The Inclusion of Nurses in the Systems Development Life Cycle.

Posted: January 17th, 2023

The Inclusion of Nurses in the Systems Development Life Cycle.


Discussion – Week 9
The Inclusion of Nurses in the Systems Development Life Cycle
In the media introduction to this module, it was suggested that you as a nurse have an important role in the Systems Development Life Cycle (SDLC). With a focus on patient care and outcomes, nurses may not always see themselves as contributors to the development of new systems. However, as you may have observed in your own experience, exclusion of nurse contributions when implementing systems can have dire consequences.The Inclusion of Nurses in the Systems Development Life Cycle.


In this Discussion, you will consider the role you might play in systems development and the ramifications of not being an active participant in systems development.The Inclusion of Nurses in the Systems Development Life Cycle.

To Prepare:

Review the steps of the Systems Development Life Cycle (SDLC) as presented in the Resources.
Reflect on your own healthcare organization and consider any steps your healthcare organization goes through when purchasing and implementing a new health information technology system.
Consider what a nurse might contribute to decisions made at each stage of the SDLC when planning for new health information technology.The Inclusion of Nurses in the Systems Development Life Cycle.
By Day 3 of Week 9
Post a description of what you believe to be the consequences of a healthcare organization not involving nurses in each stage of the SDLC when purchasing and implementing a new health information technology system. Provide specific examples of potential issues at each stage of the SDLC and explain how the inclusion of nurses may help address these issues. Then, explain whether you had any input in the selection and planning of new health information technology systems in your nursing practice or healthcare organization and explain potential impacts of being included or not in the decision-making process. Be specific and provide examples.The Inclusion of Nurses in the Systems Development Life Cycle.

Learning Resources
Required Readings
McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.The Inclusion of Nurses in the Systems Development Life Cycle.

Chapter 9, “Systems Development Life Cycle: Nursing Informatics and Organizational Decision Making” (pp. 175–187)
Chapter 12, “Electronic Security” (pp. 229–242)
Chapter 13, “Workflow and Beyond Meaningful Use” (pp. 245–261)
Agency for Healthcare Research and Quality. (n.d.a). Health IT evaluation toolkit and evaluation measures quick reference guide. Retrieved September 27, 2018, from

Agency for Healthcare Research and Quality. (n.d.b). Workflow assessment for health IT toolkit. Retrieved September 27, 2018, from

Required Media
Louis, I. (2011, August 17). Systems development life cycle (SDLC) [Video file]. Retrieved from

Laureate Education (Producer). (2018). Interoperability, Standards, and Security [Video file]. Baltimore, MD: Author.

