Exploring Nurses Perception of iAudit: A Qualitative Study

Introduction

Quality of care, particularly the delivery of ser- vices and maintenance of standards, is essential to any healthcare institution, with clinical govern- ance and ongoing service improvement are heav- ily dependent on audits and quality improvement initiatives [1]. One method of assessing and en- hancing patient care and outcomes is through clin- ical audits, which have been linked to significant and long-lasting improvements in patient care [2]. Clinical audits measure clinical outcomes or pro- cesses against clear standards, based on the princi- ples of evidence-based medicine, to determine the changes required to improve care quality [3]. However, while auditing is a crucial process for performance evaluation, some research indicates that the roles of auditor and auditee can change be- tween audits, and may even become ambiguous during the audit itself [4]. Data visualisation tools are increasingly used in the auditing process to help identify data discrep- ancies and improve audit risk management by en- hancing auditors’ analytical capabilities [5]. This trend aligns with growing academic interest in continuous auditing and monitoring, the adoption of software tools in accounting and auditing, and the relationship between information systems and audit practices [6]. As information assets are cru- cial for organisations to achieve their goals, so is managing them and their associated risks. In this context, iAudit serves as an essential digital appli- cation for managing and supporting clinical audit processes focused on practice, safety, and quality of treatment, rather than functioning as an infor- mation-seeking platform or standalone infor- mation system [7]. iAudit is a centralised audit environment that ena- bles the efficient management and organisation of internal audit data related to clinical transactions, patient safety, and quality of care, allowing such data to be collected, stored, and accessed electron- ically through a shared platform [7]. As a web- based digital tool that replaces manual, paper-

based audits, the system also generates electronic or digital trails, which enhance transparency, sup- port data confidentiality, and make audit results more accessible for authorised users [8]. iAudit of- fers a range of user-friendly features that enable quick access to audit results and allow inspection forms to be completed in minutes. In combination with the web platform, users can employ ready- made checklists, customise existing checklists, or transform them into entirely new checklists. [9]. In a case study by Cisterman (2019), the studied company found that conversion to paperless forms provided numerous benefits, including improved safety, quality, productivity, and efficiency [9]. iAudit facilitates the handling and distribution of audit documents electronically, allowing for the upload of completed forms to safe digital storage and enabling electronic distribution of reports. This process reduces administrative load, en- hances organisation of documents, and enables faster access to historical documents, as compared with traditional paper-based methods. The plat- form can also provide analytical outputs that al- lows users and administrators to track perfor- mance indicators and trends and easily identify ar- eas for improvement through automatically gener- ated reports [9]. Digital auditing using iAudit has been linked to enhanced operational efficiency and a simplified workflow process, while the ap- plication of technology-based audit tools has been demonstrated to save significant time and increase efficiency in institutional settings, enhancing safety, quality, and overall work processes. Despite the recognised importance of clinical au- diting, some audit cycles remain incomplete and several issues and problems remain unresolved. Clinical auditing is often viewed as a resource-in- tensive, time-wasting activity, due to the persistent challenges inherent in managing large volumes of healthcare data that must be organised, well- sorted, and analysed to support effective under- standing and decision-making. Moreover, audit- related work is generally reported to be highly de-

manding and time-consuming, encompassing ini- tial data collection and subsequent data analysis, thereby leaving little time for the development, implementation, and re-audit of specific action plans. Many of these challenges can be addressed through the use of a responsive, efficient, and streamlined service platform such as iAudit [3]. Evidence-based findings indicate that institutional care settings typically conduct frequent audits, of- ten involving processes that are heavily concen- trated on the initial data-collection stage. This fo- cus affects subsequent auditing activities and leads to the absence of effective data trails. Conse- quently, numerous audits remain incomplete or re- sult in findings that are not implemented due to the volume of information and the extensive manual effort required for evaluation and analysis [13]. The above identified challenges prompted the im- plementation of the iAudit system in the Cardiac Centre of this tertiary healthcare facility, to ensure that quality standards are consistently upheld in ac- cordance with the requirements of international and national accreditation boards. Training initia- tives were subsequently provided for nurses and other staff members, and this study was under- taken to evaluate the current usability of the appli- cation from the perspective of nursing personnel. This study, therefore, aims to explore the percep- tions of nurses regarding the usability of the iAudit system.

Research Methodology

Study Design The study was carried out between January 2024 and December 2024, using a qualitative phenom- enology research design. In qualitative research, open-ended inquiries concerning human realities and experiences are investigated via extended in- teractions with subjects in their natural settings, yielding rich, descriptive data that will aid in un- derstanding those subjects’ lives. Researchers fo- cus on the personal experiences of participants to explain a specific phenomenon based on the data obtained [10].

