J Med Syst (2012) 36:1139–1153
DOI 10.1007/s10916-010-9576-y
ORIGINAL PAPER
A Mobile Nursing Information System Based
on Human-Computer Interaction Design
for Improving Quality of Nursing
Kuo-Wei Su & Cheng-Li Liu
Received: 5 February 2010 / Accepted: 16 August 2010 / Published online: 9 September 2010
# Springer Science+Business Media, LLC 2010
Abstract A conventional Nursing Information System
(NIS), which supports the role of nurse in some areas, is
typically deployed as an immobile system. However, the
traditional information system can’t response to patients’
conditions in real-time, causing delays on the availability of
this information. With the advances of information tech-
nology, mobile devices are increasingly being used to
extend the human mind’s limited capacity to recall and
process large numbers of relevant variables and to support
information management, general administration, and clin-
ical practice. Unfortunately, there have been few studies
about the combination of a well-designed small-screen
interface with a personal digital assistant (PDA) in clinical
nursing. Some researchers found that user interface design
is an important factor in determining the usability and
potential use of a mobile system. Therefore, this study
proposed a systematic approach to the development of a
mobile nursing information system (MNIS) based on
Mobile Human-Computer Interaction (M-HCI) for use in
clinical nursing. The system combines principles of small-
screen interface design with user-specified requirements. In
addition, the iconic functions were designed with metaphor
concept that will help users learn the system more quickly
with less working-memory. An experiment involving
K.-W. Su
Department of Information Management,
National Kaohsiung First University of Science and Technology,
No. 2 Jhuoyue Rd., Nanzih,
Kaohsiung, Taiwan 811, Republic of China
C.-L. Liu (*)
Department of Management and Information Technology,
Vanung University,
No. 1 Vannung Rd., Chungli,
Taoyuan, Taiwan 320, Republic of China
e-mail: johnny@vnu.edu.tw
learnability testing, thinking aloud and a questionnaire
investigation was conducted for evaluating the effect of
MNIS on PDA. The results show that the proposed MNIS
is good on learning and higher satisfaction on symbol
investigation, terminology and system information.
Keywords Human-computer interaction .
Nursing information system . Personal digital assistant .
Small-screen interface design
Introduction
Mobile technology in clinical environments
With the advances of information technology, most medical
institutions have adopted information technology (IT) to
improve their efficiency and quality. Computerization for
daily operation procedure is accepted by the medical field
at present, but with the leading edge that mobile devices
provide, there have been some changes in the nursing
practice over the years. In recent years, mobile devices have
been brought increasingly into the medical field. Nurses
and physicians are highly mobile occupations due to the
fact that they move frequently between wards, offices,
conference rooms, and outpatient clinics. Stolworthy and
Suszka-Hildebrandt (2001) indicated that handheld com-
puters, or personal digital assistants (PDAs), offer the ideal
solution for accessing and managing the cornucopia of
information being produced in the healthcare industry each
year [1]. Li et al., (2005) indicated mobile nursing
technology refers to a combination of portable computers
and wireless communication and networks which offers
portability and mobile access to nurses needing information
at the point of care [2]. Numerous studies have demon-
strated widespread adoption of handheld computers in
1140
health care, and many information technology leaders and
executives have agreed that handheld computers will have a
significant role in the future of health care [3, 4].
As mentioned above, PDAs are being increasingly used
in healthcare. PDAs have the ability to allow clinicians to
enter and access data both remotely and at the point of care
[5]. The PDA provides a new method of information
management for nursing personnel via a mobile nursing
system. P. Yu and H. Yu (2004) mentioned that the PDA gives
promise for pervasive computing to enable “providing the
right information to the right health care provider about the
right patient at the right time and at the right place [6].” A
PDA can be used as a medical decision support system
(MDSS) to obtain a profile of the patients’ medication and to
check for inappropriate drugs and drug combinations, and to
reduce medication errors [7]. Additionally mobile informa-
tion and communication systems incorporated into the
clinical routine have the potential to greatly improve
communication, facilitate information access, eliminate
redundant documentation, and increase the quality of patient
care in the long run [8]. Therefore, a few domestic and
international hospitals are already using PDAs to improve
medical personnel operation. However, the interface designer
for such mobile systems faces a great challenge: because of
the small-screen of the PDA, size constraints make it harder
for the user to interact with the content.
Mobile human-computer interaction (M-HCI)
Human-computer interaction (HCI) is concerned with
investigating the relationship between people and computer
systems and applications. Users/operators generally don’t
understand the computer’s inner world of bits, bytes, files,
RAM, etc., but they understand the computer through its
interface, and the text and images that appears on the
screen. Hence, a popular saying in the computer world is
that for the user: “The Interface is the System” [9]. A
designer should concern himself with understanding the
users, their various capabilities and expectations and with
how these can be taken into consideration in the mobile
system or application design [10]. The consideration of
mobile human-computer interaction (M-HCI) on user
interface could follow HCI design concepts includes
metaphors, cognition, navigation, appearance and usability
should be considered [11]. Briefly, understanding who the
users are, what tasks they are doing, and where they are
using the system should be a critical component of HCI
investigations. It is extremely important thus, when design-
ing usable interactive systems, to consider who is going to
be using the systems and where they are going to be used.
Therefore, how to design a mobile nursing information
system (MNIS) on PDA that meets specific user require-
ments is the emphasis of the present research.
J Med Syst (2012) 36:1139–1153
Objectives of this study
The PDA holds a significant role in the medical field as
previously described. Indeed, PDA has inherent hardware
limitations. However, the screen size and other main
advantages of a PDA—that it is small and highly portable—
probably will not change. Unfortunately, there have been
few studies about the combination of a well-designed small-
screen interface with a PDA device in clinical nursing.
Determining how to appropriately display information and
utilize colors or icons to help user learning on limited small
screen is a great challenge. The objectives of this study were
the following:
(1) To determine which nursing tasks could be appropri-
ately performed on a PDA and, by referring to
principles of M-HCI and stated user requirements,
develop a prototype of a MNIS which has a friendly
for nurses and support for clinical nursing.
(2) To verify that the MNIS is easy-to-use, with high
acceptance, and is helpful to nurses in clinical nursing
by usability analysis.
Systematic approach to the development of MNIS
Initial analysis
The initial analysis was a reasoning process for identifying
specification of the context of use and of the users’ require-
ments in consideration of the small-screen interface design
with PDA. The study proceeds with two semi-structured
interviews with 5 ward nurses. The first interview adopted
workflow analysis, job analysis and interview methods to
clearly understand nurses’ daily work and focused on
investigation of the current status in order to define the usage
context specification. Therefore, the study investigated a
private hospital in the south of Taiwan, which has been
striving for several years to improve the quality of medical care
through a desktop medical information system. Thoroughly
understanding the operation, functions, content and environ-
ment of the system, the accurate and necessary medical
information could be considered to construct into the MNIS
on PDA. There are four main questions to be considered: the
daily work procedures and environment, the frequency of
medication errors, the usability of desktop medical information
system and user expectations. Meetings lasted approximately
two and a half hours and were documented with audio and
paper records. Table 1 describes a cycle of nursing workflow
in general.
After understanding the current status of nursing practice,
next, we discuss the user requirement analysis and determine
what solutions are appropriate for problems presented. The
second interview focused on findings in the documents and on
J Med Syst (2012) 36:1139–1153 1141

