Perceptions of Impact of Electronic Health Records on Nurses’ Work

Susan P. Kossman, RN, PhD

Mennonite College of Nursing, Illinois State University

School of Nursing, University of Wisconsin-Madison

Abstract

This study addresses how community hospital nurses use Electronic Health Records (EHRs) during patient care and their views of its impact on their job performance. Questionnaire, interview and observation data from 46 nurses in medical-surgical and intensive care units at two community hospitals within a regional healthcare system (second year of EHR implementation) were analyzed for themes and compared across hospital and unit dimensions. Nurses preferred EHRs to paper charts and were comfortable with technology. They felt EHR use enhanced nursing work through increased information access, improved organization and efficiency, and alert screens. They felt it hindered nursing work through increased documentation time (slow system response, multiple screens), decreased interdisciplinary communication and impaired critical thinking through overuse of checkboxes and “copy and paste” documentation. 73% spent at least half their work time using EHRs, and felt use enabled them to provide safer care but decreased quality of care. Administrative implications include streamlining EHR work processes, developing guidelines to improve consistency in documentation quality and location, increasing system speed, and choosing hardware that encourages bedside use.

Keywords: Electronic Health Record, Clinical Informatics

Introduction

Use of electronic health records (EHRs) in the United States has become more widespread during the last decade, spreading from large academic medical centers to community-based acute care and outpatient facilities. These systems represent a major investment of capital and human resources and affect multiple service providers (nurse, pharmacist, physician, ancillary departments). They have the potential to improve – or create obstacles to-- work performance, communication, and documentation. Since nurses play a key, central role in providing and coordinating inpatient care, the extent to which EHRs enhance or detract from nurses’ role performance can be expected to affect patient outcomes. There is insufficient knowledge about how nurses’ use of EHRs effects their role performance and patient outcomes in community based acute care settings. The purpose of this descriptive, qualitative study was to describe how nurses use EHRs as they provide patient care and their views of its impact on nurse’s work and patient outcomes. This report focuses on nurses’ perceptions of how EHR use affects their job performance.

Background

The literature on EHRs has focused largely on nurses’ and physicians’ attitudes toward use which is correlated with satisfaction with system1,2 effects of electronic alerting systems on patient care3 ; and impact on documentation time4. The effect of EHR use on nurses’ job performance has not been reported. The nursing role effectiveness model5 provides a theoretical framework for assessing the effect of electronic record systems on nurses’ role performance and patient outcomes. This is a Structure (nurse, unit and patient structural variables) – Process (nurses independent, dependent, and interdependent roles) – Outcomes (patient quality of care) model for assessing nurses’ contribution to health care. The model proposes that the impact of unit and nurses’ structural variables on patient outcomes is mediated through the process of nursing role performance. The model suggests that how nurses use EHRs and how this use impacts nurses’ work has an effect on patient and cost outcomes.

Improving patient safety outcomes is an international priority. The Institute of Medicine (IOM) has identified problems with the United States’ health care delivery system, which they describe as poorly organized, complex, and uncoordinated6. Additionally, they describe concerns with nurses’ work environment, including problems with staffing, unsafe work processes and poor workplace design7. Among their recommendations to improve safety is use of information technology to automate medication delivery systems, patient clinical data, and provide clinical decision support6,7. These features are key components of EHRs and add incentive for hospitals to adopt EHR systems. Does EHR use improve nurses’ ability to perform their jobs thus promoting delivery of safe and effective patient care? This study addressed this question. Findings can shed light on intended and unintended consequences of EHR use and inform development of evaluation studies of EHR use impact on nursing productivity and care outcomes.

Methodology

This descriptive qualitative study used questionnaire surveys, individual interviews, and observation techniques. Qualitative methodology was an appropriate choice because the goal was to understand the meaning of a phenomenon—EHR use and impact on role performance—from the perspective of working nurses. Rich descriptions of participants’ experiences, consideration of the context of these experiences and inclusion of multiple viewpoints allowed an overall picture of the phenomenon to emerge.

