Nurses' Use of Positive Deviance When Encountering Electronic Health Records-Related Unintended Consequences

The use of positive deviance approach to improve health service delivery and quality of care: a scoping review

BACKGROUND

Quality has been a persistent challenge in the healthcare system, particularly in resource-limited settings. As a result, the utilization of innovative approaches is required to help countries in their efforts to enhance the quality of healthcare. The positive deviance (PD) approach is an innovative approach that can be utilized to improve healthcare quality. The approach assumes that solutions to problems are already available within the community and identifying and sharing those solutions can help others to resolve existing issues. Therefore, this scoping review aimed to synthesize the evidence regarding the use of the PD approach in healthcare system service delivery and quality improvement programs.

METHODS

Articles were retrieved from six international databases. The last date for article search was June 02, 2023, and no date restriction was applied. All articles were assessed for inclusion through a title and/or abstract read. Then, articles that passed the title and abstract review were screened by reading their full texts. In case of duplication, only the full-text published articles were retained. A descriptive mapping and evidence synthesis was done to present data with the guide of the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews checklist and the results are presented in text, table, and figure formats.

RESULTS

A total of 125 articles were included in this scoping review. More than half, 66 (52.8%), of the articles were from the United States, 11(8.8%) from multinational studies, 10 (8%) from Canada, 8 (6.4%) from the United Kingdom and the remaining, 30 (24%) are from other nations around the world. The scoping review indicates that several types of study designs can be applied in utilizing the PD approach for healthcare service and quality improvement programs. However, although validated performance measures are utilized to identify positive deviants (PDs) in many of the articles, some of the selection criteria utilized by authors lack clarity and are subject to potential bias. In addition, several limitations have been mentioned in the articles including issues in operationalizing PD, focus on leaders and senior managers and limited staff involvement, bias, lack of comparison, limited setting, and issues in generalizability/transferability of results from prospects perspective. Nevertheless, the limitations identified are potentially manageable and can be contextually resolved depending on the nature of the study. Furthermore, PD has been successfully employed in healthcare service and quality improvement programs including in increasing surgical care quality, hand hygiene practice, and reducing healthcare-associated infections.

CONCLUSION

The scoping review findings have indicated that healthcare systems have been able to enhance quality, reduce errors, and improve patient outcomes by identifying lessons from those who exhibit exceptional practices and implementing successful strategies in their practice. All the outcomes of PD-based research, however, are dependent on the first step of identifying true PDs. Hence, it is critical that PDs are identified using objective and validated measures of performance as failure to identify true PDs can subsequently lead to failure in identifying best practices for learning and dissemination to other contextually similar settings.

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.

Impact of a Decision Support System on Fall-Prevention Nursing Practices

OBJECTIVES

The aim of this study was to develop a computerized decision support system (CDSS) that could automatically calculate the risk of falls using electronic medical record data and provide evidence-based fall-prevention recommendations based on risk factors. Furthermore, we analyzed the usability and effect of the system on fall-prevention nursing practices.

METHODS

A computerized fall-prevention system was developed according to the system development life cycle, and implemented between March and August 2019 in a single medical unit with a high prevalence of falls. The usability was evaluated 1 month after CDSS implementation. In terms of time and frequency, changes in fall-prevention nursing practices were analyzed using survey data and nursing documentation, respectively. Finally, the incidence of falls before and after system implementation was compared to examine the clinical effectiveness of the CDSS.

RESULTS

According to the usability test, the average ease of learning score (5.083 of 7) was the highest among 4 dimensions. The time spent engaged in fall-prevention nursing care per patient per shift increased, particularly for nursing diagnoses and planning. Moreover, the mean frequency of daily documented fall-prevention interventions per patient also increased. Particularly, nursing statements related to nonspecific interventions such as environmental modifications increased. However, the incidence of falls did not decrease after implementation of the CDSS.

