Abstract
Background
There is a lack of information on the possible attitudinal factors that might explain why professionals attend or do not attend electronic health record training. We investigated whether the dimensions defined by the Attitudes toward Guideline Scale (general attitude, usefulness, reliability, lack of individual competence, lack of organizational competence, and impracticality) were associated with attending electronic health record training among licensed practical nurses.
Methods
Cross-sectional survey data were collected in the spring of 2024 from licensed practical nurses working in Finland (N = 2295). Binary logistic regression analyses were conducted in two steps examining both the univariable and multivariable associations between attitudes and attending training.
Results
Licensed practical nurses with higher digital dedication (OR 1.10, CI 1.02–1.18) had higher odds of attending electronic health record training within the last 3 years. Lack of basic IT and documentation skills (OR 0.72, CI 0.63–0.83) and lack of support for electronic health record use within the unit (OR 0.56, CI 0.50–0.62) had lower odds of attending such training withing the last 3 years. In the multivariable analysis, lack of basic IT and documentation skills (OR 0.77, CI 0.66–0.90), and lack of support for electronic health record use within the unit (OR 0.57, CI 0.51–0.64) remained associated with a lower likelihood of attending training during the 3-year period.
Conclusions
Health and social care organizations need to especially ensure that their professionals have the basic skills to use technology and that there are supporting personnel in the work unit to offer help with using electronic health records when needed.
Clinical trial number
Not applicable.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12912-026-04632-w.
Keywords: Attitudes, Information systems, Clinical guidelines, Nurses, Survey study
Background
Information and communication technologies are transforming the work of healthcare and social services professionals and the way care is provided [1, 2]. One of the technological transformations is the progressive change from paper-based documentations to using electronic health records or client information systems, that are parts of the daily work of care professionals in many countries, including Finland [3, 4]. The electronic health records and information systems store comprehensive data on a patient’s health status (in healthcare) and important client data and documents (in social care). The primary uses of data include planning, monitoring and evaluating care, ensuring the quality of services, and protecting the juridical rights and information needs of the clients as well as the professionals. The secondary use of data provides opportunities for the data driven guiding in education, research, and decision-making in public health policies [5].
Attitudes have been found to be a crucial factor in the implementation of electronic health records in healthcare and social services [6, 7]. The relationship between attitudes and clinical behaviour has previously been examined, for example, in the implementation of clinical guidelines [8]. Healthcare professionals’ perceptions and attitudes towards clinical guidelines, such as perceived relevance, usefulness, peer and organizational support, may influence their likelihood of adhering to them in practice [9, 10].
Healthcare and social care organizations provide electronic health records training to their employees. Attending training is an important prerequisite for achieving the expected benefits of the effective use of these systems [11]. Especially in countries like Finland, where using electronic health records is mandatory for practically all professionals working in healthcare or social care, attending training may also influence individual well-being related to electronic health record use. Studies have found that nurses who felt they had received sufficient training reported higher satisfaction with the electronic health record [12] and perceived less stress related to electronic health records, as well as lower time pressure and fewer cognitive errors [13].
Similar to attitudes, training to use electronic health records has been identified as a key factor for the successful implementation of these systems [14, 15]. However, the link between attitudes and training is less clear, and information on the attitudinal factors that might explain why professionals attend or do not attend electronic health record training is particularly scarce. Understanding these attitudes could help managers to address barriers that hinder participation and tailor training content to better meet professionals’ needs. Several theoretical models have been developed to explain the acceptance behaviour of new technologies [16]. However, these models often adopt a narrow view of which attitudes are considered relevant predictors. For example, the widely used Technology Acceptance Model suggests that accepting technology is primarily a matter of its perceived ease of use and usefulness [17]. These may be important factors especially before implementing a new technology but are likely less relevant when the technology is established, and its use is mandatory. Furthermore, the Technology Acceptance Model has been criticized for simplifying the complex processes underlying human behaviour [18, 19].
In this study, we went beyond the focus of the digital technology-related literature and suggest that examining attitudes associated to electronic health records training might benefit from previous work on predictors of using evidence-based clinical guidelines [20]. Although attitudes related to guidelines and attitudes related to electronic health records have been separate fields of research, they have many similarities in multiple levels. Using guidelines and using electronic health records both require a certain type of knowledge and behaviour that health and social care organizations need and expect from their employees. Clinical guidelines and electronic health records trainings are both designed to offer professionals relevant and compact information needed in their work, in a user-friendly format. Further, the general aims of both are to improve quality of care and reduce inconsistencies between practices.
