The importance of disciplinary know-how in integrating an EHR into practice
Jun 01, 2015, By: Karen E. Furlong, RN, MN, PhD
Understanding the breadth and intensity of learning requirements associated with electronic health records (EHRs) is germane to improving successful integration. Since EHR implementations are complex endeavours that necessitate end-user engagement to achieve success, I felt it was important to explore how nurses learn to use an EHR. This research interest was also influenced by my experiences as a trainer in preparing health-care professionals for an EHR deployment that occurred over five years ago. This article shares key findings and implications from a study I conducted as part of my doctoral program.
An EHR is a digital system that provides a longitudinal view of an individual’s health history and treatment plans: specific types of information are pulled from a variety of clinical information systems. RNs typically use EHRs to review orders, diagnostic results, dictated notes and consults, and to document care, such as the administration of medications.
The setting for my study was a large tertiary hospital in Atlantic Canada where health-care professionals had been using an electronic patient record for nearly 25 years. The hospital’s new system was an EHR that provided more advanced functionality such as clinical decision supports and improved interoperability. Although “going live” was probably one of the most exciting, yet intimidating, experiences of my professional career, it was the six months I spent preparing members of the health-care team for the launch date that left me with the greatest impression. My interpretations of how RNs learn to use an EHR had been based on rather superficial assumptions that often did not accurately reflect what was happening in reality. I believed EHR trainers were missing a key element of learning that I could not explain.
Prior to commencing data collection, I obtained approval from the research ethics boards at the University of New Brunswick, Fredericton campus, and Horizon Health Network. Data collection took place in two stages over a 12-month period: focus groups (Stage One) and unstructured interviews (Stage Two). RNs who experienced the initial implementation of the EHR and were currently employed as staff nurses were invited from multiple units within the hospital.
Interview transcriptions were my primary data source. Nurses were asked to tell stories about their EHR learning. Of the nine interview participants, one was male; most held full-time positions. The majority were between 30 and 50 years old, with nursing experience that ranged from three to 36 years. Younger and middle-aged nurses tended to view themselves as technologically savvy; older nurses often expressed little interest in using technology outside of the workplace. EHR use was a mandatory job requirement for all participants. All nurses worked as part of an interdisciplinary team, sharing a commitment to provide safe and comprehensive nursing care.
My study methodology was not meant to result in a descriptive or summative account. Through analysis of rich narratives, the participants’ perceptions of their learning experiences were explored and presented as co-constructed stories. In essence, these nurses were making sense of their experiences through telling their stories.
I explained to them that the purpose of my study was not evaluative — there were no right or wrong answers, but rather opportunities for them to tell me their stories about EHR learning. Participants were aware that I viewed them as the experts. Several commented that their involvement in this study gave them opportunities to think more deeply about their experiences and gain new insights.
The participants and I engaged in a collaborative and iterative process that resulted in three co-constructed stories that resonated with us all. The frame of analysis was sensitive to context, respecting the participants’ assignment of meaning.
It became clear to me during this study that nurses may be feeling confused by what is taking place within nursing and how technology may or may not fit into their world view. Participants told me stories about how learning was difficult to navigate due to workplace challenges, especially time constraints. In addition, they explained that there had been limited (or no) structured learning or evaluative mechanisms post deployment.
It was evident that these nurses were committed to learning what they needed to know. Although they were mandated to learn to use the EHR as part of their job requirements, there was no evidence to suggest that they were fearful of this organizational directive. Learning was driven internally by their professionalism. Nonetheless, a key finding of my study is that nurses may not be adequately prepared to practise within technological environments.
Nursing competence must include informatics as fundamental knowledge requirements. This directive is supported by the ways participants told their stories. Although they framed their stories within the context of care delivery, consistently foregrounding patient safety in the access and use of an EHR, there was little discussion about the need to re-evaluate their own nursing competence. This concept is explored more fully in an excerpt from one of the co-constructed stories. Readers are encouraged to immerse themselves in the account; to consider how it is that nursing is changing in the face of technology integration. Why is it that the participants in this study generally did not explore the purpose of the EHR beyond its use to them at the bedside? It seems possible that pre-deployment training that focused solely on the technical aspects may have perpetuated this mindset.