CONCLUSIONS

Although adoption of the computerized system increased the time spent and number of records created in terms of fall-prevention practices in nurses, no improvement in clinical outcomes was observed, particularly in terms of fall rate reduction.

Unintended consequences of the electronic health record and cognitive load in emergency department nurses

AIM

The study aimed to explore the relationship between the unintended consequences of the electronic health record and cognitive load in emergency department nurses.

METHODS

The study utilized a correlational quantitative design with a survey method approach. This study had a 30.4 % response rate for a total of 304 ED nurse participants who were members of a national ED nursing organization. Data analysis included descriptive and correlational measurements of two instruments.

RESULTS

In this study, there was a statistically significant, weak negative relationship between CL and UC-EHR in ED nurses, rs (264) = -0.154, p 0.002. Although a significant weak relationship was identified in this study, the study variables, subscales, and demographic data groupings presented moderate-to-strong positive, statistically significant correlations. Descriptive frequency data unveiled EHR stimulated patient safety threats occurring once a week to monthly.

CONCLUSIONS

The novelty of this research study provided profound implications for the future of nursing practice, policy, and nursing science. EHR optimization to minimize patient safety risks is recommended with the inclusion of end-users from this study's identified subgroups. The researchers propose a reduction of EHR burden in nursing practice.

Understanding rebel nurse leadership-as-practice: Challenging and changing the status quo in hospitals

Some nurses are responding rebelliously to the changing healthcare landscape by challenging the status quo and deviating from suboptimal practices, professional norms, and organizational rules. While some view rebel nurse leadership as challenging traditional structures to improve patient care, others see it as disruptive and harmful. These diverging opinions create dilemmas for nurses and nurse managers in daily practice. To understand the context, dilemmas, and interactions in rebel nurse leadership, we conducted a multiple case study in two Dutch hospitals. We delved into the mundane practices to expand the concept of leadership-as-practice. By shadowing rebel nurse practices, we identified three typical leadership practices which present the most common "lived" experiences and dilemmas of nurses and nurse managers. Overall, we noticed that deviating acts were more often quick fixes rather than sustainable changes. Our research points to what is needed to change the status quo in a sustainable manner. To change unworkable practices, nurses need to share their experienced dilemmas with their managers. In addition, nurse managers must build relationships with other nurses, value different perspectives, and support experimenting to promote collective learning.

Information technology use and tasks left undone by nursing staff: A qualitative analysis

Nursing staff perceive information technology (IT) as time-consuming and impinging on direct patient care time. Despite this, researchers have directed little attention toward the interplay between IT use and tasks left undone by nursing staff. In this paper, we analyze interview and focus group data on hospital nursing staff's experience working with IT to identify ways IT use interacts with tasks left undone. We found that tasks left undone by nursing staff can have IT-related antecedents and that IT-related tasks are also sometimes left undone. This analysis adds to the body of knowledge by showing that tasks related to the work environment and IT can be left undone and that nursing staff avoid certain IT-supported tasks because they do not know how to do them or why they ought to be done. These findings form the basis for our call for further research on the topic.

Beyond transformational leadership in nursing: A qualitative study on rebel nurse leadership-as-practice

Most nurse leadership studies have concentrated on a classical, heroic, and hierarchical view of leadership. However, critical leadership studies have argued the need for more insight into leadership in daily nursing practices. Nurses must align their professional standards and opinions on quality of care with those of other professionals, management, and patients. They want to achieve better outcomes for their patients but also want to feel disciplined and controlled. To deal with this, nurses challenge the status quo by showing rebel nurse leadership. In this paper, we describe 47 nurses' experiences with rebel nurse leadership from a leadership-as-practice perspective. In eight focus groups, nurses from two hospitals and one long-term care organization shared their experiences of rebel nurse leadership practices. They illustrated the differences between "bad" and "good" rebels. Knowledge, work experience, and patient-driven motivation were considered necessary for "good" rebel leadership. The participants also explained that continuous social influencing is important while exploring and challenging the boundaries set by colleagues and management. Credibility, trust, autonomy, freedom, and preserving relationships determined whether rebel nurses acted visibly or invisibly. Ultimately, this study refines the concept of rebel nurse leadership, gives a better understanding of how this occurs in nursing practice, and give insights into the challenges faced when studying nursing leadership practices.