Table 1 Nursing workflow & A complete nursing system should possess some
No. Work Content important functions for reducing the workload during
clinical nursing activities as shown in Fig. 1. How-
1 Check ● Check equipment and whether ever, some functions marked with a “*” represents
amounts of all materials are which can be proceeded on the desktop system and
sufficient or not.
do not require immediate attention in MNIS design.
2 Shift ● Process shift report to illustrate
patient’s matters needing (2) Extended functions:
attention.
● Determine whether drugs on the & The nurses hope to query drug information and
patient’s order match the patient’s blood results while working. This infor-
prescription list. mation is needed often but is usually difficult to
3 Measure vital signs ● Measure temperature, respiratory remember. Hence, access to this information was an
and physical rate, pulse, blood pressure and added function on the MNIS, enabling nurses to
assessment patient’s status are according to
the prescribed order.
query the information at any time from anywhere.
4 Drug delivery ● Deliver drugs and sign according
to the order. Interface design based on M-HCI
5 Record ● Record physical assessment and
vital signs on the TPR When basic and extended functions were considered in MNIS
(Temperature-Pulse-Respiratory design, then, a prototype MNIS based on M-HCI for use in
rate) Sheet.
clinical nursing was developed. In this study, the consider-
● Recording the facts (process and
improvement) if patient occurs ations of M-HCI on MNIS interface design include metaphors,
special statuses. cognition, navigation, appearance and usability. The use of a
6 Returned drugs ● Check remaining drugs and metaphor provides knowledge about what actions are possible,
complete out checking sheet. how to accomplish tasks, and can connect a virtual world with a
Then put these on the returned user’s real world in way that utilizes common knowledge of
drugs area.
7 Input/Output ● Record and measure the patient’s
input and output values.
8 Valuation ● Count all consumed materials and
disposed items.
10 Nursing regulation ● Arrange the environment, giving
appropriate nursing
interventions for the patient,
assist the physician in
diagnosing the patient, etc.

