Nurses' Electronic Medical Record Workarounds in a Tertiary Teaching Hospital

A Systematic Review of Nurses' Perceptions of Electronic Health Record Usability Based on the Human Factor Goals of Satisfaction, Performance, and Safety

The poor usability of electronic health records contributes to increased nurses' workload, workarounds, and potential threats to patient safety. Understanding nurses' perceptions of electronic health record usability and incorporating human factors engineering principles are essential for improving electronic health records and aligning them with nursing workflows. This review aimed to synthesize studies focused on nurses' perceived electronic health record usability and categorize the findings in alignment with three human factor goals: satisfaction, performance, and safety. This systematic review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Five hundred forty-nine studies were identified from January 2009 to June 2023. Twenty-one studies were included in this review. The majority of the studies utilized reliable and validated questionnaires (n = 15) to capture the viewpoints of hospital-based nurses (n = 20). When categorizing usability-related findings according to the goals of good human factor design, namely, improving satisfaction, performance, and safety, studies used performance-related measures most. Only four studies measured safety-related aspects of electronic health record usability. Electronic health record redesign is necessary to improve nurses' perceptions of electronic health record usability, but future efforts should systematically address all three goals of good human factor design.

Impacts of technology implementation on nurses' work motivation, engagement, satisfaction and well-being: A realist review

AIM

To examine current literature for causal explanations on how, why and under what circumstances, implementation of a new hospital electronic medical record system or similar technology impacts nurses' work motivation, engagement, satisfaction or well-being.

BACKGROUND

Implementation of new technology, such as electronic medical record systems, affects nurses and their work, workflows and inter-personal interactions in healthcare settings. Multiple individual and organisational-level factors can affect technology adoption by nurses and may have negative consequences for nurses and patient safety.

DESIGN

Five-step realist review method and Realist And Meta-narrative Evidence Syntheses: Evolving Standards checklist was used to guide this review. Eight initial theories (programme theories) were used as the basis to explore, examine and refine literature from a range of sources.

DATA SOURCES

Literature from five databases (APA PsycInfo, CINAHL, Embase, IEEE Xplore and MEDLINE Complete) and grey literature (from 1 January 2000 to 31 October 2021) were systematically searched and retrieved on 4 November 2021.

RESULTS

In all, 8980 records were screened at the title and abstract level, of which 1027 full texts were screened and 10 were included in the review. Seven studies assessed concepts in both pre- and post-technology implementation. Most common contexts related to knowledge, rationale and skills to use new technology. Mechanisms that impacted nurses or nursing care delivery included: nurses' involvement in technology implementation processes; nurses' perceptions, understanding and limitations of technology impact(s) on patient care delivery; social supports; skills; implementation attitude and hardware. Work satisfaction was the most frequently examined outcome. An analysis led to nine final programme theories (including two original, six revised and one new programme theory).

CONCLUSION

Nurses must be informed about the rationale for new technology and have the knowledge and skills for its use. Understanding nurses' work motivation and attitudes related to technology adoption in the workplace can support work engagement, satisfaction and well-being.

IMPLICATIONS FOR THE PROFESSION

Complex contexts and mechanisms play a role in nurses' work motivation, engagement, satisfaction and well-being with the implementation of new technology into healthcare settings.

RELEVANCE TO CLINICAL PRACTICE

Nurses, their work and workflows are all influenced by the implementation of new technologies (such as electronic medical records), which in turn has consequences for patient safety and quality of care.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

PROSPERO REGISTRATION NUMBER

CRD42020131875 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=131875).

Woman-centred care and integrated electronic medical records within Australian maternity settings: Point prevalence audit and observational study

OBJECTIVE

Transition to paperless records brings new challenges to midwifery practice across the continuum of woman-centred care. There is limited and conflicting evidence on the relative benefits of electronic medical records in maternity settings. This article aims to inform the use of integrative electronic medical records within the maternity services' environment with attention to the midwife-woman relationship.

