48 | J Adv Nurs. 2023;79:48–67.wileyonlinelibrary.com/journal/jan
Received: 6 June 2022 | Revised: 7 October 2022 | Accepted: 19 October 2022
DOI: 10.1111/jan.15484
I N T E G R A T I V E R E V I E W
An integrative review exploring the impact of Electronic Health Records (EHR) on the quality of nurse– patient interactions and communication
Carol Forde- Johnston1,2 | Dan Butcher1 | Helen Aveyard1
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.© 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.
1School of Health and Life Sciences, Oxford Brookes University, Oxford, UK2Oxford University Hospitals NHS Foundation Trust, Oxford, UK
CorrespondenceCarol Forde- Johnston, School of Health and Life Sciences, Oxford Brookes University, Oxford, UK.Email: [email protected]
Funding informationProgramme Grants for Applied Research
AbstractAim: To explore how nurses' use of electronic health records impacts on the quality of nurse– patient interactions and communication.Design: An integrative review.Data sources: MEDLINE®, CINAHL®, PscyINFO, PubMed, BNI and Cochrane Library databases were searched for papers published between January 2005 and April 2022.Review methods: Following a comprehensive search, the studies were appraised using a tool appropriate to the study design. Data were extracted from the studies that met the inclusion criteria relating to sample characteristics, methods and the strength of evidence. Included empirical studies had to examine interactions or communication between a nurse and patient while electronic health records were being used in any healthcare setting. Findings were synthesized using a thematic approach.Results: One thousand nine hundred and twenty articles were initially identified but only eight met the inclusion criteria of this review. Thematic analysis revealed four key themes, indicating that EHR: impedes on face- to- face communication, promotes task- orientated and formulaic communication and impacts on types of communication patterns.Conclusion: Research examining nurse– patient interactions and communication when nurses' use electronic health records is limited but evidence suggests that closed nurse– patient communications, reflecting a task- driven approach, were pre-dominantly used when nurses used electronic health records, although some nurses were able to overcome logistical barriers and communicate more openly. Nurses' use of electronic health records impacts on the flow, nature and quality of communication between a nurse and patient.Impact: The move to electronic health records has taken place largely without consid-eration of the impact that this might have on nurse– patient interaction and communi-cation. There is evidence of impact but also evidence of how this might be mitigated. Nurses must focus future research on examining the impact that these systems have, and to develop strategies and practice that continue to promote the importance of nurse– patient interactions and communication.
| 49FORDE-JOHNSTON et al.
1 | INTRODUCTION
The use of electronic health records (EHR) is now a global reality. The move to EHR from paper- based records is being actioned across the globe (WHO, 2016). As a result, EHR has become an integral part of nurse– patient interactions across healthcare settings, in-cluding both face- to- face and remote consultations. Nursing is not, however, considered by many to be a transactional encounter. The importance of the nurse– patient relationship is widely espoused by scholars, educators and clinicians alike. Concern has been expressed about the move to an age where nursing is undertaken by checklists (Sims et al., 2020). In this review, we explore the existing literature focussing on the implications for nurse– patient interaction where EHR is used.
2 | BACKGROUND
2.1 | Nurse–patientinteractions
It is widely agreed that quality nursing care is underpinned by nurse– patient interactions that involve a compassionate nurse presence, shared decision- making and an open and person- centred approach to care (Dean et al., 1993; Kitson, 2018; McCormack & McCance, 2006; McLean et al., 2017). With the advent of EHR, it seems prudent to explore the effect this has on nurse– patient in-teractions and to explore best practices (Crampton et al., 2016). It is already known that tensions can arise, for example, when task- driven nursing care hinders quality nurse– patient interactions and ‘devalues’ a holistic, person- centred care approach to care (Feo & Kitson, 2016; Kitson, 2018; McCormack & McCance, 2006). EHR systems use a pre- emptive scripted approach that may affect quality nurse– patient interactions. There is a need for researchers to exam-ine how nurses' use of EHR impacts on the quality of nurse– patient interactions, to establish practices that are conducive to promoting, or hindering, person- centred care in clinical settings while also main-taining high levels of patient safety.
The term ‘interaction’ denotes communicating or being directly involved with someone or something that could include talking, recip-rocal action or a causal/mutual relationship (Merriam- Webster, 2022; Oxford English Dictionary, 2022). The word ‘communication’ refers to an act of ‘sharing information,’ whereas ‘interaction’ denotes act-ing in a manner that affects another, and there may or may not be communication taking place between parties. In practice, the terms
‘communication’ and ‘interaction’ are often used interchangeably within much of the nursing literature (Shattell, 2004). In this paper, we refer to the term ‘nurse– patient interactions,’ in order to capture additional contextual insights in multi- method or time and motion studies, such as the amount of time nurses spent interacting be-tween the EHR system and a patient, and the strategies employed by nurses to integrate EHR into nurse– patient conversations.
Nurse– patient interactions may take place directly or indirectly. Direct care usually refers to actions performed in the presence of the patient, whereas indirect refers to nursing activities taking place away from the patient, for example, when patients use digital tech-nology or mobile devices at home to share diagnostic or medical in-formation with nurses online.
With the introduction of this major technology infrastructure, there is a body of work that evaluates nurses' use of EHR systems comparing pre- and post- deployment of new technology, compar-ing previous paper- based systems with new digital systems. Most of these studies focus on the efficiency of the system (deVeer & Francke, 2010; Lezard & Deave, 2021; Moody et al., 2004; Shafiee et al., 2022; Stevenson et al., 2010; Stevenson & Nilsson, 2012; Wisner et al., 2021). They do not, however, focus on impacts on nurse– patient interaction.
Other studies have explored nurses' perceptions of nurse– patient communication as a result of EHR use (Coats et al., 2020; Misto et al., 2019; Wisner et al., 2021). Findings were mixed: – Coats et al. (2020) study identified that nurses had a positive per-ception of using the person- centred EHR narrative, as it promoted better communication and more connection with their patients. In contrast, Misto et al.'s (2019), identified a negative impact on the nurse– patient relationship, due to nurses having to document care with their back to the patient. Wisner et al.'s (2021) perceived a ‘tension between caring and charting’ when integrating EHRs that were not designed for perinatal patients and their specialty practice. Interacting with the patient and family was perceived by nurses as integral to the quality of care during labour and birth and EHR was viewed as a ‘potential threat to this dimension of their work’ (Wisner et al., 2021).
