use of empowered them [44] and had positive results in terms of
communication systems [41,54,55] and one with CDSSs [43]. diabetes management with an eHealth application [41]. One
For example, virtual visits simplified teaching and information review also cited videoconferences for conducting nursing
sharing with patients and thus became a way to transfer virtual visits as tools to increase patients’ abilities to manage
knowledge [54]. Also, patients had clearer instructions on self-care [54].
discharge and on their medication administration at home as
reported by nurse practitioners [43]. Functional Status
In three reviews [41,54,55], the results regarding the effects of
Communication and Care Coordination
communication systems on functional status (eg, physical,
Two reviews found that communication systems had positive cognitive, psychosocial functional capacity) were discussed in
impact on delivering continuous and coordinated care, on the a positive way. Computer use (in a telehealth context) and
prevention of preventing relapses into poor health [54], and on elders’ self-esteem have been positively associated [55]. In
improving communication about resident care [56]. another review [54], the results showed that communication
Professional Satisfaction systems (eg, virtual visits using videoconference) decreased
loneliness and melancholia, enhanced psychosocial and social
Nurses’ Perspectives of the Quality of Care Provided activity, and aided memory among home-dwelling elders. In
In six reviews, positive effects [41,43,44,54-56] of CDSSs, the Finkelstein et al [41] review, the results revealed that the
management, and communication systems were reported:
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health status of patients among groups did not differ with the discussed in relation to CDSSs are assessment, care planning,
use of communication systems. and evaluation; teaching of patients and families; nurses’
perspectives of the quality of care provided; satisfaction or
Satisfaction or Dissatisfaction of Patients of Using ICTs
dissatisfaction of nurses and patients using ICTs; and patient
Patients’ satisfaction with ICTs was documented in five reviews comfort and quality of life related to care.
that demonstrated positive effects [41,44,54,55,58], three that
showed negative effects [54,55,58], and two that showed no Discussion
effect [55,58]. Patient results indicated their degree of
satisfaction or dissatisfaction with ICTs; their acceptance, Summary of Main Results
acceptability, and receptiveness of their usage of ICTs; and their This overview allowed a broad understanding of the dimensions
appreciation for being able to schedule videoconferences about of nursing care influenced by using ICTs for providing care.
topics of their choice [44,54,58]. The results were presented in Regarding the primary outcomes of interest, the themes that
terms of usefulness (or uselessness); perceived and actual were most frequently reported are documentation time;
benefits or advantages, such as accessibility and flexibility [54]; assessment, care planning, and evaluation; nurses’ perspective
ease of use, usability, complexity; and the degree to which the of the quality of care provided; information quality and access;
ICTs were well-designed and functioned fully [41,55,58]. Some and time spent for patient care. For secondary outcomes,
patients were confident in using ICTs [44], whereas others were satisfaction or dissatisfaction of nurses and patients using ICTs
concerned about the confidentiality of their health information was frequently mentioned.
[58]. Results from the Husebo and Storm [54] review indicate
that patients who had visual contact with nurses through Discussion of Results With Respect to the First
communication systems felt cared for and perceived a sense of Function of the NCPF
connection. In relation to the first function of the NCPF (acquiring,
Summary Description of eHealth Domains Related to deploying, and maintaining nursing resources), many reviews
Specific Themes outlined outcomes linked to “time.” The use of ICTs affected
time management, time spent for patient care, and
On the basis of the content of Table 3, we propose a summary documentation time. This theme could also refer to a dimension
description of which eHealth domains cover specific themes of of the NCPF called maintenance and economic sustainability
nursing care. of the nursing staff [18]. Sustainability refers to the importance
Management Systems of having quality resources at the lowest cost. This dimension
highlights productivity and the necessity to optimize the outputs
The only eHealth domain reported to influence the
produced from a given set of inputs; in other words, to minimize
documentation time was management systems, such as
the amount of nursing tasks, materials, and equipment without
electronic nursing documentation [60], CCIS [47], CPOE,
sacrificing the quality of nursing services. The “time” dimension
eMAR [43], and EHRs [53]. The other themes reported with
can be understood in terms of how ICTs can impact staff,
these systems were time spent on patient care; time management;
productivity, optimization of the staff’s time management, and
information quality and access, intra and interprofessional
resources utilization. We do believe that time is an interesting
collaboration; quality of documentation; nurses’ competencies
outcome related to the resources of the overall structure (nursing
and skills; assessment, care planning, and evaluation; nurses’
staff), but it does not reflect directly on how ICTs can transform
perspectives of the quality of care provided; empowerment; and
or support what nurses do (nursing activities or interventions)
satisfaction or dissatisfaction of nurses and patients using ICTs.
within their actual scope of practice. Considering our results,
Communication Systems we do not believe that further research should focus on “time”
Communication systems was the only eHealth domain found in order to better understand the effects of ICTs on nursing care
to be applicable to the themes of nurse-patient relationship, (and specifically, on nursing processes).
autonomy for nurses in their role, and patients’ functional status. This review did not explore other dimensions and indicators
These themes were also discussed related to communication related to the first function of the NCPF, such as nursing staff
systems: teaching patients and families, knowledge update and supply. These dimensions include quantity and quality
utilization; intra and interprofessional collaboration; quality of indicators. As an example, it would be interesting to explore
documentation; assessment, care planning, and evaluation; whether the availability of ICTs in specific health care settings
communication and care coordination; nurses’ perspectives of impacts the quantity of nurses needed to perform nursing
the quality of care provided; satisfaction or dissatisfaction of services.
nurses and patients using ICTs; patient comfort and quality of
life related to care; and patients’ empowerment. Another relevant topic would be to probe whether ICTs act as
facilitator or motivator to enhance nurses’ working conditions,
Computerized Decision Support Systems (CDSSs) or serve as a barrier that inhibits them. To what extent can ICTs
CDSSs are mentioned in nurses' practice environment dimension create favorable conditions that attract nurses and reinforce
(3/4): knowledge updating and utilization; information quality stability in the workforce? A systematic review was undertaken
and access; and intra and interprofessional collaboration. on the effect of ICTs on retention and recruitment of health care
Regarding the nurses’ competencies and skills, CDSSs are professionals [62]. The results revealed that, in 9 out of the 13
involved with decision-making processes. Some other themes studies, ICT use demonstrated a positive, though often indirect,

