The experience of home nurses with an electronic nursing health record

What engagement strategies are useful in facilitating the implementation of electronic health records in health care settings? A rapid review of qualitative evidence synthesis using the normalization process theory

Objective

The study aimed to identify and describe the engagement strategies used in implementing electronic health records in health care settings and to ascertain why they were successful or not, using normalization process theory.

Methods

In this rapid review, we searched PubMed and CINAHL for qualitative and mixed methods primary studies published from 2010 to 2023 (June). We identified 41 studies that explored the implementation of EHRs, involving clinicians as participants. For quality appraisal, we employed the standards for reporting qualitative research (SRQR) tool. For analysis, a qualitative comparative analysis, using the normalization process theory was conducted. This was followed by a narrative synthesis to compile and analyze key findings.

Results

About 56% (n = 23) of the studies were conducted in hospitals, while the remaining were done in mental health, maternity, and ambulatory care settings. Participants included a range of clinicians such as nurses, physicians, doctors, dentists, pediatricians and other specialists. Evidence shows that prior to implementation, effective communication of the vision of EHRs and early user involvement in decision-making are useful engagement strategies in preparing users for implementation. Tailored training and on-demand technical support for users sustain system usage during the roll out. Lastly, ongoing engagement with users is essential for continuous user support and system improvements.

Conclusion

User engagement improves the chances of successful implementation, particularly if engagement strategies are effective for the specific stages of implementation. The success of these strategies is more evident when they ensure normalization process theory tenets, which include user coherence, cognitive participation, collective action and reflective monitoring.

Natural Language Processing Applied to Clinical Documentation in Post-acute Care Settings: A Scoping Review

OBJECTIVES

To determine the scope of the application of natural language processing to free-text clinical notes in post-acute care and provide a foundation for future natural language processing-based research in these settings.

DESIGN

Scoping review; reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

SETTING AND PARTICIPANTS

Post-acute care (ie, home health care, long-term care, skilled nursing facilities, and inpatient rehabilitation facilities).

METHODS

PubMed, Cumulative Index of Nursing and Allied Health Literature, and Embase were searched in February 2023. Eligible studies had quantitative designs that used natural language processing applied to clinical documentation in post-acute care settings. The quality of each study was appraised.

RESULTS

Twenty-one studies were included. Almost all studies were conducted in home health care settings. Most studies extracted data from electronic health records to examine the risk for negative outcomes, including acute care utilization, medication errors, and suicide mortality. About half of the studies did not report age, sex, race, or ethnicity data or use standardized terminologies. Only 8 studies included variables from socio-behavioral domains. Most studies fulfilled all quality appraisal indicators.

CONCLUSIONS AND IMPLICATIONS

The application of natural language processing is nascent in post-acute care settings. Future research should apply natural language processing using standardized terminologies to leverage free-text clinical notes in post-acute care to promote timely, comprehensive, and equitable care. Natural language processing could be integrated with predictive models to help identify patients who are at risk of negative outcomes. Future research should incorporate socio-behavioral determinants and diverse samples to improve health equity in informatics tools.

Documentation of hospitalization risk factors in electronic health records (EHRs): a qualitative study with home healthcare clinicians

OBJECTIVE

To identify the risk factors home healthcare (HHC) clinicians associate with patient deterioration and understand how clinicians respond to and document these risk factors.

METHODS

We interviewed multidisciplinary HHC clinicians from January to March of 2021. Risk factors were mapped to standardized terminologies (eg, Omaha System). We used directed content analysis to identify risk factors for deterioration. We used inductive thematic analysis to understand HHC clinicians' response to risk factors and documentation of risk factors.

RESULTS

Fifteen HHC clinicians identified a total of 79 risk factors that were mapped to standardized terminologies. HHC clinicians most frequently responded to risk factors by communicating with the prescribing provider (86.7% of clinicians) or following up with patients and caregivers (86.7%). HHC clinicians stated that a majority of risk factors can be found in clinical notes (ie, care coordination (53.3%) or visit (46.7%)).

DISCUSSION

Clinicians acknowledged that social factors play a role in deterioration risk; but these factors are infrequently studied in HHC. While a majority of risk factors were represented in the Omaha System, additional terminologies are needed to comprehensively capture risk. Since most risk factors are documented in clinical notes, methods such as natural language processing are needed to extract them.

CONCLUSION

This study engaged clinicians to understand risk for deterioration during HHC. The results of our study support the development of an early warning system by providing a comprehensive list of risk factors grounded in clinician expertize and mapped to standardized terminologies.