Similarly, studies examining the impact of physician's use of EHR suggest it may have the capacity to change interactions and communications, both positively and negatively (Booth et al., 2004; Greatbatch et al., 1993; Makoul et al., 2001; Margalit et al., 2006; McGrath et al., 2007; Newman et al., 2010; Swinglehurst et al., 2011). For example, positively encouraging patient questions during doc-tor's consultations (Makoul et al., 2001); disrupting physician– patient
Patient or Public contribution: Studies examined within this review included patient participants that informed the analysis and interpretation of data.
K E Y WO RD Snurse– patient interactions, patient communication, electronic health record, integrative review, health information technology, person- centred care
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50 | FORDE-JOHNSTON et al.
communications, due to long pauses during conversations and pa-tients' avoiding talking while doctors used a keyboard (Greatbatch et al., 1993); and taking doctor's attention away from the patient, as they faced a ‘dilemma of attention’ between the computer and patient (Swinglehurst et al., 2011) and were pre- occupied with the computer, averting their gaze from patients (Greatbatch et al., 1993).
A recent review by Moore et al. (2020) explored the impact of health information technology on nurses' time and found that nurses spent more time on documenting care but also more time with the patient. Wisner et al. (2019) undertook a review examining EHR's impact on nurses' cognitive work; they found that nurses perceived EHR to affect their work and while it might be logical to conclude that this would include interaction with the patient, the report did not look at this specifically. Crampton et al.'s (2016) review exam-ining the impact of health information technology on the clinical encounter and patient– clinician communication found clear implica-tions for eye contact, gaze, relationship building but did not focus on nurse– patient interactions.
2.2 | Checklistapproach
EHR systems use an anticipatory approach to address patient needs via digital prompts. EHR checklists and scripts aim to assure nurses, managers and employers that fundamental aspects of care have been completed to promote patient safety. If patient risk assess-ments, checklists or care activities are not signed as completed by the nurse, then the EHR system provides a summary of missing care and requires urgent nursing actions.
Despite the logical rationale for EHR, there is concern that EHR reflects a medical and systems- based approach, rather than a patient- centred approach to care (Winkelman & Leonard, 2004). An unintended consequence of the dominance of the medical model within EHR scripts, is that a patient may be viewed ‘as a body to do things to’ (Feo & Kitson, 2016), rather than a person to engage with as part of an integrated care plan (Feo & Kitson, 2016; Kitson et al., 2014). Therefore, the task- orientated approach reflected in EHR scripts may conflict with a person- centred, holistic nurs-ing approach that involves shared decision- making (McCormack & McCance, 2006).
2.3 | PracticesandstandardsforEHRuse
Hospital EHR systems are usually completed by nurses via a com-puter that may be located on a static desk or a mobile trolley that the nurse moves into the vicinity of the patient when conducting a nursing round. Some nurses may use a handheld device to access systems (Lang et al., 2019; Winstanley et al., 2017) though these are not currently widely used (Deloitte, 2019; Richardson et al., 2020).
There are several reported advantages and disadvantages of EHR use. Some reported advantages include improved communication between departments and reduced documentation errors (Shafiee
et al., 2022), ease of use for nurses and improved data accessibility (Jones & Seckman, 2018; McBride et al., 2017; Sockolow et al., 2014). Reported disadvantages include interruptions to patient commu-nication (Al- Jafar, 2013; Dudding et al., 2018; Gephart et al., 2016), nurses' dissatisfaction due to poor functionality (Gephart et al., 2015; Kim et al., 2012; Moody et al., 2004; Stevenson et al., 2010; Wisner et al., 2021) and increased time spent documenting, due to lengthy logins, templates or a complicated interface (Kohle- Ersher et al., 2012; Lezard & Deave, 2021; Shafiee et al., 2022; Stevenson et al., 2010; Ward et al., 2011; Zadvinskis et al., 2018).
Nurses must adhere to EHR user guidelines and standards, which are set out by the EHR provider, and reflect the specific EHR sys-tem being used. However, there is limited guidance on best prac-tices when nurses use EHR to interact with patients. The American Academy of Family Practice (Ventres et al., 2006) and Wuerth et al. (2014) offer practical guidance to enhance patient's expe-riences when clinicians use EHR, that includes key areas, such as integrating typing around the needs of the patient; start with the pa-tient's concerns; keep patient- centred rather than computer- centred and do not stop interacting with the patient (Ventres et al., 2006; Wuerth et al., 2014). While this guidance is useful, a detailed review of the evidence surrounding the effects of EHR on nurse– patient interactions will provide an in- depth understanding of how EHR influences interaction and what we can do to ensure any negative impacts are minimized.
3 | INTEGRATIVEREVIEW
3.1 | Aim
The aim of this integrative literature review is to explore how nurses' use of EHR impacts on the quality and person- centredness of nurse– patient interactions.
3.2 | Design
An integrative review was conducted following Whittemore and Knafl's (2005) five- stage framework that included: problem identi-fication, literature search, data evaluation, data analysis and pres-entation. The use of an integrative review allowed for the range of observational and multi- method data collection approaches and re-sulted in a comprehensive portrayal of the topic and its importance to nursing.
3.3 | Methods
3.3.1 | Literature search
Articles that covered a 17- year period from January 2005 to April 2022 were reviewed. The initial date aligns with the
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| 51FORDE-JOHNSTON et al.
commencement of a global deployment of EHR systems across healthcare settings. In 2005, all World Health Organization (WHO) Member States made the commitment to strive for uni-versal health coverage and the development of eHealth systems (WHO, 2016).
