A Systematic Review of Nurses' Experiences With Unintended Consequences When Using the Electronic Health Record

The Solutions in Health Analytics for Rural Equity Across the Northwest (SHARE-NW) Dashboard for Health Equity in Rural Public Health: Usability Evaluation

BACKGROUND

Given the dearth of resources to support rural public health practice, the solutions in health analytics for rural equity across the northwest dashboard (SHAREdash) was created to support rural county public health departments in northwestern United States with accessible and relevant data to identify and address health disparities in their jurisdictions. To ensure the development of useful dashboards, assessment of usability should occur at multiple stages throughout the system development life cycle. SHAREdash was refined via user-centered design methods, and upon completion, it is critical to evaluate the usability of SHAREdash.

OBJECTIVE

This study aims to evaluate the usability of SHAREdash based on the system development lifecycle stage 3 evaluation goals of efficiency, satisfaction, and validity.

METHODS

Public health professionals from rural health departments from Washington, Idaho, Oregon, and Alaska were enrolled in the usability study from January to April 2022. The web-based evaluation consisted of 2 think-aloud tasks and a semistructured qualitative interview. Think-aloud tasks assessed efficiency and effectiveness, and the interview investigated satisfaction and overall usability. Verbatim transcripts from the tasks and interviews were analyzed using directed content analysis.

RESULTS

Of the 9 participants, all were female and most worked at a local health department (7/9, 78%). A mean of 10.1 (SD 1.4) clicks for task 1 (could be completed in 7 clicks) and 11.4 (SD 2.0) clicks for task 2 (could be completed in 9 clicks) were recorded. For both tasks, most participants required no prompting-89% (n=8) participants for task 1 and 67% (n=6) participants for task 2, respectively. For effectiveness, all participants were able to complete each task accurately and comprehensively. Overall, the participants were highly satisfied with the dashboard with everyone remarking on the utility of using it to support their work, particularly to compare their jurisdiction to others. Finally, half of the participants stated that the ability to share the graphs from the dashboard would be "extremely useful" for their work. The only aspect of the dashboard cited as problematic is the amount of missing data that was present, which was a constraint of the data available about rural jurisdictions.

CONCLUSIONS

Think-aloud tasks showed that the SHAREdash allows users to complete tasks efficiently. Overall, participants reported being very satisfied with the dashboard and provided multiple ways they planned to use it to support their work. The main usability issue identified was the lack of available data indicating the importance of addressing the ongoing issues of missing and fragmented public health data, particularly for rural communities.

Understanding the role and impact of electronic health records in labor and delivery nursing practice: A scoping review protocol

Background

Electronic health records have a significant impact on nursing practice, particularly in specializations such as labor and delivery, or acute care maternity nursing practice. Although primary studies on the use of electronic health records in labor and delivery have been done, no reviews on this topic exist. Moreover, the topic of labor and delivery nurses' organizing work in the electronic health record-enabled context has not been addressed.

Objective

To (a) synthesize research on electronic health record use in labor and delivery nursing and (b) map how labor and delivery nursing organizing work is transformed by the electronic health record (as described in the reviewed studies).

Methods

The scoping review will be guided by a modified methodology based on selected recommendations from the Joanna Briggs Institute and the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews. A comprehensive search will be conducted in the following databases: CINAHL Complete, MEDLINE, Academic Search Complete, Web of Science, Scopus and Dissertations and Theses Abstracts and Indexes. Included sources will be primary research, dissertations, or theses that address the use of electronic health records in labor and delivery nursing practice in countries with high levels of electronic health record adoption. Data extracted from included sources will be analyzed thematically. Further analysis will theorize labor and delivery nurses' organizing work in the context of electronic health record use by utilizing concepts from Davina Allen's Translational Mobilization Theory. Findings will be presented in tabular and descriptive formats.

Conclusion

The findings of this review will help understand transformations of nursing practice in the electronic health record-enabled labor and delivery context and identify areas of future research. We will propose an extension of the Translational Mobilization Theory and theorize nurses' organizing work involving the use of the electronic health record.

Clinical decision-making and the nursing process in digital health systems: An integrated systematic review

AIMS

To identify how the nursing process (assessment, planning, intervention and outcome evaluation) has been incorporated into digital health systems (electronic medical records, electronic care plans and clinical decision support systems) to gain an understanding of known benefits and challenges posed to nurses' decision-making processes.

BACKGROUND

Nursing terminologies, including the International Classification for Nursing Practice (ICNP), and Nursing Minimum Data Set's (NMDS), have been developed to improve standardised language integration of components of nursing care into digital systems. However, there is limited evidence regarding whether the complete nursing process is effectively being incorporated into digital health systems.

METHODS

An integrative systematic review following PRISMA guidelines. A search strategy was applied to extract articles from included databases: CINAHL, MEDLINE, SCOPUS and Web of Science Core Collection. Articles were limited to English language and published January 2007-March 2022 and assessed using a pre-determined eligibility criteria. Quality assessment and a narrative synthesis were conducted.

RESULTS

A total of 3321 articles were identified, and 27 studies included. There were (n = 10) qualitative, (n = 4) quantitative non-randomised controlled trials, (n = 3) quantitative descriptive studies and (n = 10) mixed methods. Nurse assessment and planning components were the most comprehensive phases incorporated into digital health systems, and interventions and outcome evaluation were scarcely reported.

CONCLUSIONS

Inadequate capture of nursing work is a problem unresolved by digital health systems. This omission may be hindering nurse clinical decision-making for patient care and limiting the visibility of the nursing role in health care interventions and the associated impact on patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

Further research is needed on how digital systems can support nurses to apply the full nursing process and to further evaluate patient outcomes. Digital systems can support health-service level evaluation through capturing missed nursing care and the consequences on patients utilising nurse-sensitive-outcomes; however, this is not yet being realised.

Examining Care Planning Efficiency and Clinical Decision Support Adoption in a System Tailoring to Nurses' Graph Literacy: National, Web-Based Randomized Controlled Trial

BACKGROUND

The proliferation of health care data in electronic health records (EHRs) is fueling the need for clinical decision support (CDS) that ensures accuracy and reduces cognitive processing and documentation burden. The CDS format can play a key role in achieving the desired outcomes. Building on our laboratory-based pilot study with 60 registered nurses (RNs) from 1 Midwest US metropolitan area indicating the importance of graph literacy (GL), we conducted a fully powered, innovative, national, and web-based randomized controlled trial with 203 RNs.

OBJECTIVE

This study aimed to compare care planning time (CPT) and the adoption of evidence-based CDS recommendations by RNs randomly assigned to 1 of 4 CDS format groups: text only (TO), text+table (TT), text+graph (TG), and tailored (based on the RN's GL score). We hypothesized that the tailored CDS group will have faster CPT (primary) and higher adoption rates (secondary) than the 3 nontailored CDS groups.

METHODS

Eligible RNs employed in an adult hospital unit within the past 2 years were recruited randomly from 10 State Board of Nursing lists representing the 5 regions of the United States (Northeast, Southeast, Midwest, Southwest, and West) to participate in a randomized controlled trial. RNs were randomly assigned to 1 of 4 CDS format groups-TO, TT, TG, and tailored (based on the RN's GL score)-and interacted with the intervention on their PCs. Regression analysis was performed to estimate the effect of tailoring and the association between CPT and RN characteristics.

RESULTS

The differences between the tailored (n=46) and nontailored (TO, n=55; TT, n=54; and TG, n=48) CDS groups were not significant for either the CPT or the CDS adoption rate. RNs with low GL had longer CPT interacting with the TG CDS format than the TO CDS format (P=.01). The CPT in the TG CDS format was associated with age (P=.02), GL (P=.02), and comfort with EHRs (P=.047). Comfort with EHRs was also associated with CPT in the TT CDS format (P<.001).

CONCLUSIONS

Although tailoring based on GL did not improve CPT or adoption, the study reinforced previous pilot findings that low GL is associated with longer CPT when graphs were included in care planning CDS. Higher GL, younger age, and comfort with EHRs were associated with shorter CPT. These findings are robust based on our new innovative testing strategy in which a diverse national sample of RN participants (randomly derived from 10 State Board of Nursing lists) interacted on the web with the intervention on their PCs. Future studies applying our innovative methodology are recommended to cost-effectively enhance the understanding of how the RN's GL, combined with additional factors, can inform the development of efficient CDS for care planning and other EHR components before use in practice.

Unintended consequences of pharmacy information systems: A case study

BACKGROUND

Pharmacy information systems (PhIS) can cause medication errors that pharmacists may overlook due to their increased workload and lack of understanding of maintaining information quality. This study seeks to identify factors influencing unintended consequences of PhIS and how they affect the information quality, which can pose a risk to patient safety.