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influence on recruitment and retention. The influence of ICTs care planning, and evaluation are the most cited themes in the
on retention of nurses was also examined in a qualitative study nursing processes dimension, followed by teaching of patients
[63]. The results highlighted various impact of ICTs on nurse and families and, finally, by communication and care
retention (ie, little or no impact, unclear impact, or indirect coordination. Despite these outcomes, it would be helpful to
positive impact). conduct primary studies on how ICTs could influence or support
other nursing processes, such as problem and symptom
Discussion of Results With Respect to the Second management, health promotion and illness prevention, and
Function of the NCPF discharge planning.
The three dimensions corresponding to the second function,
Nurses’ professional satisfaction is conceived as the result of
transforming nursing resources into nursing services, are nurses’
nursing processes. Our results revealed two facets of this
practice environment, nursing processes, and professional
satisfaction: nurses’ perspective of the quality of care provided
satisfaction. The themes “knowledge updating and utilization”
and nurses’ satisfaction or dissatisfaction using ICTs. The NCPF
and “communication and care coordination” were not explicitly
included additional indicators that were not mentioned in the
described in the NCPF and we used them from the instrument
included reviews to capture the nurses’ professional satisfaction:
of “actual scope of nursing practice” [32]. The indicator “scope
having the time to do their job and the enjoyment derived from
of practice” is included in the nursing processes of the NCPF,
it.
but there are no explicit underlying subindicators.
The “information quality and access” theme was analyzed as Discussion of Results With Respect to the Third
an effect of ICTs on nurses’ practice environment. In other Function of the NCPF
words, ICTs are seen as a potential way to support nursing work We believe that nursing-sensitive outcomes, which are the
by allowing them to get access to various sources of information “patient outcomes,” are underrepresented in our overview
and clinical data. The theme “quality of documentation” is not because of our inclusion criteria that focused on reviews of the
part of the nurses’ practice environment because it is linked to impact or effect of ICTs on nursing resources and services.
what nurses do as activities. Thus, patient outcomes were only considered if nursing
outcomes were reported. This means that we included patients’
The capacity of nurses to deliver nursing interventions is
outcomes as primary outcomes as long as they fell within the
intimately and consistently linked with organizational processes
usage of ICTs by nurses, and then, when outcomes related to
that capture the nursing practice context and mediate its
the second function of the NCPF (nursing services and
outcomes [64,65]. These processes, defined as interventions,
processes) were reported. Dubois and colleagues [67] undertook
support nursing work and sustain a professional environment
a systematic work including three literature reviews to identify
[66]. We hypothesize that, if nurses have access to a
the priority indicators in evaluating the nursing contribution to
comprehensive set of information about patients, this would
quality of care. The results revealed that the most frequently
trickle down on nursing processes, such as quality of
examined nursing sensitive outcomes are pressure ulcers,
documentation, assessment, care planning, and evaluation. It
medication administration errors, urinary infections by catheter,
would also impact communication and care coordination to
and falls. These indicators are located in the “risk outcomes and
benefit patient outcomes.
safety” dimension of the NCPF. Despite this, there are several
A surprising result is the following: only one review mentioned systematic reviews on the effects of ICTs on patients’ outcomes
nurse autonomy in relation to the use of ICTs [59]. It would be [68-71]. However, these reviews do not necessarily explore the
interesting to know more about questions such as: How can we impact of ICTs on nursing services and processes (second
define “autonomy” in a context in which nurses use or are function of the NCPF) when considering patients’ outcomes.
exposed to ICTs to provide nursing care? How can ICTs support
or influence nurse autonomy? Can ICTs be a required training
Strengths and Potential Biases
tool in nurses’ practice environments to support their own There are many strengths of this overview. First, it employed
autonomy? a comprehensive search strategy, which was developed and
implemented by a medical librarian. Second, data extraction
The NCPF model reflects the deployment of nurses’ full scope and quality assessment were conducted by three reviewers
of practice, including assessment, planning, and evaluation; working independently. Third, the data extraction process was
problem and symptom management; health promotion and done with the use of the NCPF, which supported the
illness prevention; care coordination; and discharge planning, organization and the analysis of results. This framework
which are conceptualized through interventions and processes supported reflection on the way ICTs could influence specific
in the model. aspects of nursing care. Some new, redefined, or adapted
From a health care provider perspective, these processes grasp dimensions and indicators have been suggested in the
the technical elements of care and reflect the extent to which framework: time management, time spent for patient care and
staff are capable of using and mobilizing their competencies to documentation time, information quality and access, quality of
deploy their entire scope of practice. These processes documentation, knowledge updating and utilization as part of
demonstrate the capability of nurses to engage the needs of the nurses' practice environment, communication and care
patients [18]. Our results show that, in reference to the processes coordination, and nurse and patient satisfaction or dissatisfaction
described in the NCPF, few such processes have been described regarding their use of ICTs. Fourth, one of the authors of the
in the studies included in this overview. However, assessment, NCPF (CAD) challenged the analysis and interpretation of the