Previous research has found that professionals have had similar kinds of fears and attitudes related to both, the use of guidelines and the use of electronic health records. Attitudes have been associated with self-reported guideline use [20] as well as with electronic health record use [21]. Some professionals have been worried that guidelines or electronic health records pose a threat to their professional autonomy [9, 22]. These similarities support applying the guidelines framework to examining attitudes related to electronic health record use.
In this study, we used the Attitudes toward Guideline Scale as a framework [22]. The scale has been used in many countries, and it has found to have an acceptable level of validity and reliability also among nurses [9, 10]. It consists of seven dimensions: general attitude towards guidelines, usefulness, reliability, lack of individual or team competence, lack of organizational competence, impracticality, and availability. These dimensions reflect different attitudinal components: (1) the cognitive evaluations one has for guidelines, (2) perception of the competence one has for using guidelines, and (3) perception or support of one’s organization towards guidelines. We argue that these components are relevant also for attending electronic health records training. The literature on implementing guidelines as well as literature on implementing electronic health records highlight that promoting positive attitudes are important but not the only aspect that matters. The lack of knowledge and skills and the lack of support from one’s organization, or perceptions of these, have been seen as obstacles to electronic health record adoption [21]. For this reason, utilizing this wider conceptualization of attitudes based on the dimensions of the Attitudes toward Guideline Scale is worth exploring.
Although the Attitudes toward Guideline Scale was developed several decades ago, the dimensions of the scale are still mostly up to date and usable today. The only exception to this may be the ‘availability’ dimension, which refers to whether the guidelines are difficult to find when needed. Finding the guidelines is no longer an issue as technological developments have made them more accessible in professionals’ daily work. By using artificial intelligence, the guidelines might soon even be integrated into electronic health records to help professionals make clinical decisions [23]. As described above, availability is also not an issue for electronic health records because they are routinely used in everyday work and training for their use is offered. Consequently, in this study we decided to exclude the availability dimension from the scale.
Recent studies have examined the perceptions of nurses related to both guidelines and electronic health record use. However, studies focusing on electronic health record training have mainly involved the perspectives of educators, leaders and informatics specialists [11]. In this study we are interested in licensed practical nurses’ perceptions, because as frontline professionals they are the main end-users of the electronic health records. This is in line with healthcare digitalisation policies, which state that digital services in general should be developed in co-creation with nurses and their possible concerns and reservations related to digitalisation should be heard and addressed [1].
The aim of the study was to examine which attitude dimensions defined by the Attitudes toward Guideline Scale are associated with attending electronic health record training among licensed practical nurses.
Methods
Study context
In Finland licensed practical nurse is a registered profession regulated by law [24]. They are qualified to work with different clients in various fields such as healthcare, social care, and early childhood education and schools [25]. In 2023, altogether 115 000 licensed practical nurses were working within health and social services, which equals 30.9% of all the professionals in the field [26]. The licensed practical nurse education in Finland typically lasts two to three years and includes both theoretical and vocational studies with a total of 180 competence points. Further on-site training relating to the use of a specific electronic health record is needed to tailor the competence to an organization’s needs.
All organizations that produce healthcare services are obligated to use electronic health records, and all public social services are required to use client information systems. The largest private social care companies also use client information systems, but the transition period for full client information system adoption ends in 2026 [27].
Sample and procedure
The data were collected in spring 2024 with an online survey. The respondents were reached through three large trade unions, Union of Health and Social Care Professionals (Tehy), The Finnish Union of Practical Nurses (SuPer) and Trade Union for the Public and Welfare Sectors (JHL), which sent the survey via e-mail to all their 18 to 65-year-old members who were licensed practical nurses or equivalent. The eligible sample was thus all the licensed practical nurses that were members of one of the largest trade unions. The possibility to respond to the online survey was offered in Finnish, Swedish, and English. Two reminders were sent.
In the survey data information systems referred to both electronic health record and client information systems, but for the clarity of the methods and results sections we use electronic health record for both terms.