The inclusion criteria for papers were as follows: (1) published in the English language; (2) examined the interactions or commu-nication between a nurse and patient while EHR is being used by nurse(s) in any healthcare setting (see Table 2: Inclusion criteria). Exclusion criteria were as follows: (1) published in a language other than English; (2) no examination of the interactions or commu-nication between a nurse and patient while EHR is being used by nurse(s). For example, time and motion studies that coded nurses' actions for workload were excluded if they coded observed ‘Patient Communication’ as discussions with other healthcare professionals only, and there was no direct communication between the nurse and patient.
Search terms were discussed and confirmed with two health-care librarians. Boolean operators AND/OR were used to combine key search words, synonyms (taking into account the international terms used for EHR) and truncations and to widen and narrow the search within the MEDLINE®, CINAHL®, PscyINFO, PubMed, BNI and Cochrane Library databases. The search was undertaken using the key words and synonyms for ‘patient,’ AND ‘nurse,’ AND ‘inter-action,’ AND ‘electronic patient records’ (see Table 1: Keywords, synonyms and truncations).
Adjacent key words, to between three spaces, were included, using ‘Adj3’ for word patterns, for example, the words ‘nurse*’ and ‘patient*.’ To ensure the discovery of related words, there was an explosion of associated words such as ‘Communication’ within data-bases. Using ‘Google Scholar Advanced Scholar’ and Web of Science search engines did not find any additional studies.
Initial searching was undertaken by the lead author and two University Health Care Librarians who were involved in the assess-ment of a selection of papers against the inclusion and exclusion criteria. Where it was not certain if a paper met the criteria, these papers were discussed with the co- authors.
A PRISMA (PRISMA) flow diagram was adapted from Moher et al. (2009) to present the sourcing, identification, inclusion and ex-clusion processes (see Figure 1).
3.4 | Qualityappraisal
Published critical appraisal tools were used to evaluate the included studies. A range of tools were used as appropriate to the design and methods of included studies. The Critical Appraisal Skills Programme (CASP) (CASP, 2022) checklist was used for appraising the meth-odological quality of qualitative studies (n = 3), whereas the Mixed Methods Appraisal Tool (MMAT) (Hong et al., 2018) was used for quantitative, and mixed methods studies (n = 5). Both critical ap-praisal tools are well- defined with clear directions relating to each appraisal question. The methodological quality of the included ar-ticles was assessed by the lead author and independently reviewed by the co- authors. Following quality appraisal, no studies were ex-cluded, but the strengths and limitations of studies are acknowl-edged within the analysis of the papers, with greater weight given to the stronger papers.
3.5 | Dataextraction
Data were extracted from the eight studies that met the inclusion criteria relating to sample characteristics, methods, and strength of evidence, and observations relating to nurses' use of EHR im-pacting on nurse– patient interactions' (Whittemore & Knafl, 2005) (see Table 3: Main study characteristics and findings). Additionally, Table 4 offers an overview of the data collection methods used dur-ing observations within significant studies. The suitability of the ex-traction form was tested on two studies to ensure that it functioned. The three authors independently reviewed all extracted data for accuracy.
3.6 | Synthesis
Data from the primary sources in this review were ordered, catego-rized, compared and summarized to inform an integrated conclusion about how nurses' use of EHR may impact on nurse– patient interac-tions (Miles & Huberman, 1994). Primary data were displayed using matrices for each category and iteratively compared to inform the-matic analysis (Miles & Huberman, 1994).
TA B L E 1 Keywords, synonyms and truncations
SearchWords Synonyms Truncations used
Nurses Nurses, Nursing, Nursed Nurs*
Patient Client, patients, service- user Client* OR patient* OR service- user*
Interaction Relation, relationship, communication, intervention, interactions, interact, encounter, approach
Relation* OR communicat*, OR intervent* ORinteract* OR encount* ORapproach*
Electronic patient record Electronic patient records, e- records, electronic health record, electronic medical record, electronic record
“Electronic patient record” OR “electronic health record” OR “Electronic medical record” OR “Electronic record” OR epr OR emr OR ehr OR e- record*
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52 | FORDE-JOHNSTON et al.
The emerging themes were discussed by the authors. Abstract conceptualized data were re- reviewed as new concepts formed to ensure consistency with primary sources (Whittemore, 2005). Due to the diversity of empirical sources within this review, the method-ological quality of studies and value of information from papers, is acknowledged when discussing the following results and emerging themes.
4 | RESULTS
Following the identification of 2374 relevant articles, the software package ‘Endnote’ was used to remove duplicate papers, leaving 2072. A review of the abstracts and titles of papers that potentially met the inclusion criteria left 1920 studies. The full texts of the 1920
articles were then screened for eligibility through the application of study exclusion and inclusion criteria, which left 12 papers. These 12 papers were re- checked against the inclusion and exclusion criteria by all three authors. Eight out of these 12 papers fully met the inclu-sion criteria.
4.1 | Characteristicsofincludedstudies
The eight studies included within this review represent data from 187 Nurses, 139 Patients, 11 Doctors and 13 Allied Health Professional from the United States (US) (Dowding et al., 2015; Fore et al., 2019; Gaudet, 2016; Gomes et al., 2016), United Kingdom (UK) (Rhodes et al., 2006, 2008) and Australia (Burridge et al., 2018; Walker et al., 2019). Most studies took place on in- patient acute sur-gical or medical hospital ward settings in the US and Australia, apart from Rhodes et al. (2006 and 2008), which took place in primary care settings in the UK.
A range of research study designs were used including micro- ethnography (Gaudet (2016); exploratory (Burridge et al., 2018; Rhodes et al., 2006, 2008); multi- site case study (Dowding et al., 2015); and time and motion; Fore et al., 2019; Gomes et al., 2016; Walker et al., 2019). Seven out of eight studies included observational data collection methods when examining the impact
TA B L E 2 Inclusion criteria
Inclusion criteria
• Published in the English language
• Study examines interactions or direct communications between a nurse and patient while EHR is being used by nurses
• Nurses' use of EHR may take place in any healthcare setting
• Empirical research
F IGURE 1 PRISMA Flow diagram of screening and exclusion process. Adapted from Moher et al. (2009).