Questionnaire surveys were collected first to explore the boundaries of the phenomenon of how nurses use EHRs and perceive its impact on work performance and outcomes. Next, the researcher observed nurses on the study units use EHRs and concurrently interviewed them. These observation/interviews allowed the investigator to identify practice patterns, problems encountered with EHR use and “work-around” solutions nurses employed. They broadened understanding of the phenomenon and allowed clarification of issues or conflicts noted in survey data. Trustworthiness was addressed through using multiple methods of data collection (triangulation) and representativeness was increased by using multiple units and nurse participants. Human subjects protection was ensured through IRB review at the hospitals and researcher’s University.

Analysis was concurrent with data collection. Interview data was coded using open coding techniques and N-Vivo software. Emerging codes and concepts influenced observations and questions in later interviews, as clarification, validation or refutation was sought.

Setting:

The study was conducted in medical-surgical and intensive care units at two community hospitals within a regional Midwestern Healthcare system, both in the second year of EHR implementation. Nurses used laptops on carts and desk computers. Hospital 1 is 157 beds, located in a mid-sized city (110,000); hospital 2 is 47 beds, located in a rural community. These two types of units were chosen because they differ in attributes that theoretically may affect nurses’ work: patient acuity, workload, and pace of work.

Sample

Participants were a convenience sample of nurses working in ICU and medical-surgical floors who volunteered to participate after solicitation through an email and letter describing the study distributed at their work setting and flyers posted in the units’ break rooms. Inclusion criteria were that nurses worked in the hospital on one of the research units and used EHRs for at least 6 months. There were no age, gender, or race exclusions.

Participants completed informed consent and demographic data forms, including a self-rating of comfort with technology use, years of experience, age, in addition to completing a survey and/or participating in observation/interview. Data collection continued until saturation (indicated by no newly emerging themes or concepts) occurred.

Table 1: Demographic Data

Age / Education
Years / # / % / Degree / # / %
20s / 14 / 35 / BSN / 22 / 55
30s / 10 / 25 / ADN / 18 / 45
40s / 5 / 12.5
50s / 9 / 22.5
60s / 2 / 5 / Years employed:
Mean age: 37.7 / Mean years: 13
Range: 22 - 63 / Range: 0.5 - 40
Technology Comfort / % time using EHR
Level / # / % / Time / # / %
1 / 1 / 2.5 / 25 / 4 / 10
2 / 1 / 2.5 / 30-40 / 7 / 17.5
3 / 5 / 12.5 / 50-60 / 16 / 40
4 / 18 / 45 / 70 -80 / 10 / 25
5 / 15 / 37.5 / >80 / 3 / 7.5
Mean comfort: 4.1 / Mean time: 56.6%
Range: 1-5 / Range: 25 – 98%

Forty-six nurses participated (representing a 50% response rate at both sites). At the larger hospital 31 nurses completed 29 surveys and 15 interview/observations. At the smaller hospital 15 nurses completed 13 surveys and 7 interview/ observations. Demographic data is presented in Table 1. Six nurses who participated in interview/ observations did not complete demographic data forms, so percentages in the table are based on 40 participants. Since 60% of participants were younger than 40, it may be that the sample over represents younger nurses; however the sample’s mean age of 37.7 years is close to that of nurses working at the hospitals (40 years) suggesting that it reflects the nurse workforce. Additionally, the sample may over represent BSN prepared nurses; they comprised 55% of the sample vs. 47% of the hospitals’ nurses.

Findings:

How nurses use EHRs

Nurses reported using EHRs for all aspects of patient care documentation, including reviewing and charting assessments, care planning, treatments, medication administration, admissions and discharges. They accessed pertinent clinical information including transcribed reports, laboratory and diagnostic test results, interdisciplinary notes and past history. They organized their shifts through accessing and updating worklists (scheduled treatments) and medication lists. Computerized provider order entry was available in the study hospitals, but not widespread; only a few nurses and physicians used it, leaving order entry to unit secretaries and pharmacists (medications only). Nurses described comprehensive use of EHRs:

For virtually all documentation of care. For worklists, both task and medication. To review orders, labs, radiology. Also linked to reference technology

They also described frequent use of EHRs:

I use them constantly to look up information, record information, and to communicate with all departments.