Interoperability, Standards, and Security
Program Transcript
NARRATOR: To maximize the benefits of informatics for the health care
community, various health information systems must be able to communicate
efficiently and securely. Dr. Stuart Speedie, Dr. Ken Majkowski, and Dr. Donald
Rucker describe challenges of information exchange and identify standards that
are guiding the industry toward greater interoperability. And Stephanie Reel
outlines steps organizations can take to safeguard sensitive clinical and
administrative information.
STUART M SPEEDIE: A provider of health care, regardless of where they are
located, if they have to take care of a patient they should be able to have access
to all of the relevant information about that patient or to make the best possible
medical decisions for the patients. The patients are taken care of in a variety of
different settings. They may go to their primary care physician for most of their
basic care. That primary care physician maintains– in these days, we hope– an
electronic medical record.
If they are in an auto accident, they will go to the hospital or the emergency
room. And they might well get admitted to the hospital. Then they become part of
another electronic medical record system in the hospital.
They may need to have outpatient surgery at some point, perhaps by an
orthopedic surgeon, in order to repair the damage as a result of that accident. If
that takes place in a surgery center, then there’s another medical record that’s
being created for that patient.
Now ideally, all of those different electronic medical record systems at the
various locations should be able to share the information about the patient. And
so from those various sources you build a complete and coherent picture of the
patient’s medical condition based upon the observations and reporting of all of
the professionals involved. So that’s the goal that we’re trying to do.
The hows of doing it– that turns out to be a much more interesting and
admittedly difficult situation involving focusing on standards, on how we have
standards for information exchange, and how we also set agreements to protect
privacy, and how we secure that information, and how we make sure that it
doesn’t go to the wrong parties in that kind of exchange of information. So all of
those factors come into play when we think about, if you will, exchanging
information between hospitals.The Inclusion of Nurses in the Systems Development Life Cycle.
We tend to think of an electronic medical record as a single system. In most
health care organizations, there are many such systems. And some might
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Interoperability, Standards, and Security
support the radiology department and storing and transmitting x-rays. Others
might support the pharmacy department in terms of keeping track of medications.
There’s a whole host of those systems. Those systems have to also
communicate with each other in order to do the kinds of information exchange
within an institution. There, it’s a matter of working with the different vendors and
making sure that there are proper standards in place so that the information that
is generated by one system is able to be understood by the system that’s
receiving it and vice versa. And that’s really the key when we talk about the
notion of interoperability.
KEN MAJKOWSKI: Can one system talk to another system? Can many systems
talk to many other systems? Interoperability has a lot of different meanings.
And it really needs to be phased in over time. So when we talk about
interoperability in e-prescribing, we’re able to get, for example, payer data in real
time to a physician’s application so that decisions can be made about the
We can also talk about interoperability of that same physician’s application able
to transmit that prescription to literally 47,000, 48,000 pharmacies across the
United States, wherever that patient might want that prescription transmitted, and
to do all of this electronically. We can take an electronic prescribing
interoperability to the next step and say, is that e-prescribing application
interoperable with the patient’s electronic medical record?
So when the physician writes the prescription to be sent electronically, does that
same prescription then go into the electronic medical record, so that it’s
documented that that patient had that drug prescribed? And then even take it a
little bit further. If it’s an enterprise system, that system is being used not only in a
physician’s office but maybe in a hospital system as well. Because that physician
is employed by that hospital system. When that patient is admitted to the
hospital, are all those records then available to the hospital system when the
patient is being treated there as well?
So we can continue to take interoperability even further. Now that it exists in that
patient’s EMR, when that patient is being seen in a different hospital system
across town, can it be transferred to a different hospital system? And that’s what
health information exchanges are attempting to do.
And to take it even further, the national health information network which has
been proposed is, let’s take the patient who is being seen by a physician and has
information in their EMR in St. Paul, Minnesota, but is vacationing in Phoenix,
Arizona and needs to go to an emergency room in Phoenix, Arizona. How fast
can you get that patient’s records to that emergency room in Phoenix, Arizona?
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Interoperability, Standards, and Security
Now we’re really starting to talk about true interoperability. It’s not just a single
system talking to a single system, but a system being able to talk to all systems.
There are many challenges to interoperability. There are many moving parts. The
way to try to overcome some of those obstacles is by using technical standards.
And people are saying, are there standards for the delivery of this specific
In electronic prescribing we’re very, very lucky. We have some very good
technical standards that have been in use for six or seven years. They have been
tested in CMS e-prescribing pilots– there’s five different pilots– in the late 2000s.
And these pilots have looked at the standards and said, yes. These are practical
and useful and appropriate standards for e-prescribing.
Now if we think about interoperability of all medical records, we have to start
talking about technical standards for laboratory, for imagery, for documentation,
for a variety of things. And all those are being worked on by various committees
and organizations, both government and private, across the country. In eprescribing there is a standards organization referred to as NCPDP, or the
National Council for Prescription Drug Programs, which has created technical
standards for the pharmacy industry.
