You Want Me To Document What: A Qualitative Descriptive Study of ED Nurses' Perceived Role in the Use of Electronic Healthcare Records in a Learning Healthcare System

Abstract

Objective: Nurses are challenged with collecting and using information in the form of electronic healthcare records (EHR) data. Learning healthcare systems (LHS) are reliant on nurses collecting accurate patient information in EHR, yet nurses are challenged with the process of documenting while focusing on patient care. This split focus can impact converting information into meaningful knowledge later. No research describing nurses’ perceived role in a LHS exists. Method: This qualitative study was conducted to obtain insight in nurses’ perceived role in collecting and using data as part of a LHS. The research questions explored were: 1) What are nurses’ perceptions of what it takes to collect information representing the patient’s health in the EHR? 2) What are nurses’ perceptions of their role in capturing and recording information in the form of EHR data? 3) What challenges do nurses face in EHR usability when trying to capture information in the form of data? 4) How do nurses use data to influence their practice? A qualitative descriptive design was used. Seven emergency department nurses from two Midwestern hospitals were interviewed using semi-structured interview questions. Results: Using inductive data analysis four themes were identified: 1) The impact hospital’s electronic healthcare systems have on human factors. 2) Hospitals’ leadership influences collected patient information and the nursing documentation process. 3) Nurses are concerned about the impact of electronic healthcare record documentation on patient safety and quality of care. 4) Nurses use the electronic healthcare record documentation process to assist in nursing decision-making as they care for patients. Conclusion: Findings revealed nurses perceive their roles as a complex interaction with patients and EHR. They are continuously challenged with meeting internal and external demands. There is a need to provide enhanced education on the strengths and capabilities of the EHR systems. Leadership’s development of ways to help support nurses in their daily activities is necessary. They valued quality metric reporting as a means of patient safety and quality improvement. Lastly, nurses should be provided with education on the importance of their role in the entire system when it comes to collecting and using EHR data.