Connecting Professional Practice and Technology at the Bedside: Nurses' Beliefs about Using an Electronic Health Record and Their Ability to Incorporate Professional and Patient-Centered Nursing Activities in Patient Care

An integrative review exploring the impact of Electronic Health Records (EHR) on the quality of nurse-patient interactions and communication

AIM

To explore how nurses' use of electronic health records impacts on the quality of nurse-patient interactions and communication.

DESIGN

An integrative review.

DATA SOURCES

MEDLINE®, CINAHL®, PscyINFO, PubMed, BNI and Cochrane Library databases were searched for papers published between January 2005 and April 2022.

REVIEW METHODS

Following a comprehensive search, the studies were appraised using a tool appropriate to the study design. Data were extracted from the studies that met the inclusion criteria relating to sample characteristics, methods and the strength of evidence. Included empirical studies had to examine interactions or communication between a nurse and patient while electronic health records were being used in any healthcare setting. Findings were synthesized using a thematic approach.

RESULTS

One thousand nine hundred and twenty articles were initially identified but only eight met the inclusion criteria of this review. Thematic analysis revealed four key themes, indicating that EHR: impedes on face-to-face communication, promotes task-orientated and formulaic communication and impacts on types of communication patterns.

CONCLUSION

Research examining nurse-patient interactions and communication when nurses' use electronic health records is limited but evidence suggests that closed nurse-patient communications, reflecting a task-driven approach, were predominantly used when nurses used electronic health records, although some nurses were able to overcome logistical barriers and communicate more openly. Nurses' use of electronic health records impacts on the flow, nature and quality of communication between a nurse and patient.

IMPACT

The move to electronic health records has taken place largely without consideration of the impact that this might have on nurse-patient interaction and communication. There is evidence of impact but also evidence of how this might be mitigated. Nurses must focus future research on examining the impact that these systems have, and to develop strategies and practice that continue to promote the importance of nurse-patient interactions and communication.

PATIENT OR PUBLIC CONTRIBUTION

Studies examined within this review included patient participants that informed the analysis and interpretation of data.

The Relationship Between Nursing Informatics Competency and Clinical Decision-Making Among Nurses in West Bank, Palestine

This study aimed to examine the relationship between nursing informatics competencies and clinical decision-making by taking into account nurses' individual characteristics and job-related characteristics. A cross-sectional design was used. The cluster random sampling method was adopted to select 14 governmental hospitals in West Bank, Palestine, in which all nurses in these hospitals were invited to participate in this study. Results found that the total mean (SD) score for the nursing informatics competency scale was 2.6 (0.88), which indicates that the nurses had lower nursing informatics competency, and the informatics skills subscale had the lowest mean score (mean [SD], 2.4 [1.00]). Concerning clinical decision-making, the total mean (SD) score was 2.59 (0.38), which indicates that the nurses had lower clinical decision-making. Regarding clinical decision-making subscales, searching for information and unbiased assimilation of new information had the highest mean score (mean [SD], 2.64 [0.39]); on the contrary, the canvassing of objectives and values subscale had the lowest mean score (mean [SD], 2.53 [0.38]). Nursing informatics competency had a positive relationship with clinical decision-making. Thus, it is necessary to enhance nurses' informatics competency, especially informatics skills and clinical decision-making, by developing training programs about this technology directed to nurses.

Nurses' Experience and Perception of Technology Use in Practice: A Qualitative Study Using an Extended Technology Acceptance Model

The purposes of this study are to provide insight into the factors identified as benefits and drawbacks of technology use by nurses and obtain suggestions on improving technology, based on challenges identified to improve patient outcomes. Holden's extended technology acceptance model was used to describe nurses' perception of technology use in practice. A descriptive design and thematic analysis were used to evaluate participants' logged reflections of their experiences and suggestions for improvements of health information technology. Findings indicate that nurses' experiences and perceptions regarding the use of various types of technology (electronic health records, large databases, crowdsourcing, bio-surveillance) were positive. New subdomains emerged for job performance and efficiency, usefulness for public health, contribution to nursing science, and better communication. Identified challenges were insufficient training and support, lack of interoperability, risk of low-quality care from reliance on technology, increased cost, glitches, and alarm fatigue. Understanding nurses' perceptions of technology is anticipated to enhance care quality and possibly lead to improved outcomes. Nurses' perceptions of the use and acceptance of technology are important as their view is associated with performance and may directly influence clinical outcomes and patient satisfaction. Thematic findings include recommendations from participants to improve patient outcomes and patient care.