The inclusion criteria for participation were (1) working currently as nurse in healthcare sector or social services (excluding those working in schools and early childhood education or care), and (2) using electronic health records in their current work. The respondents who did not meet these criteria, were excluded from the survey data, resulting to 2 341 respondents who completed the survey. From these, we further included only those respondents, who had a valid answer to the survey question regarding attending electronic health record training, which was the dependent variable of this study. At this point, 46 respondents were excluded, resulting in 2 295 respondents in the final data. The trade union membership information is confidential and thus an affirmative response rate cannot be given.
Measures
Attitudes towards electronic health record
Independent variables from the survey on electronic health records were chosen and categorized under the chosen six dimensions of the Attitudes toward Guideline Scale [22]. For the analyses, all scales of the independent variables were coded to follow the directions of the dimensions in the scale (e.g., regarding the impracticality dimension, the higher the value the stronger the perception of impracticality). We computed mean scores for the individual variables conditional on participants having responded to at least half of the items.
Reflecting the general attitude dimension, we used three items measuring digital dedication derived from the TechnoWES instrument [28]. The original measure uses word ‘technology’ which was further specified and replaced in this study with ‘digital tools’ (e.g., electronic health record, programmes and end-devices, video connection, communication service such as chat, or remote monitoring). The respondents were asked to estimate how often the following kinds of feelings and thoughts arise: 1) I am enthusiastic about utilising digital tools in my job, 2) Utilising digital tools inspire me in my job, and 3) I am proud that I utilise digital tools in my work. The response format was 1 = daily, 2 = weekly, 3 = monthly, 4 = less than monthly, 5 = not at all. For the analyses, item scales were reverse coded, and a mean score was computed to represent digital dedication. The internal consistency (Cronbach’s alpha) was 0.94 and was in line with a previous study using the same items among registered nurses [29].
Under usefulness dimension, we examined the perceived advantages and disadvantages of electronic health record in general with four statements and the potential benefits of documentation by using electronic health record with another two statements. The items regarding the electronic health records in general were: (1) Electronic health records help in preventing errors and mistakes associated with medications, (2) Electronic health records help to avoid duplicate tests and examinations, (3) Electronic health records help to ensure continuity of care, (4) Electronic health records help to improve quality of care, and (5) The electronic health record takes too much time out of the nurse’s time with clients/patients. This item scale was used as reverse coded. The benefits of documentation by using electronic health record were assessed with two statements: (1) I find other people’s documentation useful, and (2) I find patients/clients benefit from documentation. Both measures had a five-point Likert scale with the response format from 1 (fully disagree) to 5 (fully agree). The Cronbach’s alpha was 0.80 for the attitudes on electronic health records generally and 0.65 for the benefits of documentation.
The reliability dimension was assessed with the functionality of the electronic health record used, measured with four items: (1) The electronic health record is stable in terms of technical functionality (does not crash, no downtime), (2) The electronic health record responds quickly to inputs, (3) Faulty function of electronic health record has caused a serious adverse event for a patient (reverse coded), and (4) Faulty function of electronic health record has nearly caused a serious adverse event for a patient (reverse coded). These items had a five-point Likert scale response format from 1 (fully disagree) to 5 (fully agree). The Cronbach’s alpha was 0.75.
The lack of individual competence dimension was assessed with a question reflecting the lack of basic IT and documentation skills: How well do you feel you master the following skills required by the electronic health record: (1) Basic IT skills (such as email, word processor, information retrieval), and (2) Documentations to an electronic health record. The original scale in this question was 1 = excellently, 2 = well, 3 = satisfactorily, 4 = passably, and 5 = my organization does not require this skill. We recoded the last option in the scale to missing information. The Cronbach’s alpha for the final scale was 0.71.
The lack of organizational competence dimension was examined with a question reflecting the lack of support for electronic health record use in unit: My unit has: (1) an orientation programme for new employees, which includes guidance on the use of the electronic health record, and (2) a designated person who supports others in the use of the electronic health record. The original answer options were 1 = yes, 2 = no, 3 = I don’t know. We combined the last two options and made a sum variable and the interitem correlation was 0.29.
The impracticality dimension was assessed with items reflecting problems related to documentation using electronic health record: (1) I have to spend an unnecessary amount of time on documentation, (2) Unclear documentation have caused misunderstandings in my work unit, (3) Flawed/missing nursing documentation have caused problems in my work unit, and (4) The same information must be documented in several places. These items had a five-point Likert scale response format from 1 (fully disagree) to 5 (fully agree). Cronbach’s alpha was 0.61.