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results. Some debriefing meetings were held to discuss the way emerging or novel ICTs that have been published from 2015
the themes were presented related to their organization in the until now could not be captured.
NCPF (under specific subsystems, functions, dimensions, and
indicators).
Differences Between Protocol and Overview
As stated in the protocol [25], one of the objectives was to
There are also limitations to this overview. First, as mentioned explore whether specific categories of ICTs (management
by other authors [27,72], we were limited by the information systems, communication systems, CDSSs, or information
provided by the review authors. The granularity of details systems) could have an impact on nursing care. As mentioned
available was limited and some information was lacking earlier, the heterogeneity of reviews and the lack of granularity
regarding both the description of ICTs (eg, their features, regarding extracted data or information were some reasons why
components, contexts of use, and area of practice) as well as we could not pursue the initial objective.
findings regarding the dimensions of nursing care influenced
by ICTs. Therefore, it was not possible to make significant When we planned this overview, we were particularly interested
conclusions about how a specific ICT influenced one or many in the dimensions of nursing care inherent to the second and
indicators (themes) of nursing care, and it was challenging to the third function of the NCPF, which are nurses’ practice
categorize these extracted findings (impact of ICTs) within the environment, nursing processes, professional satisfaction
NCPF. A comprehensive description of interventions (ICTs) (second function or subsystem), and nursing-sensitive outcomes
would have been helpful. Further research could be done to gain (third function or subsystem). Throughout the data extraction
knowledge about how a specific ICT used in a certain area of process, we realized that some outcomes, particularly those
practice can impact on one or many dimensions and indicators related to the time and efficiency, were frequently mentioned.
of nursing care. We then decided to extract these results based on their frequency
and their impact on the nursing care.
Third, the nature of the topic was not easy to capture in the
reported data of systematic reviews. It was difficult to establish Authors’ Conclusions
if nurses experienced changes in their practice with the use of To the best of our knowledge, this is the first attempt to draw
ICTs, or if instead they believed that ICTs would change their a broad understanding and a schematization of specific
practice and work environment without really experiencing dimensions and indicators of nursing care influenced by ICTs.
these transformations. Some outcomes related to the use of ICTs Using the NCPF was useful to illustrate the way ICTs can impact
are reported in terms of “barriers.” However, it is not always 3 subsystems (nursing resources, nursing services or processes,
clear if it is a barrier to use ICTs or an effect or impact of having and nursing sensitive outcomes or patients’ outcomes), 5
used them. Systematic reviews on the determinants of nurses’ dimensions, and 19 themes corresponding to the NCPF
acceptance and use of ICTs are plenty [31,73-75], but do not indicators. Findings of this overview are a good starting point
inform on the real effects of ICTs on nursing practice. from which we could deepen our conceptualization on the way
Fourth, we used AMSTAR to assess methodological quality of nursing care system performance can be affected by ICTs.
qualitative and mixed-method reviews even if this tool was not According to a systemic perspective, it is plausible to believe
developed for types of reviews other than quantitative using that the adoption and implementation of ICTs in the nursing
mainly RCT designs. The results of this work should be care system must be addressed under a multidimensional
interpreted with caution. Although it provides a broad perspective, considering that the 3 subsystems are interrelated.
perspective on the phenomenon of interest, the main If nurses use ICTs to support their interventions, and the impact
shortcoming of a review of systematic reviews is the of such ICTs are positive or negative on the work they do, this
heterogeneity in terms of population, interventions (types of could possibly reverberate on patient outcomes. We have to
ICTs), types of reviews, and the variety of outcomes, which keep this broad representation in mind when it will be the time
might lead to the possibility of biased conclusions. For further to plan and to implement emerging ICTs in health care settings.
research and methodological development in this domain, we Takeaway Messages
strongly recommend a consolidated tool to evaluate the quality
Using the NCPF was relevant to draw a broad, multidimensional,
of different types of reviews on a common scale. The results of
and a system-based perspective on the dimensions and indicators
the assessment of methodological quality of mixed-method and
of nursing care that can be impacted by ICTs.
qualitative reviews must be interpreted with caution, considering
that AMSTAR is not used and designed for that purpose. In ICTs have a mixed impact on 19 indicators related to nursing
fact, some criteria do not fit the specificities of other types of care: documentation time, time spent for patient care, time
reviews because there are no gold standards or guidelines management, knowledge updating and utilization, information
allowing us to perform this task. Consequently, mixed-method quality and access, nurse autonomy, intra and interprofessional
and qualitative reviews started with a lower score, which cannot collaboration, nurses competencies-skills, nurse-patient
lead to a judgment about the likely bias and methodological relationship, quality of documentation, assessment, care planning
limitations inherent in the majority of reviews summarized in and evaluation, teaching of patients and families, communication
Table 2. and care coordination, nurses’ perspectives of the quality of
care provided, patient comfort and quality of life related to care,
Finally, this overview draws a picture of the reality of ICTs that
empowerment, functional status, and satisfaction or
covered a period extended from 2002 to the start of 2015. The
dissatisfaction of nurses and patients using ICTs.