Compassionate nursing care and the use of digital health technologies: A scoping review

BACKGROUND

Compassion is an essential component of quality patient-centered care and a core value in nursing practice. Although much work has been done to enhance nurses' informatics competency, there is limited understanding of how nurses can use, express, and preserve compassion when they use digital health technologies in the provision of patient care.

PURPOSE

This study aimed to explore the nursing literature on how nurses provide compassionate care when they use digital health technologies. A secondary aim was to identify best practices that could be used to guide nursing education and practice toward enhancing compassionate care in digital environment.

METHOD

A scoping review was conducted to address the following research question: What is known about compassionate care in relation to the use of digital health technologies within the nursing literature? A comprehensive search strategy was applied to CINAHL Plus with full text, Ovid Medline, Ovid HealthStar, Embase, APAPsychINFO, Scopus, and ProQuest Dissertations and Theses. In addition, a search of selected organizational websites and a hand search of reference lists of included studies were conducted. The eligibility of articles was determined by two reviewers independently. Descriptive and content analyses were applied. Findings were presented narratively and in a tabular format.

RESULTS

Twenty-eight articles were included in this review. Most of this research was published between 2004 and 2020, using mostly qualitative methods. Narrative results were organized into three themes: 1) evolving understanding of compassionate nursing care in relation to use of digital health technology, 2) compassionate nursing care in relation to the type of digital health technology, and 3) strategies and interventions to improve education and competence relevant to digital health and compassionate nursing care.

CONCLUSION

The use of technology influences how nurses do their work and interact with patients. As advances in digital health continue to evolve, future research should aim to expand understanding of compassion relevant to digital health by articulating its characteristics and associated competencies for nurses to further enhance their ability to provide compassionate care when digital health technologies and services are used to support care delivery. Tweetable abstract: A scoping review that identified how nurses can provide compassionate nursing care in technologically rich practice environments.

Orthopaedic nurses' experiences with real-time documentation in a high-tech ward: A qualitative study

BACKGROUND

Real-time documentation is a novel process that changes nursing workflow; however, nurses' experiences of real-time documentation are unknown.

AIM

This study aimed to explore nurses' experiences with real-time documentation in an orthopaedic ward.

DESIGN

This qualitative study took a phenomenological-hermeneutic approach.

METHODS

Data were generated from three semi-structured focus group interviews with 18 nurses from an orthopaedic ward. Data analysis was based on Ricoeur's theory of narrative and interpretation and included naïve reading, structural analysis and critical interpretation, and discussion.

RESULTS

Five themes emerged from the structural analysis: 1) nurses were initially sceptical and outside of their comfort zone; 2) implementation required support from the head nurse and other colleagues; 3) increased time with patients led to better relationships, but nurses lacked time for reflection; 4) increased patient involvement could also present challenges; and 5) documentation became more integrated into orthopaedic nursing.

CONCLUSION

Real-time documentation improved orthopaedic nursing documentation and increased patient involvement. Nurses spent more time with patients, leading to better relationships, but they had decreased time with their colleagues and the opportunity to reflect. Real-time documentation leads to changes in workflow, so, nurses should be provided with training and the opportunity to reflect.

Nurses

ObjectiveThe aim of this study was to describe nurses' and midwives' experiences following the first phase of the implementation of an electronic medical record (EMR) system at a large public health service in metropolitan Melbourne, Australia.MethodsFour focus groups were held 8-10 months after implementation of the EMR. Transcripts were analysed using thematic analysis.ResultsOf 39 participants, 25 were nurses (64%), 12 were midwives (31%) and two did not provide this information. The mean (±s.d.) duration of clinical experience was 15.6±12.2 years (range 2-40 years). Three main themes were identified: (1) effects on workflow: although some participants reported that EMR facilitated easier access to real-time patient data, others indicated that workflow was disrupted by the EMR being slow and difficult to navigate, system outages and lack of interoperability between the EMR and other systems; (2) effects on patient care and communication: some participants reported that the EMR improved their communication with patients and reduced medication errors, whereas others reported a negative effect on patient care and communication; and (3) negative effects of the EMR on nurses' and midwives' personal well-being, including frustration, stress and exhaustion. These experiences were often reported in the context of cognitive workload due to having to use multiple systems simultaneously or extra work associated with EMR outages.ConclusionNurses' and midwives' experiences of the EMR were complex and mixed. Nurses and midwives require significant training and ongoing technical support in the first 12 months after implementation of an EMR system. Including nurses and midwives in the design and refinement of the EMR will ensure that the EMR aligns with their workflow.What is known about the topic?Studies reporting nurses' and midwives' experiences of using EMR are scarce and mostly based in countries where whole-of-service implementations are carried out, funded by governments.What does this paper add?Nurses and midwives perceive benefits of using an EMR relatively soon after implementation in terms of their workflow and patient care. However, in the first year after EMR implementation, nurses and midwives experience some negative effects on workflow, patient care and their own well-being. The effects on clinical workflow are further compounded by EMR downtime (scheduled and unscheduled) and hybrid systems that require users to access other technology systems alongside the EMR.What are the implications for practitioners?In countries like Australia, whole-of-service, simultaneous implementation of EMR systems using best-available server technology may not be possible due to funding constraints. In these circumstances, nurses and midwives may initially experience increased workload and frustration. Ongoing training and technical support should be provided to nurses and midwives for several months following implementation. Including nurses and midwives in the design of the EMR will result in better alignment with their specific workflow, thus maximising benefits of EMR implementation.