Attending electronic health record training
The dependent variable was based on the question: I have last participated in training provided by the organization, related to the use of the electronic health record: (1) Less than six months, (2) Six months – less than one year, (3) One year – less than three years, (4) Three years – six years, (5) More than six years ago, and (6) Never. We created a dummy variable, in which 1 = Attended training within last three years, and 0 = Attended training over three years ago or never. The cut-off point was determined at three years because it can be assumed that the electronic health records are constantly developed and thus attending training on a regular need basis is highly recommended [30, 31].
Confounders
Potential confounding variables were age, years of working as a licensed practical nurse, working sector, employment contract, years of using the electronic health record, and the question: Has a new electronic health record been implemented in your unit within the past 6–12 months. The scales of these variables are presented in Table 1. These variables were considered as potential confounders based on previous studies. For example, younger physicians and those with more skills in technology use have been found more likely to have positive attitudes towards using electronic health record [7]. Also, highly experienced nurses have seemed to rate the benefits of electronic health records higher than nurses who have just started working [32] and registered nurses who had been using a particular electronic health record for more than 6 months were slightly more confident on their nursing documentation skills than others [33].
Table 1.
The potential confounders in different outcome variable classes (N = 2 266–2 295)
| Potential confounders | Outcome variable | p-value for differencec | |
|---|---|---|---|
| Has attended training over three years ago or never (N = 1 009) | Has attended training within the last three years (N = 1 286) | ||
| Age | |||
| 18–34 years | 130 (12.9%) | 130 (10.1%) | 0.11 |
| 35–54 years | 439 (43.5%) | 576 (44.8%) | |
| over 55 years | 440 (43.6%) | 580 (45.1%) | |
| Years of working as a licensed practical nurse | |||
| less than 6 months – 5 years | 150 (14.9%) | 185 (14.4%) | 0.41 |
| 6–20 years | 509 (50.4%) | 684 (53.2%) | |
| over 20 years | 350 (34.7%) | 417 (32.4%) | |
| Working sector | |||
| social care | 459 (45.5%) | 553 (43.0%) | 0.46 |
| healthcare | 419 (41.5%) | 565 (43.9%) | |
| othera | 131 (13.0%) | 168 (13.1%) | |
| Employment contract | |||
| permanent | 891 (88.7%) | 1198 (93.4%) | < 0.001 |
| otherb | 113 (11.3%) | 84 (6.6%) | |
| Years of using electronic health record | |||
| less than 6 months – 3 years | 320 (31.7%) | 570 (44.3%) | < 0.001 |
| 3–6 years | 366 (36.3%) | 406 (31.6%) | |
| over 6 years | 323 (32.0%) | 310 (24.1%) | |
| A new electronic health record implemented in the unit within the past 6–12 months | |||
| yes | 141 (14.2%) | 321 (25.2%) | < 0.001 |
| no | 853 (85.8%) | 951 (74.8%) | |
aNot specified (e.g. working in nongovernmental organization)
bFixed-term employment contract or working temporary for example through staff rental company
cStatistical significance test based on Χ2 test
Statistical analyses
The characteristics of the study participants were described using proportions (%) divided to two groups based on had the respondents attended to training over three years ago (or never) or within three years. Means and standard deviations were provided of the attitudinal dimensions. Binary logistic regression analyses were used to examine the associations of the attitudinal variables with attending electronic health record training in two steps. First, separate univariable analyses were conducted to examine the association of each independent variable with the dependent variable. Second, all the independent variables were added simultaneously to the model to examine which variables were the most relevant predictors. The potential confounders were included in the analyses in both phases.
Odds ratios, 95% confidence intervals (CI), and p-values are provided. R version 4.2.1 for Windows 11 [34] was applied to the analyses.
Results
Most of the respondents were over 35 years old, had worked as nurse for several years, and had a permanent work contract (Table 1). Most had attended electronic health record training within the last three years. Employment contract, years of using electronic health record, and a recently implemented new electronic health record were significantly associated (p<.001) with attending electronic health record training within the last three years. More specifically, of those who had attended training within last 3 years, most had a permanent work contract, had less than 3 years’ experience of using the electronic health record, and worked in a unit where a new electronic health record had been implemented within the last year.
Means and standard deviations of the independent variables are presented in Table 2. On average the attitudes towards electronic health records were positive. Specifically, the benefits of documentation by using electronic health record (usefulness dimension) and functionality of the electronic health record used (reliability dimension) were mainly found positive (means 4.12 and 3.50, respectively).