MATERIALS AND METHODS

This qualitative, explanatory case study evaluated PhIS in ambulatory pharmacies in a hospital and a clinic. Data were collected through observations, interviews, and document analysis. We applied the socio-technical interactive analysis (ISTA) framework to investigate the socio-technical interactions of pharmacy information systems that lead to unintended consequences. We then adopted the human-organization-process-technology-fit (HOPT-fit) framework to identify their contributing and dominant factors, misfits, and mitigation measures.

RESULTS

We identified 28 unintended consequences of PhIS, their key contributing factors, and their interrelations with the systems. The primary causes of unintended consequences include system rigidity and complexity, unclear knowledge, understanding, skills, and purpose of using the system, use of hybrid paper and electronic documentation, unclear and confusing transitions, additions and duplication of tasks and roles in the workflow, and time pressure, causing cognitive overload and workarounds. Recommended mitigating mechanisms include human factor principles in system design, data quality improvement for PhIS in terms of effective use of workspace, training, PhIS master data management, and communication by standardizing workarounds.

CONCLUSION

Threats to information quality emerge in PhIS because of its poor design, a failure to coordinate its functions and clinical tasks, and pharmacists' lack of understanding of the system use. Therefore, safe system design, fostering awareness in maintaining the information quality of PhIS and cultivating its safe use in organizations is essential to ensure patient safety. The proposed evaluation approach facilitates the evaluator to identify complex socio-technical interactions and unintended consequences factors, impact, and mitigation mechanisms.

Electronic Health Record Stress and Burnout Among Clinicians in Hospital Settings: A Systematic Review

Background

There is growing evidence to suggest that EHRs may be associated with clinician stress and burnout, which could hamper their effective use and introduce risks to patient safety.

Objective

This systematic review aimed to examine the association between EHR use and clinicians' stress and burnout in hospital settings, and to identify the contributing factors influencing this relationship.

Methods

The search included peer-reviewed published studies between 2000 and 2023 in English in CINAHL, Ovid Medline, Embase, and PsychINFO. Studies that provided specific data regarding clinicians' stress and/or burnout related to EHRs in hospitals were included. A quality assessment of included studies was conducted.

Results

Twenty-nine studies were included (25 cross-sectional surveys, one qualitative study, and three mixed methods), which focused on physicians (n = 18), nurses (n = 10) and mixed professions (n = 3). Usability issues and the amount of time spent on the EHR were the most significant predictors, but intensity of the working environment influenced high EHR-related workload and thereby also contributed to stress and burnout. The differences in clinicians' specialties influenced the levels of stress and burnout related to EHRs.

Conclusions

This systematic review showed that EHR use was a perceived contributor to clinicians' stress and burnout in hospitals, primarily driven by poor usability and excessive time spent on EHRs. Addressing these issues requires tailored EHR systems, rigorous usability testing, support for the needs of different specialities, qualitative research on EHR stressors, and expanded research in Non-Western contexts.

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.

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.

The Alliance for Healthier Communities as a Learning Health System for primary care: A qualitative analysis in Ontario, Canada

RATIONALE, AIMS AND OBJECTIVES

A learning health system model can be used to efficiently evaluate and incorporate evidence-based care into practice. However, there is a paucity of evidence describing key organizational attributes needed to ensure a successful learning health system within primary care. We interviewed stakeholders for a primary care learning health system in Ontario, Canada (the Alliance for Healthier Communities) to identify strengths and areas for improvement.

METHOD

We conducted a qualitative descriptive study using individual semistructured interviews with Alliance stakeholders between December 2019 and March 2020. The Alliance delivers community-governed primary healthcare through 109 organizations including Community Health Centres (CHCs). All CHC staff within the Alliance were invited to participate. Interviews were audio-recorded and transcribed verbatim. We performed a thematic analysis using a team approach.

RESULTS

We interviewed 29 participants across six CHCs, including Executive Directors, managers, healthcare providers and data support staff. We observed three foundational elements necessary for a successful learning health system within primary care: shared organizational goals and culture, data quality and resources. Building on this foundation, people are needed to drive the learning health system, and this is conditional on their level of engagement. The main factors motivating staff member's engagement with the learning health system included their drive to help improve patient care, focusing on initiatives of personal interest and understanding the purpose of different initiatives. Areas for improvement were identified such as the ability to extract and use data to inform changes in real-time, better engagement and protected time for providers to do improvement work, and more staff dedicated to data extraction and analysis.

CONCLUSIONS

We identified key components needed to establish a learning health system in primary care. Similar primary care organizations in Canada and elsewhere can use these insights to guide their development as learning health systems.

Effects of patient accessible electronic health records on nurses' work environment: a survey study on expectations in Sweden

OBJECTIVES

The introduction of information and communication technology influences the work environment of large groups of employees in healthcare. In Sweden, a national healthcare service providing patient accessible electronic health records (PAEHR) has been deployed, and this paper investigates nurses' expected effects of this implementation.

SETTING

Nurses associated with the Swedish Association of Health Professionals working in healthcare such as primary care, hospitals and midwives in Sweden. Before a full-scale national implementation of PAEHR, a web survey study was distributed nationally. The respondents represented all 21 Swedish regions. Questions included five-point Likert scale questions and open questions.

PARTICIPANTS

A survey link was distributed via email to 8460 registered nurses, midwives and union representatives in Sweden. The response rate was 35.4% (2867 respondents: registered nurses 84%; midwives 6%; chief position 5%; in projects 2% and other 3%). Three reminders were sent out, all of them increasing the response rate. A majority of the respondents were female (89.9%), 8.4% male, whereas 1.7% did not indicate their gender. 31.4% were under 40 years old, 53.8% 40-59 and 13.7% over 60.

RESULTS

Data were analysed using exploratory factor analysis with principal component analysis as the extraction method. The analysis revealed three distinct factors related to nurses' expectations of PAEHR: (1) PAEHR improves the quality of care, (2) PAEHR improves the quality of the work environment and (3) risk and fears concerning patients' well-being. Some interesting results include that more experienced nurses are more favourable to PAEHR. Our analysis also shows that the view of the nurse-patient relationship is an essential underlying factor related to positive or negative expectations.

CONCLUSIONS

Results show that the expectations and perceptions of PAEHR vary depending on the nurse's view of who the electronic record belongs to. Younger nurses are somewhat more negative towards PAEHR than older nurses.

Identifying and adapting interventions to reduce documentation burden and improve nurses' efficiency in using electronic health record systems (The IDEA Study): protocol for a mixed methods study

Background

Although EHR systems have become a critical part of clinical care, nurses are experiencing a growing burden due to documentation requirements, taking time away from other important clinical activities. There is a need to address the inefficiencies and challenges that nurses face when documenting in and using EHRs. The objective of this study is to engage nurses in generating ideas on how organizations can support and optimize nurses’ experiences with their EHR systems, thereby improving efficiency and reducing EHR-related burden. This work will ensure the identified solutions are grounded in nurses’ perspectives and experiences and will address their specific EHR-related needs.

Methods

This mixed methods study will consist of three phases. Phase 1 will evaluate the accuracy of the EHR system’s analytics platform in capturing how nurses utilize the system in real-time for tasks such as documentation, chart review, and medication reconciliation. Phase 2 consists of a retrospective analysis of the nursing-specific analytics platform and focus groups with nurses to understand and contextualize their usage patterns. These focus groups will also be used to identify areas for improvement in the utilization of the EHR. Phase 3 will include focus groups with nurses to generate and adapt potential interventions to address the areas for improvement and assess the perceived relevance, feasibility, and impact of the potential interventions.

Discussion

This work will generate insights on addressing nurses’ EHR-related burden and burnout. By understanding and contextualizing inefficiencies and current practices, opportunities to improve EHR systems for nursing professional practice will be identified. The study findings will inform the co-design and implementation of interventions that will support adoption and impact. Future work will include the evaluation of the developed interventions, and research on scaling and disseminating the interventions for use in different organizations, EHR systems, and jurisdictions in Canada.

Nurses’ Experiences After Implementation of an Organization-Wide Electronic Medical Record: Qualitative Descriptive Study

Background

Reports on the impact of electronic medical record (EMR) systems on clinicians are mixed. Currently, nurses’ experiences of adopting a large-scale, multisite EMR system have not been investigated. Nurses are the largest health care workforce; therefore, the impact of EMR implementation must be investigated and understood to ensure that patient care quality, changes to nurses’ work, and nurses themselves are not negatively impacted.