Records identified through database searching (n = 2374)
Records after duplicates removed andirrelevant records removed
(n = 2072)
Number of duplicatesand irrelevant records
removed (n = 302)
Title and abstracts that potentially met inclusion
criteria (n = 1920)
Full-text articlesscreened for eligibilityand quality (n = 12)
Inclusion and Exclusioncriteria applied
8 articles included
Number of articles removed following full
text appraisal and data extraction
(n = 4)
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| 53FORDE-JOHNSTON et al.
TAB
LE 3
M
ain
stud
y ch
arac
teris
tics
and
findi
ngs
Aut
hor,
year
& c
ount
ryStudyaim(s)/objective(s)
Studydesign&setting
Dat
a co
llect
ion
met
hods
& s
ampl
eKeyfindings:howdoesnurses'useofEHR
impa
ct o
n nu
rse–
patie
nt in
tera
ctio
ns?
Them
es
Gau
det (
2016
) Uni
ted
Stat
ed (U
S)To
exp
lore
the
cultu
re
of n
urse
– pat
ient
in
tera
ctio
ns a
ssoc
iate
d w
ith e
lect
roni
c be
dsid
e do
cum
enta
tion
Mic
ro- e
thno
grap
hy in
3
hosp
ital u
nits
24 ×
1 h
nur
se– p
atie
nt a
udio
tape
d ob
serv
atio
ns &
fiel
d no
tes
(14
Nur
ses
& 1
9 Pa
tient
s)Se
mi- s
truc
ture
d nu
rse
Inte
rvie
ws
(2 N
urse
s)In
terv
iew
s: N
urse
s as
ked:
“Can
yo
u te
ll m
e ab
out y
our
expe
rienc
e w
ith e
lect
roni
c do
cum
enta
tion
and
patie
nt
care
?”
Ove
rall,
3 k
ey th
emes
sum
mar
ized
by
Gau
det (
2016
) as:
‘int
erru
ptio
ns’, ‘
gam
e of
ta
g’ a
nd ‘m
achi
ne- li
ke in
tera
ctio
ns’
Stat
iona
ry c
ompu
ters
‘cha
lleng
ed th
e lo
gist
ics
of th
e ex
chan
ge’ w
ith c
ontin
ual
inte
rrup
tions
Elec
tron
ic re
cord
s cr
eate
d ‘a
n au
tom
atic
, m
achi
ne- li
ke, t
ask-
cent
red
beds
ide
envi
ronm
ent’
Nur
ses
obse
rved
mov
ing
from
com
pute
r to
pat
ient
in a
‘gam
e of
tag’
. Nur
ses
in
inte
rvie
ws
also
exp
ress
ed c
once
rn a
bout
th
e im
pact
on
wor
kflo
w.
Nur
ses'
resp
onse
s ch
arac
teriz
ed b
y lim
ited
exch
ange
with
pat
ient
and
resp
onse
s us
ed to
col
lect
dat
a. N
urse
s re
spon
ded
with
del
iber
ativ
e an
d au
tom
atic
re
spon
ses.
Del
iber
ativ
e re
spon
ses
valid
ated
pat
ient
s' re
plie
s. A
utom
atic
re
spon
ses
wer
e ch
arac
teriz
ed b
y lim
ited
exch
ange
with
pat
ient
. Del
iber
ativ
e re
spon
ses
wer
e ev
iden
t on
12 o
ccas
ions
in
volv
ing
med
icat
ion
adm
inis
trat
ion.
A
utom
atic
resp
onse
s w
ere
pres
ent
durin
g 10
obs
erva
tions
, whe
n ad
ditio
nal
com
mun
icat
ion
mig
ht h
ave
been
war
rant
ed
to a
scer
tain
the
patie
nt's
need
.Av
erag
e du
ratio
n of
an
inte
ract
ion
was
11
min
, 14
s. S
hort
est i
nter
actio
n la
sted
2 m
in, 2
3 s,
an
d lo
nges
t int
erac
tion
last
ed 2
3 m
in, 5
0 s
Impa
ct o
n fa
ce- t
o- fa
ce
com
mun
icat
ion
Tend
ency
tow
ards
ta
sk- o
rient
ated
co
mm
unic
atio
nPr
omot
es fo
rmul
aic
com
mun
icat
ion
styl
e
Impa
ct o
n ty
pes
of
com
mun
icat
ion
patt
erns
Impa
ct o
n ty
pes
of
com
mun
icat
ion
patt
erns
(Con
tinue
s)
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54 | FORDE-JOHNSTON et al.
Aut
hor,
year
& c
ount
ryStudyaim(s)/objective(s)
Studydesign&setting
Dat
a co
llect
ion
met
hods
& s
ampl
eKeyfindings:howdoesnurses'useofEHR
impa
ct o
n nu
rse–
patie
nt in
tera
ctio
ns?
Them
es
Rhod
es e
t al.
(200
6)
Uni
ted
Kin
gdom
(U
K)
To e
xam
ine
the
inte
ract
ion
betw
een
nurs
es a
nd
patie
nts
with
type
2
diab
etes
dur
ing
rout
ine
cons
ulta
tions
in
prim
ary
care
se
ttin
gs th
at u
se
a C
ompu
teriz
ed
Che
cklis
t, an
d w
hat
this
mea
ns fo
r Pat
ient
– C
entr
ed C
are
Expl
orat
ory
stud
y in
pr
imar
y ca
re a
cros
s 9
GP
prac
tices
Pre-
cons
ulta
tion
inte
rvie
ws
to
iden
tify
patie
nts'
expe
ctat
ions
Vid
eota
ped
25 c
onsu
ltatio
ns fo
r pa
tient
s w
ith ty
pe 2
dia
bete
s (2
5 Pa
tient
s, 4
Doc
tors
and
9
Nur
ses)
Ove
rall
them
e: R
hode
s et
al.
(200
6) id
entif
ied
two
cont
radi
ctor
y fe
atur
es b
etw
een
‘pat
ient
– cen
tred
pra
ctic
e’ a
nd th
e ‘e
mph
asis
on
bio
med
ical
aud
it’; s
ugge
st a
chie
vem
ent
of fo
rmer
mig
ht b
e co
mpr
omis
ed b
y de
man
ds o
f lat
ter.