Table 2.
Means and standard deviations of the attitudes toward electronic health record dimensions (N = 2 295)
| Attitude dimension | Mean (SD) |
|---|---|
| General attitude: Digital dedication (range 1–5) | 2.93 (1.23) |
| Usefulness I: Advantages and disadvantages of electronic health record (range 1–5) | 2.99 (0.79) |
| Usefulness II: Benefits of documentation by using electronic health record (range 1–5) | 4.12 (0.80) |
| Reliability: Functionality of the electronic health record used (range 1–5) | 3.50 (0.86) |
| Lack of individual competence: Lack of basic IT and documentation skills (range 1–4) | 2.11 (0.66) |
| Lack of organizational competence: Lack of support for electronic health record use in unit (range 0–2) | 1.04 (0.80) |
| Impracticality: Problems related to documentation using electronic health record (range 1–5) | 2.57 (0.80) |
The results showed three statistically significant predictors of attending electronic health record training when the individual associations of independent variables were examined (Table 3). Licensed practical nurses with higher digital dedication (OR 1.10, CI 1.02–1.18) had attended electronic health record training within last 3 years more likely than others. Those with lack of basic IT and documentation skills (OR 0.72, CI 0.63–0.83) and those with lack of support for electronic health record use in unit (OR 0.56, CI 0.50–0.62) had attended electronic health record training within last 3 years less likely than others. In the multivariable analysis (Table 4) the lack of basic IT and documentation skills (OR 0.77, CI 0.66–0.90) and the lack of support for electronic health record use in unit (OR 0.57, CI 0.51–0.64) were associated with attending electronic health record training within 3 years less likely than others.
Table 3.
The association between attitudes towards electronic health records and attending electronic health record training within 3 years (univariable binary logistic regression analyses)
| Variable | Univariable analyses |
|---|---|
| Odds Ratio (95% Confidence Interval) | |
| Digital dedication | 1.10 (1.02–1.18)** |
| Advantages and disadvantages of electronic health record | 1.06 (0.95–1.19) |
| Benefits of documentation by using electronic health record | 1.10 (0.99–1.23) |
| Functionality of the electronic health record used | 1.01 (0.92–1.12) |
| Lack of basic IT and documentation skills | 0.72 (0.63–0.83)*** |
| Lack of support for electronic health record use in unit | 0.56 (0.50–0.62)*** |
| Problems related to documentation using electronic health record | 1.01 (0.91–1.13) |
* = p<.05, ** = p<.01, *** = p<.001
Note: All analyses adjusted for age, years of working as a licensed practical nurse, working sector, employment contract, years of using electronic health record, new electronic health record implemented within 6–12 months
Table 4.
The association between attitudes towards electronic health records and attending electronic health record training within 3 years (multivariable binary logistic regression analyses)
| Variable | Multivariable analyses |
|---|---|
| Odds Ratio (95% Confidence Interval) | |
| Digital dedication | 0.99 (0.92–1.08) |
| Advantages and disadvantages of electronic health record | 0.95 (0.83–1.09) |
| Benefits of documentation by using electronic health record | 1.05 (0.93–1.18) |
| Functionality of the electronic health record used | 0.98 (0.87–1.10) |
| Lack of basic IT and documentation skills | 0.77 (0.66–0.90)** |
| Lack of support for electronic health record use in unit | 0.57 (0.51–0.64)*** |
| Problems related to documentation using electronic health record | 0.97 (0.86–1.10) |
* = p<.05, ** = p<.01, *** = p<.001
Note: All analyses adjusted for age, years of working as a licensed practical nurse, working sector, employment contract, years of using electronic health record, new electronic health record implemented within 6–12 months
Discussion
Using a framework related to attitudes toward guidelines, we examined whether attitudes related to electronic health records were associated with attending training related to the system use. When examined individually, a high level of enthusiasm toward electronic health records (digital dedication), lack of basic IT and documentation skills and lack of support for electronic health record use within the unit were associated with attending training. The role of self-efficacy, which is based on knowing at least the basics of technology use, seems to have been overlooked in previous research, which has focused more on the role of perceived usefulness [16]. Zaman and colleagues have studied the associations of different factors and presented a mediated model, where general computer skills, self-efficacy, and training influenced perceived usefulness through perceived ease of use [4]. The conclusion of our results is that besides offering the training on using electronic health record, the health and social care organizations need to understand the importance of ensuring that their professionals have basic IT skills and that there are supporting personnel to offer help when needed. Especially older nurses may have completed their education at a time when it did not include technology skills [33]. Soon, solutions incorporating artificial intelligence may change documentation practices for all and thus ensuring sufficient competence is relevant for every nurse [35]. Enthusiasm and being inspired by digital tools (digital dedication) can create a positive circle: professionals with positive attitudes toward digital tools are more likely to join training and successful training experiences might further increase their confidence and motivation in using technology.