Objective

This study aims to explore Australian nurses’ postimplementation experiences of an organization-wide EMR system.

Methods

This qualitative descriptive study used focus group and individual interviews and an open-ended survey question to collect data between 12 and 18 months after the implementation of an EMR across 6 hospital sites of a large health care organization in Victoria, Australia. Data were collected between November 2020 and June 2021, coinciding with the COVID-19 pandemic. Analysis comprised complementary inductive and deductive approaches. Specifically, reflexive thematic analysis was followed by framework analysis by the coding of data as barriers or facilitators to nurses’ use of the EMR using the Theoretical Domains Framework.

Results

A total of 158 nurses participated in this study. The EMR implementation dramatically changed nurses’ work and how they viewed their profession, and nurses were still adapting to the EMR implementation 18 months after implementation. Reflexive thematic analysis led to the development of 2 themes: An unintentional divide captured nurses’ feelings of division related to how using the EMR affected nurses, patient care, and the broader nursing profession. This time, it’s personal detailed nurses’ beliefs about the EMR implementation leading to bigger changes to nurses as individuals and nursing as a profession than other changes that nurses have experienced within the health care organization. The most frequent barriers to EMR use by nurses were related to the Theoretical Domains Framework domain of environmental context and resources. Facilitators of EMR use were most often related to memory, attention, and decision processes. Most barriers and facilitators were related to motivation.

Conclusions

Nurses perceived EMR implementation to have a mixed impact on the provision of quality patient care and on their colleagues. Implementing technology in a health care setting was perceived as a complex endeavor that impacted nurses’ perceptions of their autonomy, ways of working, and professional roles. Potential negative consequences were related to nursing workforce retention and patient care delivery. Motivation was the main behavioral driver for nurses’ adoption of EMR systems and hence a key consideration for implementing interventions or organizational changes directed at nurses.

Impact of Electronic Health Records on Information Practices in Mental Health Contexts: Scoping Review

Background

The adoption of electronic health records (EHRs) and electronic medical records (EMRs) has been slow in the mental health context, partly because of concerns regarding the collection of sensitive information, the standardization of mental health data, and the risk of negatively affecting therapeutic relationships. However, EHRs and EMRs are increasingly viewed as critical to improving information practices such as the documentation, use, and sharing of information and, more broadly, the quality of care provided.

Objective

This paper aims to undertake a scoping review to explore the impact of EHRs on information practices in mental health contexts and also explore how sensitive information, data standardization, and therapeutic relationships are managed when using EHRs in mental health contexts.

Methods

We considered a scoping review to be the most appropriate method for this review because of the relatively recent uptake of EHRs in mental health contexts. A comprehensive search of electronic databases was conducted with no date restrictions for articles that described the use of EHRs, EMRs, or associated systems in the mental health context. One of the authors reviewed all full texts, with 2 other authors each screening half of the full-text articles. The fourth author mediated the disagreements. Data regarding study characteristics were charted. A narrative and thematic synthesis approach was taken to analyze the included studies’ results and address the research questions.

Results

The final review included 40 articles. The included studies were highly heterogeneous with a variety of study designs, objectives, and settings. Several themes and subthemes were identified that explored the impact of EHRs on information practices in the mental health context. EHRs improved the amount of information documented compared with paper. However, mental health–related information was regularly missing from EHRs, especially sensitive information. EHRs introduced more standardized and formalized documentation practices that raised issues because of the focus on narrative information in the mental health context. EHRs were found to disrupt information workflows in the mental health context, especially when they did not include appropriate templates or care plans. Usability issues also contributed to workflow concerns. Managing the documentation of sensitive information in EHRs was problematic; clinicians sometimes watered down sensitive information or chose to keep it in separate records. Concerningly, the included studies rarely involved service user perspectives. Furthermore, many studies provided limited information on the functionality or technical specifications of the EHR being used.

Conclusions

We identified several areas in which work is needed to ensure that EHRs benefit clinicians and service users in the mental health context. As EHRs are increasingly considered critical for modern health systems, health care decision-makers should consider how EHRs can better reflect the complexity and sensitivity of information practices and workflows in the mental health context.

Change in nurses’ psychosocial characteristics pre- and post-electronic medical record system implementation coinciding with the SARS-CoV-2 pandemic: pre- and post-cross-sectional surveys

Background

The impacts of electronic medical record implementation on nurses, the largest healthcare workforce, have not been comprehensively examined. Negative impacts on nurses have implications for quality of patient care delivery and workforce retention.

Objective

To investigate changes in nurses’ well-being, intention to stay, burnout, work engagement, satisfaction, motivation and experience using technology pre- and post-implementation of an organisation-wide electronic medical record in Victoria, Australia.

Methods

The natural experiment comprised an electronic medical record system implementation across six hospitals of a large tertiary healthcare organisation. Cross-sectional surveys were collected pre-electronic medical record implementation prior to the SARS-CoV-2 pandemic in 2019, and 18-months post-electronic medical record implementation during the pandemic in 2020, and findings compared.

Results

A total of 942 surveys were analysed (550 pre-electronic medical record (response rate 15.52%) and 392 post-electronic medical record (response rate 9.50%)). Post-electronic medical record, nurses’ work satisfaction (r = 0.23, p=<0.001), intention to stay (r = 0.11, p = 0.001) and well-being (r = 0.17, p=<0.001) decreased. Nurses’ perceived competence increased (r = 0.10, p = 0.002) despite decreased autonomy (r = 0.10, p = 0.003). Two of three dimensions of work engagement worsened (vigour r = 0.13, p=<0.001; dedication r = 0.13, p=<0.001) and all dimensions of burnout increased (exhaustion r = 0.08, p = 0.012, cynicism r = 0.07, p = 0.04 and reduced efficiency r = 0.32, p=<0.001). Nurses reported more burnout symptoms (95% CI 4.6–4.7%, p = 0.036), were less engaged (95% CI 49.6–49.9%, p=<0.001) and career trajectory satisfaction decreased (r = 0.15, p=<0.001). Matched data from 52 nurses showed changes in the same direction for all items except career trajectory satisfaction, hence validated findings from the larger unmatched sample.

Conclusions

Implementation of an electronic medical record immediately followed by the SARS-CoV-2 pandemic was associated with negative changes in nurses’ well-being, intention to stay, burnout, work engagement and satisfaction.

Evaluation of an Electronic Medical Record Module for Nursing Documentation in Paediatric Palliative Care: Involvement of Nurses with a Think-Aloud Approach

BACKGROUND

Paediatric palliative care (PPC) is a noncurative approach to the care of children and adolescents with life-limiting and life-threatening illnesses. Electronic medical records (EMRs) play an important role in documenting such complex processes. Despite their benefits, they can introduce unintended consequences if future users are not involved in their development.

AIM

The aim of this study was to evaluate the acceptance of a novel module for nursing documentation by nurses working in the context of PPC.

METHODS

An observational study employing concurrent think-aloud and semi-structured qualitative interviews were conducted with 11 nurses working in PPC. Based on the main determinants of the unified theory of acceptance and use of technology (UTAUT), data were analysed using qualitative content analysis.

RESULTS

The main determinants of UTAUT were found to potentially influence acceptance of the novel module. Participants perceived the module to be self-explanatory and intuitive. Some adaptations, such as the reduction of fragmentation in the display, the optimization of confusing mouseover fields, and the use of familiar nursing terminology, are reasonable ways of increasing software adoption.

CONCLUSIONS

After adaptation of the modules based on the results, further evaluation with the participation of future users is required.

Barriers to Adoption of Electronic Health Record Systems from the Perspective of Nurses: A Cross-sectional Study

This study report aimed to investigate the barriers to implementation of electronic health record systems from the perspective of nurses. The research data comprised responses from nurses working in a university hospital. Our data collection instruments were the Participant Information Form and EHR Nurse Opinion Questionnaire, which were developed by the researchers. Data analysis was presented as summary statistics, including mean values of variables, standard deviation, frequency, and percentages. A total of 160 nurses participated in the study. The mean age of participants was 30.94 ± 0.59 years, and 77.5% were university graduates. Barriers to adoption of the electronic health record system included high number of patients (82.8%), limited time (79%), lack of knowledge and skills for effective use of the system (22.9%), lack of user-friendly interface and inability to create a common language within the team (17.8%), and attachment to the traditional method (17.2%). Although most nurses thought that the electronic health record system offered some advantages, they reported that factors such as large numbers of patients, limited time, and lack of user-friendly interface hindered its adoption. Innovative strategies should be explored to develop user-friendly designs for electronic health records and to produce solutions for nursing shortages to increase the time allocated for patient care.