According to the Canadian Association of Schools of Nursing (CASN, 2012), education is the key component for both future and practising nurses to learn how to integrate technology. Education should include helping nurses to understand an EHR beyond its technical use. In other words, nurses must understand how EHRs fit within the bigger picture of health-care delivery, rather than just how to use them as necessary in day-to-day practice. Furthermore, in discussions of nursing competencies, critical thinking, evidence-informed practice and technical competence are often referred to as distinct practice requirements for nursing in the 21st century (CASN, 2010). It is ironic that there are several disciplinary components intertwined in the definition of nursing informatics, yet we have failed to deliver the same message in defining the discipline of nursing. It is time to merge these various components, making it clear that it is not possible to have one without the other. Nurses must perceive both computer literacy and information literacy as components of nursing competence, rather than isolated skill sets.
The excerpt from this co-constructed story is authentic: it is grounded in the data and presents new ways of thinking about what it was like for nurses to learn to use the EHR. This story is told through the perspective of a nurse named Angela Johnson, a composite character. My decision to create a composite character occurred during the analysis of interview data, in response to how the stories were told. Participants seldom used I as a subject pronoun; rather, they used we and described learning collectively as a group. Most participants read this story more than once and participated in ongoing refinements.
Practice Implications and Recommendations
I began this investigation thinking nurses would tell me stories about learning to use the EHR. In time, I realized it was necessary to consider the nurses’ world in its entirety. Their stories question the prevailing view that accentuates the grandeurs of technology. The rigid mindset that technology is flawless potentiates end-user acceptance.
In the interviews, participants tended to emphasize EHR learning that occurred while caring for their patients; their discussions mainly involved cognitive workflow adjustments. The fast-paced nature of hospital units inevitably influenced learning; participants tended to remember critical and high stress incidents when time was of the essence.
To this end, nurses must be made aware of how an EHR will be safely implemented. They need to understand that modifications to current workflow practices may be needed and know how to respond to situations where the EHR malfunctions. Understanding that critical incidents are an inevitable part of how learning occurs is important, and such incidents should be simulated during pre-deployment training sessions.
Nurses in my study seemed unaware of the extent of their professional practice responsibilities when working with various point-of-service applications. Although they consistently reported EHR functionality issues, and asked for help when uncertain, they seemed to be using the EHR without really knowing if their approach aligned with organizational goals. It was unclear to them whether the organizational goals had changed because of the new system. It seems unfathomable that an EHR would be deployed without users understanding how it is meant to change and hopefully advance care-delivery practices — and yet, that’s what happened in this situation.
A critique of the organization’s knowledge management infrastructure was beyond the scope of this study. However, the nurses’ limited view of the potential benefits of EHRs within the broader domain of care delivery is not new; Hollander, Corbett and Pallan (2010) cite similar quandaries. The lack of knowledge of the potential benefits to be derived from EHR use is of concern; Gill, Leonard and Jonker (2010) state that these unknowns jeopardize implementation outcomes.
Looking forward, nurses’ disciplinary knowledge base must be inclusive of informatics entry-to-practice competencies, as outlined by CASN (2012). In fact, these competencies are a part of accreditation standards for undergraduate nursing programs. Nursing knowledge is a critical element of safety in the access and use of various health-care technologies.
This study sheds light on nurses’ fears of losing the humanistic element of nursing in the face of technology integration. The participants’ stories suggest that fear can be minimized by helping nurses understand how their knowledge and critical thinking skills are paramount when using an EHR.
Let me tell you a story about nursing
My name is Angela Johnson. My work as a nurse on a busy surgical unit for the past 25 years has taught me many things. There is no better feeling than to be able to help someone who needs you — you know, to make a difference in someone’s life. Quite often it is the simple things that matter — like taking the time to talk to a patient when I am assessing their vital signs. Many nurses just pay attention to the computer — it bothers me that the technology seems to, I don’t know — it seems to keep us away from our patients.
Now, let me tell you about something that happened a few weeks ago.
As I am listening to the audio recording of the night report, I wonder what kind of a shift this is going to be. I tend to worry more these days. I am always concerned that I might miss something or order something wrong. Sometimes I even worry that my patients will die!
It is a long day filled with several unexpected happenings, the worst being Mrs. Inglewood’s sudden deterioration. This patient was scheduled to go home today; however, while doing her morning care at the bathroom sink, she became suddenly short of breath. Janet, a young inexperienced nurse, is caring for this patient. Janet is in the room with another patient when Mrs. Inglewood called out for help. Janet promptly pulled the emergency bell and two other team members helped her return Mrs. Inglewood to bed.
As I enter the room, Janet turns to me and asks me to listen to Mrs. Inglewood’s lungs. Janet is not sure of her assessment findings. She questions if there is any air entry in the right lower lobe. I assure Janet that the resident is “in the building” and that he is on his way. As I am performing a respiratory assessment, Janet leaves the room momentarily. She returns with the Work Station on Wheels (the computer) — something we will need for sure, yet not something that I had thought about. The resident and the respiratory therapist enter the room at the same time. I give a thorough report of what is happening.