Setting The study took place at a cardiac centre in a tertiary healthcare setting in Riyadh, Saudi Arabia. This centre was selected for its high acuity and regular use of iAudit as a strategy to improve care quality. Respondents The nine nurses who participated in the study were employed across various departments of the Car- diac Centre. The sample size was set according to the principle of data saturation, a commonly-used criterion in qualitative research to determine the point at which no new concepts or meaningful un- derstandings can be obtained through the collec- tion of additional data [10,11]. Data saturation was considered achieved when successive interviews yielded repetitive information regarding the usa- bility of iAudit. After the ninth interview, no new themes or categories emerged, and participant re- cruitment was thus discontinued. The participants possessed sufficient and relevant work experience, and represented a diverse range of backgrounds, including varying shift assign- ments, levels of seniority, and degrees of familiar- ity with information technology (IT) and the iAu- dit system. It was ensured that all participants in- volved in the study had engaged meaningfully and possessed hands-on experience with the system. Sampling Technique This qualitative study employed a non-probability, purposive sampling method to select participants most pertinent to the research objectives. Qualita- tive research often uses purposive sampling to en- sure the inclusion of participants with direct expe- rience of the phenomenon of interest [10,12]. In this study, nurses were chosen for their direct in- volvement in iAudit activities, experience with au- diting tasks in their department, and appropriate duration of employment at the Cardiac Centre. Participants were recruited by identifying nurses across various units and shift schedules and invit- ing them to participate either through email or in person. This strategy ensured representation of the various degrees of seniority, shifts, and IT skills.

Recruitment proceeded until data saturation was reached; this was determined as the stage at which no new insights or data were obtained by inter- viewing additional participants [11]. Data Collection Instrument and Procedure Data were collected using a semi-structured inter- view guide. Semi-structured interviews are com- mon in qualitative studies because they enable a thorough examination of the lived experiences of participants, as well as flexibility in the question- ing process [10]. Core questions were prepared be- forehand to suit the purpose of the study, with fur- ther probing questions brought about during the participants’ interviews. The interview guide con- sisted of two sections (Appendix): Part 1 exam- ined the participants’ demographic information, while Part 2 explored nurses' experiences and opinions regarding iAudit’s ease of use. Participation was voluntary, and the interview rules and standards were clearly explained to all participants. The necessary orientation was pro- vided, and written informed consent was obtained before data collection began. To ensure the partic- ipants’ comfort and privacy, individual interviews were conducted in a hospital conference room af- ter working hours. The interviews lasted between 20 and 40 minutes, depending on the depth and flow of the conversation. As English is the hospital’s official language of communication, all interviews were conducted in English. However, individuals who wished to clarify any points in Arabic were allowed to do so. The primary researcher, who is fluent in both Ar- abic and English, translated these Arabic re- sponses into English during transcription. The transcripts were reviewed twice; first by the re- searcher and later by a second bilingual nurse with qualitative research experience. Participants were not given verbatim transcripts, but key responses were clarified and validated during the interviews in line with standard practices to ensure trustwor- thiness [12]. Member checking was also under- taken during the analysis process to confirm the

accuracy of emerging ideas. Open-ended questions were used during the inter- views, including, “Please tell me about your expe- riences using iAudit in your unit.”; “What do you think is the purpose of conducting an iAudit?”; and “What are your views on using the iAudit software based on standard indicators?” This allowed the participants to introduce additional topics that were not discussed in the handbook. The interview was subjective and exploratory, consistent with phenomenological research which aims to broadly understand lived experiences [11,10]. With the participants’ permission, all interviews were audio recorded and transcribed verbatim. Non-verbal cues and contextual data were also recorded as field notes to aid data analysis and in- crease confirmability [12]. All members of the research team were nurses trained in qualitative interviewing and knowledge- able about phenomenological research methodol- ogies, and they conducted the interviews accord- ingly. The researchers also practiced reflexivity to reduce bias; this was done by documenting as- sumptions, beliefs, and thoughts in a research di- ary—a method recommended to reduce re- searcher bias and preserve the authenticity of par- ticipants’ perspectives [12,11]. Such process guar- anteed that the interpretation of the data was based on the views of the participants rather than based on the expectations of the researcher.