A systematic review of the impact of health information technology on nurses' time

OBJECTIVE

Nursing time represents one of the highest costs for most health services. We conducted a systematic review of the literature on the impact of health information technology on nurses' time.

MATERIALS AND METHODS

We followed PRISMA guidelines and searched 6 large databases for relevant articles published between Jan 2004 and December 2019. Two authors reviewed the titles, abstracts, and full texts. We included articles that included a comparison group in the design, measured the time taken to carry out documentation or medication administration, documented the quantitative estimates of time differences between the 2, had nurses as subjects, and was conducted in either a care home, hospital, or community clinic.

RESULTS

We identified a total of 1647 articles, of which 33 met our inclusion criteria. Twenty-one studies reported the impact of 12 different health information technology (HIT) implementations on nurses' documentation time. Weighted averages were calculated for studies that implemented barcode medication administration (BCMA) and 2 weighted averages for those that implemented EHRs, as these studies used different sampling units; both showed an increase in the time spent in documentation (+22% and +46%). However, the time spent carrying out medication administration following BCMA implementation fell by 33% (P < .05). HIT also caused a redistribution of nurses' time which, in some cases, was spent in more "value-adding" activities, such as delivering direct patient care as well as inter-professional communication.

DISCUSSION AND CONCLUSIONS

Most of the HIT systems increased nursing documentation time, although time fell for medication administration following BCMA. Many HIT systems also resulted in nurses spending more time in direct care and "value-adding" activities.

Electronic Health Record-Related Stress Among Nurses: Determinants and Solutions

Background: Documentation and navigation through electronic health records (EHRs) is an essential, but stressful, task. We present the magnitude, determinants of such events, and solutions proposed by nurses to address EHR-related stress (EHR-S) at a tertiary eye hospital in Saudi Arabia. Methods: Nurses of an eye hospital were surveyed in 2019 about EHR-S. A Likert scale was used to assess the responses of 10 components of EHR-related work. The total score was graded as follows: minimum (<-10), mild (<0 to -10), moderate (1-10), and severe (>11). The score was correlated with determinants. Solutions suggested by nurses to reduce stress were reviewed. Results: This survey covered 212 nurses. Of them, 106 (50%; 95% confidence interval: 43.3-56.7) reported EHR-S. The median EHR-S score was -3.0 (interquartile range: -9.0; +8.0). Thirty-five (16%) nurses reported severe EHR-S. Senior nurses (M-W, p < 0.02) and those working in emergency and recovery units (M-W, p < 0.01) had statistically higher EHR-S. The main stressors were incomplete EHR work by other departments affecting nursing care (70.8%), difficulty in correction after entering the data (60.4%), and difficulty in data retrieval (60.4%). The main solutions to reduce EHR-S were to reduce the frequency of changes to configuration of the EHR (58%), more training (54.2%), and appreciation of good work (52.8%). Conclusions: EHR-S is experienced by half of the nurses working at an eye care hospital. Implementation of solutions such as better training and fewer changes to the EHR system could reduce stress levels of nurses.

Methods used to examine technology in relation to the quality of nursing work in acute care: A systematic integrative review

AIMS AND OBJECTIVES

To systematically locate, assess and synthesise research to describe methods used to examine technology in relation to the quality of nursing work in acute care. Specific objectives were to (a) describe the types of nursing work examined; (b) describe methods used to examine technology in nursing work; (c) identify outcomes used to evaluate technology in relation to the quality of nursing work; and (d) make recommendations for future research.

BACKGROUND

New technologies can offer numerous benefits to nurses; however, it is challenging to evaluate health information technologies in relation to the quality of nurses' complex day-to-day work.

DESIGN

A systematic integrative review using a five-step process.