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.

Effortlessness and Security: Nurses' Positive Experiences With Work-Related Information Technology Use

Nurses' well-being at work has been an increasing concern the past few years, in particular in connection with work-related information technology use. Researchers have thus been called to explore ways of fostering nurses' well-being at work. However, little is known about the factors related to information technology that contribute to nurses' positive experience of and well-being at work. In this study, we sought to understand the appraisals and emotions at the core of nurses' positive experiences with information technology use at work. We conducted focus groups and semistructured interviews with 15 ward nurses working at a large Swedish hospital. The data were analyzed qualitatively using process and causation coding. We found appraisals of easy goal accomplishment, doing less of a particular task, knowing what the situation is and what has to be done, mastering the system, reduced risk of mistakes and omissions, and assured access to patient information. Using design theory, we connected these appraisals with four positive emotions: joy, relief, confidence, and relaxation. These findings suggest that effortlessness and security are central to nurses' positive experience of information technology. Implementing information technology-related features and practices associated with them in healthcare organizations may foster nurses' well-being at work.

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.

Not another box to check! Using the UTAUT to explore nurses' psychological adaptation to electronic health record usability

BACKGROUND

As the integration of electronic health records (EHRs) continues to expand throughout healthcare organizations worldwide, nurses are faced with the challenge to acclimate to a dynamic technology-based environment of patient care. As technology advances, EHR usability may influence nurses' clinical performance and require nurses to adapt to a wide range of situations associated with electronic documentation. While perceived benefits of EHRs include improvements in healthcare delivery and patient outcomes, there are also unintended consequences associated with EHR usability.

AIMS

The aim of this article is to explore dimensions of EHR usability that may influence nurses' psychological adaptation to the use of EHRs in daily practice.

MATERIALS AND METHODS

The unified theory of acceptance and use of technology (UTAUT) consists of four constructs theorized to have a direct influence on end-user behavior and acceptance of technology: performance expectancy, effort expectancy, social influence, and facilitating conditions. The UTAUT provides the framework to explore EHR usability as found in literature and describe the positive and negative psychological responses of nurses related to the use of EHRs in daily practice.

RESULTS

Integration of EHRs into daily nursing practice can result in positive experiences or have a negative impact on nurses ability to perform their role as patient caregivers.

DISCUSSION

While integration of EHRs into healthcare systems can facilitate improvements in patient outcomes, the delivery of patient care and nurses' daily practices can simultaneously be complicated by EHR usability issues.

CONCLUSION

Although positive and negative experiences of nurses in relationship to EHR usability can be found in literature, there is limited evidence on nurses' psychological adaptation to use of EHRs. Further research on EHR usability is needed based on nursing perspectives and feedback to determine the psychological impact EHRs exert on nurses, discover effective methods for resolving issues, and promote positive trends associated with EHR usability.

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.

A scoping review of rebel nurse leadership: Descriptions, competences and stimulating/hindering factors

AIMS

To (1) give an overview of rebel nurse leadership by summarising descriptions of positive deviance, tempered radicals and healthcare rebels; (2) examine the competences of nurse rebel leadership; and (3) describe factors that stimulate or hinder the development of rebel nurse leadership.

BACKGROUND

Research shows nurses have lower intention to leave their jobs when they can control their work practices, show leadership and provide the best care. However, organisational rules and regulations do not always fit the provision of good care, which challenges nurses to show leadership and deviate from the rules and regulations to benefit the patient. Three concepts describe this practice: positive deviance, healthcare rebels and tempered radicals.

DESIGN

Scoping review using the Joanna Briggs Institute methodology and PRISMA-ScR checklist.