Data Analysis The interview data were examined using content analysis, an established and systematic approach in qualitative nursing studies for identifying pat- terns and themes within textual data [11,12]. This data-driven, inductive methodology enabled the development of themes from the participants’ nar- ratives. All of the interviews were transcribed ver- batim, and the transcripts were reviewed repeat- edly to ensure full immersion in the data. The pri- mary researcher conducted the initial open coding by identifying significant sentences, recurring

ideas, and noteworthy phrases; these codes were grouped according to similarities in meanings. To enhance reliability, the second researcher coded a portion of the transcripts separately, and the coding decisions were then compared. Differ- ences, which were mainly associated with cate- gory assignment, were resolved through discus- sion until agreement was reached, according to suggested measures for enhancing rigour in quali- tative research [12]. With further analysis, the cat- egories were grouped into wider themes and sub- themes. They were constantly contrasted with the raw data to ensure that they reflected the partici- pants’ statements. Additional credibility and confirmability were achieved through peer debriefing with individuals with previous experience in conducting qualitative research, and in line with established guidelines to ensure the rigour of the methodology [12]. Mem- ber checking occurred during the interviews, whereby participants were asked to clarify mean- ings and confirm the researcher’s interpretations in real time. Transcript interpretation and other sup- porting methods, including field notes, which cap- tured tone, pauses and contextual cues, were also employed to improve trustworthiness. The analysis also included a purposeful analysis of negative or deviant cases. In this study, no partici- pants expressed unfavourable views regarding the usability or effectiveness of iAudit. All nine nurses consistently indicated that iAudit was effective and enhanced efficiency in their auditing and clin- ical responsibilities. Some participants showed more familiarity with certain system features than with others, but none reported experiences that disagreed with the general positive view. There is an explicit recognition of the lack of deviant cases in the analytic process. Through this systematic and iterative process, the data were organised into clear themes and sub- themes that accurately represent nurses’ percep- tion and experiences regarding the usability of iAudit. Ethical Considerations

The study was carried out with the endorsement of the Institutional Review Board of King Fahad Medical City, Riyadh (IRB Log No. 24-034). Pre- ceding the data collection, the objectives of the study, the voluntary nature of participation, and the right to withdraw at any time without repercus- sions were explained to all participants. Each par- ticipant gave their written agreement to participate. During the transcription process, all identifying in- formation was removed from the transcripts to protect privacy and anonymity; each participant was assigned a number for data analysis and re- porting. Only the research team had access to the password-protected computer where audio re- cordings, transcripts, and field notes were kept. Hard copies of documents were secured in a locked cabinet within a secure office. All data will be kept for the duration prescribed by institutional policy, after which it will be destroyed. These steps are in line with best standards for keeping qualitative research rigorous, open, and safe for participants [12,11]. Throughout the study, reflexivity was used to re- duce researchers’ bias and to ensure that the results reflected participants’ viewpoints rather than re- searchers’ preconceptions. The lead researcher had previously used the iAudit program and be- lieved it to be effective, easy to use, and timely. To address these preconceptions, the researcher kept a reflective notebook to record reflections and pre- sumptions during data collection and analysis. This practice is a well-known method for enhanc- ing credibility and reducing personal bias [11,12]. The professional positions of the study team, which included a Director of Nursing, a head nurse, a charge nurse, a quality nurse, and the head of the hospital’s research team, were recognised as factors that might influence participants’ re- sponses. As such, participants were guaranteed that their replies would be kept private and would not have any effect on their job, performance re- views, or position in their department. This method, in line with advice on qualitative research [12], helped level the playing field and encouraged

people to share their experiences honestly and openly [12].

Results

Demographic Profile

The study included nine nurses, most of whom were women between the ages of 31 and 40. Most participants were registered nurses, although the

sample also included a charge nurse and unit man- agers. Many participants had a lot of experience in their field; more than half said they had been nurses for more than ten years. Participants were distributed among several units of the Cardiac Centre, including the Medical/Surgical, Proce- dural, and Critical Care units, thus guaranteeing representation of a range of clinical settings.

Discussion

Nursing has an obligation to the public to establish measures for quality of care that enhance patient safety and system efficiency [13]. This study ex- plored nurses’ perceptions of the iAudit system, and participants highlighted its importance in im- proving auditing efficiency, as well as error detec- tion and correction. They also emphasised the im- pact of the system on job efficacy and effective- ness and the delivery of quality healthcare ser- vices. Results show that iAudit improves auditing effi- ciency through workflow simplification, task pri- oritisation, and standardised documentation. The literature recognises iAudit as a digital tool that supports audit processes, enabling centralised and transparent data management and ensuring high quality auditing practices and technological up- dates. It facilitates risk analysis and operational ef- ficiency, and aids decision-making [14]. Addition- ally, iAudit provides insights to help improve safety and quality standards by collecting con- sistent data, standardising procedures, and gener- ating reports. The application records performance and generates important indicators to identify ar- eas for improvement. It can also generate reports at set intervals and store historical reports for easy access at any time [9]. Digital auditing practices, team support, and man- agement all have a significant influence on audi- tors’ performance [15]. Digital transformation en- hances auditing by providing integrated system features that support audit processes [16]. With the advent of information technology, organisations have greater opportunities to improve internal au- dit performance, as such technology positively in- fluences the effectiveness of internal audit systems [17].