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Management systems, including, for instance, electronic nursing Communication systems have been described exclusively
documentation system, CCIS, CPOE, eMAR, and EHRs, have regarding nurse-patient relationship, autonomy for nurses in
been discussed exclusively with the theme “documentation their role, and patients’ functional status (eg, physical, cognitive,
time” (in the included reviews). and psychosocial functional capacity).

Acknowledgments
This research is funded thanks to a Knowledge Transfer (KT) Canada Student Research Stipend, awarded to GR, an initiative
funded by the Canadian Institutes of Health Research (CIHR; grant #88368). MPG holds the Tier 2 Canadian Research Chair in
Technologies and Practices in Health and JC holds the Research Chair in Innovative Nursing Practices. Special thanks to William
Witteman, who planned and performed the search strategy, and Suzana Anjos for the linguistic revision of this manuscript. We
acknowledge the precious work of the three reviewers: D Dowding, JM Carrington, and P Johansson.

Authors' Contributions
GR conceived and designed the overview with input from MPG and JC. GR informed the search strategy and performed the
search, with the help of a health librarian. GR, JPG, and EH were responsible for data extraction. GR, MPG, JC, JPG, EH, and
CAD have been involved in data analysis and interpretation of results. GR, MPG, JC, JPG, EH, and CAD were engaged in the
drafting of this manuscript and they all read and approved the final manuscript.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Search strategies.
[PDF File (Adobe PDF File), 378 KB-Multimedia Appendix 1]

Multimedia Appendix 2
List of included reviews.
[PDF File (Adobe PDF File), 122 KB-Multimedia Appendix 2]

Multimedia Appendix 3
Excluded articles and reasons for exclusion.
[PDF File (Adobe PDF File), 198 KB-Multimedia Appendix 3]

Multimedia Appendix 4
General characteristics of included reviews.
[PDF File (Adobe PDF File), 164 KB-Multimedia Appendix 4]

Multimedia Appendix 5
Review objectives, limitations, and main conclusions.
[PDF File (Adobe PDF File), 268 KB-Multimedia Appendix 5]

Multimedia Appendix 6
eHealth domains, interventions, and comparisons.
[PDF File (Adobe PDF File), 319 KB-Multimedia Appendix 6]

References
1. Eng T. The e-Health Landscape: A Terrain Map of Emerging Information and Communication Technologies in Health and
Health Care. Princeton, NJ: The Robert Wood Johnson Foundation; 2001.
2. World Health Organization. 2016. e-Health URL: http://www.who.int/topics/ehealth/en/ [accessed 2017-01-21] [WebCite
Cache ID 6ngZcO7Y5]
3. Carrington JM, Tiase VL. Nursing informatics year in review. Nurs Adm Q 2013;37(2):136-143. [doi:
10.1097/NAQ.0b013e3182869deb] [Medline: 23454993]

http://www.jmir.org/2017/4/e122/ J Med Internet Res 2017 | vol. 19 | iss. 4 | e122 | p. 16

(page number not for citation purposes)
XSL• FO
RenderX
 JOURNAL OF MEDICAL INTERNET RESEARCH Rouleau et al

4. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies
press; 2011.
5. Monteiro AP. Cyborgs, biotechnologies, and informatics in health care - new paradigms in nursing sciences. Nurs Philos
2016 Jan;17(1):19-27. [doi: 10.1111/nup.12088] [Medline: 25919864]
6. Mair F, May C, Murray E, Finch T, Anderson G, O'Donnell C, et al. NETSCC. 2009. Understanding the implementation
and integration of e-Health services URL: http://www.netscc.ac.uk/hsdr/files/project/SDO_FR_08-1602-135_V01.pdf
[accessed 2016-09-21] [WebCite Cache ID 6kge8Bkve]
7. Sullivan DH. Technological advances in nursing care delivery. Nurs Clin North Am 2015 Dec;50(4):663-677. [doi:
10.1016/j.cnur.2015.07.005] [Medline: 26596655]
8. Kossman SP, Scheidenhelm SL. Nurses' perceptions of the impact of electronic health records on work and patient outcomes.
Comput Inform Nurs 2008;26(2):69-77. [doi: 10.1097/01.NCN.0000304775.40531.67] [Medline: 18317257]
9. Nagel DA, Penner JL. Conceptualizing telehealth in nursing practice: advancing a conceptual model to fill a virtual gap. J
Holist Nurs 2016 Mar;34(1):91-104. [doi: 10.1177/0898010115580236] [Medline: 25858897]
10. Barrett D. The role of telemonitoring in caring for older people with long-term conditions. Nurs Older People 2012
Sep;24(7):21-25. [doi: 10.7748/nop2012.09.24.7.21.c9257] [Medline: 23008916]
11. Greenberg ME. A comprehensive model of the process of telephone nursing. J Adv Nurs 2009 Dec;65(12):2621-2629.
[doi: 10.1111/j.1365-2648.2009.05132.x] [Medline: 19941546]
12. Purc-Stephenson RJ, Thrasher C. Nurses' experiences with telephone triage and advice: a meta-ethnography. J Adv Nurs
2010 Mar;66(3):482-494. [doi: 10.1111/j.1365-2648.2010.05275.x] [Medline: 20423383]
13. Romero YM, Angelo M, Muñoz GL. Imaginative construction of care: the nursing professional experience in a remote care
service. Rev Lat Am Enfermagem 2012;20(4):693-700 [FREE Full text] [Medline: 22990154]
14. de Veer AJ, Fleuren MA, Bekkema N, Francke AL. Successful implementation of new technologies in nursing care: a
questionnaire survey of nurse-users. BMC Med Inform Decis Mak 2011;11:67 [FREE Full text] [doi:
10.1186/1472-6947-11-67] [Medline: 22032728]
15. Stevenson JE, Nilsson GC, Petersson GI, Johansson PE. Nurses' experience of using electronic patient records in everyday
practice in acute/inpatient ward settings: a literature review. Health Informatics J 2010 Mar;16(1):63-72. [doi:
10.1177/1460458209345901] [Medline: 20413414]
16. Urquhart C, Currell R, Grant MJ, Hardiker NR. Nursing record systems: effects on nursing practice and healthcare outcomes.
Cochrane Database Syst Rev 2009 Jan 21(1):CD002099. [doi: 10.1002/14651858.CD002099.pub2] [Medline: 19160206]
17. Anderson JA, Willson P. Clinical decision support systems in nursing: synthesis of the science for evidence-based practice.
Comput Inform Nurs 2008;26(3):151-158. [doi: 10.1097/01.NCN.0000304783.72811.8e] [Medline: 18438151]
18. Dubois C, D'Amour D, Pomey M, Girard F, Brault I. Conceptualizing performance of nursing care as a prerequisite for
better measurement: a systematic and interpretive review. BMC Nurs 2013 Mar 07;12:7 [FREE Full text] [doi:
10.1186/1472-6955-12-7] [Medline: 23496961]
19. Smith V, Devane D, Begley CM, Clarke M. Methodology in conducting a systematic review of systematic reviews of
healthcare interventions. BMC Med Res Methodol 2011;11(1):15 [FREE Full text] [doi: 10.1186/1471-2288-11-15]
[Medline: 21291558]
20. Reid P, Grossman JH, Fanjiang G. Building a better delivery system: a new engineering/health care partnership. Washington,
DC: National Academies Press; 2005.
21. Donabedian A. Models for organizing the delivery of personal health services criteria for evaluating them. Milbank Mem
Fund Q 1972;50(4):103-154.
22. Parsons T. Structure and Process in Modern Societies. New York, NY: Free Press; 1960.
23. Rapin J, D'Amour D, Dubois C. Indicators for evaluating the performance and quality of care of ambulatory care nurses.
Nurs Res Pract 2015;2015:861239 [FREE Full text] [doi: 10.1155/2015/861239] [Medline: 26380108]
24. VanFosson CA, Jones TL, Yoder LH. Unfinished nursing care: an important performance measure for nursing care systems.
Nurs Outlook 2016;64(2):124-136. [doi: 10.1016/j.outlook.2015.12.010] [Medline: 26850334]
25. Rouleau G, Gagnon M, Côté J. Impact of information and communication technologies on nursing care: an overview of
systematic reviews (protocol). Syst Rev 2015 May 23;4:75 [FREE Full text] [doi: 10.1186/s13643-015-0062-y] [Medline:
26002726]
26. Becker L, Oxman A. Cochrane Handbook for Systematic Reviews of Interventions. 2011. Chapter 22: Overviews of reviews
URL: http://handbook.cochrane.org/chapter_22/22_overviews_of_reviews.htm [accessed 2016-09-20] [WebCite Cache
ID 6keSUnVWK]
27. Worswick J, Wayne SC, Bennett R, Fiander M, Mayhew A, Weir MC, et al. Improving quality of care for persons with
diabetes: an overview of systematic reviews - what does the evidence tell us? Syst Rev 2013;2:26 [FREE Full text] [doi:
10.1186/2046-4053-2-26] [Medline: 23647654]
28. O'Connor D, Green S, Higgins J. Cochrane Handbook for Systematic Reviews of Interventions. 2011. Chapter 5: Defining
the review question and developing criteria for including studies URL: http://handbook.cochrane.org/chapter_5/
5_defining_the_review_question_and_developing_criteria_for.htm [accessed 2016-09-21] [WebCite Cache ID 6kgi5pz4I]

http://www.jmir.org/2017/4/e122/ J Med Internet Res 2017 | vol. 19 | iss. 4 | e122 | p. 17

(page number not for citation purposes)
XSL• FO
RenderX
 JOURNAL OF MEDICAL INTERNET RESEARCH Rouleau et al