So we use something called the NCPDP script standard to transmit things like
medication history and electronic prescriptions between physicians and
pharmacies and between payers and physicians.
DONALD W RUCKER: We’re talking about extraordinarily complex biological
workflows. And in those very complex workflows, can you represent everything
uniformly, let’s say, in just the United States? And the answer to that, somewhat
obviously, but somewhat not obviously, is probably not. Right?
There are simply so many differences. That is not a simple thing to automatically
say, everything will interoperate. Hospital software is about embedded workflows.
Office medical software is about embedded workflows.
All enterprise software is about embedded workflows, no matter what you have.
And so your degree of interoperability– your degree of standards– have to reflect
on some level the richness of those embedded workflows. There are some areas
that we have clearly been able to very successfully standardize.
And so if you look at standards out there now– for example, HL7, Health Level 7,
is probably the workhorse standard for clinical communication. So if you’re doing
lab ordering and lab result transmission, those would be HL7 standards. And
radiology and radiology information systems and PACS systems– again, the
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Interoperability, Standards, and Security
Picture Archiving and Communication Storage– the DICOM standards, D-I-C-OM, that have been a combination of the radiology community and the National
Electrical Manufacturers Association– so the manufacturers of this equipment–
have been very successful standards.
And then of course all these sit on the wire standards. And those are the ones
you know– internet protocols, HTTP. Those are the basic ones that are out there.
Now there are some richer standards being developed– for example, the
Continuity of Care Documentation standards that are part of the HITSP, the
Health IT Standards Program that Health and Human Services has funded.
Those standards are currently evolving.
So that’s standards to allow sharing of medical problem lists and medication lists
and allergy lists. So they’re an evolution. They’re of course richer standards.
Because as you might imagine, the name of disease might not be exactly the
same for everybody.
So congestive heart failure might be one person’s idea of heart failure.
Somebody else may subcharacterize congestive heart failure into diastolic failure
and systolic failure. A cardiologist may subcategorize congestive heart failure into
exactly what the valve is, what the etiology is, and what the ejection fraction is.
Well it sounds like it’s one disease. But they’re really very different levels of
characterization. So the communications you build up– these richer standards–
is a challenge.
STUART M SPEEDIE: When we talk about the exchange of information between
organizations, there are a number of legal ramifications in addition to the
technical ramifications of simply moving information from one system to another.
And those legal ramifications are actually governed, first of all, by the HIPAA
regulations– the Health Information Portability and Accessibility Act that was
passed about a decade ago. And that has subsequently been updated by the
ARRA or the stimulus bill. That has changed some of the components of that
But fundamentally, what that says is that each organization has a legal
responsibility to protect the information of that patient and to assure its
appropriate use, regardless of where that use might be. As a result, it’s not
simply a matter of exchanging a data file from one organization to another. The
organizations have to have a legal agreement between themselves in order to
exchange that information to make sure that the patient is properly protected. So
that adds another layer onto the technical issues of information exchange.
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Interoperability, Standards, and Security
STEPHANIE L REEL: One of the responsibilities that information technology
professionals have– and in particular CIOs have– is to protect the assets of the
organization. And those assets may include financial information, administrative
information, or in our case, they certainly include patient-related information. And
we take the protection of those assets very, very seriously.
We know that our patients trust us with the most sensitive information about their
life and death experiences, life-altering experiences. They trust us with their
health. And they trust us with their health information.
Several years ago, Johns Hopkins was cited for a theft of clinical information. A
couple of workstations were stolen from our campus. And they included on them
clinical information associated with a clinical research protocol.
After many, many, many hours stressing over what could have been and should
have been done differently, we developed what we fondly came to refer to as a
12-step plan for how to protect information that resides on workstations, resides
on portable media, as well as fixed media– to ensure that we were doing
everything possible to protect our patients and to protect the information assets
of the organization.
Our 12-step plan can be easily boiled down to three components. We said, first
and foremost, we will educate. We will educate the user community as to the
risks associated with this huge repository of information that they have the ability
to help manage and maintain.
The second step was another E. It was the E of environment– that it was
everyone’s responsibility to create an environment that was conducive to privacy
and security. That meant we would each allow ourselves to be held accountable
for the environment within which we work.
So that may be physical security. It may be virtual security. It may mean that as
we share information with others, we take great pains to ensure that it is shared
It means that we would create less paper. Because paper has its own set of
vulnerabilities. So we encouraged less printing of information.
And the third E was a very tactical one. It was encryption. So education,
environment, and encryption became the three legs of our stool, if you will,
associated with information security.
So we embraced a very aggressive program associated with encrypting
information. So information that would reside on any portable device would be
encrypted. So should it be misplaced, lost, or stolen, there’d be a great deal of
difficulty in anyone being able to access it. And in fact, if information is encrypted,
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Interoperability, Standards, and Security
you’re also protected a bit from possible penalties in litigation that might follow.
So it became important to us that we use this three-pronged approach in all