Barriers and Benefits of Information Communication Technologies Used by Health Care Aides

BACKGROUND

Although information and communication technologies (ICT) are becoming more common among health care providers, there is little evidence on how ICT can support health care aides. Health care aides, also known as personal care workers, are unlicensed service providers who encompass the second largest workforce, next to nurses, that provide care to older adults in Canada.

OBJECTIVE

The purpose of this literature review is to examine the range and extent of barriers and benefits of ICT used by health care workers to manage and coordinate the care-delivery workflow for their clients.

METHODS

We conducted a literature review to examine the range and extent of ICT used by health care aides to manage and coordinate their care delivery, workflow, and activities. We identified 8,958 studies of which 40 were included for descriptive analyses.

RESULTS

We distinguished the following five different purposes for the use and implementation of ICT by health care aides: (1) improve everyday work, (2) access electronic health records for home care, (3) facilitate client assessment and care planning, (4) enhance communication, and (5) provide care remotely. We identified 128 barriers and 130 benefits related to adopting ICT. Most of the barriers referred to incomplete hardware and software features, time-consuming ICT adoption, heavy or increased workloads, perceived lack of usefulness of ICT, cost or budget restrictions, security and privacy concerns, and lack of integration with technologies. The benefits for health care aides' adoption of ICT were improvements in communication, support to workflows and processes, improvements in resource planning and health care aides' services, and improvements in access to information and documentation.

CONCLUSION

Health care aides are an essential part of the health care system. They provide one-on-one care to their clients in everyday tasks. Despite the scarce information related to health care aides, we identified many benefits of ICT adoption.

Electronic Health Records in Danish Home Care and Nursing Homes: Inadequate Documentation of Care, Medication, and Consent

BACKGROUND

Electronic health records (EHRs) are used in long-term care to document the patients' condition, medication, and care, thereby supporting communication among caregivers and counteracting adverse drug events. However, the use of EHRs in long-term care has lagged behind EHR use in hospitals. In addition, most EHR research focuses on hospitals.

OBJECTIVE

This study gives a countrywide status of the documentation-related risks to patient safety in Danish home care and nursing homes, which are the two main providers of long-term care. Such a status provides a basis for national improvement efforts and international comparisons.

METHOD

The study is based on the reports from 893 inspections of home care and nursing homes by the Danish Patient Safety Authority (Styrelsen for Patientsikkerhed [STPS]).

RESULTS

As much as 69% of the inspected institutions document inadequately to an extent that has led to demands (i.e., issues the institution is legally obliged to rectify) or requests (i.e., issues the institution is merely asked to rectify) from STPS. Documentation issues about the patients' condition and care are present in nearly all institutions that receive demands (97%) and in the majority of those that receive requests (68%). Documentation issues about medication and consent to care are also common, but less so. The predominant risk to patient safety is incomplete documentation. It covers 72% of the documentation issues identified in the institutions that received demands; the remaining risks concern inconsistent (11%), nonexistent (7%), inaccessible (5%), and noncompliant (5%) documentation. The documentation inadequacies are similar for home care and nursing homes.

CONCLUSION

Inadequate EHR documentation is a widespread problem in Danish long-term care. While previous research mainly focuses on how EHR documentation affects patient medication, this study finds that documentation issues about the patients' condition and care are more prevalent and that issues about their consent are also common.

Staff experiences within the implementation of computer-based nursing records in residential aged care facilities: a systematic review and synthesis of qualitative research

BACKGROUND

Since the introduction of electronic nursing documentation systems, its implementation in recent years has increased rapidly in Germany. The objectives of such systems are to save time, to improve information handling and to improve quality. To integrate IT in the daily working processes, the employee is the pivotal element. Therefore it is important to understand nurses' experience with IT implementation. At present the literature shows a lack of understanding exploring staff experiences within the implementation process.

METHODS

A systematic review and meta-ethnographic synthesis of primary studies using qualitative methods was conducted in PubMed, CINAHL, and Cochrane. It adheres to the principles of the PRISMA statement. The studies were original, peer-reviewed articles from 2000 to 2013, focusing on computer-based nursing documentation in Residential Aged Care Facilities.

RESULTS

The use of IT requires a different form of information processing. Some experience this new form of information processing as a benefit while others do not. The latter find it more difficult to enter data and this result in poor clinical documentation. Improvement in the quality of residents' records leads to an overall improvement in the quality of care. However, if the quality of those records is poor, some residents do not receive the necessary care. Furthermore, the length of time necessary to complete the documentation is a prominent theme within that process. Those who are more efficient with the electronic documentation demonstrate improved time management. For those who are less efficient with electronic documentation the information processing is perceived as time consuming. Normally, it is possible to experience benefits when using IT, but this depends on either promoting or hindering factors, e.g. ease of use and ability to use it, equipment availability and technical functionality, as well as attitude.