users’ responses in order to confirm what additional functions

should be built into MNIS and find appropriate tasks whose
functions can be accomplished on a PDA-based system. In
addition, there was a need to understand some issues related to
operation of the desktop NIS. Hence, the study prepared drafts
version of the MNIS with information from relevant research
so that nurses could understand the design concept underlying
the MNIS. The meeting lasted approximately three hours and
was documented with audio and paper records. The results of
this interview, combined with those of the first interview,
show that there are basic and extended functions should be
considered in MNIS design for improving operational
efficiency and reduce medication errors of nursing:
(1) Basic functions:
& Generally, the common use of nursing forms, from
patient admission to discharge, can be divided into
those for nursing history and for general records. Fig. 1 The nursing processes and related nursing forms
1142
long-term memory for easily mapping the user’s learning
information and reducing the size of working memory [12].
For example, the “deletion” operation has often been
metaphorized with a trash can icon. Therefore, a metaphor
applied in MNIS must consider a nurse’s cognition base, so
that they can directly associate each symbol with a specific
function without memorization [13]. A cognitive model is
used to describe how a user’s knowledge of a system is
stored in long-term memory, and how it is influenced by the
frequency with which the system is used, or by specific
interactions or contexts are experienced [14]. A defective
user interface is due mainly to a lack of understanding of the
user’s cognitive needs. Based on cognitive theories, part of
the reason for lack of retention is hypothesized to be the
user’s inability to form a mental picture, or schema, of the
information presented via a computer screen [15]. Therefore,
additional basic research is needed to understand the users,
their work activities, and their reasoning processes in order
to adequately address their cognitive needs [16]. The
conclusions of initial analysis described in the preceding
section could be used as user cognitive needs. In information
systems, navigation is the process of goal-directed locating
and traversing hyperlinked information. In general, mobile
devices aren’t aesthetically pleasing enough and navigation
is troublesome [17]. Navigation or travel would be better in
adaptive menu and familiar metaphors. In addition, con-
sideration of appearance is an important task to determine
how to condense information onto the small-screen size of
PDA. P. Yu and H. Yu (2004) indicated that small screen size
of PDA is hard to support viewing of large tables/electronic
health records in a single screen and PDA should not be used
for performing complicated tasks such as graphics process-
ing or to support a database [18]. Mohageg and Wagner
(2000) proposed five design considerations for information
applications on the small screen; one of them was to
Fig. 2 The conceptual model of
the PDA solution
Nurse
Patient
J Med Syst (2012) 36:1139–1153
“simplify,” which puts the focus on important functions,
relegating others to other platforms [19]. Finally, Usability is
defined as both an attribute of software quality as well as a
higher design objective [20]. Jones and Marsde (2006)
mentioned that usability is also about whether the device
works in harmony with the things around it [21]. They said
that poor usability can come when there is a lack of thought
into how the mobile device might integrate with a user’s
other resources and the way they wish to carry out their
work and broader lives. In general, usability consists of some
kinds of attributes such as learnability, efficiency and
satisfaction [22]. Learnability is the system should be easy
to learn so that users can rapidly begin accomplishing work
with the system. Efficiency is the system should be efficient
so that users can achieve a high level of productively after
learning to use the system. Satisfaction is the system should
be pleasant to use, evidenced by users being subjectively
satisfied when using it.
System implementation
The design of MNIS was not only based on HCI concepts
but also on the results of analysis in a real environment.
The study assumes that the MNIS works under a wireless
local area network (WLAN). Nurses carry PDA with MNIS
to perform paperless clinical nursing, and inputting records
right away on the PDA via the WLAN upon receiving
patient-related information. Medical personnel can retrieve
the newest information from the desktop system in the
nursing station, clinical laboratory or general practitioner’s
(GP’s) office. Figure 2 shows the conceptual model of the
PDA solution. The hardware choice was a Dopod P100
Pocket PC. The structure of the MNIS includes three layers:
identification, main functions and sub-functions, as shown
in Fig. 3. The contents and operating conception are based
WLAN
•
•
•
•
•
Clinical Laboratory
Nursing Station Server
GP' s Office
J Med Syst (2012) 36:1139–1153
Layer 1 Layer 2 Layer 3
Fig. 3 The structure of the MNIS
on the desktop NIS of the hospital and on users’ habits. The
summaries are as follows.
(1) The first layer is identification. The first screen is the front
page of the system where nurses must input their
username and password. If correct, nurses must then
check whether their unit number is correct. The unit
number should be modified if incorrect before the system
is ready for use.
(2) The second layer shows the main functions of MNIS,
which include accessing the general nursing record,
nursing history, drug searches and blood test results,
help, and logout. The general nursing record deals
with daily health status of the patient. The nursing
history records the patient’s background and first-time
assessment data. The functions of drug searches and
blood test results function help nurses query such
information at the bedside. Help assists users when
they have questions about operation of the system.
(3) The third layer includes sub-functions of the second
layer and it is here that a user can fully complete a task.
Presentation of the MNIS interfaces
The main menu of the MNIS is shown in Fig. 4. There are
five functions including in the main menu: general nursing
1143
record, nursing history, drug search and blood test results,
help, and logout. There are five iconic symbols designed in
the system as shown on the left side, with characters and
colors, so that novices can easily learn to use them and to
economize on screens use. The use of color depends on the
characteristics of icons to help nurses easy to discriminate.
When user clicks the function button in main menu, the
screen will transfer to the sub-menu of the function. For
example, Fig. 5(a) shows the sub-menu of the general
nursing record: (1)vital signs; (2)physical assessment; (3)
nursing planning; (4)nursing instruction, and (5)nursing
record. The color of these buttons is blue, as its main-menu
button (in Fig. 4). In addition, the sub-menu has a reminder
at the right-top corner. The advantages of this design
include that the user can know what kind of function they
clicked and hence reduce the amount of working memory
needed. If the user chooses vital signs from the general
nursing record, the top of the blue area will show “General
Nursing Record” and the top of the white area will show
“Vital Signs” (see Fig. 5(b)). The main screen of each sub-
menu is divided into three parts as in Fig. 5(c). The first
part and third parts are shown on every work page. The first
part includes the location, a patient combo box edit button,
and a back function. The top of the blue area shows the
main menu are where the user is (general nursing record,
nursing history, drug search and blood test results, and
help) and the top of the white area shows the sub-menu.
The second part is a green area which lists the contents of
the function. The third part is a shortcut bar which lets the
user come and go freely. Even with a good system the user
may forget the meaning of the symbols. A click of the
house symbol will allow the user to return to this main-
menu at any time. If a nurse would like to enter another
main function, s/he can click the icon of the main function
on the shortcut bar. Finally, the system offers appropriate
feedback with audio when needs user pay attention as
shown in Fig. 7, including: (a)login error; (b)unit number
error; (c)deletion request; (e)deletion success and a save
success (f).
Metaphor
General Nursing Record
Nursinghistory
Drug Search and
Blood Test Results
Help
Logout
Fig. 4 Main menu of MNIS
1144 J Med Syst (2012) 36:1139–1153