video 2 transcript
Managing Health Informatics and Technology
Program Transcript
FEMALE SPEAKER: As new health information systems are being planned,
implemented, and maintained, effective management is needed every step of the
way. Dr. Kevin Johnson, Stephanie Reel, Dr. Mark Frisse and Dr. John Glaser
outline the systems development life cycle and describe common duties and
challenges that managers must address. They also explain the role of
governance in managing these expensive and strategic endeavors.
DR. KEVIN JOHNSON: The four major stages of the systems development life
cycle are essentially a planning stage, a design stage, an implementation stage,
and then a maintenance and evaluation stage. An essential part of the cycle–
and I think the most essential part of the cycle– is to recognize that it is a cycle.
And so much of what fails in an IT planning initiative is the belief that once we
have implemented, we are done, and it’s time to move on.
And I can’t overstate the importance of the planning component. The planning
component begins with very simple processes that help to determine what is the
need for a particular system.
STEPHANIE REEL: Routinely were called upon to define or describe solutions
for problems that may not be quite clearly identified or explored or documented.
That requires a very thoughtful definition or description of the expectation of the
customer– the functional requirements, the technical requirements that that
system needs to satisfy.
Oftentimes, as part of our system evaluation process, we might look to our peers.
We may call upon colleagues and other academic medical centers to see what
solutions they’ve implemented. And that informs our decision processes often.
However, because of the complexity of our environment, it’s critically important
that we also document our expectations and define our expectations. We think
much more strategically not about what the individual components are of the
information system, but much more about what the outcome is.
And I think that’s not only true for the RFP process or for the decision process
associated with selection of a system. But as we deploy these systems, it’s much
less important that we talk about what the specific functionality of the system is,
but much more about the outcome, much more about the results, much more
about the ability to meet the strategic imperatives of the institution associated
with patient safety, associated with financial benefit, or regulatory benefit.
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Managing Health Informatics and Technology
DR. MARK FRISSE: The RFP process is basically a definition of your
organization’s values and goals. It is every bit as important as a good mission
statement. It should explain uniquely what you want and what you are about.
All too often we relegate the RFP to contractual language and busy work. And
then you don’t always get the results you want because you’ve basically set
some technical gobbley gook out there, and it’s not going to meet your needs.
I strongly urge people that do RFP’s to spend a lot of time visiting across the
enterprise– what system they’re trying to build it for, what goals they’re trying to
accomplish, who they are, and articulate in the first page– say, this is who we
are. This is what we aspire to be. This is a kind of service we’re seeking from
DR. KEVIN JOHNSON: The systems implementation phase of the life cycle at
the highest level essentially concerns the process of taking a well designed
system and getting that system into a meaningful use state across all of the
stakeholders within a particular enterprise whether small or large. That will
include steps such as installing the actual software– making sure that runs
consistently– installing the actual hardware– making sure that it’s an all of the
locations where it’s needed– checking to make sure network functionality works.
And then it starts to get really tricky– training providers, making sure that policies
and procedures are in place that are in alignment with the use of the system,
understanding how that system will be supported, understanding how that
system will be evaluated, and developing a plan for feeding that evaluation back
into the systems development process.
STEPHANIE REEL: We have a relatively structured approach to implementation.
We have an expectation that each project will have an executive oversight
committee. And that speaks to ownership, sponsorship, responsibility ultimately
for the success of the project. And that is almost always a senior leader within
the management structure of Johns Hopkins Medicine. We also have a steering
committee that may be inclusive of handfuls of users who can represent different
areas within Johns Hopkins.
So if we’re deploying a major clinical information system, we may have five or six
physicians from different disciplines within Johns Hopkins. We may have five or
six nurses who represent different areas of expertise within nursing. We may
have a couple of clinical administrators who can help us understand some of the
business imperatives associated with a clinical system deployment. We would
typically include our chief medical information officer who has a good overall
sense of the clinical imperatives of the enterprise. And they may form the
steering committee for a clinical information systems.
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Managing Health Informatics and Technology
And they provide direction. They are called upon often to give quick decisions
when needed. And they may meet every two weeks to ensure that the project
stays on track.
Probably more important to the success of the deployment is an implementation
team, and this will be made up of usually a larger group of representatives from
the end user community. And they may meet as frequently as once a week, or in
some cases, maybe twice a week depending upon what phase we are in the
deployment of an information system.
The absence of strong leadership, strong ownership, and strong sponsorship
almost always leads to delays and waste, inefficient decision making, costly
decision making.
Our most successful projects have benefited not only from a structure that keeps
the project on track, but also processes that keep the project on track. So we
carefully manage vendor relationships. We hold one another accountable for
milestones and deadlines that are embedded within a project plan. The project
plan itself is a key component of the deployment of a successful information
systems solution.
And again, it’s developed in concert with the user community, in concert with the
vendor, and it serves as the foundation for what we do going forward. It helps us
identify the critical milestones that we must achieve. We also provide routine
updates to senior leadership. So that if we happen to be getting off track or get a
bit misguided as to what some of the imperatives are, we have the benefit of
executive leadership in helping to get us back on track. And I think that’s equally