Lack of basic IT and documentation skills, and lack of support for electronic health record use within the unit remained associated with attending training less within 3 years also when all attitudinal dimensions were included in the model simultaneously. In this study, lack of support for electronic health record use in unit referred to the organization not having an orientation programme for new employees (including guidance on electronic health record) and not having a designated person to support with the use of electronic health record. Previous studies have acknowledged the role of management support on attitudes, and specifically the importance of having peer coaches or superusers in optimizing the use of the electronic health records and assisting and providing practical help in the clinical environment [11, 14, 36]. In general, organizational contextual factors (including managerial support) appear to explain a considerable part of professionals’ attitudes toward the use of electronic health records [36]. The results of our study, together with previous research, suggest that the right kind of support system might be one important organizational activator to increase positive attitudes toward technology, which in turn might in the end help achieving the desired outcomes of the electronic health records. Another suggestion is the need to focus on all professionals’ getting the basic IT and documentation skills. Our results imply that without the basic skills, the professionals might not have the courage to attend to electronic health record training, because they might think it requires more advanced digital competence to understand the contents of the training.
The other attitudinal dimensions, which were related to perceived advantages, benefits or functionality of electronic health record, or problems related to documentation, were not significantly associated with attending training in this study. These results are understandable considering the main goal of electronic health record training, which is to give the professionals the practical skills of using the specific electronic health record in their unit. In this regard, the professionals’ perceptions of the electronic health record might be irrelevant in terms of attending training, because using the system is often mandatory, whether they like it or not, and regardless of whether the system functions well or not (see also [4]). Previous research has also emphasized aligning the training especially with specific training needs, training objectives, the system utilized, and organizational environment [31].
An important aspect of our study was examining the attitudes toward electronic health record by using the framework of attitudes toward (medical) guidelines. The aim was to test and raise discussion on whether the guidelines scale (and its different dimensions) could offer a suitable framework capturing the essential attitudinal factors related to attending training on electronic health records. We conclude that the guidelines framework worked well as a theoretical framework, and its use can also be recommended for research on technology attitudes. The guidelines framework has already gone through an extensive development and evaluation process [37], which other fields of research can benefit from. For example, the dimensions of the Attitudes toward Guideline Scale help to highlight the aspects and complexity of human behaviour. Importantly, based on our results, the question is not only whether the electronic health records are perceived useful (which in fact was not a significant explanatory factor), but whether the professionals know how to use the systems, and is there support available, reflecting issues that are more practical, day‑to‑day realities.
Nurse managers and training program designers should especially support nurses to feel confident in their computer skills in the training phase, evaluate the quality of the trainings and engage nurses to develop trainings to fit better to their daily workflows [4, 11, 14]. Those planning the training programs need to understand the key organizational, human and technological factors that may act as obstacles to attending training [14]. Addressing possible resistance to change and diverse skill levels as well as offering alternatives for traditional training, such as e-learning or simulation training have been considered important [11, 14]. The support offered by the organizations should be tailored to be context specific. For example, the managers in healthcare organizations should consider, is there a need for a constant or more temporary support, in person or online, and is the need for support related more to leadership or administrative type of issues [11]. Furthermore, the current rapidly changing environment requires strategic leadership that supports learning and renewal throughout the organization.
