Development and Application Evaluation of a Nursing Simulation Teaching Information System Based on Hospital Information Systems

Background The extensive application of hospital information systems in the current information-driven era suggests that nursing education should focus on information education. Methods The newly developed hospital information system was used and evaluated by 544 students to explore the feasibility and necessity of such applications for teaching. Results Overall, 97.1% of the students expressed satisfaction, and 96.0% supported simulated information education for nursing. The usability was good, with the system receiving a usability score of 72.625 ± 13.0907. The junior students had a higher score than the sophomores regarding system availability, and the difference was statistically significant. Conclusions Students generally had a high degree of satisfaction with the simulated information nursing education system and highly approved of the teaching method. However, the system needs to be upgraded.


Introduction
In the current technology-driven era, those in the public health feld should focus on informatics and information technology tools [1,2]. Te extensive use of hospital information systems (HISs) refects the infuence of information technology on medical and health services. Such systems comprise social technology subsystems for hospitals and involve networks, computers, and other modern technologies to transform various medical data into information [3]. Many studies confrm that HISs improve clinical management at the diagnostic and therapeutic levels and reduce the costs associated with paper medical records and error rates [4,5].
Te largest group of HISs users is nurses, and efective training has a signifcant positive efect on their perceptions regarding the ease and usefulness of HISs [6]. Moreover, training is usually the most efective among students [7]. Te basic requirements that nursing students face are conducting clinical work and improving their practical skills [8], meaning nursing colleges need to be aware of the importance of simulating clinical scenarios in discipline education [9]. Research shows that, compared with the traditional teaching model, simulation teaching improves students' knowledge, confdence, and satisfaction [10]. However, nursing simulation information education based on HISs is relatively rare. Te reasons for this may include the complexity of HIS, which involves diferent business modules from the hospital, or ethical factors, such as patient privacy, which make it difcult to directly apply HISs and data to school teaching.
Te International Council of Nurses, the Honorary Society of Nursing International, and many national nursing associations advocate for the integration of information technology into nursing education [10]. Furthermore, the University of Athens has designed and implemented an elearning system, including learning and practice modules, to provide and consolidate HIS-related knowledge for medical students and proposes that an application of a HIS demonstration program should be attempted in the future to simplify the learning process [11]. Te Wright State University Miami Valley School of Nursing was one of the frst schools in the United States to provide connectivity via computers in the school's student computer lab to a real hospital information system, achieving positive results [12]. When we search for keywords in the database, such as HISs or nursing information education, we seldom consult the literature of relevant research or search the literature for information on the direct application of HISs to nursing colleges.
In China, nursing simulation information education is still in the exploratory stage [13], and due to the limitations of the main teaching points, it is not practical for most nursing students to access actual HISs during school [14]. To address this issue, our team has cooperated with a digital technology company to develop a nursing simulation teaching information system based on HISs in 2018 and has carried out applied research at Southern Medical University in Guangzhou, China.

Study Design and Setting.
Tis study was cross-sectional and used a descriptive research method. Te development test for the course was arranged as part of the "Medical and Nursing Instruments" section of the required course for nursing students (Figure 1).

Development of the Nursing Simulation Teaching
Information System. Developing a simulated information system suitable for nursing experimental teaching is a necessary hardware condition for carrying out nursing information education. Te system was self-developed with a digital technology company and supported by the Innovation and Entrepreneurship Education Reform Research Project. It is based on the functional modules and methods of the nurse workstation in clinical HISs and combined with the training objectives and teaching needs of nursing undergraduates. Te system is required to do the following: (1) contain all the functions involved in the nurses' work in the HISs; (2) achieve the teaching goal of nursing students to master the common functions of HISs through laboratory simulation training; (3) provide teaching support for internal and surgical nursing, health assessment, basic nursing, and other courses because the system simulation cases cover common diseases in various departments; (4) ensure the simulated cases cover the whole patient process, from admission to discharge, and related information, such as medical records, nursing records, surgical records, doctor's orders, nursing evaluations, temperature sheets, and auxiliary examinations; (5) ensure nursing students are automatically assigned patients and can carry out the simulated management of patients, including medical advice processing, vital sign input, nursing records, nursing evaluation form flling, and execution sheet printing; (6) ensure the clinical case time changes dynamically each day in real time to enhance the sense of imitation and clinical substitution; (7) increase the teaching auxiliary function module, where teachers can use the system to arrange preclass preview tasks, set case time nodes, assign classroom tasks, and the above operations, such as medical advice processing and vital sign input, while students can use the system to conduct selfassessment and mutual evaluation, upload operation video fles, and upload postclass work documents; (8) use the enterprise-level cloud system framework.
Te system for all business-related processes and operating interfaces is consistent with mainstream HISs. Te enterprise cloud system framework is used to ensure the stability, security, compatibility, and scalability of the system when designing the system's technical architecture. Te system is compatible with mainstream devices, such as PCs, MACs, iPads, and Android pads, and corresponding apps are being developed to enable teachers and students to log in and use the system at any time. See Figure 1 for system architecture functions.