DR. KEVIN JOHNSON: The number one challenge to implementation is people,
and it’s in particular those stakeholders who will be using the system– so our
customers, if you will– who will be using the system when it’s implemented.
The challenges that we face when working with customers include things like
change. The idea that as all of us like things that are new and exciting, we hate
the process of moving from the old and perhaps less exciting to the new and
exciting. And every system implementation, every upgrade to a major system,
involves change.
So trying to get a group of stakeholders, especially a large group of stakeholders,
to agree about how the system will be implemented, how screens will appear,
what the right performance level should be– all of those stages require a
significant amount of resource from the administrative side to get the right
amount of opinions, to mitigate the challenges associated with dissenting views–
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Managing Health Informatics and Technology
because only one will win– and to train people so that they can use something
that is undoubtedly neither their preference or something that they may have
been comfortable with from the very beginning.
So that is, I think, the biggest challenge in the implementation process.
DR. JOHN GLASER: It is difficult because you’re taking a whole bunch of people,
and these are smart people, educated people, people who work hard– and
saying you need to change.The Inclusion of Nurses in the Systems Development Life Cycle.
They’re going to have to develop a mastery of something for which they don’t
have mastery yet, and they will struggle with that. And they will wonder, why am I
going through this particular change in some very basic way? What’s in it for me?
So it really is a dialogue between people who need to work with each other and
need to come together on common ground and a common approach. So the A
number one thing to do is engage in a true partnership, a relationship with those
who will be affected by the change.
The second thing to do– is these are large, complex projects and require skilled
project management. If you don’t manage complex projects, they have a way of
getting derailed or blowing up or adverse things along those lines.
The third is to realize once you put this system into place, the world will not
operate perfectly. It takes an adjustment period. So be patient and be rapid.
When people say, this isn’t working, go rapidly and fix it. And so there is this
support issue of making sure training occurs, that there’s a rapid response to
issues and problems that occur, and that there’s a tolerance of degraded
organizational performance, and frankly, a tolerance of people whose patience
may have run out as they deal with the new world that you’ve inflicted upon them.
Engage them, manage it well, and help them through the aftermath.
DR. KEVIN JOHNSON: The process of implementing systems assumes that
there’s going to be a level of governance to support the entire development life
cycle. However, there are many different approaches to setting up that
governance structure.
Almost always the governance structures that succeed give people who are as
close to the system as possible some function to both report concerns and to
report back solutions.
Even with a group of kind of reluctant participants, as long as there’s very good
alignment between the governance structure and the expectations, that system
can be successful, and it can meet the needs that were originally designed for it.
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Managing Health Informatics and Technology
The most successful governance structures have some level of user participation
typically by having either a chief medical information officer who is a physician or
a nurse who also uses the system during their clinic time or potentially by having
a steering committee comprised of physician or nurse champions from a series of
DR. JOHN GLASER: What exactly is governance? If you look at what
management folks write about governance, it is the distribution of responsibility
for making decisions– who gets to decide what the budget is, who gets to decide
what projects are number one versus number 200, who gets to decide decisions
about projects, et cetera. So it is a distribution of these decision rights that go
across the board. So that’s what governance is.
Governance says what questions and decisions will we have to make? Well, we’ll
have to make a decision about strategy. We’ll have to make a decision about
what are the five most important IT initiatives [INAUDIBLE] go on. Well, where
should those occur?
And you might say, well, we have a senior management form that already is
engaged in big decisions about the organization. These decisions ought to occur
Or you could decide, we ought to have an IS steering committee devoted solely
to this topic, and those decisions ought to occur there.
Neither is right or wrong. Both can be equally effective. What is right or wrong is
that you take those questions and have thoughtful discussions about how we
want to handle it.
And you have to remember in your decisions about these that the organization
has to view that process as having legitimacy. So if it’s really a backroom
conversation, be prepared that those who are affected by the decision say, wait a
minute. How did that happen. I wasn’t part of that conversation. I don’t think that
was a good process for arriving at the decisions. And it has to fit with the culture
and the management style that one has regarding governance issues broadly on
not just the IT.
DR. MARK FRISSE: IT governance is one of the most complicated topics around
because it’s so elusive. I have a very simple mantra about IT governance, and
that is the minute the patient leaves the room, the governance will fail. In other
words, if the governance is not focused on the needs of the primary customer
who is the patient seeking care and if the primary output of that isn’t to
demonstrate quality and efficiency and delivery of that care to that individual– if
you disconnected those central goals from what you’re doing, it doesn’t matter a
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Managing Health Informatics and Technology
All too often governance is kind of a turf issue. Well, this person’s not going to
add very much, but they’re a very important person. So if we invite this person,
but then we better invite that person too. They’re not going to add very much
because that’s not going to add anything either. All of a sudden, it becomes like a
social club or a birthday party where you have to invite everybody. It’s not. It’s
governance. It’s fiscal responsibility. It’s getting results.
So you’ve got to draw this fine line. You’ve got to separate management, formal
management, fiduciary responsibility, top-down kind of budgets, milestones,
communication from a bottom-up groundswell of need, if you will. And
governance kind of sits in the middle of that.
You’ve got to keep that focus to the people who are going to live and die b