One
exa
mpl
e co
nsul
tatio
n de
mon
stra
tes
a co
mm
on fe
atur
e in
the
data
set s
how
ing
that
the
nurs
e's
use
of a
‘com
pute
r te
mpl
ate
impo
ses
a ro
utin
e st
ruct
ure
to th
e co
nsul
tatio
n an
d so
cial
izes
the
patie
nt in
to
wha
t is
cons
ider
ed a
ccep
tabl
e be
havi
our’
At n
o po
int d
oes
the
nurs
e in
vite
the
patie
nt
to a
sk h
is o
wn
ques
tions
or e
xpre
ss a
ny
conc
erns
he
mig
ht h
ave.
Thi
s w
as a
feat
ure
of m
ore
than
a th
ird (9
of 2
5) o
f the
co
nsul
tatio
ns in
the
data
set a
nd h
alf o
f the
co
nsul
tatio
ns u
nder
take
n by
a n
urse
(9 o
f 18
)Th
e fo
llow
ing
feat
ures
wer
e co
mm
on to
man
y of
the
cons
ulta
tions
in th
e da
tase
t:•
Nur
ses
spen
t muc
h of
thei
r tim
e ga
zing
at t
he
com
pute
r scr
een
or a
t pap
ers
on th
eir d
esk
• Q
uest
ions
wer
e di
ctat
ed b
y th
e ch
eckl
ist
rath
er th
an fo
llow
ing
the
natu
ral f
low
of
conv
ersa
tion.
Que
stio
ns w
ere
aske
d ou
t of
cont
ext.
Nur
ses
cut p
atie
nts'
answ
ers
shor
t to
ask
the
next
que
stio
n•
Onc
e th
e re
quis
ite d
ata
wer
e ob
tain
ed a
nd
ente
red,
nur
ses
wou
ld im
med
iate
ly m
ove
on to
the
next
che
cklis
t ite
m. D
evia
tion
or
digr
essi
on fr
om th
e ch
eckl
ist a
gend
a w
as
disc
oura
ged
Tend
ency
tow
ards
ta
sk- o
rient
ated
co
mm
unic
atio
n
Impa
ct o
n fa
ce- t
o- fa
ce
com
mun
icat
ion
Tend
ency
tow
ards
ta
sk- o
rient
ated
co
mm
unic
atio
n
Impa
ct o
n fa
ce- t
o- fa
ce
com
mun
icat
ion
Tend
ency
tow
ards
ta
sk- o
rient
ated
co
mm
unic
atio
n
Tend
ency
tow
ards
ta
sk- o
rient
ated
co
mm
unic
atio
n
TAB
LE 3
(C
ontin
ued)
13652648, 2023, 1, Dow
nloaded from https://onlinelibrary.w
iley.com/doi/10.1111/jan.15484, W
iley Online L
ibrary on [14/05/2023]. See the Term
s and Conditions (https://onlinelibrary.w
iley.com/term
s-and-conditions) on Wiley O
nline Library for rules of use; O
A articles are governed by the applicable C
reative Com
mons L
icense
| 55FORDE-JOHNSTON et al.
Aut
hor,
year
& c
ount
ryStudyaim(s)/objective(s)
Studydesign&setting
Dat
a co
llect
ion
met
hods
& s
ampl
eKeyfindings:howdoesnurses'useofEHR
impa
ct o
n nu
rse–
patie
nt in
tera
ctio
ns?
Them
es
Rhod
es e
t al.
(200
8) U
KTo
com
pare
2
cons
ulta
tions
in
prim
ary
care
dia
bete
s cl
inic
s us
ing
extr
acts
fr
om v
ideo
reco
rdin
gs
of in
tera
ctio
ns
betw
een
nurs
es a
nd
patie
nts
To p
rese
nt d
iffer
ent
styl
es o
f int
erac
tion,
in
whi
ch th
e nu
rse'
s ga
ze
was
eith
er p
rimar
ily
tow
ards
the
com
pute
r sc
reen
or d
irect
ed
mor
e to
war
ds th
e pa
tient
Part
of R
hode
s et
al.
(200
6) a
bove
Ex
plor
ator
y st
udy
in
prim
ary
care
acr
oss
9 G
P pr
actic
es
Dat
a fr
om 2
con
sulta
tions
furt
her
anal
ysed
follo
win
g on
from
Rh
odes
et a
l. (2
006)
stu
dy2
Vid
eota
ped
cons
ulta
tions
for
patie
nts
with
type
2 d
iabe
tes
(26
Patie
nt, 4
Doc
tor a
nd 9
N
urse
)
Ove
rall
them
e: T
wo
diff
eren
t sty
les
of
inte
ract
ion
wer
e ch
arac
teriz
ed a
s ‘b
urea
ucra
tic’ o
r ‘pa
rtic
ipat
ive
or p
atie
nt
cent
red’
. Con
sulta
tions
pre
sent
ed d
iffer
ent
styl
es o
f int
erac
tion
whe
re th
e nu
rse'
s ga
ze
was
prim
arily
tow
ards
the
com
pute
r scr
een
or d
irect
ed m
ore
tow
ards
the
patie
ntN
urse
s' ga
ze o
rient
atio
ns w
ere
rein
forc
ed
by th
eir b
ody
orie
ntat
ions
. Cas
e 1:
N
urse
s bo
dy o
rient
atio
n, w
ith le
gs a
nd
tors
o tu
rned
tow
ards
the
com
pute
r, co
mm
unic
ates
dom
inan
t eng
agem
ent
with
the
com
pute
r. C
ase
2: N
urse
sat
m
uch
of th
e tim
e w
ith w
hole
bod
y fa
cing
th
e pa
tient
, sig
nalli
ng th
at, e
ven
thou
gh
she
mig
ht te
mpo
raril
y sh
ift h
er g
aze
to th
e co
mpu
ter s
cree
n, h
er d
omin
ant
enga
gem
ent w
as w
ith th
e pa
tient
Alth
ough
bot
h nu
rses
follo
w a
com
pute
rized
ch
eckl
ist,
the
seco
nd n
urse
did
not
allo
w
its p
rese
nce
to o
verr
ide
a po
ssib
le a
gend
a of
the
patie
nt. S
he in
vite
d th
e pa
tient
to
expr
ess
her c
once
rns,
the
chec
klis
t age
nda
was
sus
pend
ed a
nd th
e nu
rse
chan
ged
her
body
pos
ture
and
sus
pend
ed h
