This study used a survey of RACFs to explore information exchange both within RACFs and between the facilities and GPs, community pharmacists and hospitals. The results revealed that information processing is a major staff activity and that information input and exchange were time consuming, especially for RNs. Inefficient and potentially unsafe practices [14
] were identified, such as the vast amount of transcribing information from paper to computer systems, a task which was reported by nearly 70% of respondents. Further, the extensive reliance upon faxes as the main conduit for communication between external providers highlights the urgent need for interoperable information systems to facilitate efficient and accurate communication. A concerning finding was that around 30% of respondents reported that they sometimes or never had access to information following a resident’s hospital admission; this is another aspect of communication which could be enhanced by improved information systems use.
Staff completed a high volume of documentation with a median of 6 forms filled out per staff member per shift. This rate nearly doubled for respondents working in a RACF that mainly used paper documentation systems. Documentation was found to be a time consuming process, which confirms previous reports [15
]. This was particularly the case for those involved in incident reporting and for RNs who spent more time on documentation than ENs and AINs. This in part confirms the qualitative literature which describes RNs as the information gatekeepers, and ENs and AINs as the hands on workers [18
]. This documentation is critical to the care process; however studies have shown that staff believe this time could be better spent attending to residents [3
]. Thus from a staff member perspective, a user friendly documentation system that reduced time spent on documentation- related tasks would be favourable. There is some evidence to suggest that electronic nursing documentation systems encompassing electronic progress notes, care plans, handover sheets, scheduling and funding calculations within facilities reduce the time spent on documentation [22
]. Electronic documentation systems could also potentially reduce the time spent at handover as nurses would not have to search for information from different locations as is currently performed [23
]. However, prior evidence, as well as the findings from this study, suggest that internal facility electronic documentation systems either make no difference or even increase documentation time [24
]. These conflicting reports suggest that a greater understanding of the work processes and information exchange requirements of RACFs is needed to inform the design and implementation of IT systems that are efficient, user friendly, and which better support data input related to clinical and care tasks [8
Results of this study confirm prior findings [12
], which have shown that the majority of care is documented at nurses’ stations, away from the point-of-care and whenever staff have the opportunity. The use of mobile technology may assist in reducing the delay in data input, as well as improve the accuracy of data as it would be entered into the electronic system directly (rather than transcribed) thus reducing the potential chance of transfer error or omission of information. Only 40% of respondents indicated that they always had information available at the point-of-care, the majority of whom came from a facility using paper based documentation systems, suggesting that if electronic information systems are to be implemented, they need to be designed so that they are readily accessible at the point-of-care for information retrieval. This could either occur by having appropriate ratios of computers to staff, having computers located where staff document, or having mobile technology that enables documentation at the resident bedside. However surprisingly, we also found that staff who had access to computers at the bedside or on mobile medication carts reported that they rarely used these computers. Previous studies have found that mobile technologies available to clinicians in hospital often do not choose to use them at patients’ bedsides [27
]. Considerably more research is required to understand when and what benefits mobile technologies deliver within healthcare settings [28
Communication with external providers was found to be cumbersome with a high reliance on calls and faxes as a means of communication between RACFs and GPs and pharmacists. Results showed that a median of 2 faxes were sent to pharmacy and 1.5 faxes were sent to General Practitioners per staff member per shift. Additionally, 2 calls were made to pharmacy and 1.5 calls were made to General Practitioners per staff member per shift. Communication with hospitals regarding a resident’s stay in hospital was found to be lacking, with only a third of staff always having access to information related to a resident’s recent hospital stay. A potential explanation as to why the majority of nursing staff in our study didn’t always have access to this information could be that the RNs at an RACF receive and process incoming information from the hospital then filter it down to ENs and AINs in a different format. Other studies have also identified this lack of communication between hospitals and RACFs; McCloskey’s ethnographic study in one nursing home and one Emergency Department (ED) in an urban centre in Canada, made observations of hospital-to- nursing home transfer. Even though nursing staff from the ED reported that the ED record was routinely sent back with the residents, the investigator observed few cases of this actually happening, and even when a record was sent to the facility, it contained little information as to what had transpired whilst a resident was in the ED [29
]. Unlike internal facility issues, these issues of external communication are more challenging to resolve with IT as it relies on the interoperability between facility and GP or pharmacist or hospital IT systems. National efforts to link up electronically controlled health records via a personally controlled electronic health record, as is envisioned for Australia [30
], would greatly facilitate the exchange of information between aged care facilities and other health facilities and practitioners and would aid in reducing the excessive amount of telephone calling and faxing to these providers by RACFs. Additionally, interoperable electronic systems in which health records were accessed by providers could reduce the need for multiple health records of residents/patients, allowing for a more consistent record to be kept. A study conducted by Burns et al. [31
], in four RACFs trialling electronic medication charts, found GPs reduced their need for duplicate copies of patients’ notes at the surgery once they could remotely access the electronic medication chart at the RACF. The development of interoperable systems may also overcome the silo effect of communication, as if often described [32
], amongst these three entities.
The results revealed that, for internal communication, face-to-face communication was favoured as it allowed staff to clarify issues with one another more easily, and also it was the most effective means of communicating a large amount of information about a resident’s care to colleagues. Studies looking at handover
communication between nursing staff, found that a combined oral and written communication at handover achieved higher standards of documentation of care, than if verbal communication alone was used. [33
]. Thus, while face-to-face communication is a fundamental part of health care provision and appropriately the most central form of communication, it is likely that innovative use of IT could potentially enhance internal communication processes within the RACF, such as handover.
We acknowledge that there are general limitations with using surveys as a research tool [34
], including participants’ understanding of the questions as a result of having English as a second language. We did not ascertain whether English was a second language for participants, as the nurse managers in the focus group recommended that inclusion of this question may deter participants who wanted to remain anonymous. Even had we asked whether workers had English as a second language, this still would not have provided us with an indication of English language proficiency. While this study represents one of the few multi-site surveys of RACFs, and the first to provide a detailed examination of information exchange processes, the sample size was modest. Larger scale studies would be valuable to confirm the generalisability of the findings. The nature or purpose of documentation outside incident and medication-related documentation was not ascertained in this survey. This information would be valuable for further investigation in future studies.