The information system stress, informatics competence and well-being of newly graduated and experienced nurses: a cross-sectional study

BACKGROUND

The use of information systems takes up a significant amount of nurses' daily working time. Increased use of the systems requires nurses to have adequate competence in nursing informatics and is known to be a potential source of stress. However, little is known about the role of nursing informatics competence and stress related to information systems (SRIS) in the well-being of nurses. Moreover, the potential impact of nurses' career stage on this matter is unknown. This study examined whether SRIS and nursing informatics competence are associated with stress and psychological distress in newly graduated nurses (NGNs) and experienced nurses.

METHODS

A cross-sectional study was conducted in Finland between October and December 2018. The participants were NGNs (n = 712) with less than two years of work experience and experienced nurses (n = 1226) with more than two years of work experience. The associations of nursing informatics and SRIS with nurses' stress and psychological distress were analyzed with linear regression analysis. Analyses were conducted separately for NGNs and experienced nurses. Models were adjusted for age, gender, and work environment.

RESULTS

SRIS was associated with stress / psychological distress for both NGNs (β = 0.26 p < 0.001 / β = 0.22 p < 0.001) and experienced nurses (β = 0.21 p < 0.001/ β = 0.12 p < 0.001). Higher nursing informatics competence was associated with lower stress (β = 0.20 p < 0.001) and psychological distress (β = 0.16 p < 0.001) in NGNs, but not among experienced nurses.

CONCLUSIONS

SRIS appears to be an equal source of stress and distress for nurses who are starting their careers and for more experienced nurses, who are also likely to be more experienced users of information systems. However, informatics competence played a more important role among NGNs and a lack of adequate competence seems to add to the strain that is already known to be high in the early stages of a career. It would be important for educational institutions to invest in nursing informatics so that new nurses entering the workforce have sufficient skills to work in increasingly digital health care.

Implementation of Electronic Medical Records in Mental Health Settings: Scoping Review

BACKGROUND

The success of electronic medical records (EMRs) is dependent on implementation features, such as usability and fit with clinical processes. The use of EMRs in mental health settings brings additional and specific challenges owing to the personal, detailed, narrative, and exploratory nature of the assessment, diagnosis, and treatment in this field. Understanding the determinants of successful EMR implementation is imperative to guide the future design, implementation, and investment of EMRs in the mental health field.

OBJECTIVE

We intended to explore evidence on effective EMR implementation for mental health settings and provide recommendations to support the design, adoption, usability, and outcomes.

METHODS

The scoping review combined two search strategies that focused on clinician-facing EMRs, one for primary studies in mental health settings and one for reviews of peer-reviewed literature in any health setting. Three databases (Medline, EMBASE, and PsycINFO) were searched from January 2010 to June 2020 using keywords to describe EMRs, settings, and impacts. The Proctor framework for implementation outcomes was used to guide data extraction and synthesis. Constructs in this framework include adoption, acceptability, appropriateness, feasibility, fidelity, cost, penetration, and sustainability. Quality assessment was conducted using a modified Hawker appraisal tool and the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses.

RESULTS

This review included 23 studies, namely 12 primary studies in mental health settings and 11 reviews. Overall, the results suggested that adoption of EMRs was impacted by financial, technical, and organizational factors, as well as clinician perceptions of appropriateness and acceptability. EMRs were perceived as acceptable and appropriate by clinicians if the system did not interrupt workflow and improved documentation completeness and accuracy. Clinicians were more likely to value EMRs if they supported quality of care, were fit for purpose, did not interfere with the clinician-patient relationship, and were operated with readily available technical support. Evidence on the feasibility of the implemented EMRs was mixed; the primary studies and reviews found mixed impacts on documentation quality and time; one primary study found downward trends in adverse events, whereas a review found improvements in care quality. Five papers provided information on implementation outcomes such as cost and fidelity, and none reported on the penetration and sustainability of EMRs.

CONCLUSIONS

The body of evidence relating to EMR implementation in mental health settings is limited. Implementation of EMRs could benefit from methods used in general health settings such as co-designing the software and tailoring EMRs to clinical needs and workflows to improve usability and acceptance. Studies in mental health and general health settings rarely focused on long-term implementation outcomes such as penetration and sustainability. Future evaluations of EMRs in all settings should consider long-term impacts to address current knowledge gaps.

Effectiveness of nudges as a tool to promote adherence to guidelines in healthcare and their organizational implications: A systematic review

The shift in the United States in recent years toward value-based healthcare delivery models has brought renewed pressure on healthcare organizations to improve adherence to clinical and administrative guidelines designed to deliver high quality care at lower costs. However, getting clinicians to adhere to these guidelines remains a persistent problem for many organizations. The use of nudges has emerged as a popular intervention in healthcare settings to promote adherence to both sets of guidelines. This systematic review aims to assess the empirical evidence base on the use of various types of nudges and their effectiveness as a tool to promote this adherence and to identify the boundary conditions under which they are effective. In our assessment of 83 empirical studies, we found compelling evidence that nudges are an effective tool for promoting adherence to guidelines. However, much of this evidence relies heavily on studies focused on three types of nudges (increasing salience, providing feedback, and default). Other types of nudges (anticipated error reduction, structuring of complex problems, and understanding mapping) received far less attention. We also found that this literature is primarily focused on whether nudge interventions work, with little consideration for organizational issues such as cost effectiveness, impact on healthcare workers, and disruptions of established workflows and routines. We offer observations and recommendations on how research at the intersection of organizational studies and health services can improve our understanding of nudge interventions.

Negative Emotions Induced by Work-Related Information Technology Use in Hospital Nursing

There is a lack of research into the implications of information technology-related issues for nurses' experiences and well-being at work. However, negative work experiences can generate negative emotions, which, in turn, can negatively affect well-being. Despite this, research has not systematically addressed negative emotions generated by work-related information technology use in hospital nursing. Drawing on data collected through focus groups and interviews with a total of 15 ward nurses, this paper identifies the discrete negative emotions that emerge from work-related information technology use in hospital nursing and maps the identified emotions onto the perceptions associated with and triggering them. The analysis was qualitative and included process, emotion, and causation coding alongside extensive memo writing. We identified six primary negative emotions: frustration, moral distress, alienation, psychological distress, anxiety, and perplexity. All of the identified emotions can be associated with four types of experiences of feeling hindered: mental effort, inability to carry out a task, doing extra or unnecessary work, and failing to complete a task successfully. The framework we present may support healthcare organizations in identifying potentially harmful information technology-related configurations in their infrastructure and implementing appropriate measures to foster nurses' well-being at work.

The association between perceived electronic health record usability and professional burnout among US nurses

OBJECTIVES

To measure nurse-perceived electronic health records (EHR) usability with a standardized metric of technology usability and evaluate its association with professional burnout.

METHODS

A cross-sectional survey of a random sample of US nurses was conducted in November 2017. EHR usability was measured with the System Usability Scale (SUS; range 0-100) and burnout with the Maslach Burnout Inventory.

RESULTS

Among the 86 858 nurses who were invited, 8638 (9.9%) completed the survey. The mean nurse-rated EHR SUS score was 57.6 (SD 16.3). A score of 57.6 is in the bottom 24% of scores across previous studies and categorized with a grade of "F." On multivariable analysis adjusting for age, gender, race, ethnicity, relationship status, children, highest nursing-related degree, mean hours worked per week, years of nursing experience, advanced certification, and practice setting, nurse-rated EHR usability was associated with burnout with each 1 point more favorable SUS score and associated with a 2% lower odds of burnout (OR 0.98; 95% CI, 0.97-0.99; P < .001).

CONCLUSIONS

Nurses rated the usability of their current EHR in the low marginal range of acceptability using a standardized metric of technology usability. EHR usability and the odds of burnout were strongly associated with a dose-response relationship.

Why Is the Electronic Health Record So Challenging for Research and Clinical Care?

BACKGROUND

 The electronic health record (EHR) has become increasingly ubiquitous. At the same time, health professionals have been turning to this resource for access to data that is needed for the delivery of health care and for clinical research. There is little doubt that the EHR has made both of these functions easier than earlier days when we relied on paper-based clinical records. Coupled with modern database and data warehouse systems, high-speed networks, and the ability to share clinical data with others are large number of challenges that arguably limit the optimal use of the EHR OBJECTIVES:  Our goal was to provide an exhaustive reference for those who use the EHR in clinical and research contexts, but also for health information systems professionals as they design, implement, and maintain EHR systems.