General Nursing Record

Back
Vital Edit
signs
Reminder
Physical
assessment
Nursing Patient
planning list
Nursing
instruction

Nursing
record

(a) Sub-menu (b) Vital signs

Diagnosis
Start time
Finish time

Name of nursing plan

Content of nursing plan
Plan in finish

(c) Physical assessment (d) Nursing planning

Instruction items Handling

Save

(e) Nursing instruction (f) Nursing record

Fig. 5 The contents of the general nursing record

A summary of MNIS’s design with principles of M-HCI (2) Cognition

is as follows:

(1) Metaphor 1. Reduce short-term memory load

& Pictorial realism: as shown in Fig. 4, the meta- & Iconic menu: as shown in Fig. 4, characters of
phor was designed to look like the variable that it commands are metaphorical by iconic symbols that are
represents. easy to recollect the function menu in layer 2 or layer 3.
J Med Syst (2012) 36:1139–1153
(a) Sub-menu
(c) Results of drug
Fig. 6 The contents of the drug search and blood test results function
& Shortcut bar: as shown in bottom of Fig. 5(c), the
shortcut bar is consolidated in working pages. There-
fore, users spend little time and effort to search or type
information from page to page.
& Reminder: as shown in Fig. 5(a) and 6(a), the bigger
iconic symbols remind the user of his or her location
and of the function’s meaning.
& Location: as shown in Figs. 5 and 6, function name was
shown on the top of each working page, so that it
reminds users where they are, users don’t need any
effort to remember where they are.
& Consistency: as shown in Fig. 5, the same information
and buttons were presented consistently on all screens
to facilitate recognition (e.g., edit, back, save, delete,
and shortcut bar) to reduce users’ search and identifi-
cation time.
1145
(b) Drug search
(d) Blood test results
2. Support internal locus of control
& Edit button: as shown in Fig. 5(b), the system allows
users to modify the patient list clicking the “edit”
button.
& Feedback: as shown in Fig. 7, the system offers feed-
back messages when users are performing certain tasks.
3. Design dialogs to yield closure
& As shown in Fig. 7, giving confirmative and affirmative
dialogues when tasks are completed or when a deletion
action will occur is important for users.
(3) Navigation
1. Adaptive menu and familiar metaphors
& Functional menu: as shown in Fig. 4, menu was designed
in structure according to daily nursing procedures.
1146
(a) Login error (b) Unit number error
(c) Delete or not (d) Delete success
(e) Save success
Fig. 7 Notice message of system feedback
& Familiar metaphors: as shown in Fig. 4, iconic symbols
were designed with characters and colors, so that
novices can easily learn to use them and to economize
on screens use.
2. Goal-directed locating and traversing hyperlink
& Function button: as shown in Figs. 4 and 5, a click of
the function button in main menu, the screen will
transfer to the sub-menu of the function. In addition, the
sub-menu has a reminder metaphor of main function at
the right-top corner.
& House symbol: as shown in Fig. 5, a click of the house
symbol will allow the user to return to this main-menu
at any time.
& Back button: as shown in Fig. 5(b), if the user enters an
undesired page, it is easy to return to a previous page by
clicking the “back” button.
& Shortcut bar: as shown in bottom of Fig. 5(c), if the
user enters an undesired page, it is easy to return to the
sub-menu page by clicking the icon button. Users can
navigate freely without worry.
3. Offer informative feedback
& As shown in Fig. 7, the system offers appropriate
feedback messages. If the system continuously or
obsessively informs the user about what it is doing,
users will become impatient with system.
4. Permit easy reversal of actions
& Back button: as shown in Fig. 5(b), it is easy to return
to a previous by clicking the “back” button.
& Edit button: as shown in Fig. 5(b), the system allows
users to modify patient list by clicking the “edit” button
when they selected their patients.
J Med Syst (2012) 36:1139–1153
(4) Appearance
1. Strive for consistanc
& Layout: as shown in Figs. 5 and 6, buttons (e.g., edit,
back, save, delete, and shortcut bar), the user’s name,
and page description maintain a fixed location.
& Font and Size: as shown in Figs. 4, 5 and 6, the
English font is Times New Roman and the Chinese
font is MingLiU. The font size of reading text is 10, 12
for sub-titles, 14 for menu buttons, and 20 for menu
titles. Differentiable sizes can be distinguished by
users.
& Color: as shown in Figs. 4, 5 and 6, no more than 7
colors are used for easy discrimination.
2. Prevent errors
& Highlight: as shown in Fig. 5(b), highlight of patient
list can catch the user’s attention, so that the number of
errors will decrease.
& Notice message: as shown in Fig. 7(c), the system
offers notice when users perform a deletion action in
order to prevent errors.
(5) Usability
& Iconic menu: as shown in Fig. 4, characters of
commands are metaphorical by iconic symbols,
which are namely metaphors used to achieve a
system mapping to the user’s conceptual model of
the information.
& Shortcut bar: as shown in bottom of Figs. 5 and 6.
Not every button can be incorporated into the
shortcut bar. The buttons are available to directly
access important functions that users may fre-
quently need.
& Highlight: as shown in Figs. 5 and 6, the study
uses various ways to attract the user’s attention,
including highlights by use of color, icon, font,
font size, and boldface typesetting.
& Reminder: as shown in Figs. 5(a) and 6(a), the
bigger iconic symbols enhance the user’s memory
and help them know where they are.
& Location: as shown in Figs. 5 and 6, function
name was shown on the top of each working
page, so that it reminds users where they are. To
avoid disorientation, users are given directive
reminders.
& Consistency: as shown in Fig. 5, the same informa-
tion and buttons were presented consistently on all
screens to facilitate recognition (e.g., edit, back,
save, delete, and shortcut bar). Hence, users can
easily gain system comprehension even with only
partial knowledge of how the system works.
J Med Syst (2012) 36:1139–1153 1147