Participants.
From March to May 2021, the second-and third-year nursing students at the university were given the lecture and questionnaire survey, resulting in a total of 544 participants.

Measurement Tool
(1) Nursing Information System Questionnaire: Te questionnaire was modifed from the "assessment of the quality of a web-based learning system for nurses" tool [15], with questions added about the students' understanding of the nursing simulation teaching information system and an evaluation of its efects. All the entries were repeatedly revised and completed by three nursing experts. Te revised questionnaire was reviewed by two clinical nursing management experts and one associate professor to confrm the validity of its content. Te questionnaire had a content validity index of 0.939, and a pilot trial was undertaken with 54 third-year nursing students from March to May 2019. Te questionnaire consisted of 20 items, including two open questions regarding the system's benefts and suggestions. Te response options correspond to a fve-point Likert scale, with "5" representing strongly agree, "4" representing agree, "3" representing neutral, "2" representing disagree, and "1" representing strongly disagree. Te Cronbach's α coefcient of the questionnaire was determined to be 0.868, indicating good reliability and validity. (2) System Usability Scale (SUS): As a simple and effective measurement tool, the SUS is the most widely used tool in the world for the overall evaluation of feasibility [16][17][18]. Te SUS was originally compiled by John Brooke [19] in 1986 and consists of 10 items, including fve positive description items and fve negative description items. In 2008, Bangor et al. [20] conducted a large-sample study, revealing that Cronbach's α coefcient for the SUS was 0.91. Tis scale uses a Likert 5-point scale and a score of 0-100. According to previous research results [21], SUS scores ranging from 50.9 to 71.4 are considered acceptable, those from 71.4 to 85.5 are considered good, and those from 85.5 to 90.9 are considered excellent.

Statistical Analysis.
Te collected data were analyzed using SPSS 26.0. Te general characteristics and observed variables were analyzed using descriptive statistics, and the Kolmogorov-Smirnov test was used to test for normality. Te Levene test was used for variance homogeneity, and the t-test or nonparametric tests were used for comparisons. Te signifcance level was set to 0.05. Te open questions were analyzed using NVivo 12.0 by classifying and thematizing the responses and counting the response frequencies [22].

Study Ethics.
Tis study passed an ethical review by the Medical Ethics Committee of Southern Hospital, Southern Medical University. All survey responses were anonymous. Tere were no student names or identifcation (ID) on the questionnaires, and the teachers were not present when the students were flling out the questionnaires. Any patient information in the system was desensitized and anonymized.

Nursing Information System Questionnaire Scores.
Overall, 542 questionnaires were recovered, and 64 invalid questionnaires were excluded, including 45 with missing data, 17 with repeated options, and two with inconsistent data, representing an efective response rate of 88.19% ( Figure 2).

SUS Score.
In total, 544 scales were recovered, with 14 invalid scales excluded, including 10 with missing data, two with repeated data-flling, and two with identical answers. Te efective response rate for the scale was 97.43%. After the calculations, the mean score was 72.625 ± 13.091 (mean-± standard deviation), the median was 72.500, and the range was 27.5-100.0. Statistically signifcant diferences were found regarding the total scores on the SUS for the classes in diferent years, with the third-year students scoring higher than the second-year students (Table 1).

Open Questions.
A total of 369 benefts were sorted and coded into 465 nodes, while 241 suggestions were obtained and coded into 276 nodes (Table 2). In the open question on the benefts of the nursing simulation teaching information system, some students expressed that they had the opportunity to use the system by themselves, while others stated that it helped them to understand the clinical nursing workfow in advance. Some of the responses are as follows: Student 4: "Knowing how to use the nurse station and information system will help me master it in clinical practice in the future and enhance my confdence.  International Journal of Clinical Practice electronic version can save more time and is more convenient. I can feel the convenience of information." Student 200: "Te zero-distance contact with the nursing simulation teaching information system is very novel and deepens the impression of learning."