METHODS

Papers describing positive deviance, healthcare rebels and tempered radicals in nursing were identified by searching Scopus, CINAHL, PubMed and PsycINFO. After data extraction, these three concepts were analysed to study the content of descriptions and definitions, competences and stimulating and hindering factors.

RESULTS

Of 2705 identified papers, 25 were included. The concept descriptions yielded three aspects: (1) positive deviance approach, (2) unconventional and non-confirmative behaviour and (3) relevance of networks and relationships. The competences were the ability to: (1) collaborate in/outside the organisation, (2) gain and share expert (evidence-based) knowledge, (3) critically reflect on working habits/problems in daily care and dare to challenge the status quo and (4) generate ideas to improve care. The factors that stimulate or hinder the development of rebel nurse leadership are as follows: (1) dialogue and reflection, (2) networking conditions and (3) the managers' role.

CONCLUSIONS

Based on our analysis, we summarise the descriptions given of rebel nurse leadership, the mentioned competences and provide an overview of the factors that stimulate or hinder rebel nurse leadership.

RELEVANCE TO CLINICAL PRACTICE

The descriptions produced in this review of rebel nurse leadership and the stimulating or hindering factors listed should help nurses and managers encourage rebel leadership.

Nurses

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

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.

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.

When breaking the rule becomes necessary: The impact of leader-member exchange quality on nurses pro-social rule-breaking

Aim

Despite the literature on nursing leadership, the research on the quality of exchange relationship between nursing leaders and nurses is in its initial stages. Also, the underlying mechanism that exists between leader–member exchange and employee outcomes warrants further inquiry. This study aimed to fill these gaps by investigating the role of leader–member exchange relationships and organizational identification in nurses' intentional violation of hospital regulations to promote their patients' welfare, also called pro‐social rule‐breaking. In contrast to a vast number of previous studies, we argue that pro‐social rule‐breaking can be positive for organizations. Therefore, nurses should be given margin and autonomy to break hospital rules when needed by establishing a high‐quality exchange relationship with the supervisor.

Design

A quantitative study was conducted on nurses working in hospitals in Pakistan by utilizing a non‐probability convenience sampling technique.

Method

Data from nurses and their colleagues (n = 224) were collected at three‐time points between June 2019 and August 2019 through questionnaires.

Results

The results proved that nurses' possessing a high‐quality exchange relationship with their supervisor feels a higher level of identification with their organization. In turn, they are more likely to engage in pro‐social rule‐breaking as a form of constructive deviance.

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.

An Essential Clinical Dataset Intervention for Nursing Documentation of a Pediatric Admission History Database

PURPOSE

The purpose of this study was to improve nursing documentation efficiencies and satisfaction of a pediatric admission history workflow. Secondary aims determined if defining essential data elements was associated with decreased pediatric admission history documentation time, increased dataset completion rate, and increased satisfaction.

DESIGN AND METHODS

A quasi-experimental between-group difference comparison was conducted for a nurse-led quality improvement study that included implementation of a pediatric essential clinical dataset (ECD) tool for pre/post-intervention analysis of nursing admission history documentation time, dataset completion rate, and satisfaction. A survey was administered to nurses pre- and post-intervention to compare documentation satisfaction.

RESULTS

Nursing admission history documentation time decreased by 1 min 31 s and the number of clicks decreased 38%. Dataset utilization increased 8% indicating improved nursing documentation of essential questions within a pediatric admission history form. Nursing documentation satisfaction with the pediatric admission history form was minimally impacted by the pediatric ECD study intervention.

CONCLUSIONS

Defining what is essential for nurses to document positively influenced nursing documentation time, dataset completion rate, and satisfaction.

PRACTICE IMPLICATIONS

The study contributed to EHR content standardization, optimization, and documentation efficiencies for nurses within a pediatric organization with implications for clinical and informatics collaboration to create real-world evidence, leveraging an intervention that decreased documentation burden and increased time for children and families.

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.