METHODS

 This study includes a panel of 24 biomedical informatics researchers, information technology professionals, and clinicians, all of whom have extensive experience in design, implementation, and maintenance of EHR systems, or in using the EHR as clinicians or researchers. All members of the panel are affiliated with Penn Medicine at the University of Pennsylvania and have experience with a variety of different EHR platforms and systems and how they have evolved over time.

RESULTS

 Each of the authors has shared their knowledge and experience in using the EHR in a suite of 20 short essays, each representing a specific challenge and classified according to a functional hierarchy of interlocking facets such as usability and usefulness, data quality, standards, governance, data integration, clinical care, and clinical research.

CONCLUSION

 We provide here a set of perspectives on the challenges posed by the EHR to clinical and research users.

Measuring Nurses' Experiences With Unintended Adverse Consequences in EMR Use in Acute Care Settings

Adverse effects of EMR use have been rarely reported in South Korea. This study examined nurses' experiences with unintended adverse consequences associated with EMR implementation. The participants were 155 nurses using the EMR for patient care in three public hospitals. The statistically tested 21-item instrument and the same 21 open-ended questions were used for data collection. The data collected were analyzed using descriptive statistics and two-way analysis of variance, and the descriptions were grouped by meaning. The participants frequently experienced unintended adverse consequences that resulted from EMR use, and their experiences were organized into 11 subgroups under four dimensions of the unintended consequences instrument including the malfunction and inefficient design of EMR screens dimension (two groups), extra work from EMR implementation dimension (three groups), EMR incompatibility and changes in the prescription pattern dimension (three groups), and patient safety and EMR dependence (three groups). Successful implementation of EMRs is possible when unintended adverse consequences identified by the users are corrected and EMRs are tailored to user needs. Healthcare organizations should provide administrative support, timely technical remedy, and user training to increase user acceptance on a system.

Electronic Health Record Usability: Associations With Nurse and Patient Outcomes in Hospitals

BACKGROUND

Electronic health record (EHR) usability issues represent an emerging threat to the wellbeing of nurses and patients; however, few large studies have examined these relationships.

OBJECTIVE

To examine associations between EHR usability and nurse job (burnout, job dissatisfaction, and intention to leave) and surgical patient (inpatient mortality and 30-day readmission) outcomes.

METHODS

A cross-sectional analysis of linked American Hospital Association, state patient discharge, and nurse survey data was conducted. The sample included 343 hospitals, 1,281,848 surgical patients, and 12,004 nurses. Logistic regression models were used to assess relationships between EHR usability and outcomes, before and after accounting for EHR adoption level (comprehensive vs. basic or less) and other confounders.

RESULTS

In fully adjusted models, nurses who worked in hospitals with poorer EHR usability had significantly higher odds of burnout [odds ratio (OR), 1.41; 95% confidence interval (CI), 1.21-1.64], job dissatisfaction (OR, 1.61; 95% CI, 1.37-1.90) and intention to leave (OR, 1.31; 95% CI, 1.09-1.58) compared with nurses working in hospitals with better usability. Surgical patients treated in hospitals with poorer EHR usability had significantly higher odds of inpatient mortality (OR, 1.21; 95% CI, 1.09-1.35) and 30-day readmission (OR, 1.06; 95% CI, 1.01-1.12) compared with patients in hospitals with better usability. Comprehensive EHR adoption was associated with higher odds of nurse burnout (OR, 1.14; 95% CI, 1.01-1.28).

CONCLUSION

Employing EHR systems with suboptimal usability was associated with higher odds of adverse nurse job outcomes and surgical patient mortality and readmission. EHR usability may be more important to nurse job and patient outcomes than comprehensive EHR adoption.

Unintended Consequences and Workarounds of Electronic Medical Record Implementation in Clinical Nursing Practice

Nurses have experienced unintended consequences and workarounds associated with health information technology implementation. However, examination of this occurrence is rare. This study aimed to examine the unintended consequences and workarounds produced by the implementation of electronic medical record systems in clinical nursing practice. A total of 143 nurses participated in a survey using statistically tested instruments. The data were analyzed using descriptive statistics and a nonparametric test. The descriptive data were analyzed by meaning. The participants experienced unintended consequences and workarounds related to electronic medical record implementation at moderate or high levels based on the responses to questions scored on 5-point Likert scales. The unintended consequences were closely associated with workarounds. The degree of experience with unintended consequences and the use of workarounds differed significantly according to the level of education, job position, and years in nursing practice. The nursing examples of unintended consequences and workarounds were organized into four categories of unintended consequences. By presenting unintended consequences and workarounds together, this study enhances the understanding of the problems encountered in EMR implementation and the action of nurses. Nurses' needs should be considered as an important resource in developing, redesigning, or purchasing and implementing health information technology in healthcare settings.

Electronic health record usability and workload changes over time for provider and nursing staff following transition to new EHR

The ubiquity of EHRs in healthcare means that small EHR inefficiencies can have a major impact on clinician workload. We conducted a sequential explanatory mixed methods study to: 1) identify EHR-associated workload and usability effects for clinicians following an EHR change over time, 2) determine workload and usability differences for providers (MD and Advance Practice Nurses) versus nurses (RNs and MAs), 3) determine if usability predicts workload, 4) identify potential sources of EHR design flaws. Workload (NASA-Task Load Index) and usability (System Usability Scale) measures were administered pre, 6-8 month and 30-32 months post-implementation. We found significant increase in perceived workload post-implementation that persisted for 2.5 years (p < .001). The workload increase was associated with usability ratings, which in turn may relate to EHR interface design violations identified by a heuristic evaluation. Our findings suggest further innovation and attention to interface design flaws are needed to improve EHR usability and reduce clinician workload.

Evaluation of the Accuracy of Nursing Diagnoses Determined by Users of a Clinical Decision Support System

PURPOSE

To analyze the accuracy of nursing diagnoses determined by users of a clinical decision support system (CDSS) and to identify the predictive factors of high/moderate diagnostic accuracy.

METHODS

This is an exploratory-descriptive study carried out from September 2017 to January 2018. Participants were nurses, resident nurses, and senior year undergraduates. Two written case studies provided the participants with the clinical data to fill out the assessment forms in the CDSS. The accuracy of the selected diagnostic labels was determined by a panel of experts using the Diagnostic Accuracy Scale, Version 2. Descriptive statistics were used to describe the level of accuracy according to each group of participants. Analysis of variance was used to compare the mean percentages of accuracy categories across groups. A linear regression model was used to identify the predictors of diagnostic accuracy. The significance level was 5%. The study was approved by the Ethics Committee.

RESULTS

Fifteen undergraduates, 10 residents, and 22 nurses were enrolled in the study. Although resident nurses and students had selected predominantly highly accurate diagnoses (51.8 ± 19.1 and 48.9 ± 27.4, respectively), and nurses had selected mostly diagnoses of moderate accuracy (54.7 ± 14.7), there were no differences in the accuracy level of selected diagnoses across groups. According to the linear regression model, each diagnosis added by the participants decreased the diagnostic accuracy by 2.09% (p = .030), and no experience or a low level of experience using the system decreased such diagnostic accuracy by 5.41% (p = .022).

CONCLUSIONS

The CDSS contributes to decision making about diagnoses of less experienced people. Adding diagnoses not indicated by the CDSS and experience with the system are predictors of diagnostic accuracy.

CLINICAL RELEVANCE

In-service education regarding the use of CDSSs seems to be crucial to improve users' clinical judgment and decision making.

Applying Computational Ethnography to Examine Nurses' Workflow Within Electronic Health Records

OBJECTIVE

The aim of this study was to describe computational ethnography as a contemporary and supplemental methodology in EHR workflow analysis and the relevance of this method to nursing research.

METHODS

We explore the use of audit logs as a computational ethnographic data source and the utility of data mining techniques, including sequential pattern mining (SPM) and Markov chain analysis (MCA), to analyze nurses' workflow within the EHRs. SPM extracts frequent patterns in a given transactional database (e.g., audit logs from the record). MCA is a stochastic process that models a sequence of states and allows for calculating the probability of moving from one state to the next. These methods can help uncover nurses' global navigational patterns (i.e., how nurses navigate within the record) and enable robust workflow analyses.

RESULTS

We demonstrate hypothetical examples from SPM and MCA, such as (a) the most frequent sequential pattern of nurses' workflow when navigating the EHR using SPM and (b) transition probability from one record screen to the next using MCA. These examples demonstrate new methods to address the inflexibility of current approaches used to examine nursing EHR workflow.