Te Nursing Simulation Teaching Information System Can
Tis is the frst time that students have had direct access to complete patient information in school. Students can browse and search relevant patients' information in the simulation system at will, process medical orders, fll in nursing assessment forms, and other perform operations, which helps students quickly become familiar with the clinical nursing workfow. In hospitals, students do not have an ID for the HIS, so they cannot log in and operate the system. Te simulation system can be practiced repeatedly, which helps students quickly adapt to clinical practice.

Nursing Students Generally Support the Use of Nursing Simulation Teaching Information Systems in Teaching, Which can Improve Students' Learning Initiative and Interest and
Deepen Teir Learning Impression. A total of 98.5% of students approved of the use of the nursing simulation teaching information system, and 92.5% agreed that the nursing information system helped make up for the shortcomings of the previous teaching method.
Te application of HISs has been popularized in hospitals. Te corresponding teaching is very important, but it is missing [23,24]. Te results of this study demonstrated that when the nursing simulation teaching information system combined theory with practice, it improved the learning experiences of students (98.1%), created a sense of clinical reality (93.7%), and improved students' motivation and enthusiasm (94.3%). Generally, information technology can increase students' interest and motivation by simulating clinical work situations [25]. Tis is one of the reasons why the students in this study praised and recommended the system.
Carrying out nursing information technology education in colleges and universities has become popular [26]. HISs not only reduce cost and time but also reduce medical errors and patient mortality, promote nursing workfow, and improve the quality of nursing services for patients [27,28]. Although the clinical application of HISs still faces many obstacles, including imperfect systems, data loss, information security problems, and a lack of systematic training [29,30], such systems play an important role in clinical practice. In a previous study [31], Yu et al. selected six nursing colleges to conduct a questionnaire survey, and the results showed that the nursing information skills of nursing master's students were below the medium level, indicating nursing colleges should pay more attention to the teaching and adoption of HISs before nursing student internships. In this study, 97.5% of nursing students believed that they should master HISs use while in school.

Comparison with Existing Software.
To the best of our knowledge, there is no report on similar HISs that can be used for laboratory simulation teaching, and there are no similar software products in the market. When building our nursing simulation teaching center, our original intention was to purchase the existing software. However, after contacting several companies, we were unsuccessful. In addition, we tried out software from other companies', such 4 1 Using this system can give me a sense of clincal involvement.
2 The system has all the functions a nurse needs.
3 The process is simple and helpful for learning.
4 Complex function and pressure during use.
5 I'm interested in this system and hope to learn more.
6 I think I should master the use of nursing information system at school.
7 This system of teaching makes up for the shortcomings of previous practice teaching. 8 The combination of theory and practice has deepened the impression.
9 Improve the initiative and enthusiasm of learning.
10 Not helpful for learning.
14 The response time is short after I click. 13 I think the interface of the system is simple and beautiful.
12 I recommend using this system for teaching. 11 I prefer to learn the processing of medical orders through videos, pictures or text instructions. 20 I endorse the use of nursing information systems as a form of teaching. 19 Overall, I am satisfied with the nursing information system. 18 The content provided by the system is easy to understand. 17 I can quickly find the information I want in the system. 16 The system meets my needs for all kinds of information (including condition, care, treatment, etc.). 15 The system provides me with the latest information (such as doctor's order, progress records, etc.). Figure 2: Strongly disagree � 1, disagree � 2, neutra1 � 3, agree � 4, strongly agree � 5.  [32,33], but it is limited to the virtual simulation of a single case of a disease rather than the overall information system. Tis software lacks dynamic changes in cases from admission to discharge. In clinical practice, patients' situations are constantly changing, so the contents of the nursing assessment and nursing problems often difer. Terefore, the dynamic changes of cases should be integrated into the simulation teaching to help students improve their clinical ability and critical thinking skills. However, the functions of the existing HIS in the hospital are too large and complex and involve diferent departmental modules of the hospital. In addition, for ethical reasons, it is difcult to directly use the hospital's HIS and its data during simulation teaching.
Nowadays, the hardware facilities of simulation teaching centers (simulation hospitals) built by universities or hospitals are becoming increasingly perfect and high-end. Computer-human patient simulators and digital virtual simulation facilities are routinely equipped. However, they lack a simulation teaching management system like the hospital HISs. It is a "central system" that improves how simulation centers are run. Without this central management system, each simulation unit can only conduct repeated training and assessments around a single case. It is difcult to achieve real "simulation" and create actual clinical scenarios.