Factors associated with nurse well-being in relation to electronic health record use: A systematic review

OBJECTIVE

Although nurses comprise the largest group of health professionals and electronic health record (EHR) user base, it is unclear how EHR use has affected nurse well-being. This systematic review assesses the multivariable (ie, organizational, nurse, and health information technology [IT]) factors associated with EHR-related nurse well-being and identifies potential improvements recommended by frontline nurses.

MATERIALS AND METHODS

We searched MEDLINE, Embase, CINAHL, PsycINFO, ProQuest, and Web of Science for literature reporting on EHR use, nurses, and well-being. A quality appraisal was conducted using a previously developed tool.

RESULTS

Of 4583 articles, 12 met inclusion criteria. Two-thirds of the studies were deemed to have a moderate or low risk of bias. Overall, the studies primarily focused on nurse- and IT-level factors, with 1 study examining organizational characteristics. That study found worse nurse well-being was associated with EHRs compared with paper charts. Studies on nurse-level factors suggest that personal digital literacy is one modifiable factor to improving well-being. Additionally, EHRs with integrated displays were associated with improved well-being. Recommendations for improving EHRs suggested IT-, organization-, and policy-level solutions to address the complex nature of EHR-related nurse well-being.

CONCLUSIONS

The overarching finding from this synthesis reveals a critical need for multifaceted interventions that better organize, manage, and display information for clinicians to facilitate decision making. Our study also suggests that nurses have valuable insight into ways to reduce EHR-related burden. Future research is needed to test multicomponent interventions that address these complex factors and use participatory approaches to engage nurses in intervention development.

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.

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.

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.

Organizational diagnostics: a systematic approach to identifying technology and workflow issues in clinical settings

Objectives

Healthcare organizations need to rapidly adapt to new technology, policy changes, evolving payment strategies, and other environmental changes. We report on the development and application of a structured methodology to support technology and process improvement in healthcare organizations, Systematic Iterative Organizational Diagnostics (SIOD). SIOD was designed to evaluate clinical work practices, diagnose technology and workflow issues, and recommend potential solutions.

Materials and Methods

SIOD consists of five stages: (1) Background Scan, (2) Engagement Building, (3) Data Acquisition, (4) Data Analysis, and (5) Reporting and Debriefing. Our team applied the SIOD approach in two ambulatory clinics and an integrated ambulatory care center and used SIOD components during an evaluation of a large-scale health information technology transition.

Results

During the initial SIOD application in two ambulatory clinics, five major analysis themes were identified, grounded in the data: putting patients first, reducing the chaos, matching space to function, technology making work harder, and staffing is more than numbers. Additional themes were identified based on SIOD application to a multidisciplinary clinical center. The team also developed contextually grounded recommendations to address issues identified through applying SIOD.

Discussion

The SIOD methodology fills a problem identification gap in existing process improvement systems through an emphasis on issue discovery, holistic clinic functionality, and inclusion of diverse perspectives. SIOD can diagnose issues where approaches as Lean, Six Sigma, and other organizational interventions can be applied.

Conclusion

The complex structure of work and technology in healthcare requires specialized diagnostic strategies to identify and resolve issues, and SIOD fills this need.

The electronic health record's impact on nurses' cognitive work: An integrative review

BACKGROUND

Technology use can impact human performance and cognitive function, but few studies have sought to understand the electronic health record's impact on these dimensions of nurses' work.

OBJECTIVE

The purpose of this review was to synthesize the literature on the electronic health record's impact on nurses' cognitive work.

DESIGN

Integrative review.

DATA SOURCES

MEDLINE/PubMed, CINAHL, Embase, Web of Science, and PsycINFO.

REVIEW METHODS

The literature search focused on 3 concepts: the electronic health record, cognition, and nursing practice, and yielded 4910 articles. Following a stepwise process of duplicate removal, title and abstract review, full text review, and reference list searches, a total of 18 studies were included: 12 qualitative, 4 mixed-methods, and 2 quantitative studies from the United States (13), Scandinavia (2), Australia (1), Austria (1), and Canada (1). The Mixed Methods Appraisal Tool was used to assess the quality of eligible studies.