METHODS

Five databases were searched using search terms "nurs*," "workload," "task," "time." Data screening, extraction and interpretation were conducted independently by at least two authors and agreement verified by discussion. Data extraction followed PRISMA guidelines.

RESULTS

Of the 41 studies included, most (87.8%, n = 36) examined physical dimensions of nursing work; 31.7% (n = 13) organisational dimensions; 17.1% (n = 8) cognitive dimensions; and only 12.2% (n = 5) emotional dimensions. More than half (58.5%, n = 24) examined only one dimension; one captured all four dimensions. Most frequently examined technologies were electronic medical/health records (36.5%) and electronic medication management (19.5%). Direct observation (58.8%, n = 28) and multiple methods (19.5%, n = 8) were the most common methods; nurse tasks, frequency, duration and time distribution were variables most often measured.

CONCLUSIONS

Examinations of technology in nursing work often failed to capture the multiple dimensions of this work nor did they recognise the complexity of day-to-day nursing work in acute care. There is a paucity of literature to inform how and what technology should be measured in relation to the quality of nursing care.

RELEVANCE TO CLINICAL PRACTICE

The outcomes inform useful research methods to comprehensively examine technology to enhance the quality of complex nursing work.

Perceptions of allied health staff of the implementation of an integrated electronic medical record across regional and metropolitan settings

ObjectiveThe aim of this study was to investigate the perceptions of allied health professionals (AHPs) to implementation of an integrated electronic medical record (EMR) across both regional and metropolitan settings. MethodsThe study was conducted as a cross-sectional electronic survey. AHPs working at three hospital sites within Queensland Health were sent an electronic survey link. Participation was voluntary and recruitment via a snowball sampling technique was encouraged. Responses were analysed descriptively. ResultsIn all, 104 responders completed the survey. Responders were distributed across three sites within the selected health service, with most (75%; n=78) being at the largest site. Physiotherapy accounted for the largest number of responders (22%). Most responders were female (87%; n=90) and between 20 and 40 years of age (68%; n=71). On a scale from 0 (being anxious) to 100 (being excited), at the time EMR implementation was announced, there was a trend towards excitement (mean score 59). The most commonly reported factor hindering EMR implementation was the opportunity to practice with EMR (34%), whereas clinical ‘change champions’ were reported as the most common facilitators (61%). Overall, 60% of responders were very satisfied or satisfied with the EMR, but limited effects on efficiency and patient care were reported. ConclusionsThe results suggest an overall positive response to EMR implementation. Minimal staff reported effects such as stress or anxiety in the workplace related to EMR implementation, and a perception of ‘comfort’ was cited once EMR was part of usual practice. However, responders did not report a significant effect on speed, efficiency or quality of patient care following EMR implementation. What is known about the topic?A growing body of literature exists regarding the perceptions of staff (particularly medical officers) in moving towards EMRs, but there is limited evidence regarding the perceptions of AHPs, and the barriers and facilitators to this change. What does this paper add?This paper presents a novel perspective regarding the perceptions of AHPs regarding the implementation of an EMR and provides a perspective of the barriers and facilitators that supported a smooth transition at three sites. What are the implications for practitioners?Despite being a large-scale service change, the introduction of an EMR did not significantly increase AHPs’ subjective feelings of anxiety. Services considering EMR implementation should invest in the provision of timely information, ‘at-elbow’ support and opportunities to practice the new system.

Perspectives of nurse managers on information communication technology and e-Leadership

AIM

We sought nurse managers' perspectives on challenges and opportunities with technology and how it may influence communication and leadership.

BACKGROUND

e-Leadership is a conceptual framework used to understand and teach organisational leaders about the application of technology to leadership. Technology is integral to leadership, yet little is understood about how nurse managers may use this technology and how they negotiate the complexity of the multiple communication systems currently in use.

METHODS

Sixteen nurse managers from individual hospitals within a large US healthcare system participated in qualitative open-ended interviews and focus groups.

RESULTS

Four themes emerged from the qualitative data regarding the nurse managers' perspectives of e-Leadership and their use of information and communication technologies: (a) Can't live without it, (b) Too much, too many, (c) Poor onboarding education and (d) Difficulty maintaining virtual relationships.

IMPLICATIONS FOR NURSING MANAGEMENT

Effective and safe patient care is dependent on multiple technology applications that require significant knowledge and practice. Nursing leadership may consider the need for more supported mentorship, and engaging programs to educate nurse managers about the dozens of applications required to effectively manage and lead. For technology to be used to its full potential it should be designed with nursing involvement.