CONCLUSIONS

In summary, the findings showed that members of staff experience IT as a benefit when it simplifies their daily working routines and as a burden when it complicates their working processes. Whether IT complicates or simplifies their routines depends on influencing factors. The line between benefit and burden is semipermeable. The experiences differ according to duties and responsibilities.

Restraint use in home care: a qualitative study from a nursing perspective

Background

Despite the growing demand for home care and preliminary evidence suggesting that the use of restraint is common practice in home care, research about restraint use in this setting is scarce.

Methods

To gain insight into the use of restraints in home care from the perspective of nurses, we conducted a qualitative explorative study. We conducted semi-structured face-to-face interviews of 14 nurses from Wit-Gele Kruis, a home-care organization in Flanders, Belgium. Interview transcripts were analyzed using the Qualitative Analysis Guide of Leuven.

Results

Our findings revealed a lack of clarity among nurses about the concept of restraint in home care. Nurses reported that cognitively impaired older persons, who sometimes lived alone, were restrained or locked up without continuous follow-up. The interviews indicated that the patient’s family played a dominant role in the decision to use restraints. Reasons for using restraints included “providing relief to the family” and “keeping the patient at home as long as possible to avoid admission to a nursing home.” The nurses stated that general practitioners had no clear role in deciding whether to use restraints.

Conclusions

These findings suggest that the issue of restraint use in home care is even more complex than in long-term residential care settings and acute hospital settings. They raise questions about the ethical and legal responsibilities of home-care providers, nurses, and general practitioners. There is an urgent need for further research to carefully document the use of restraints in home care and to better understand it so that appropriate guidance can be provided to healthcare workers.

Bridging the information divide: health information sharing in home care

As in many health sectors, in home care there have been significant investments made in electronic health information systems (EHIS) and accompanying standardized assessment instruments. While the potential of these systems to enhance the quality of care has been recognized, it has yet to be fully realized in Canadian home care settings. Data on EHIS barriers and facilitators were collected using a survey (n = 22).The results were discussed at a workshop (n = 30) and a "world café" session was held to consider strategies and interventions for improving health information exchange, with a focus on home care rehabilitation.

Contribuições dos registros eletrônicos para a segurança do paciente em terapia intensiva: uma revisão integrativa

Revisão integrativa que analisou nas publicações as contribuições dos registros eletrônicos em saúde para a segurança do paciente em unidades de terapia intensiva. A pesquisa foi realizada nas bases de dados CINAHL, MEDLINE e SciELO, utilizando os descritores: registros eletrônicos de saúde, sistemas de informação, informática em enfermagem, informática médica, unidades de terapia intensiva, segurança do paciente e gerenciamento de segurança. Foram incluídos 64 artigos, sendo analisados em três categorias: "sistemas de informação e informática em saúde: o registro eletrônico para a continuidade do cuidado de Enfermagem", "sistemas de apoio à decisão: contribuições para a segurança do paciente" e "indicadores de qualidade do cuidado e de segurança do paciente partir dos registros eletrônicos". Os estudos apontaram como contribuições a continuidade do cuidado, a tomada de decisão baseada nos sistemas de apoio à decisão e a criação de indicadores de qualidade e segurança do paciente a partir dos registros eletrônicos.

A survey of student nurses' and midwives' experiences of learning to use electronic health record systems in practice

AIM

The study aimed to investigate student nurses' and midwives' experiences of learning to use electronic health records (EHR) in practice.

BACKGROUND

Good record keeping and documentation are integral to nursing and midwifery practice. As EHRs become more widespread, student nurses and midwives need opportunities to access and learn how to use them in practice.

METHOD

A survey of nursing and midwifery students was conducted using questionnaires (n = 215) and three focus groups: one with midwifery students (n = 6); one with mental health nursing students (n = 5) and one with adult nursing students (n = 6). The University research ethics committee approved the study. The questionnaire data were analysed using SPSS v19. The focus group data were analysed thematically following transcription.

RESULTS

The results presented relate to two themes: 1) Preparation for using EHRs and skills development; 2) Access to EHRs and involvement. Students had variable experiences in relation to opportunities to access and use EHRs, training on EHR systems used in practice and guidance from mentors. Some mentors had concerns about students' legitimacy to access EHRs and verification of students' EHR entries was a challenging issue in some areas.

CONCLUSION

To promote opportunities for students to develop competence in using EHRs in practice, training on EHR systems in use, and clear processes for authorised access, are needed. Following the survey, the University and practice partners collaboratively established formalised EHR training for students with clear governance procedures for access and use.