DISCUSSION

Within a clinical context, the use of computational ethnographic data and data mining techniques can inform the optimization of the EHR. Results from these analyses can be used to supplement the data needed in redesigning the EHR, such as organizing and combining features within a screen or predicting future navigation to improve the record that nurses use.

Nurse Motivation, Engagement and Well-Being before an Electronic Medical Record System Implementation: A Mixed Methods Study

Implementation of an electronic medical record (EMR) is a significant workplace event for nurses in hospitals. Understanding nurses' key concerns can inform EMR implementation and ongoing optimisation strategies to increase the likelihood of nurses remaining in the nursing workforce. This concurrent mixed-methods study included surveys from 540 nurses (response rate 15.5%), and interviews with 63 nurses to examine their perceptions of using a new EMR prior to implementation at a single healthcare organisation. Survey findings revealed 32.2% (n = 174) of nurses reported low well-being scores and 28.7% (n = 155) were experiencing burnout symptoms. In contrast, 40.3% (n = 216) of nurses reported high work satisfaction, 62.3% (n = 334) had high intentions of staying in their role, and 34.3% (n = 185) were engaged in their work. Nearly half (n = 250, 46.3%) reported intrinsic motivation towards EMR use. Thematic analysis of focus group interviews revealed two themes, each with three subthemes: (1) Us and Them, detailed the juxtaposition between nurses' professional role and anticipated changes imposed on them and their work with the EMR implementation; and (2) Stuck in the middle, revealed nurses' expectations and anticipations about how the EMR may affect the quality of nurse-patient relationships. In conclusion, anticipation of the EMR implementation emerged as a stressor for nursing staff, with some groups of nurses particularly vulnerable to negative consequences to their well-being.

Four Years Later: Examining Nurse Perceptions of Electronic Documentation Over Time

OBJECTIVE

To examine changes in registered nurse (RN) perceptions of electronic documentation over a 4-year period.

BACKGROUND

The investigators previously reported differences in RN perceptions prior to and 1 year after adoption of a comprehensive electronic health record (EHR).

METHODS

Investigators repeated the study 4 years after adoption, using the Nurses' Perceptions of Electronic Documentation tool and interviews with a subset of RNs.

RESULTS

Nurses scored higher on ease of use domain and lower on concern about the EHR domain and showed no difference on the impacts of the EHR domain. Interviews revealed that 4 years later, some aspects of documentation were easier; the tool was comprehensive, but not without risk, and nurses remained ambivalent about the EHR.

CONCLUSIONS

Use of EHR technology impacts nursing work. It is important to understand how nurses' perceptions change over time. This study gives nursing leaders insight into adoption and acceptance of an EHR.

The Associations of Electronic Health Record Usability and User Age With Stress and Cognitive Failures Among Finnish Registered Nurses: Cross-Sectional Study

BACKGROUND

Electronic health records (EHRs) are expected to provide many clinical and organizational benefits. Simultaneously, the end users may face unintended consequences, such as stress and increased cognitive workload, due to poor EHR usability. However, whether the effects of usability depend on end user characteristics, such as career stage or age, remains poorly understood.

OBJECTIVE

The objective of this study was to examine the associations of EHR usability and user age with stress related to information systems and cognitive failures among registered nurses.

METHODS

A cross-sectional survey design was employed in Finland in 2017. A total of 3383 registered nurses responded to the nationwide electronic survey. Multiple linear regression was used to examine the associations of EHR usability (eg, how easily information can be found and a patient's care can be documented) and user age with stress related to information systems and cognitive failures. Interaction effects of EHR usability and age were also tested. Models were adjusted for gender and employment sector.

RESULTS

Poor EHR usability was associated with higher levels of stress related to information systems (β=.38; P<.001). The strength of the association did not depend on user age. Poor EHR usability was also associated with higher levels of cognitive failures (β=.28; P<.001). There was a significant interaction effect between age and EHR usability for cognitive failures (β=.04; P<.001). Young nurses who found the EHR difficult to use reported the most cognitive failures.

CONCLUSIONS

Information system stress due to poor EHR usability afflicts younger and older nurses alike. However, younger nurses starting their careers may be more cognitively burdened if they find EHR systems difficult to use compared to older nurses. Adequate support in using the EHRs may be particularly important to young registered nurses, who have a lot to learn and adopt in their early years of practice.

Identification of important factors in an inpatient fall risk prediction model to improve the quality of care using EHR and electronic administrative data: A machine-learning approach

BACKGROUND

Inpatient falls, many resulting in injury or death, are a serious problem in hospital settings. Existing falls risk assessment tools, such as the Morse Fall Scale, give a risk score based on a set of factors, but don't necessarily signal which factors are most important for predicting falls. Artificial intelligence (AI) methods provide an opportunity to improve predictive performance while also identifying the most important risk factors associated with hospital-acquired falls. We can glean insight into these risk factors by applying classification tree, bagging, random forest, and adaptive boosting methods applied to Electronic Health Record (EHR) data.

OBJECTIVE

The purpose of this study was to use tree-based machine learning methods to determine the most important predictors of inpatient falls, while also validating each via cross-validation.

MATERIALS AND METHODS

A case-control study was designed using EHR and electronic administrative data collected between January 1, 2013 to October 31, 2013 in 14 medical surgical units. The data contained 38 predictor variables which comprised of patient characteristics, admission information, assessment information, clinical data, and organizational characteristics. Classification tree, bagging, random forest, and adaptive boosting methods were used to identify the most important factors of inpatient fall-risk through variable importance measures. Sensitivity, specificity, and area under the ROC curve were computed via ten-fold cross validation and compared via pairwise t-tests. These methods were also compared to a univariate logistic regression of the Morse Fall Scale total score.

RESULTS

In terms of AUROC, bagging (0.89), random forest (0.90), and boosting (0.89) all outperformed the Morse Fall Scale (0.86) and the classification tree (0.85), but no differences were measured between bagging, random forest, and adaptive boosting, at a p-value of 0.05. History of Falls, Age, Morse Fall Scale total score, quality of gait, unit type, mental status, and number of high fall risk increasing drugs (FRIDs) were considered the most important features for predicting inpatient fall risk.

CONCLUSIONS

Machine learning methods have the potential to identify the most relevant and novel factors for the detection of hospitalized patients at risk of falling, which would improve the quality of patient care, and to more fully support healthcare provider and organizational leadership decision-making. Nurses would be able to enhance their judgement to caring for patients at risk for falls. Our study may also serve as a reference for the development of AI-based prediction models of other iatrogenic conditions. To our knowledge, this is the first study to report the importance of patient, clinical, and organizational features based on the use of AI approaches.

Relationship Between Burnout and Professional Behaviors and Beliefs Among US Nurses

OBJECTIVE

To evaluate the relationship between burnout and professional behaviors and beliefs among US nurses.

METHODS

We used data from 2256 nurses who completed a survey that included the Maslach Burnout Inventory and items exploring their professional conduct (documented something they had not done so they could "close out" an encounter in the EHR or part of the assessment not completed, requested continuing education credit for an activity not attended) and beliefs about reporting impaired colleagues.

RESULTS

On multivariable analysis, burnout was independently associated with higher odds of reporting 1 or more unprofessional behaviors in the last year and not believing nurses have a duty to report impairment among colleagues due to substance use or mental health problems.

CONCLUSIONS

Occupational burnout is associated with self-reported unprofessional behaviors and less favorable beliefs about reporting impaired colleagues among nurses.

State of the Science of Dimensions of Nurses' User Experience When Using an Electronic Health Record

This integrative review synthesized relevant studies in the last decade associated to nurses' experience with the electronic health record using Robert and Lesage's dimensions of User Experience: functional, physical, perceptual, cognitive, psychological, and social. A comprehensive search was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance across four electronic databases. We included articles if they were specific to nurses' electronic health record experience and workflow, published between January 2008 and June 2018, and available in English. The search resulted in 793 records with 26 articles included in the final analysis. Articles ranged from quantitative, qualitative, mixed-methods, and quality improvement studies. Across studies, the suboptimal design of the electronic health record affected the functional experience of nurses, often resulting in interruptions. The navigational design contributed to nurses' perceptual experience leading to many workarounds and workflow mismatches. Most of the studies reported overall satisfaction with the electronic health record that represented the psychological dimension of nurses' experience. Communication barriers due to the use of the electronic health record prevented nurses from having meaningful interaction with other clinicians and patients. Although nurses reported substandard user experience, many stated that reverting to a linear paper-based system was not an option.

The Influence of Electronic Health Record Use on Physician Burnout: Cross-Sectional Survey

Background

Physician burnout has a direct impact on the delivery of high-quality health care, with health information technology tools such as electronic health records (EHRs) adding to the burden of practice inefficiencies.