29. Centre for reviews dissemination. 2009. Systematic reviews: CRD's guidance for undertaking reviews in health care URL:
https://www.york.ac.uk/media/crd/Systematic_Reviews.pdf [accessed 2017-01-27] [WebCite Cache ID 6npTBjkDu]
30. Bashshur RL, Shannon GW, Krupinski EA, Grigsby J, Kvedar JC, Weinstein RS, et al. National telemedicine initiatives:
essential to healthcare reform. Telemed J E Health 2009;15(6):600-610. [doi: 10.1089/tmj.2009.9960] [Medline: 19534591]
31. Gagnon M, Desmartis M, Labrecque M, Car J, Pagliari C, Pluye P, et al. Systematic review of factors influencing the
adoption of information and communication technologies by healthcare professionals. J Med Syst 2012 Feb;36(1):241-277
[FREE Full text] [doi: 10.1007/s10916-010-9473-4] [Medline: 20703721]
32. D'Amour D, Dubois C, Déry J, Clarke S, Tchouaket E, Blais R, et al. Measuring actual scope of nursing practice: a new
tool for nurse leaders. J Nurs Adm 2012 May;42(5):248-255. [doi: 10.1097/NNA.0b013e31824337f4] [Medline: 22525288]
33. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement
tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007;7:10 [FREE Full text] [doi:
10.1186/1471-2288-7-10] [Medline: 17302989]
34. Shea BJ, Hamel C, Wells GA, Bouter LM, Kristjansson E, Grimshaw J, et al. AMSTAR is a reliable and valid measurement
tool to assess the methodological quality of systematic reviews. J Clin Epidemiol 2009 Oct;62(10):1013-1020. [doi:
10.1016/j.jclinepi.2008.10.009] [Medline: 19230606]
35. Weir MC, Ryan R, Mayhew A, Worswick J, Santesso N, Lowe D, et al. The Rx for change database: a first-in-class tool
for optimal prescribing and medicines use. Implement Sci 2010;5:89 [FREE Full text] [doi: 10.1186/1748-5908-5-89]
[Medline: 21087505]
36. Sharif MO, Janjua-Sharif FN, Sharif FN, Ali H, Ahmed F. Systematic reviews explained: AMSTAR-how to tell the good
from the bad and the ugly. Oral Health Dent Manag 2013 Mar;12(1):9-16. [Medline: 23474576]
37. Lunny C, Brennan SE, McDonald S, McKenzie JE. Evidence map of studies evaluating methods for conducting, interpreting
and reporting overviews of systematic reviews of interventions: rationale and design. Syst Rev 2016 Jan 06;5:4 [FREE Full
text] [doi: 10.1186/s13643-015-0178-0] [Medline: 26739283]
38. Pieper D, Buechter R, Jerinic P, Eikermann M. Overviews of reviews often have limited rigor: a systematic review. J Clin
Epidemiol 2012 Dec;65(12):1267-1273. [doi: 10.1016/j.jclinepi.2012.06.015] [Medline: 22959594]
39. Popay J, Roberts H, Sowden A. Lancaster. 2006. Guidance on the conduct of narrative synthesis in systematic reviews:
final report URL: http://www.lancaster.ac.uk/shm/research/nssr/research/dissemination/publications.php [accessed
2016-09-21] [WebCite Cache ID 6kgid2HMT]
40. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting
systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS
Med 2009 Jul 21;6(7):e1000100 [FREE Full text] [doi: 10.1371/journal.pmed.1000100] [Medline: 19621070]
41. Finkelstein J, Knight A, Marinopoulos S, Gibbons MC, Berger Z, Aboumatar H, et al. Enabling patient-centered care
through health information technology. Evid Rep Technol Assess (Full Rep) 2012 Jun(206):1-1531. [Medline: 24422882]
42. Free C, Phillips G, Watson L, Galli L, Felix L, Edwards P, et al. The effectiveness of mobile-health technologies to improve
health care service delivery processes: a systematic review and meta-analysis. PLoS Med 2013 Jan;10(1):e1001363 [FREE
Full text] [doi: 10.1371/journal.pmed.1001363] [Medline: 23458994]
43. McKibbon KA, Lokker C, Handler SM, Dolovich LR, Holbrook AM, O'Reilly D, et al. Enabling medication management
through health information technology (Health IT). Evid Rep Technol Assess (Full Rep) 2011 Apr(201):1-951. [Medline:
23126642]
44. Bowles KH, Baugh AC. Applying research evidence to optimize telehomecare. J Cardiovasc Nurs 2007;22(1):5-15 [FREE
Full text] [Medline: 17224692]
45. Kitsiou S, Paré G, Jaana M. Effects of home telemonitoring interventions on patients with chronic heart failure: an overview
of systematic reviews. J Med Internet Res 2015;17(3):e63 [FREE Full text] [doi: 10.2196/jmir.4174] [Medline: 25768664]
46. Lewin S, Glenton C, Munthe-Kaas H, Carlsen B, Colvin CJ, Gülmezoglu M, et al. Using qualitative evidence in decision
making for health and social interventions: an approach to assess confidence in findings from qualitative evidence syntheses
(GRADE-CERQual). PLoS Med 2015 Oct;12(10):e1001895 [FREE Full text] [doi: 10.1371/journal.pmed.1001895]
[Medline: 26506244]
47. Mador RL, Shaw NT. The impact of a Critical Care Information System (CCIS) on time spent charting and in direct patient
care by staff in the ICU: a review of the literature. Int J Med Inform 2009 Jul;78(7):435-445. [doi:
10.1016/j.ijmedinf.2009.01.002] [Medline: 19261544]
48. Nieuwlaat R, Connolly SJ, Mackay JA, Weise-Kelly L, Navarro T, Wilczynski NL, CCDSS Systematic Review Team.
Computerized clinical decision support systems for therapeutic drug monitoring and dosing: a decision-maker-researcher
partnership systematic review. Implement Sci 2011;6:90 [FREE Full text] [doi: 10.1186/1748-5908-6-90] [Medline:
21824384]
49. Mickan S, Atherton H, Roberts NW, Heneghan C, Tilson JK. Use of handheld computers in clinical practice: a systematic
review. BMC Med Inform Decis Mak 2014;14:56 [FREE Full text] [doi: 10.1186/1472-6947-14-56] [Medline: 24998515]
50. Randell R, Mitchell N, Dowding D, Cullum N, Thompson C. Effects of computerized decision support systems on nursing
performance and patient outcomes: a systematic review. J Health Serv Res Policy 2007 Oct;12(4):242-249. [doi:
10.1258/135581907782101543] [Medline: 17925077]