Although many principles of interface design are addressed, Table 2 The sequence of task scenarios in experiment
the prototype of MNIS is still necessary to evaluate the usability Targets Tasks
for users in order to design a satisfactory system. Next section is
to explore more usability problems from experimental design. A. Identification 1) Input username and passwords,
then modify the unit number
2) Select patients from the
patient list page
Experimental design for measure usability of MNIS
B. Nursing History 1) Complete patient information
2) Complete nursing assessment
Usability analysis
3) Complete admission nursing
C. General Nursing Record 1) Complete vital signs
The purposes of experiment were to determine problems of
2) Complete physical assessment
usability stemming from interface design, to obtain objective
and subjective data which can be used as a source of 3) Complete nursing instruction
quantifiable and qualitative information for verifying the D. Drug Search and Blood 1) Search for drug information on
Test Results AMOBITAL SODIUM/inhalants
system’s usability. In general, there are three types of usability
evaluation methods, which include testing, inspection and 2) Search blood test results
E. Patient List 1) Modify self patient list
inquiry [23]. The inspection and inquiry methods need
usability specialists, software developers and other profes-
sionals to examine the system. However, the specialists or
professionals are not easy to find or may be not adaptive.
Therefore, in this study, we inspected usability of the students in the school of continuing education, practice and
prototype of MNIS with usability testing. Here, usability serve as the nurse’s assistants in the hospital in the daytime,
testing was implemented in laboratory settings, and involved and go back to school and have lessons in the evening.
thinking aloud and questionnaires as forms of subjective They were divided into N1 group and N2. In N1 group,
assessment (user attitude, such as satisfaction and attractive- they worked in the nursing station and helped to key in the
ness) and objective assessment (user performance, such as clinical records into the desktop system (i.e. NIS) in most
learnability test). Thinking aloud can be particularly useful if of the time, sometimes, helped nurses to deal with nursing
you have mobile devices you want to evaluate in lab care. In N2 group, they were assistants in the ward to take
settings [10]. In this process, the user’s voice and browse down the general nursing records on the nursing record
route were recorded; meanwhile, the study also utilized sheet, but didn’t need to key in materials into the NIS.
usability analysis software “LOGSQare,” which records user Therefore, the N1 group was defined as experimental group
activities and screen shots, to analyze user behavior. The (who have NIS operating experience), the N2 group was
QUIS was developed by a multi-disciplinary team of defined as control group (who haven’t NIS operating
researchers in the Human-Computer Interaction Lab (HCIL) experience).
at the University of Maryland at College Park and was
designed to estimate users’ subjective satisfaction with Environment and apparatus
specific aspects of the user interface. It consists of six
constructs: participant demographics, screen, symbol investi- The experiment was took place in a controlled room which
gation, terminology and system information, learning, and was divided into three areas for learning, testing, and filling
overall user reactions and uses a 5 point Likert scale (1 being out questionnaire, respectively. Furthermore, two notebooks
poor and 5 being excellent). Learnability test is a proper aspect were prepared for tuition and for testing based on the
of usability testing which can be used to evaluate how easily LOGSQare software. A Dopod P100 PDA was used for
the prototype can be learned and how quickly the user can learning. Participants used a Pocket PC simulator on a
start to use the system [24]. In addition, there were a series of desktop during testing because so that their operating
task scenarios to implement the usability testing for screens could be record by LOGSQare.
exploring participants’ NIS operating experience.
Experimental variables

Participants In learnability test for objective evaluation of usability, the

performance variable was time spent on a task, which is
A laboratory experimental method was employed in this noted as the time to finish the task. The spending time of the
study. There were 12 female undergraduate students (aged two groups (N1 and N2) was tested to determine whether
20–23) in the nursing department participated. They are there was a difference between them or no? Whether the
1148 J Med Syst (2012) 36:1139–1153

Table 3 Spending time of each participant in each task (seconds)