Comparison with Existing Teaching Models.
Nurses need to skillfully use HISs in their daily nursing work, which can actively help nurses to provide efective, safe, and high-quality nursing services for patients [34]. Studies have shown that training HISs users can help them make better use of such systems [35]. However, because there was no simulation HISs for teaching before, nursing students did not learn how to operate HISs and nurse stations during the school day. In China, HISs are introduced in the knowledge expansion section of the teaching material, which is not included in the formal teaching content. At the hospital internship stage, because the interns are not regular employees, the hospital will not assign students IDs for the HISs. Students can only see the teacher's demonstration and cannot operate the system by themselves.
After the completion of the system development, we added the learning content and practice of HISs to the fundamentals of nursing courses from 2020. Each nursing student has a system ID and can log in at any time to understand the information about the patients assigned by the teacher. Students can also process medical orders, fll in nursing assessment forms, write nursing records, and complete other operations online. At present, this system has been used to assist in the teaching of multiple courses, including the fundamentals of nursing, health assessment, implementation of nursing plans for senior nursing students, and emergency and critical care. It is expected to become more popular in the future and become a necessary software support system for nursing teaching.

Further Optimization of the Nursing Simulation Teaching
Information System. Most nursing students were satisfed with the content, interface, reactivity, and learnability of the system, and 97.2% were satisfed with the system overall. Te mean score on the SUS was 72.625 ± 13.0907, International Journal of Clinical Practice demonstrating that the evaluations of the system were good but that the system requires further optimization. Te system developed by our team is still in the exploration stage, with 55.6% of the students mentioning that it was sometimes unresponsive. Tis was one of the factors hindering nursing staf from using HISs, as pointed out by Handayani et al. [34]. In the open questions, some students also suggested adding a "help" button and an annex for drug descriptions. In terms of teaching, it was suggested that the teacher should demonstrate the operation in advance, after which the students would be divided into groups to simulate and operate it by themselves, assign tasks after class to consolidate the knowledge learned in class, and increase the time for students to operate the system by themselves. Some students suggested supplementing the system training with teaching videos or instructional books to improve learning efciency. Meanwhile, two students suggested that the curriculum arrangement for the system teaching should be moved to the end of the semester because the system practice should be based on certain theoretical knowledge to make it more similar to clinical practice. Te results of this study revealed that the junior nursing students gave higher SUS scores than the sophomores because, compared with the sophomores, the juniors had richer professional knowledge and clinical practice experience and a more intuitive understanding and evaluation of the nursing simulation teaching information system's application. Booth et al. [37] suggested that the design and application of electronic information systems should consider the composition of team members, which should be suitable for those students who are still in the formative stage of their education or professional knowledge. All these factors provide direction and suggestions for optimizing the system in the future.

Limitations of the Study.
A self-compiled questionnaire was used as a survey in this study. Although expert consultations and demonstrations were carried out during the early stages, there may still have been deviations in the results. Open questions were used as a supplement to the survey content to reduce any bias. None of the student participants in this study had participated in a clinical internship, and the sample was relatively concentrated. Nursing education can be carried out in the future based on the nursing simulation teaching information system improvements made after this study, and collegiate partnerships will be considered to expand the audience.

Conclusion
Tis study designed and extended a nursing simulation teaching information system and improved the corresponding teaching models, leading to a high degree of satisfaction among nursing students. Te nursing students proposed suggestions about the teaching format and system optimization, which provides a reference for future education using the nursing simulation teaching information system. Based on this, the simulation teaching information system can be popularized and applied in the teaching of other medical majors, such as clinical medicine, clinical pharmacy, and medical testing technology, to make medical education more similar to clinical practice.

Data Availability
Te data used to support the fndings of this study are available from the corresponding author upon reasonable request.

Ethical Approval
Tis study passed an ethical review by the Medical Ethics Committee of Southern Hospital, Southern Medical University.