http://www.jmir.org/2017/4/e122/ J Med Internet Res 2017 | vol. 19 | iss. 4 | e122 | p. 18

(page number not for citation purposes)
XSL• FO
RenderX
 JOURNAL OF MEDICAL INTERNET RESEARCH Rouleau et al

51. Georgiou A, Prgomet M, Paoloni R, Creswick N, Hordern A, Walter S, et al. The effect of computerized provider order
entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative
literature. Ann Emerg Med 2013 Jun;61(6):644-653.e16. [doi: 10.1016/j.annemergmed.2013.01.028] [Medline: 23548404]
52. Dowding D, Randell R, Gardner P, Fitzpatrick G, Dykes P, Favela J, et al. Dashboards for improving patient care: review
of the literature. Int J Med Inform 2015 Feb;84(2):87-100. [doi: 10.1016/j.ijmedinf.2014.10.001] [Medline: 25453274]
53. Poissant L, Pereira J, Tamblyn R, Kawasumi Y. The impact of electronic health records on time efficiency of physicians
and nurses: a systematic review. J Am Med Inform Assoc 2005 Oct;12(5):505-516 [FREE Full text] [doi:
10.1197/jamia.M1700] [Medline: 15905487]
54. Husebø Anne Marie Lunde AML, Storm M. Virtual visits in home health care for older adults. The Scientific World Journal
2014;2014:689873 [FREE Full text] [doi: 10.1155/2014/689873] [Medline: 25506616]
55. Jones JF, Brennan PF. Telehealth interventions to improve clinical nursing of elders. Annu Rev Nurs Res 2002;20:293-322.
[Medline: 12092513]
56. Meißner A, Schnepp W. Staff experiences within the implementation of computer-based nursing records in residential aged
care facilities: a systematic review and synthesis of qualitative research. BMC Med Inform Decis Mak 2014;14:54 [FREE
Full text] [doi: 10.1186/1472-6947-14-54] [Medline: 24947420]
57. Mäenpää T, Suominen T, Asikainen P, Maass M, Rostila I. The outcomes of regional healthcare information systems in
health care: a review of the research literature. Int J Med Inform 2009 Nov;78(11):757-771. [doi:
10.1016/j.ijmedinf.2009.07.001] [Medline: 19656719]
58. Nguyen L, Bellucci E, Nguyen LT. Electronic health records implementation: an evaluation of information system impact
and contingency factors. Int J Med Inform 2014 Nov;83(11):779-796. [doi: 10.1016/j.ijmedinf.2014.06.011] [Medline:
25085286]
59. Bartoli L, Zanaboni P, Masella C, Ursini N. Systematic review of telemedicine services for patients affected by chronic
obstructive pulmonary disease (COPD). Telemed J E Health 2009 Nov;15(9):877-883. [doi: 10.1089/tmj.2009.0044]
[Medline: 19919194]
60. Kelley TF, Brandon DH, Docherty SL. Electronic nursing documentation as a strategy to improve quality of patient care.
J Nurs Scholarsh 2011 Jun;43(2):154-162. [doi: 10.1111/j.1547-5069.2011.01397.x] [Medline: 21605319]
61. Darbyshire P. 'Rage against the machine?': nurses' and midwives' experiences of using computerized patient information
systems for clinical information. J Clin Nurs 2006 Feb;13(1):17-25. [doi: 10.1111/j.1365-2702.2006.01180.x] [Medline:
16422744]
62. Gagnon M, Pollender H, Trépanier A, Duplàa E, Ly BA. Supporting health professionals through information and
communication technologies: a systematic review of the effects of information and communication technologies on
recruitment and retention. Telemed J E Health 2011 May;17(4):269-274. [doi: 10.1089/tmj.2010.0175] [Medline: 21476881]
63. Gagnon M, Breton E, Paré G, Courcy F, Côté J, Trépanier A, et al. [The impact of information and communication
technologies on nurse retention]. Sante Publique 2013;25(3):305-313. [Medline: 24007906]
64. Aiken LH, Clarke SP, Sloane DM. Hospital restructuring: does it adversely affect care and outcomes? J Health Hum Serv
Adm 2001;23(4):416-442. [Medline: 11924307]
65. Sidani S, Doran DM, Mitchell PH. A theory-driven approach to evaluating quality of nursing care. J Nurs Scholarsh
2004;36(1):60-65. [Medline: 15098420]
66. Lake ET. Development of the practice environment scale of the nursing work index. Res Nurs Health 2002 Jun;25(3):176-188.
[doi: 10.1002/nur.10032] [Medline: 12015780]
67. Dubois C, D'Amour D, Brault I. Indicateurs prioritaires pour évaluer la contribution infirmière à la qualité des soins : revue
systématique des écrits. Montréal: Secrétariat international des infirmières et infirmiers de l'espace francophone (SIDIIEF);
2015.
68. Agboola SO, Ju W, Elfiky A, Kvedar JC, Jethwani K. The effect of technology-based interventions on pain, depression,
and quality of life in patients with cancer: a systematic review of randomized controlled trials. J Med Internet Res
2015;17(3):e65 [FREE Full text] [doi: 10.2196/jmir.4009] [Medline: 25793945]
69. Lima IC, Galvão MTG, Alexandre HO, Lima FET, Araújo TL. Information and communication technologies for adherence
to antiretroviral treatment in adults with HIV/AIDS. Int J Med Inform 2016 Aug;92:54-61. [doi:
10.1016/j.ijmedinf.2016.04.013] [Medline: 27318071]
70. Singh TP, Vangaveti VN, Kennedy RL, Malabu UH. Role of telehealth in diabetic foot ulcer management - a systematic
review. Aust J Rural Health 2016 Aug;24(4):224-229. [doi: 10.1111/ajr.12284] [Medline: 27098271]
71. Raaijmakers LC, Pouwels S, Berghuis KA, Nienhuijs SW. Technology-based interventions in the treatment of overweight
and obesity: a systematic review. Appetite 2015 Dec;95:138-151. [doi: 10.1016/j.appet.2015.07.008] [Medline: 26165415]
72. Cheung A, Weir M, Mayhew A, Kozloff N, Brown K, Grimshaw J. Overview of systematic reviews of the effectiveness
of reminders in improving healthcare professional behavior. Syst Rev 2012;1:36 [FREE Full text] [doi:
10.1186/2046-4053-1-36] [Medline: 22898173]
73. Gephart S, Carrington JM, Finley B. A systematic review of nurses' experiences with unintended consequences when using
the electronic health record. Nurs Adm Q 2015;39(4):345-356. [doi: 10.1097/NAQ.0000000000000119] [Medline: 26340247]