Student Number Task A Task B Task C Task D Task E Total

a.1 a.2 b.1 b.2 b.3 c.1 c.2 c.3 d.1 d.2 e.1

N1 S01 30.4 22.4 40.7 53.0 34.7 59.0 33.6 16.9 22.6 17.0 29.6 359.9
S03 32.2 23.8 49.0 80.6 49.9 66.2 45.1 17.2 34.7 14.7 59.3 472.7
S06 32.5 26.1 46.7 69.0 40.2 83.5 31.7 20.4 51.5 36.1 56.7 494.4
S08 20.3 28.8 32.1 65.8 64.4 71.8 36.4 20.1 30.3 21.4 46.0 437.4
S09 44.1 31.1 30.0 70.5 52.0 69.7 89.9 21.2 35.0 20.0 37.2 500.7
S12 42.4 36.3 31.3 71.8 51.5 75.4 41.0 16.0 45.7 20.1 45.3 476.8
Mean 33.7 28.1 38.3 68.5 48.8 70.9 46.3 18.6 36.6 21.6 45.7 457.0
S.D. 8.7 5.1 8.3 9.1 10.3 8.3 21.9 2.2 10.5 7.5 11.3 52.5
N2 S02 19.5 37.0 30.2 58.3 39.4 67.3 47.6 41.1 83.0 19.5 54.5 497.4
S04 19.0 31.7 46.3 94.4 47.0 101.9 59.9 19.7 43.7 20.7 35.9 520.2
S05 46.2 42.8 44.8 40.6 95.4 82.9 67.5 22.1 31.8 16.4 24.6 515.1
S07 36.3 48.7 26.1 112.4 68.5 62.4 30.3 17.3 31.1 19.1 37.0 489.2
S10 38.1 27.6 37.1 76.3 44.9 70.4 52.0 24.4 23.8 38.9 34.6 468.1
S11 42.1 48.0 28.6 56.4 70.8 94.8 39.1 17.5 37.5 16.5 32.3 483.6
Mean 33.5 39.3 35.5 73.1 61.0 80.0 49.4 23.7 41.8 21.9 36.5 495.6
S.D. 11.6 8.7 8.6 26.7 21.2 15.9 13.6 9.0 21.3 8.5 9.9 19.6

MNIS was good on learning or not? Additionally, in
subjective evaluation of usability, the satisfaction of end
users was analyzed by QUIS.
Task scenarios
mouse trajectory and screen contents, are recorded in the
testing phase as important research information. If partic-
ipants finished all tasks, they will complete a questionnaire
for User Interaction Satisfaction (QUIS).

Andrews (2003) noted that tasks for testing were provided
should be prioritized by frequency and importance, as well
as selected from among those most frequent and critical
[25]. The study goes through the nursing procedure and
asks nurses for advice, so as to list appropriate task
scenarios to test. When participants were doing the tasks,
LOGSQare software recorded their operating screens in.
Five targets and 11 tasks were tested. The sequence of task
scenarios was listed in Table 2.
Experimental procedure
Before the experiment beginning, participants were informed
the experimental purposes and procedure. There were two
steps in the learning process: tuition via power point and self-
learning with the PDA in the first experiment. Tuition
included a picture of each screen, function, and icon.
Participants also practiced for three minutes on their own
before performing the tasks. In the meanwhile, they could ask
any question about the system and receive answers.
In the testing stage, participants were encouraged to
vocalize questions, but would receive no responses. This
method is called “Thinking Aloud”. Audio, as well as the
Results
Table 3 shows the overall performance data (i.e. spending
time) for both the N1 group and N2. Since the sample size
of the study is less 50, the Shapiro-Wilk was employed.
The results show that all significances associated with the
test of normality are >0.05, so the spending time is
normally distributed. First, the independent samples t-test
was performed to test whether NIS operating experience
would affect participants’ learning ability. The result shows
that the differences of spending time on five tasks between
N1 and N2 are all insignificant (t (22) Task A= 1.525, p=
0.071; t (34) Task B=0.676, p =0.252; t (34) Task C = 0.659,
p =0.257; t (22) Task D= 0.431, p =0.335; t (10) Task E = 1.502,
p =0.08). Because the most operation function of MNIS
was designed according to NIS. The participants have ever
used the NIS would be easy to use the MNIS. However, the
difference of spending time between N1 and N2 are not
significant. That is, when the users were first introduced to
MNIS, their adaptation to the system was much quicker.
Additionally, subjective measurement on QUIS exhibits
high reliability (range of Cronbach’s alpha scores from 0.68
to 0.88). The results of the QUIS are summarized in
J Med Syst (2012) 36:1139–1153 1149

Table 4 Subjective satisfaction with the interface

Construct Measure Average S.D.

1.1 Characters on the computer screen are easy to read 4.33 0.49
1.2 Highlights on the screen are helpful to you (e.g.,
4.33 0.78
colors, icons, boldfaces, and front sizes)
1.3 Information and hint on the screen are sufficient to
4.08 0.79
operate
1.4 Information Arrangement on the screen is
4.42 0.51
Screen consistent
1.5 The levels of system structure are clear
4.08 0.51
(main menusub-menucontent)
1.6 Can go to any screen easily 4 0.74
1.7 The current location is easy to know 4 0.74
Total 4.18 0.66
2.1 “Back to Main Menu” is easy to associate with the
4.58 0.67
“ ” symbol
2.2 “General Nursing Record” is easy to associate with
4.42 0.51
the “ ” symbol
2.3 “Nursing History” is easy to associate with the
4.58 0.51
“ ” symbol
2.4 “Drug Search and Blood Test Results” is easy to
4.83 0.39
Symbols associate with the “ ” symbol
Investigation
2.5 “Help” is easy to associate with the “ ” 4.42 0.90
symbol
2.6 “Logout” is easy to associate with
4.42 0.79
The “ ” symbol
2.7 The size of symbols is easy to see 4.33 0.65
2.8 Iconic functions help to learn the system 4.50 0.52
Total 4.51 0.63
3.1 Use of computer and nursing terminology are
4.08 0.51
Terminology consistent on the system
3.2 Use of nursing terminology conforms with your
and System 4.33 0.49
specialty
Information 3.3 System gives appropriate feedback (save success!) 4.50 0.67
Total 4.31 0.58
4.1 Learning how to operate system is easy 4.25 0.45
4.2 Remembering function names and usages are easy 4.25 0.75
Learning
4.3 The number of steps of each task is acceptable 4.08 0.51
Total 4.19 0.58
5.1 The system is helpful to you. 4.25 0.45
5.2 The aesthetic of the interface design is satisfactory. 4.33 0.89
Overall User
5.3 You are willing to use the system in the future. 4.33 0.49
Reactions
5.4 The system is satisfactory after using. 4.17 0.58
Total 4.27 0.61
(Questionnaire Category: Strongly Agree=5; Agree=4; No opinion=3; Disagree=2; Strongly Disagree=1;
S. D.=Standard Deviation)