Limitations and future research
The cross-sectional study design leaves open the question whether positive attitudes lead to participation in electronic health record training, or whether the training increases positive attitudes towards the electronic health record. Both ways are theoretically possible, and examining the direction between the two would be an interesting research question for longitudinal studies in the future (see also [11]). Another limitation of our study is, that we relied solely on self-reported measures, which can bias the results due to common method variance [38]. However, it is difficult to get information on attitudes without asking the person’s own evaluations on them. If future studies involve also the persons’ organizations, it could be possible to get some information directly from the organizations. For example, organizations could provide information on training participation, and on which support mechanisms (such as named support persons) for using electronic health record are available, and this information could then be compared to the perceptions the employees have on the same issues. Also, we examined the impact of certain attitudinal factors on attending electronic health record training. There are multiple other factors that were not possible to examine in this study but might equally well affect attending training. These include for example how the training is organized in practice and does the work situation allow for attending training. Previous literature or decrees related to healthcare professionals’ training have not set any specific regulations on how often professionals should attend to training. We used a three-year cut-off point in this study, but we also tested the results by using a six-year cut-off point (see Supplement). There was only a slight change in results when using a different cut-off point, indicating that it is more relevant to align the training with training needs and changes in the electronic health records utilized than setting a specific timeline of how often one should attend training [31]. And another limitation is also that our respondents represented older and experienced licensed practical nurses, and therefore the results may not be generalizable to all nurses working in Finland. However, in general, the professionals working in the field of health and social care are of older age and nurses is one profession group in Finland that will have the most retirements in the next few years [39].
We also had a few limitations related to the scale used and measurement issues. First, the aim of our scale was to capture relevant attitudes related to electronic health record. Our definition of the word attitude can be understood to follow a rather wide conceptualization of the construct, but similar approach was used also in the Attitudes toward guidelines scale. In this conceptualization, the scale also includes dimensions that aim to capture the resources and the capabilities the person and the organization have, in this case to using electronic health record. In the thorough development process of creating the Attitudes toward guidelines scale, these aspects were found to have an important role when trying to change the behaviour of a person, and thus they were included in that scale [37]. Second, some of the scales had poor internal consistency (Cronbach’s alpha below 0.70) which may attenuate associations. Non-significant associations may thus be due to measurement error and not true null effects. However, our study is not an exception in this because some of the dimensions in the Attitudes toward guidelines scale have similarly also reported low internal consistencies in previous studies [10, 20]. Third, a limitation and a difference between our scale and the guidelines scale is, that our measurement scales are not comparable because our scale was created from a combination of questions with mixed response formats (from Likert scales to binary items) in the data. To ensure more meaningful interpretations, future studies could create and test a validated scale like the Attitudes toward guideline scale is, for measuring the different dimensions of attitudes related to electronic health records. As a final limitation, we also excluded the availability dimension which was in the original guidelines measure and linked electronic health record perspective to a framework on guidelines, although the scales of these measures differ from each other and thus they are not entirely comparable. Although the electronic health record is at use and available for nurses, there might be organizations that have limited number of computers to use and thus making documentations may be delayed [40]. Future studies should examine whether the results are similar among younger professionals who have worked their whole career in the digital era. Examining the results in other countries and different healthcare systems is also needed to validate the results.
Conclusions
Our study suggests that individual and organizational factors, such as lack of competence or support from one’s work unit play more important roles in attending training than perceptions of the electronic health record in general. Ensuring that the professionals have the basic IT skills and support available in their unit, might lead to increased attendance to electronic health record training and further promote the level of professional competency.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
The authors acknowledged trade unions Tehy, JHL, and Super for sending the online surveys and all licenced practical nurses for responding the survey.
Author contributions
Substantial contribution to study conception and design and drafting of the manuscript: L.H., M.E., A-M.K., T.V. Data collection, data analysis and interpretation of data: L.H., M.E., T.V. All authors read and approved the final manuscript.
Funding
Open Access funding provided by Finnish Institute for Health and Welfare. ME was supported by the Finnish Research Council (339390) and A-MK was supported by the Strategic Research Council of Finland (352501). The funders had no role in the study’s design, data collection, analysis, interpretation, or the decision to publish the findings.
Data availability
The datasets generated and analysed during the current study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy and ethical restrictions.
Declarations
Ethics approval and consent to participate
The research was conducted following the ethical principles stated in The Finnish National Board on Research Integrity (TENK guidelines, 2019) and the Declaration of Helsinki. Ethics approval (THL/620/6.02.01/2024 § 963) for conducting the online survey was obtained from the Institutional review board (IRB) of The Finnish Institute for Health and Welfare (THL). The participants were given information on the study, and it was emphasized that participating the study was completely voluntary. The participants did not receive any compensation for their participation in the study. Filling the online survey was considered as giving informed consent.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated and analysed during the current study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy and ethical restrictions.