er g
aze
at
the
com
pute
r. Th
e nu
rse
enco
urag
ed th
e pa
tient
to e
xpan
d co
nver
satio
ns, s
igna
lling
he
r ful
l att
entio
n th
roug
h co
ntin
ued
eye
cont
act a
nd b
ody
orie
ntat
ion,
fully
tu
rned
to fa
ce th
e pa
tient
. In
case
1, t
he
patie
nt w
as s
till l
eft w
ith u
nexp
lain
ed
sym
ptom
s. T
he n
urse
app
eare
d re
luct
ant
to e
ngag
e w
ith th
e pa
tient
's co
ncer
ns, a
nd
syst
emat
ical
ly b
lock
ed fu
rthe
r dis
cuss
ion
until
con
fron
ted
by a
dire
ct q
uest
ion
Cas
e 2:
Mai
n ta
sk o
f the
con
sulta
tion
was
im
med
iate
ly fr
amed
with
in th
e te
rms
of
the
EMR
chec
klis
t as
the
nurs
e de
vote
d he
r att
entio
n to
it, i
ndic
ated
thro
ugh
body
po
stur
e an
d di
rect
ion
of g
aze
Impa
ct o
n ty
pes
of
com
mun
icat
ion
patt
erns
Impa
ct o
n fa
ce- t
o- fa
ce
com
mun
icat
ion
Impa
ct o
n fa
ce- t
o- fa
ce
com
mun
icat
ion
&
impa
ct o
n ty
pes
of
com
mun
icat
ion
patt
erns
Tend
ency
tow
ards
ta
sk- o
rient
ated
co
mm
unic
atio
n
TAB
LE 3
(C
ontin
ued)
13652648, 2023, 1, Dow
nloaded from https://onlinelibrary.w
iley.com/doi/10.1111/jan.15484, W
iley Online L
ibrary on [14/05/2023]. See the Term
s and Conditions (https://onlinelibrary.w
iley.com/term
s-and-conditions) on Wiley O
nline Library for rules of use; O
A articles are governed by the applicable C
reative Com
mons L
icense
56 | FORDE-JOHNSTON et al.
Aut
hor,
year
& c
ount
ryStudyaim(s)/objective(s)
Studydesign&setting
Dat
a co
llect
ion
met
hods
& s
ampl
eKeyfindings:howdoesnurses'useofEHR
impa
ct o
n nu
rse–
patie
nt in
tera
ctio
ns?
Them
es
Burr
idge
et a
l. (2
018)
A
ustr
alia
(Aus
)To
inve
stig
ate
the
use
of
elec
tron
ic m
edic
al
reco
rds
(eM
Rs) i
n a
spin
al c
ord
inju
ry
reha
bilit
atio
n un
it an
d th
e im
plic
atio
ns fo
r pe
rson
– cen
tred
car
e
Expl
orat
ory
mix
ed
met
hods
stu
dy in
40
– bed
Spi
nal I
njur
y U
nit
50 o
bser
vatio
ns to
talli
ng 1
7.5
h of
ob
serv
atio
ns o
f pra
ctiti
oner
– pa
tient
enc
ount
ers
50 p
atie
nt- e
xper
ienc
e su
rvey
s af
ter o
bser
vatio
ns (5
0 Pa
tient
s)10
focu
s gr
oups
aft
er o
bser
vatio
ns
to d
iscu
ss to
pics
: eM
R w
ork
and
impa
ct o
n pa
tient
in
tera
ctio
ns; w
ork
proc
esse
s,
team
com
mun
icat
ion
and
coor
dina
tion;
cha
lleng
es a
nd
oppo
rtun
ities
for P
CC; a
nd
com
patib
ility
of e
MRs
with
PC
C in
the
com
plex
long
– ter
m
care
set
ting
(53
prac
titio
ners
: 3
Med
ics,
37
Nur
ses
& 1
3 A
HPs
)
Ove
rall
them
e: S
ome
eMR
docu
men
tatio
n di
srup
ted
info
rmal
com
mun
icat
ions
and
as
pect
s of
per
son-
cent
red
care
.M
ost p
ract
ition
er- p
atie
nt e
ncou
nter
s ob
serv
ed
wer
e nu
rsin
g in
patie
nt h
ando
vers
and
m
edic
al o
utpa
tient
con
sulta
tions
. The
ob
serv
ed e
ncou
nter
s be
twee
n ou
tpat
ient
s an
d do
ctor
s su
gges
ted
that
eM
Rs w
orke
d w
ell i
n th
e lo
cal o
ffic
e se
ttin
g.Le
ngth
of c
linic
ian-
patie
nt e
ncou
nter
s 1–
66
min
and
the
mea
n tim
e sp
ent w
ith p
atie
nts
21 m
in66
% o
f nur
ses
in n
ursi
ng h
ando
ver u
sed
eMRs
to
con
duct
saf
ety
chec
ks, f
ocus
ing
on
chec
klis
ts ra
ther
than
pat
ient
sN
urse
focu
s gro
ups h
ighl
ight
ed n
urse
s' co
ncer
ns
that
inte
ract
ions
had
bee
n di
spla
ced
by ti
me-
in
tens
ive
eMR
docu
men
tatio
n an
d ‘p
erso
n-
cent
redn
ess s
eem
ed e
lusiv
e, u
nder
min
ing
the
qual
ity o
f the
pra
ctiti
oner
– pat
ient
re
latio
nshi
p.’ N
urse
s' fe
lt th
at p
ract
ition
ers
gene
rally
now
reso
rted
to p
atie
nts'
reco
rds
for i
nfor
mat
ion
mor
e re
adily
than
to p
atie
nts
them
selv
esU
se o
f eM
R im
pact
ed p
ract
ition
ers
in d
iffer
ent
way
s, de
pend
ing
on th
e ta
sk- o
rient
atio
n of
th
eir d
iscip
line,
with
nur
ses
expe
rienc
ing
mos
t pre
ssur
e. N
urse
s wer
e co
ncer
ned
abou
t th
e in
trus
ion
of te
chno
logy
into
pat
ient
en
coun
ters
, and
wha
t thi
s sig
nifie
d fo
r the
ir pa
tient
s, be
caus
e ‘y
ou a
re lo
okin
g at
the
scre
en in
stea
d of
look
ing
at y
our p
atie
nt’
Maj
ority
of p
atie
nts
held
pos
itive
opi
nion
s on
the
valu
e of
the
eMR.
