Translational & Implementation Science
Barriers and facilitators of critical care nursing workflow using electronic health records Alison Trinkoff* Alison Trinkoff Ayse P. Gurses Hyang Baek Janelle Faiman Daniel France T Ryan MIles Oluseyi Daodu Patience Osei Kelly Gleason Dawn Luzetsky Judy Ascenzi Stephanie Morgenstern Charlotte Seckman Shijun Zhu Shilo Anders
Background: Nurses spend the most time of any profession using the Electronic Health Record (EHR), mostly for clinical workflow and to document care provision. However, there has been minimal inquiry into the usability of EHR as designed for nursing care, and EHR demands among nurses are a growing concern. Using a Human Factors/Systems Engineering approach, we specifically targeted nurses’ EHR use during critical clinical events and transitions, including admissions, discharges, and medication administration, while they were caring for extremely high acuity patients.
Methods: In this multi-centered, multi-method study, 40 critical care nurses were observed and interviewed using a qualitative approach combining semi-structured interviews and observations of nurses while using the EHR in their natural work environment. Interviews were recorded using Zoom/MS Teams with transcripts enabled. Data were coded using MaxQDA and checked for inter-rater reliability across study sites for consistency and accuracy. For this analysis, we focused on nurse-identified barriers or obstacles to care from the EHR system, along with EHR facilitators beneficial to their work.
Results: Major barriers of EHR use included time demands associated with locating up-to-date information and needing to prioritize patient-care activities over charting. Other barriers were associated with the inability to customize the EHR to specific critical care environments. Major EHR facilitators included EHR promotion of communication across teams and disciplines, especially during admissions, as this was viewed as a team activity, and assisting with organizational aspects of task load and communication across teams.
Conclusions: Input from nurses can identify EHR barriers requiring redesign and enhance features that promote optimal utility for clinical workflow, building on strengths of the EHR system. Human factors qualitative approaches yielded details that can be addressed through EHR modifications in implementation studies. Future research will relate EHR system features to missed nursing care and medication errors, quantitatively.