The room is now filled with several health-care providers — for the most part, it is controlled chaos. I have responded to these situations many times before. I know what I need to do.
The patient’s condition rapidly deteriorates. She becomes unresponsive with a respiratory rate of 40 breaths per minute. Her lips are blue. This patient is crashing. We are rushing her to the intensive care unit (ICU). The resident continues putting orders in the computer as we are moving the patient to the ICU. When we arrive in the ICU, the nurses are ready for us. They knew we were on our way; however, they cannot access the patient on their computer and there is no hard copy of the doctor’s orders. They are still printing out on our floor even though the patient is physically no longer on our unit. Admitting can’t change it. They can’t transfer the patient in the computer. It is a disaster. I end up calling the help desk and saying: “This is the critical situation: a patient’s life is at risk, you need to put this patient somewhere so the nurses and doctors have access to information.”
The computer support person created something, but it was a terrible feeling...a terrible situation and everybody felt very frustrated. The clinicians working with the computer system felt frustrated; I’m sure the computer people felt frustrated, too, and you can imagine if you were the nurses or doctors taking care of the patient and you couldn’t access those things that you need.
This isn’t the first time the computer has let us down when we needed it the most. This situation caused me to question my nursing competence, and this is not a nice feeling. I need to be in control. This is not fair to my patients, who depend upon me. So, although we rely on the computer to get things done — to see what we need to see — it sometimes gets in our way. Today it failed us at the most inopportune time.
I approach Janet part way through our next shift together. It is another busy day. We have yet to be given an explanation for yesterday’s computer glitch. All we know is that the computer experts continue to work on the problem — if it is like the other times, we may be waiting a long time for an answer. I tell Janet that she did a good job, noting the accuracy of her nursing assessments and of course her promptness in making sure the necessary tasks were done in the computer.
Janet is about to leave the medication room when she stops and looks back at me. She tells me how she loves nursing and that she appreciates my support. Then she tells me some things that cause me to think differently about what it is we are learning about [the EHR system]. Janet talks about how even though she is an inexperienced nurse, she feels that it is nice to be able to give back — to be acknowledged for her computer skills. She also mentions how she thinks differently now about what makes her safe. You see, Janet found the training itself was easy…a series of buttons and this screen and that screen. This is what you do here, and this is what you do there. She taught many of us older nurses how to use the computer; we felt reliant upon Janet, yet we didn’t realize that she needed us just as much as we needed her.
Learning to use the system was the easy part for Janet. She told me today that when you’re caring for patients, everything changes. Although she initially thought she was prepared because she knew how to use the technology, she now realizes that nursing knowledge is a critical piece in learning how to use it safely. Through experience, Janet has come to appreciate that in the real world it’s the critical thinking that comes into play. A computer can’t do the critical thinking for you.
I know I saw tears in Janet’s eyes as she hurried off to her patient’s room. Maybe it is possible to sustain nursing in the face of technology. I think it is time to understand the reasons for the technology. Why is it such a big part of what we do as nurses? We need to set aside the computer and take a closer look at what we do — to define what it is that we know. We also need to understand what it is that we need to learn about.
The author thanks the registered nurses who participated in the study and Lynn Nagle, member of the author’s doctoral committee, for advice and support throughout her doctoral journey.
Canadian Association of Schools of Nursing. (2010). The case for healthier Canadians: Nursing workforce education for the 21st century (pp. 1-12). Ottawa: Author.
Canadian Association of Schools of Nursing. (2012). Nursing informatics entry-to-practice competencies for registered nurses (pp. 1-15). Ottawa: Author.
Gill, N., Leonard, K. J., & Jonker, A. (2010). Does e-health adoption enable improved health outcomes? Encouraging evidence from Ontario hospitals. Healthcare Quarterly, 13(3), 50-57.
Hollander, M. J., Corbett, C., & Pallan, P. (2010). Time for a paradigm shift: Managing smarter by moving from data and information to knowledge and wisdom in healthcare decision-making. Healthcare Quarterly, 13(2), 49-54.
Karen E. Furlong, RN, MN, PhD, is a senior teaching associate, Nursing and Health Sciences, University of New Brunswick, Saint John campus, and a recipient of a Canadian Institutes of Health Research Regional Partnerships Program — New Brunswick Fellowship. She is a member of the Canadian Association of Schools of Nursing Digital Health Nursing Faculty Peer Network; president elect, New Brunswick Nursing Informatics Group; and president elect, Canadian Nursing Informatics Association.