DESIGN

This descriptive two-part study includes 1) an audit of electronic records in the early period following implementation (2-time points); and 2) an observational study to observe midwives' practice relating to electronic record use.

SETTING

Two regional tertiary public hospitals PARTICIPANTS: Midwives providing care for childbearing women across antenatal, intrapartum and postnatal areas.

FINDINGS

400 integrated electronic medical records were audited for completeness. Most fields had high levels of complete data in the correct location. However, between time 1 (T1) and time 2 (T2), persistent missing data (foetal heart rate documented 30 minutely T1 36%; T2 42%), and incomplete or incorrectly located data (pathology results T1:63%; T2 54%; perineal repair T1 60%; T2 46%) were identified. Observationally, midwives were actively engaged with the integrative electronic medical record between 23% to 68% (median 46%; IQR 16) of the time.

CONCLUSION

Midwives spent a significant amount of time completing documentation during clinical episodes of care. Largely, this documentation was found to be accurate, yet exceptions to data completeness, precision and location remained, indicating some concerns with software usability.

IMPLICATIONS FOR PRACTICE

Time-intensive monitoring and documentation may hinder woman-centred midwifery care.

Validity and Reliability Testing of an Instrument Measuring Nurses' Experiences With Electronic Medical Record-Related Unintended Adverse Consequences and Statistical Interpretations of Exploratory Factor Analysis Outputs

Background and Purpose: Nurses frequently experience unintended consequences of health information technology implementation. The study aimed to test the validity and reliability of a new instrument to measure nurses' experiences with the unintended adverse consequences of electronic medical record use. Methods: The psychometric properties of the developed 21 items were examined using a convenience purposive sample of 287 nurses from eight hospitals. Results: The content validity index was 1.00. The sample was adequate to proceed with exploratory factor analysis. Four factors were clustered with factor loadings between 0.43 and 0.82. The variance explanatory proportion was 63.1%. Cronbach's alpha was .93. Conclusions: The psychometric testing results indicated that the instrument was valid and reliable. The instrument can serve as an indicator of unintended consequences of health information technology implementation.

Workarounds in Electronic Health Record Systems and the Revised Sociotechnical Electronic Health Record Workaround Analysis Framework: Scoping Review

BACKGROUND

Electronic health record (EHR) system users devise workarounds to cope with mismatches between workflows designed in the EHR and preferred workflows in practice. Although workarounds appear beneficial at first sight, they frequently jeopardize patient safety, the quality of care, and the efficiency of care.

OBJECTIVE

This review aims to aid in identifying, analyzing, and resolving EHR workarounds; the Sociotechnical EHR Workaround Analysis (SEWA) framework was published in 2019. Although the framework was based on a large case study, the framework still required theoretical validation, refinement, and enrichment.

METHODS

A scoping literature review was performed on studies related to EHR workarounds published between 2010 and 2021 in the MEDLINE, Embase, CINAHL, Cochrane, or IEEE databases. A total of 737 studies were retrieved, of which 62 (8.4%) were included in the final analysis. Using an analytic framework, the included studies were investigated to uncover the rationales that EHR users have for workarounds, attributes characterizing workarounds, possible scopes, and types of perceived impacts of workarounds.

RESULTS

The SEWA framework was theoretically validated and extended based on the scoping review. Extensive support for the pre-existing rationales, attributes, possible scopes, and types of impact was found in the included studies. Moreover, 7 new rationales, 4 new attributes, and 3 new types of impact were incorporated. Similarly, the descriptions of multiple pre-existing rationales for workarounds were refined to describe each rationale more accurately.

CONCLUSIONS

SEWA is now grounded in the existing body of peer-reviewed empirical evidence on EHR workarounds and, as such, provides a theoretically validated and more complete synthesis of EHR workaround rationales, attributes, possible scopes, and types of impact. The revised SEWA framework can aid researchers and practitioners in a wider range of health care settings to identify, analyze, and resolve workarounds. This will improve user-centered EHR design and redesign, ultimately leading to improved patient safety, quality of care, and efficiency of care.