The Inclusion of Nurses in the Systems Development Life Cycle

The consequences of a healthcare organization not involving nurses in each stage of the SDLC

There are many consequences of the failure of a healthcare organization to include nurses in all stages of the SDCL during the purchase and implementation of a novel information technology system. Failure of the inclusion can result in a poor transition to the novel technology and decrease nurses’ of the system.   According to Murray (2017), the purchase of an information technology system must be integrated with the organization and needs resources for development and maintenance.  Since it is a large investment, the process must involve input from organizational members, including nurses. The inclusion of nurses during the implementation phase of a health information system can make nurses unable to adopt and fully utilize the system for failure of understanding how the system works.

Potential issues at each stage of the SDLC

In the planning and analysis case, there can be a lack of approval of the system by committees and individuals and lack of enough money. In the design phase, the system can fail to fulfill the intended purpose because it is complex.  The implementation and support phase may be faced by the failure of the system to be utilized to its full potential. Even after the adoption of technology, the evaluation phase might be hindered by the lack of a structured process that can accurately track and evaluates how well the technology has been incorporated into work processes (Langhan et al., 2017).

The inclusion of nurses might assist in addressing potential issues at each stage of the SDLC. The involvement of nurses in system design can make the system simpler for nurses to utilize.   Involvement nurses may promote the adoption of a novel technology because nurses easily accept a technology if they have been provided with the chance to offer. Involvement of nurses in the processes of planning and implementation has to offer them with the chance to carry out trials of the system in a  clinical setting, as well as the process of evaluation through which they can verify the effectiveness of the changes intended to lead to improvements in the work environment (Weckman &  Janzen, 2009).

Input in the selection and planning of new health information technology systems

I was provided an opportunity to provide my input had an input in the selection and planning of an electronic patient record system in my organization.  I offered the requirements for the system, entailing nursing data and documentation forms, the flow of information and its accordance with the work processes of nursing as well as exchange mechanisms with information systems of other departments in the hospital. Involvement enabled me to easily transition from paper charting transition to the new system because I understood the software and hardware components and how the system works. Being included in the decision-making process to have trust in the system and motivated me to adopt it.  As indicated by Qin et al., (2017), even though a new technology may be initiated by managers, a commitment by organizational staff over the direction and result is required from the success of the technology.

The Inclusion of Nurses in the Systems Development Life Cycle.

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