Effect of EHR use on nursing work

All nurses described ways EHR use both enhanced their ability to work and also hindered it, for example:

EHRs affect how I do my work by both slowing down and speeding up charting and investigating patients records. Sometimes the computers are down and this slows the charting process down. Otherwise, it speeds up the process to give medications, get reports, and to communicate with other facilities.

Overall they felt the benefits of EHR use outweighed its detractions; only two nurses stated a preference for paper charting. However, problems encountered with EHR use caused frustration and a sense of decreased effectiveness in job performance and patient care.

It can be very frustrating and a cause for concern if the computers go down unexpectedly. When this happens, I feel like I don’t know what needs to be done and I usually don’t know if a med is due.

At first I though it made a big damper on patient care…all you ever saw was nurses on computers. You never saw nurses with patients. I still feel like there’s days where you’re trying to balance your patient care and your charting, because it takes a while. And I never really noticed it when we were still doing the paper charting.

Enhances Nursing Work:

Nurses identified increased access to patient care information, improved efficiency and organization as EHR attributes that enhanced their work performance.

Increased access to patient information

Nurses identified several ways increased access to patient information enhanced their job performance. First, they spent less time searching for records and finding the patient’s chart:

I have quicker access to test/lab results. I can chart and review a chart anytime, even if another nurse/doctor/secretary is accessing the chart. I have easy access to much of a patient’s old chart. It’s nice having everything at my fingertips.

Second, nurses could more easily access patient information needed for clinical decision making:

If I wanted to find when the last time a medication was given, just a couple clicks and I have the answer.

A nurse described using the EHR to find information on a patient who would be admitted for postoperative care later in the shift:

I’m checking on a surgical patient who’s in the OR now. Checking what the preop(erative) screening put in about diagnosis, discharge-- want to check who is the support person in case he gets an ostomy… This gives me an idea on what to ask the OR nurses in report…what else I need to know.

Increased Efficiency

Nurses felt EHR use improved their efficiency through quicker documentation and information retrieval processes. Nurses said:

It speeds up the process to give medications, get reports, and to communicate with other facilities.

(It is) quicker to type or “click” on information than to hand chart.

Nurses also felt automatic notifications and alert screens improved efficiency:

If you have new orders …, when you check your med sheet it pops right away, you’re not having to go straight to the chart. It automatically gives you an alert for that. So that makes it more efficient.

Other aspects of EHR use identified as improving efficiency were having “portable workstations so you’re not confined to being at a desk” and spending less time deciphering written notes and orders.

Improved Organization

Nurses felt EHR use made them more organized through provision of task lists, systematic charting and prompts, and less reliance on their memory or written notes.

I have work lists to help me remember what needs to be done…The work list shows what I have to do today by patient and medications listed and treatments.

A nurse described charting assessments:

I work down and across, that way I don’t forget things, starting with vital signs. Then I go down to Intake/Output and record anything there that needs to be recorded. We’re just going sequentially down and across when things pop-up. And that’s what keeps you organized.

Hinders nursing work

Nurses also identified several ways that EHR use hindered their job performance, including increasing time spent retrieving or documenting information, decreasing time spent with the patient, interfering with written interdisciplinary communication and hindering critical thinking.

Slows nurses down

Several computer and EHR related issues increased time nurses spent on the computer. System speed, downtime, and lack of available or functional computers interfered with nurses’ ability to efficiently manage time.

It’s very slow, the computer is slow. When there is a glitch or a problem with it, it can really upset your whole day. It can stack everything up…and the more it stacks up the less gets entered.

Computers tend to run slowly causing increased frustration. Lack of a computer when you need one. Getting up to answer the call light and you come back to find someone has logged you off your computer and took it over. Aughh!