95%
of p
atie
nts
agre
ed o
r str
ongl
y ag
reed
that
they
wer
e tr
eate
d w
ith re
spec
t, w
ell- i
nfor
med
and
in
volv
ed in
dec
isio
ns a
bout
thei
r car
e.
Patie
nts
notic
ed th
e va
lue
of q
uick
acc
ess
to th
eir e
lect
roni
c re
cord
s ve
rsus
pap
er-
base
d re
cord
. Min
ority
repo
rted
that
pr
actit
ione
rs h
ad n
ot s
hare
d in
form
atio
n w
ith th
em fr
om th
eir e
lect
roni
c re
cord
Tend
ency
tow
ards
ta
sk- o
rient
ated
co
mm
unic
atio
n
Tend
ency
tow
ards
ta
sk- o
rient
ated
co
mm
unic
atio
nTe
nden
cy to
war
ds
task
– orie
ntat
ed
com
mun
icat
ion
Impa
ct o
n fa
ce- t
o- fa
ce
com
mun
icat
ion
Prom
otes
form
ulai
c co
mm
unic
atio
n st
yle
TAB
LE 3
(C
ontin
ued)
13652648, 2023, 1, Dow
nloaded from https://onlinelibrary.w
iley.com/doi/10.1111/jan.15484, W
iley Online L
ibrary on [14/05/2023]. See the Term
s and Conditions (https://onlinelibrary.w
iley.com/term
s-and-conditions) on Wiley O
nline Library for rules of use; O
A articles are governed by the applicable C
reative Com
mons L
icense
| 57FORDE-JOHNSTON et al.
Aut
hor,
year
& c
ount
ryStudyaim(s)/objective(s)
Studydesign&setting
Dat
a co
llect
ion
met
hods
& s
ampl
eKeyfindings:howdoesnurses'useofEHR
impa
ct o
n nu
rse–
patie
nt in
tera
ctio
ns?
Them
es
Dow
ding
et a
l. (2
015)
U
STo
exp
lore
how
nur
ses
use
an in
tegr
ated
El
ectr
onic
Hea
lth
Reco
rd (E
HR)
in
prac
tice
Mul
ti- si
te c
ase
stud
y ac
ross
two
hosp
itals
14 o
bser
vatio
ns o
f Nur
ses
usin
g EH
R, to
talli
ng 9
0 h
38 m
in o
f ob
serv
atio
n, a
vera
ge d
urat
ion
of o
bser
vatio
n 6
h 27
min
(13
Nur
ses,
1 N
urse
obs
erve
d tw
ice)
26 S
emi- s
truc
ture
d in
terv
iew
s to
ex
plor
e th
eir p
erce
ptio
ns o
f th
e EH
R an
d ho
w it
aff
ecte
d th
eir p
ract
ice
(26
Nur
ses
and
Man
ager
s)
Dur
ing
obse
rvat
ions
, man
y nu
rses
acr
oss
both
ca
se s
ites
deve
lope
d a
‘soph
istic
ated
abi
lity
to ju
ggle
thes
e co
mpe
ting
dem
ands
’ and
wer
e ab
le to
fill
out a
sses
smen
t inf
orm
atio
n qu
ickl
y an
d to
ok v
ital s
igns
mea
sure
s an
d pu
t the
m in
to th
e EH
R by
the
beds
ide
imm
edia
tely
EHR
perc
eive
d to
impr
ove
effic
ienc
y, s
afet
y an
d co
mm
unic
atio
n by
maj
ority
of n
urse
s w
ho w
ere
inte
rvie
wed
. Som
e nu
rses
, acr
oss
both
cas
e si
tes,
hig
hlig
hted
how
EH
R ha
d im
prov
ed th
eir a
bilit
y to
com
mun
icat
e w
ith th
eir p
atie
nts,
as
they
cou
ld p
rovi
de
up to
dat
e in
form
atio
n, a
nd s
how
pat
ient
s in
form
atio
n di
rect
ly o
n th
e co
mpu
ter
scre
enD
urin
g in
terv
iew
s, n
urse
s fr
om b
oth
case
si
tes
refle
cted
on
the
cons
tant
pro
blem
s th
ey h
ad b
etw
een
docu
men
ting
care
and
m
eetin
g ca
re d
eman
ds fr
om p
atie
nts
Impa
ct o
n fa
ce- t
o- fa
ce
com
mun
icat
ion
&
prom
otes
form
ulai
c co
mm
unic
atio
n st
yle
Prom
otes
form
ulai
c co
mm
unic
atio
n st
yle
Impa
ct o
n ty
pes
of
com
mun
icat
ion
patt
erns
Fore
et a
l. (2
019)
US
To e
xplo
re: (
1) th
e av
erag
e tim
e to
com
plet
e co
mm
on n
ursi
ng
task
s do
cum
ente
d in
th
e el
ectr
onic
hea
lth
reco
rd, (
2) n
ursi
ng-
rela
ted
task
s th
at
rem
ain
undo
cum
ente
d,
(3) t
he a
ssoc
iatio
n be
twee
n ob
serv
atio
n da
ta a
nd a
ctua
l nur
sing
do
cum
enta
tion
and
(4) c
onsi
dera
tions
for
mod
el d
evel
opm
ent
and
repo
rt d
esig
n to
be
used
for a
ctiv
ity- b
ased
co
st a
ccou
ntin
g in
nu
rsin
g
Wor
kflo
w ti
me
stud
y us
ing
obse
rvat
ions
ac
ross
25
acut
e ca
re
inpa
tient
nur
sing
un
its
250
h of
obs
erva
tion
of n
urse
s' w
orkf
low
, tot
allin
g 25
0 h
of
obse
rvat
ion.