Objective

The aim of this study was to determine the extent of burnout among physicians and learners (residents and fellows); identify significant EHR-related contributors of physician burnout; and explore the differences between physicians and learners with regard to EHR-related factors such as time spent in EHR, documentation styles, proficiency, training, and perceived usefulness. In addition, the study aimed to address gaps in the EHR-related burnout research methodologies by determining physicians’ patterns of EHR use through usage logs.

Methods

This study used a cross-sectional survey methodology and a review of administrative data for back-end log measures of survey respondents’ EHR use, which was conducted at a large Canadian academic mental health hospital. Chi-square and Fisher exact tests were used to examine the association of EHR-related factors with general physician burnout. The survey was sent out to 474 individuals between May and June 2019, including physicians (n=407), residents (n=53), and fellows (n=14), and we measured physician burnout and perceptions of EHR stressors (along with demographic and practice characteristics).

Results

Our survey included 208 respondents, including physicians (n=176) and learners (n=32). The response rate was 43.2% for physicians (full-time: 156/208, 75.0%; part-time: 20/199, 10.1%), and 48% (32/67) for learners. A total of 25.6% (45/176) of practicing physicians and 19% (6/32) of learners reported having one or more symptoms of burnout, and 74.5% (155/208) of all respondents who reported burnout symptoms identified the EHR as a contributor. Lower satisfaction and higher frustration with the EHRs were significantly associated with perceptions of EHR contributing toward burnout. Physicians’ and learners’ experiences with the EHR, gathered through open-ended survey responses, identified challenges around the intuitiveness and usability of the technology as well as workflow issues. Metrics gathered from back-end usage logs demonstrated a 13.6-min overestimation in time spent on EHRs per patient and a 5.63-hour overestimation of after-hours EHR time, when compared with self-reported survey data.

Conclusions

This study suggests that the use of EHRs is a perceived contributor to physician burnout. There should be a focus on combating physician burnout by reducing the unnecessary administrative burdens of EHRs through efficient implementation of systems and effective postimplementation strategies.

Nurse workarounds in the electronic health record: An integrative review

OBJECTIVE

The study sought to synthesize published literature on direct care nurses' use of workarounds related to the electronic health record.

MATERIALS AND METHODS

We conducted an integrative review of qualitative and quantitative peer-reviewed research through a structured search of Academic Search Complete, EBSCO Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, Engineering Village, Ovid Medline, Scopus, and Web of Science. We systematically applied exclusion rules at the title, abstract, and full article stages and extracted and synthesized their research methods, workaround classifications, and probable causes from articles meeting inclusion criteria.

RESULTS

Our search yielded 5221 results. After removing duplicates and applying rules, 33 results met inclusion criteria. A total of 22 articles used qualitative approaches, 10 used mixed methods, and 1 used quantitative methods. While researchers may classify workarounds differently, they generally fit 1 of 3 broad categories: omission of process steps, steps performed out of sequence, and unauthorized process steps. Each study identified probable causes, which included technology, task, organizational, patient, environmental, and usability factors.

CONCLUSIONS

Extensive study of nurse workarounds in acute settings highlights the gap in ambulatory care research. Despite decades of electronic health record development, poor usability remains a key concern for nurses and other members of care team. The widespread use of workarounds by the largest group of healthcare providers subverts quality health care at every level of the healthcare system. Research is needed to explore the gaps in our understanding of and identify strategies to reduce workaround behaviors.

Usability study of a new tool for nutritional and glycemic management in adult intensive care: Glucosafe 2

The new decision support tool Glucosafe 2 (GS2) is based on a mathematical model of glucose and insulin dynamics, designed to assist caregivers in blood glucose control and nutrition. This study aims to assess end-user acceptance and usability of this bedside decision support tool in an adult intensive care setting. Caregivers were first trained and then invited to trial GS2 prototype on bedside computers. Data for qualitative analysis were collected through semi-structured interviews from twenty users after minimum three trial days. Most caregivers (70%) rated GS2 as convenient and believed it would help improving adherence to current guidelines (85%). Moreover, most nurses (80%) believed that GS2 would be timesaving. Nurses' risk perceptions and manual data entry emerged as central barriers to use GS2 in routine practice. Issues emerged from the caregivers were compiled into a list of 12 modifications of the GS2 prototype to increase end-user acceptance and usability. This usability study showed that GS2 was considered by ICU caregivers as helpful in daily clinical practice, allowing time-saving and better standardization of ICU patient's care. Important issues were raised by the users with implications for the development and deployment of GS2. Integrating the technology into existing IT infrastructure may facilitate caregivers' acceptance. Further clinical studies of the performance and potential health outcomes are warranted.

Improving Accuracy and Timeliness of Nursing Documentation of Pediatric Early Warning Scores

Introduction

Accurate and timely documentation of pediatric early warning scores (PEWS) by the bedside nurse into the electronic health record (EHR) is important to promote early identification of patients in stages of deterioration. Through the implementation of a PEWS calculator embedded in the EHR, we hope to improve the accuracy of the recorded score and reduce the time between vital sign collection and final documentation in the EHR.

Methods

Identification of the highest PEWS value in the 24 hours before all unplanned transfers or rapid response activations without a transfer occurred between the period November 1, 2013, through December 31, 2016. The accuracy of the calculated cardiac or respiratory subscore based on heart rate or the respiratory rate at the time of PEWS calculation was determined. We tracked the calculation of the time to chart via the difference between nursing documentation of PEWS compared to vital sign collection. Before September 3, 2015, PEWS was calculated mentally by the bedside nurse; afterward, the nurse entered the unique PEWS features into the EHR, and the EHR automatically calculated PEWS.

Results

This study evaluated 2,409 PEWS scores, 1,411 before and 998 after initiation of the PEWS calculator. Accuracy before the EHR calculator was 71%, and the median time to document was 55 minutes. Following the implementation of the calculator, no scores were incorrectly calculated too low, and the median time to document was 20 minutes.

Conclusions

Transition to an EHR-based PEWS calculator eliminated inaccurately low PEWS values and reduced time to document.

The Role of Nurse Managers in the Adoption of Health Information Technology: Findings From a Qualitative Study

OBJECTIVE

This study aims to investigate the role of nurse managers in supporting point-of-care nurses' health information technology (IT) use and identify strategies employed by nurse managers to improve adoption, while also gathering point-of-care nurses' perceptions of these strategies.

BACKGROUND

Nurse managers are essential in facilitating point-of-care nurses' use of health IT; however, the underlying phenomenon for this facilitation remains unreported.

METHODS

A qualitative descriptive study was conducted with 10 nurse managers and 14 point-of-care nurses recruited from a mental health hospital environment in Ontario, Canada. Inductive and deductive content analyses were used to analyze the semistructured interviews.

RESULTS

Nurse managers adopt the role of advocate, educator, and connector, using the following strategies: communicating system updates, demonstrating use of health IT, linking staff to resources, facilitating education, and providing IT oversight.

CONCLUSIONS

Nurse managers use a variety of strategies to support nurses' use of health IT. Future research should focus on the effectiveness of these strategies.

A Real-Time Automated Patient Screening System for Clinical Trials Eligibility in an Emergency Department: Design and Evaluation

Background

One critical hurdle for clinical trial recruitment is the lack of an efficient method for identifying subjects who meet the eligibility criteria. Given the large volume of data documented in electronic health records (EHRs), it is labor-intensive for the staff to screen relevant information, particularly within the time frame needed. To facilitate subject identification, we developed a natural language processing (NLP) and machine learning–based system, Automated Clinical Trial Eligibility Screener (ACTES), which analyzes structured data and unstructured narratives automatically to determine patients’ suitability for clinical trial enrollment. In this study, we integrated the ACTES into clinical practice to support real-time patient screening.

Objective

This study aimed to evaluate ACTES’s impact on the institutional workflow, prospectively and comprehensively. We hypothesized that compared with the manual screening process, using EHR-based automated screening would improve efficiency of patient identification, streamline patient recruitment workflow, and increase enrollment in clinical trials.

Methods

The ACTES was fully integrated into the clinical research coordinators’ (CRC) workflow in the pediatric emergency department (ED) at Cincinnati Children’s Hospital Medical Center. The system continuously analyzed EHR information for current ED patients and recommended potential candidates for clinical trials. Relevant patient eligibility information was presented in real time on a dashboard available to CRCs to facilitate their recruitment. To assess the system’s effectiveness, we performed a multidimensional, prospective evaluation for a 12-month period, including a time-and-motion study, quantitative assessments of enrollment, and postevaluation usability surveys collected from the CRCs.