RESULTS

Five themes identified how nurses and other clinicians used the electronic health record and perceived its impact: 1) forming and maintaining an overview of the patient, 2) cognitive work of navigating the electronic health record, 3) use of cognitive tools, 4) forming and maintaining a shared understanding of the patient, and 5) loss of information and professional domain knowledge. Most studies indicated that forming and maintaining an overview of the patient at both the individual and team level were difficult when using the electronic health record. Navigating the volumes of information was challenging and increased clinicians' cognitive work. Information was perceived to be scattered and fragmented, making it difficult to see the chronology of events and to situate and understand the clinical implications of various data. The template-driven nature of documentation and limitations on narrative notes restricted clinicians' ability to express their clinical reasoning and decipher the reasoning of colleagues. Summary reports and handoff tools in the electronic health record proved insufficient as stand-alone tools to support nurses' work throughout the shift and during handoff, causing them to rely on self-made paper forms. Nurses needed tools that facilitated their ability to individualize and contextualize information in order to make it clinically meaningful.

CONCLUSION

The electronic health record was perceived by nurses as an impediment to contextualizing and synthesizing information, communicating with other professionals, and structuring patient care. Synthesizing and communicating information at the individual and team levels are known drivers of patient safety. The findings from this review have implications for electronic health record design.

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.

Assessing the Effect of an Educational Intervention on Nurses' and Patient Care Assistants' Comprehension and Documentation of Functional Ability in Pediatric Patients with Sickle Cell Disease

PURPOSE

In 2014, the Youth Acute Pain Functional Ability Questionnaire (YAPFAQ) was developed to investigate patient's self-rated functional ability during times of acute pain in the inpatient clinical setting. Although it has great potential, the application of this tool has not been made a standard of care. The purpose of this multiple methods study was to determine if, through an educational intervention, hospital staff could consistently document the YAPFAQ in children with sickle cell disease (SCD) during a vaso-occlusive episode.

DESIGN AND METHODS

Twenty-two staff members participated in an educational intervention and semi-structured group discussions. Pre/post surveys measured knowledge of the YAPFAQ before and after the intervention. Group discussions were recorded, transcribed verbatim, and analyzed for thematic clusters. Retrospective chart reviews of children with SCD were reviewed for YAPFAQ documentation frequency before and after the intervention.

RESULTS

Staff knowledge of who completes the YAPFAQ increased after the intervention, (p<.001). YAPFAQ documentation decreased after the intervention, (p<.001). Qualitative analysis identified personal, physical, and patient barriers to completing the YAPFAQ and multiple recommendations to change the method of documentation in the electronic health records (EHR).

CONCLUSIONS

Although the staff expressed high interest in utilizing the YAPFAQ, application was inhibited by delayed translation to the EHR. The YAPFAQ continues to hold high potential for directing nursing care, but requires staff investment for clinical practice change.

PRACTICAL APPLICATIONS

A seamless integration between nursing education and translation through EHR is recommended as technology continues to integrate into nursing practice.

Two Strategies for Qualitative Content Analysis: An Intramethod Approach to Triangulation

The overarching aim of qualitative research is to gain an understanding of certain social phenomena. Qualitative research involves the studied use and collection of empirical materials, all to describe moments and meanings in individuals' lives. Data derived from these various materials require a form of analysis of the content, focusing on written or spoken language as communication, to provide context and understanding of the message. Qualitative research often involves the collection of data through extensive interviews, note taking, and tape recording. These methods are time- and labor-intensive. With the advances in computerized text analysis software, the practice of combining methods to analyze qualitative data can assist the researcher in making large data sets more manageable and enhance the trustworthiness of the results. This article will describe a novel process of combining two methods of qualitative data analysis, or Intramethod triangulation, as a means to provide a deeper analysis of text.