Table 4. The percentage indicates that the 12 participants’ can be improved. Afterwards, the subjective satisfaction of
responses and all averages of the assessable items are all the two groups is summarized in Table 5. The results reveal
above 4 points, which is between agree and strongly agree. the two groups are all over 4 points and the N2 group shows
However, the item 1.6 and 1.7 on the screen construct still a little satisfaction higher than the N1 group. Though N2 has
1150 J Med Syst (2012) 36:1139–1153

Table 5 Subjective satisfaction

of the two groups Construct NIS Experience Part 1 Part 2 Part 3 Part 4 Part 5

N1 N2 N1 N2 N1 N2 N1 N2 N1 N2

Mean 4.17 4.19 4.50 4.52 4.28 4.33 4.17 4.22 4.21 4.33
S.D. 0.41 0.63 0.40 0.44 0.40 0.44 0.59 0.40 0.60 0.26

not used the desktop NIS, they gave good feedback about
MNIS such as screen layout, symbols, use of terminology
and learning. It means that the MNIS is good on learning
and using for persons have no NIS operating experience. In
general, according to objective and subjective data, there
are no significant differences on overall spending time for
the two groups and the subjective satisfaction results reveal
that the averages of all constructs have over 4 points on
the scale. Once again, the results prove the system is
satisfactory for persons who have experience on desk NIS
or none. Especially, it is easy-to-learn for persons have no
experience on desk NIS.
Further, this study got the full and meaningful questions
using the participants’ own knowledge in the operating
process from their voice and experimental screen. With
their responses, the study can not only understand their
perspectives, but these important responses will be the basis
for improving the MNIS prototype. Some analyzed sugges-
tions were summarized from the thinking aloud and
LOGSQare software as follows. (S = Subject; the numeral
is the serial number)
(1) Screen
& S7: The layout and color is clear.
& S12: Low system speed.
(2) Symbol Investigation
& S4: It is a little difficult to associate symbols the
first time, but familiar later.
& S6: It is better if the function name appears when
the cursor moves to icon.
& S12: The designs of iconic functions and search
functions (drug information and blood test results)
are very good.
(3) Terminology and System Information
& S3: The terminology need be clearer in function of
“Physical assessment.”
(4) Learning
& S6: I don’t know the “Edit” button’s meaning.
& S7: The system is very easy to use with low difficulty.
& S12: The system is very easy to understand and
may decrease the time required to perform nursing
work.
(5) Overall User Reactions
& S9: I feel that the screen layout is consistent and the
system is easy to use.
& S11: The system almost shows nursing information
on the screen for the nurse to click. Although it is
convenient in nursing practice, it may reduce the
nurse’s competence.
& S12: The PDA is necessary to apply in the nursing
field. The MNIS can reduce our workload.
The results showed that suggestions in “Terminology
and system information” S3 and “Learning” S6 are
problems of description of function. It means that the
recognition of user on function definition or button name
should be proved clearly again. The suggestion in “screen”
S12 is problem of information technique. It is not discussed
temporarily in this study. Nevertheless, other suggestions
are mostly satisfied.
Discussion
Mainly a PDA was believed to improve patient care and
save time for nurses because it was regarded as a
convenient medium to provide and access electronic
medical records at any time and any place [4]. Rodríguez
et al., (2009) found that nurses were significantly more
satisfied with the PDA-based system than with the paper-
based system with every interaction and system aspect
evaluated on their study [26]. A PDA has the potential to be
a part of nurses’ routine care planning. However, the small-
screen of the PDA, size constraints make it harder for the
user to interact with the content. In recent years there are
some researches discussed the design on the small-screen.
Zhao et al., (2001) suggested that type of information display
significantly affect user performance [27]. When the display
was in color, participants performed better. Participants
preferred less information and they rated displays with
intermediate amounts of information most comfortable.
Churchill and Hedberg (2008) reported that design for one
step interaction, minimize scrolling, design for short contact
time and design to match the task would be effective design
of learning objects on the small-screen. However, these
studies are mostly focused on display of the small-screen
[28]. At this stage availability of relevant guidelines and a
J Med Syst (2012) 36:1139–1153
solid literature in relation to consider the appropriately
performed on a PDA in clinical nursing including specifi-
cation and requirements on users and M-HCI consideration
is very limited. In this study, we integrated the method of
initial analysis and the principles of M-HCI to develop a
prototype of MNIS which has a friendly for nurses and
support for clinical nursing. The initial analysis including
workflow analysis, job analysis and interview methods was a
reasoning process for confirming what additional functions
should be built into MNIS in consideration of the small-
screen interface. Here we found that the initial analysis is very
important. Via initial analysis, the designer can clearly
understand nurses’ daily work and focused on investigation
of the current status in order to define the usage context
specification and easily confirm appropriate tasks whose
functions can be accomplished on a PDA-based system.
Thus, the essential information can be mastered thoroughly to
define the major function on a small-screen with PDA. Then,
the concepts of M-HCI (metaphors, cognition, navigation,
appearance and usability) can be adapted to develop MNIS.
The results by usability testing indicated that our view
supported by the applications of the principles of the M-