The nurses in this study emphasised the iAudit system’s ability to detect errors automatically, en- sure compliance with standards, and improve the auditing process, thus fostering continuous system improvement and enhancing operational trouble- shooting. Research indicates that strong internal controls and active audit committees are crucial for preventing and detecting fraud [18]. Digital au- diting technologies in the public sector allow for in-depth examination of budget fund utilisation, resulting in improved fiscal management and more effective resource allocation [19]. Further- more, the consistent application of digital technol- ogies provides a robust defense against budgetary fraud. Lastly, research has shown a clear positive correlation between the overall strength of internal controls, sophisticated accounting information systems, and efficient internal audit procedures [20]. Nurses in this study also expressed that iAudit helps to optimise staffing, improve productivity, foster motivation, and ensure accountability, all of which help create a more engaged and efficient workforce in the healthcare setting. The integra- tion of digital technology integration in auditing has clearly increased auditor satisfaction and audit efficiency [21]. Auditors can more successfully carry out their auditing responsibilities by modify- ing processes using digital tools, which will im- prove efficiency and deliver greater reliability with fewer resources [22]. Furthermore, research from Serbia indicates that digitisation significantly improves audit quality through positive shifts in auditors’ perceptions, changes in auditors’ work practices, and transfor- mations in auditors’ professional profiles [23]. Ul- timately, the utilisation of digital technologies ex- pands the opportunities for deeper client under- standing, improved documentation, reduced audit risk, and enhanced decision-making support [24]. According to the nurses in this study, iAudit’s de- ployment has greatly improved the general stand- ard of healthcare services by facilitating early de- tection and prompt correction of errors. They also

stated that, by simplifying procedures and freeing healthcare professionals to spend more time with patients rather than on administrative duties, iAu- dit has helped maintain a focus on patient-centred care. Additionally, the system enhances auditors’ data management skills, ensuring compliance with policies and procedures. Numerous studies corroborate the findings of this research, demonstrating the positive impact of in- formation technology on healthcare quality man- agement. For instance, implementing IT tools in nursing practice significantly reduces nurses’ workloads, enhances head nurses’ job satisfaction, and improves overall nursing quality [25]. Simi- larly, electronic audits have been shown to con- tribute to enhanced quality of care within hospital settings [26]. Additionally, auditing procedures are used by healthcare systems to ensure adher- ence to evidence-based practices, and studies have shown the effectiveness of electronic data collec- tion in supporting quality improvement programs [27]. Thus, the literature supports the overall use of iAu- dit as a tool, highlighting the benefits of improved documentation in enhancing care quality, patient safety, and system efficiency.

Conclusion

The quality features of iAudit include its accessi- bility, ease of use and navigation, centralised pro- gramming tools, and general user-friendliness, all of which enable accurate and timely reporting. Workflow efficiency is improved through faster execution of auditing tasks, rapid identification of problems, and less reliance on paper-based proce- dures. By eliminating paper-based and manual procedures, auditors can work more productively and focus on important assessments rather than administrative duties. In general, the ability to quickly execute tasks and integrate systems allows for more effective completion of auditing work. Practitioners are thus able to prioritise patient needs and focus on improving health outcomes with the aid of current digital auditing tools.

Limitations

Notwithstanding these encouraging results, sev- eral restrictions should be noted. First, the study was conducted in only one cardiac centre within a tertiary healthcare facility, which may limit the generalisability of the findings to other settings. Second, all participants were nurses who were al- ready involved in auditing activities, which may indicate greater familiarity with quality improve- ment practices compared with nurses who do not routinely conduct audits. Furthermore, participa- tion and perception may have been impacted by several factors that may lead to variations in per- ceived usability when user support varies. Finally, the study relied on self-reported observations, which might be affected by personal attitudes, past experiences, or departmental professional cultures. Study Implications Administrators may benefit from the study’s in- sights, as these provide clarity on the usability of iAudit and may help them make well-informed decisions. Developers can identify opportunities for software updates and determine whether addi- tional capabilities are needed, as the usability find- ings highlight the notable effects of iAudit’s use in this setting. Finally, through a deeper understand- ing of nurses’ perspectives on the effective use of iAudit to enhance the audit process, this study sup- ports managers and nursing leaders involved in quality improvement.