Results

Compared with manual screening, the use of ACTES reduced the patient screening time by 34% (P<.001). The saved time was redirected to other activities such as study-related administrative tasks (P=.03) and work-related conversations (P=.006) that streamlined teamwork among the CRCs. The quantitative assessments showed that automated screening improved the numbers of subjects screened, approached, and enrolled by 14.7%, 11.1%, and 11.1%, respectively, suggesting the potential of ACTES in streamlining recruitment workflow. Finally, the ACTES achieved a system usability scale of 80.0 in the postevaluation surveys, suggesting that it was a good computerized solution.

Conclusions

By leveraging NLP and machine learning technologies, the ACTES demonstrated good capacity for improving efficiency of patient identification. The quantitative assessments demonstrated the potential of ACTES in streamlining recruitment workflow and improving patient enrollment. The postevaluation surveys suggested that the system was a good computerized solution with satisfactory usability.

Protecting healing relationships in the age of electronic health records: report from an international conference

We present findings of an international conference of diverse participants exploring the influence of electronic health records (EHRs) on the patient–practitioner relationship. Attendees united around a belief in the primacy of this relationship and the importance of undistracted attention. They explored administrative, regulatory, and financial requirements that have guided United States (US) EHR design and challenged patient-care documentation, usability, user satisfaction, interconnectivity, and data sharing. The United States experience was contrasted with those of other nations, many of which have prioritized patient-care documentation rather than billing requirements and experienced high user satisfaction. Conference participants examined educational methods to teach diverse learners effective patient-centered EHR use, including alternative models of care delivery and documentation, and explored novel ways to involve patients as healthcare partners like health-data uploading, chart co-creation, shared practitioner notes, applications, and telehealth. Future best practices must preserve human relationships, while building an effective patient–practitioner (or team)-EHR triad.

Evaluating a handheld decision support device in pediatric intensive care settings

OBJECTIVE

To evaluate end-user acceptance and the effect of a commercial handheld decision support device in pediatric intensive care settings. The technology, pac2, was designed to assist nurses in calculating medication dose volumes and infusion rates at the bedside.

MATERIALS AND METHODS

The devices, manufactured by InformMed Inc., were deployed in the pediatric and neonatal intensive care units in 2 health systems. This mixed methods study assessed end-user acceptance, as well as pac2's effect on the cognitive load associated with bedside dose calculations and the rate of administration errors. Towards this end, data were collected in both pre- and postimplementation phases, including through ethnographic observations, semistructured interviews, and surveys.

RESULTS

Although participants desired a handheld decision support tool such as pac2, their use of pac2 was limited. The nature of the critical care environment, nurses' risk perceptions, and the usability of the technology emerged as major barriers to use. Data did not reveal significant differences in cognitive load or administration errors after pac2 was deployed.

DISCUSSION AND CONCLUSION

Despite its potential for reducing adverse medication events, the commercial standalone device evaluated in the study was not used by the nursing participants and thus had very limited effect. Our results have implications for the development and deployment of similar mobile decision support technologies. For example, they suggest that integrating the technology into hospitals' existing IT infrastructure and employing targeted implementation strategies may facilitate nurse acceptance. Ultimately, the usability of the design will be essential to reaping any potential benefits.

Surgical perioperative pathways-Patient experiences of unmet needs show that a person-centred approach is needed

AIM

To explore patients' and healthcare professionals' experiences of patients' surgical pathways in a perioperative setting.

BACKGROUND

Elective surgical pathways have improved over the past decades due to fast-track programmes, but patients desire more personalised and coordinated care and treatment. There is little knowledge of how healthcare professionals' collaboration and communication affect patients' pathways.

DESIGN

The overall framework was complex intervention method. A phenomenological-hermeneutic approach was used for data analyses. COREQ checklist was used as a guideline to secure accurate and complete reporting of the study.

METHODS

Field observations (120 hr) and semi-structured interviews (24 patients) were undertaken during 2016-2017. Healthcare professionals involved in the pathways were interviewed: (a) 13 single interviews and (b) 13 focus group interviews (37 healthcare professionals) were conducted. The Consolidated Criteria for Reporting Qualitative Research checklist was used.

RESULTS

Patients asked for individualised information adapted to their life and illness experiences. Furthermore, healthcare professionals need access to a quick overview of individual patients and their perioperative pathway in the electronic patient journal (EPJ). Agreements made with patients did not always reach the right receiver, there was poor interpersonal communication and the complex teamwork between many healthcare professionals made pathways incoherent and uncoordinated. Healthcare professionals who had the time to talk about other subjects than the disease with smiles and good humour gave patients a feeling of security.

CONCLUSION

Patients wanted to be treated as individuals, but often they received standard treatment. Healthcare professionals had the intention of treating patients individually, but the EPJ and information provided to patients were not easy to access.

RELEVANCE TO CLINICAL PRACTICE

Visible information about the patient's whole pathway could improve healthcare professionals' care and treatment. In addition, systematic feedback from patients' could make it possible to adjust information, care and treatment to achieve a more coherent pathway. Particular attention needs to be paid to how electronic healthcare systems can underpin relational coordination in pathways.

Electronic Health Record Adoption and Nurse Reports of Usability and Quality of Care: The Role of Work Environment

BACKGROUND

Despite evidence suggesting higher quality and safer care in hospitals with comprehensive electronic health record (EHR) systems, factors related to advanced system usability remain largely unknown, particularly among nurses. Little empirical research has examined sociotechnical factors, such as the work environment, that may shape the relationship between advanced EHR adoption and quality of care.

OBJECTIVE

The objective of this study was to examine the independent and joint effects of comprehensive EHR adoption and the hospital work environment on nurse reports of EHR usability and nurse-reported quality of care and safety.

METHODS

This study was a secondary analysis of nurse and hospital survey data. Unadjusted and adjusted logistic regression models were used to assess the relationship between EHR adoption level, work environment, and a set of EHR usability and quality/safety outcomes. The sample included 12,377 nurses working in 353 hospitals.

RESULTS

In fully adjusted models, comprehensive EHR adoption was associated with lower odds of nurses reporting poor usability outcomes, such as dissatisfaction with the system (odds ratio [OR]: 0.75; 95% confidence interval [CI]: 0.61-0.92). The work environment was associated with all usability outcomes with nurses in better environments being less likely to report negatively. Comprehensive EHRs (OR: 0.83; 95% CI: 0.71-0.96) and better work environments (OR: 0.47; 95% CI: 0.42-0.52) were associated with lower odds of nurses reporting fair/poor quality of care, while poor patient safety grade was associated with the work environment (OR: 0.50; 95% CI: 0.46-0.54), but not EHR adoption level.

CONCLUSION

Our findings suggest that adoption of a comprehensive EHR is associated with more positive usability ratings and higher quality of care. We also found that-independent of EHR adoption level-the hospital work environment plays a significant role in how nurses evaluate EHR usability and whether EHRs have their intended effects on improving quality and safety of care.

Use of Health Information Technology in Patients Care Management: a Mixed Methods Study in Iran

Introduction

New technologies, including health information technologies, play an important role in effectiveness of management and nursing care services.

Aim

This study was aimed to determining the use of health information technology in patient care management in a case study in Iran.

Methods

This Mixed method study was conducted in 2018 in Kowsar Hospital of Semnan, Iran. Data gathered by an observational checklist and one questionnaire included two main parts, one demographic and another assessment of information technology use in care management of inpatients. The researcher prepared the questionnaire and its validity was verified. The data were organized and analyzed in the form of a descriptive analytic report. In the process of data collection, 10 participants including nurses, head nurses, physicians, radiology experts and Information Technology (IT) managers were interviewed and data analyzed using Directed Content Analysis.

Results

Nurses were satisfied with the computerized system and believed it can facilitate the affair. From the nurse's viewpoint, the most common use of the Health Information Technology (HIT) were access (observation) of patients admit and discharge information (100%), providing medicine and equipment, transfer of patients (92.3%). The least of them were retrieve of evidence in the care process (0 %) and judgment and analysis of radiological diagnostic procedures (0%). The potential of electronic record is not still applicable.

Conclusion

Use of modern information and communication technology in hospitals facilitates access and transfer of information, and also accelerates patient's admission and discharge process, relation between hospital units, providing medical equipment supporting affairs' process and diagnostic procedures. However, modifying organizational policies, improve the infrastructure and enhancing nurses' motivation in documenting nursing reports can be effective in increasing the impact of information technology in care management processes especially in electronic record and nurse's clinical judgment and evidence-based care.