HCI have an agreeable usability design besides satisfying
the user’s need of content and functions. According to the
results, some findings of this study are worth summarizing:
(1) Based on the results of objective assessment, the T-test
showed that there is no significant difference between
N1 (NIS operating experience users) and N2 (non-
experience users). It means that the MNIS is no
difference on learning and using for persons between
have NIS operating experience and no. The MNIS is
good on learning and using for persons have no NIS
operating experience.
(2) Based on the results of the subjective assessment, the
questionnaires showed that the degree of satisfaction is
higher on symbol investigation, terminology and
system information, and overall user reactions to the
constructs. It means that when users first use a new
system, the recognition and comprehension of symbol
and constructs of information and function would be
important for users to understand how to use the
system and what function in the system.
(3) On the whole, participants felt satisfied after using the
MNIS, but items 1.6 (ability to go to any screen easily)
and 1.7 (the current location is easy to know) in QUIS
have lower satisfaction levels which may lead us to
reconsider how to improve navigation in the future.
(4) The difference of N1 group (S.D.=0.6) on Part 5
(overall user reflections) of QUIS was larger than the
N2 group (S.D.= 0.26) and the standard deviation of
total spending time (S.D.= 52.5) was also larger than
N2 group (S.D.= 19.6). The study infers that there are
1151
different transformation and comprehension capabili-
ties from the N1 group. It means that past experience
might not be help user in studying the new things.
Because every desktop NIS of hospital is different,
and because of differences in transforming information
from a larger screen to a smaller screen, different
reactions may arise for these reasons as well.
Based on related studies, the user interface is an important
aspect of the system design that can affect whether users are
willing to use the system or not. The results show that the
small-screen design of the MNIS prototype is approved by
users through objective and subjective assessments. Further,
nurses indicated that in addition to in the general ward, the
emergency room should be considered for implementation of
a similar system. However, it should be noted that nurses who
work in emergency room must care for more patients than
nurses who work in general ward and that their work involves
more multifarious information to deal with.
Conclusions
The study developed a mobile medical system “MNIS” on
PDA, the experimental results indicate that the subjective
satisfaction on each construct was significant. It means the
system is easy-to-use, easy-to-learn and artistically pleasing
for nurses. Therefore, the designer must take into account
not only the technological aspects of the system, but also
the users’ cognitive model, so that the system can result in
successful interaction with the user. Some of the practical
and academic contributions of this study are as follows:
(1) This study develops a prototype MNIS to support
clinical nursing. Nurses can not only carry a PDA
during the daily clinical routine, but can perform
paperless recording of nursing information. In addi-
tion, they can perform self-learn about drug informa-
tion via the drug search and blood test results function
embedded in the MNIS.
(2) According to related literatures, PDA-based systems
promote operational efficiency, reduce nurses’ work-
load, and can reduce medical errors [29, 30]. Generally
speaking, the MNIS improves (a) operational effi-
ciency; (b) reduces medication errors; (c) increases
patients’ safety because of the reduction of medication
errors and increase time for nurses to care for patients;
and (e) improves overall healthcare quality as a result.
(3) Very little of the related research focuses on the
combination of a well-designed interface and mobile
medical system. In additional to concepts from M-HCI,
iconic functions are considered in the design process.
The fruitful results offer a new innovation regarding the
design of a traditional medical system.
 (4) Use of a mobile device solving the main problem of information inconvenience during the clinical routine is a good way.
However, researchers must think about what information and tasks are needed for nurses. The adopted methodologies of this
study serve as a pattern for related research. This study adopted HCI concepts to analyze the current and users’ requirements for
discovering problems, and incorporated concepts of M-HCI for creating a friendly user interface in the development of MNIS.

The focus of this study was on small-screen interface design with M-HCI guidelines. The study identified several aspects to be
considered for further research as follows:

(1) The MNIS is a prototype system and has much room for improvement. The next stage is to improve the MNIS based on users’
suggestions and then obtain a deeper analysis from usability experts and wider- ranging participants.
(2) Push the MNIS into a real environment and popularize for an emergency room or others that most need information improvement. The
study may reveal a difference in usability for a controlled laboratory experiment and a real environment. Undoubtedly, that the MNIS
can be used well in practice is the ultimate goal.
(3) Because of considering the differences among partic- ipants on age and experience, participants were chosen in consider with the
same age level. The probationers with 20–23 years old are the most in the investigated hospital and so considered to be subjects
in this study. However, there are only six persons with 20–23 years old have NIS operating experience, in considering equal
number of participants, there are also six persons in the control group (N2 group). Future studies with more hospitals to
investigate the effects of MNIS would be considered.

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