http://www.jmir.org/2017/4/e122/ J Med Internet Res 2017 | vol. 19 | iss. 4 | e122 | p. 19

(page number not for citation purposes)
XSL• FO
RenderX
 JOURNAL OF MEDICAL INTERNET RESEARCH Rouleau et al

74. McGinn CA, Grenier S, Duplantie J, Shaw N, Sicotte C, Mathieu L, et al. Comparison of user groups' perspectives of
barriers and facilitators to implementing electronic health records: a systematic review. BMC Med 2011;9:46 [FREE Full
text] [doi: 10.1186/1741-7015-9-46] [Medline: 21524315]
75. Young LB, Chan PS, Cram P. Staff acceptance of tele-ICU coverage: a systematic review. Chest 2011 Feb;139(2):279-288
[FREE Full text] [doi: 10.1378/chest.10-1795] [Medline: 21051386]

Abbreviations
ADE: adverse drug event
ADL: activities of daily living
AMSTAR: assessment of multiple systematic reviews
APN: advanced practice nurse
BCMA: bar-coded medication administration
CCIS: critical care information system
CDSSs: computerized decision support systems
CINAHL: Cumulative Index to Nursing and Allied Health Literature
COPD: chronic obstructive pulmonary disease
CPIS: computerized patient information systems
CPOE: computerized provider order entry
CS: communication systems
D-RHIS: disease-specific regional health care information systems
ECG: electrocardiogram
ED: emergency department
EHR: electronic health record
eMAR: electronic medication administration record systems
EMR: electronic medical record
EPR: electronic personal record
ES-NIS: expert system nursing information system
EWS: early warning score
HCPs: health care providers
HIT: health information technology
ICTs: information and communication technologies
ICU: intensive care unit
I-RHIS: integrated regional health care information systems
IT: information technology
LOS: length of stay
MeSH: Medical subject heading
MMIT: medication management health information technology
MS: management systems
NCPF: nursing care performance framework
NHS: National Health Service
ORA: organization risk analyzer
PCC: patient-centered care
PDA: personal digital assistant
PHR: personal health record
PICOs: participants, interventions, comparisons, outcomes and studies
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analysis
RCT: randomized controlled trial
RHIO: regional health care information organization
RHIS: regional health care information system
RN: registered nurse
SMS: short message service
TDMD: therapeutic drug monitoring and dosing
WAP: wireless application protocol

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Edited by G Eysenbach; submitted 23.09.16; peer-reviewed by D Dowding, JM Carrington, P Johansson; comments to author 29.12.16;
revised version received 27.01.17; accepted 05.03.17; published 25.04.17
Please cite as:
Rouleau G, Gagnon MP, Côté J, Payne-Gagnon J, Hudson E, Dubois CA
Impact of Information and Communication Technologies on Nursing Care: Results of an Overview of Systematic Reviews
J Med Internet Res 2017;19(4):e122
URL: http://www.jmir.org/2017/4/e122/
doi: 10.2196/jmir.6686
PMID: 28442454

©Geneviève Rouleau, Marie-Pierre Gagnon, José Côté, Julie Payne-Gagnon, Emilie Hudson, Carl-Ardy Dubois. Originally
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