Obs
erva
tions
w
ere
2– 4
h in
dur
atio
n (6
3 N
urse
s)
Nea
rly 6
0% (n
= 1
763)
of t
he o
bser
ved
nurs
ing
activ
ities
did
not
fit i
nto
cate
gorie
s re
adily
ava
ilabl
e in
, and
eas
ily a
bstr
acte
d fr
om, t
he E
HR;
thes
e ac
tiviti
es re
mai
ned
undo
cum
ente
d. A
bout
5%
of o
bser
ved
nurs
ing
time
(10
h, 4
0 m
in) w
as s
pent
do
ing
none
nur
sing
task
s an
d ab
out 8
.5%
of
the
time,
the
nurs
e w
as n
ot p
erfo
rmin
g pr
oduc
tive
wor
kU
ndoc
umen
ted
activ
ities
acc
ount
ed fo
r ove
r ha
lf of
obs
erve
d ta
sks
and
equa
ted
to
near
ly 1
30 h
, ove
r 40
h w
ere
spen
t on
the
activ
ity o
f doc
umen
tatio
n/ch
artin
g. N
early
36
h w
as s
pent
on
com
mun
icat
ion,
follo
wed
by
13.
5 h
on m
onito
ring/
surv
eilla
nce
Aver
age
amou
nt o
f tim
e to
com
plet
e an
yone
nu
rsin
g ta
sk w
as le
ss th
an 5
min
Impa
ct o
n ty
pes
of
com
mun
icat
ion
patt
erns
Impa
ct o
n ty
pes
of
com
mun
icat
ion
patt
erns
TAB
LE 3
(C
ontin
ued)
13652648, 2023, 1, Dow
nloaded from https://onlinelibrary.w
iley.com/doi/10.1111/jan.15484, W
iley Online L
ibrary on [14/05/2023]. See the Term
s and Conditions (https://onlinelibrary.w
iley.com/term
s-and-conditions) on Wiley O
nline Library for rules of use; O
A articles are governed by the applicable C
reative Com
mons L
icense
58 | FORDE-JOHNSTON et al.
Aut
hor,
year
& c
ount
ryStudyaim(s)/objective(s)
Studydesign&setting
Dat
a co
llect
ion
met
hods
& s
ampl
eKeyfindings:howdoesnurses'useofEHR
impa
ct o
n nu
rse–
patie
nt in
tera
ctio
ns?
Them
es
Wal
ker e
t al.
(201
9) A
usTo
mea
sure
, com
pare
and
de
scrib
e nu
rse
time
spen
t on
patie
nt c
are
prio
r to,
and
follo
win
g im
plem
enta
tion
of a
n in
tegr
ated
ele
ctro
nic
heal
th re
cord
roll-
out
usin
g a
stan
dard
ized
ap
proa
ch
Con
tinuo
us o
bser
vatio
n Pr
e- po
st ti
me
and
mot
ion
desi
gn
acro
ss s
urgi
cal a
nd
med
ical
hos
pita
l w
ards
(no
num
ber
give
n)
Tota
l of 6
209
nurs
ing
activ
ities
ob
serv
ed fo
r dur
atio
n of
en
tire
shift
(33
shift
s) o
r du
ring
med
icat
ion
roun
d (1
9 m
edic
atio
n ro
unds
obs
erve
d)
(51
Nur
ses)
Obs
erve
d di
rect
car
e ac
tiviti
es
incl
uded
inte
ract
ion/
co
mm
unic
atio
n w
ith p
atie
nts
and
thei
r fam
ily fo
r pla
nnin
g ca
re, e
duca
tion,
inte
rven
ing
and
eval
uatio
n
Con
clus
ion:
The
mov
e fr
om p
aper
– bas
ed
patie
nt re
cord
s to
an
inte
grat
ed E
HR
did
not s
igni
fican
tly c
hang
e th
e am
ount
of
nur
se ti
me
at th
e be
dsid
e, o
r for
the
prep
arat
ion
and
adm
inis
trat
ion
of o
rder
ed
med
icat
ions
. How
ever
, the
re w
as a
cl
ear a
nd c
onsi
sten
t tre
nd o
f inc
reas
ed
docu
men
tatio
n tim
e an
d ac
tiviti
es fo
llow
ing
impl
emen
tatio
n of
the
elec
tron
ic h
ealth
re
cord
.In
the
surg
ical
div
isio
n, d
irect
car
e ac
tiviti
es
show
ed a
sig
nific
ant d
ecre
ase
(p ≤
.001
), al
thou
gh s
how
ed s
igni
fican
t inc
reas
es in
m
edia
n du
ratio
n. T
he n
umbe
r of i
ndire
ct
care
act
iviti
es a
lso
incr
ease
d (p
= .0
10),
alth
ough
ther
e w
as a
dow
nwar
d tr
end
in th
eir m
edia
n du
ratio
n (p
= .0
15).
Doc
umen
tatio
n (s
uch
as c
ompu
ter d
ata
entr
y) in
crea
sed
sign
ifica
ntly
in n
umbe
r of
activ
ities
(p ≤
.001
), an
d m
edia
n du
ratio
n (p
= .0
02).
In th
e m
edic
al d
ivis
ion,
ther
e w
ere
no s
igni
fican
t cha
nges
in d
irect
or
indi
rect
car
e or
war
d- re
late
d ac
tiviti
es o
r m
edia
n tim
e. H
owev
er, d
ocum
enta
tion
activ
ities
and
ass
ocia
ted
med
ian
dura
tion
incr
ease
d si
gnifi
cant
ly (p
≤ .0
01)
Impa
ct o
n ty
pes
of
com
mun
icat
ion
patt
erns
Impa
ct o
n ty
pes
of
com
mun
icat
ion
patt
erns
TAB
LE 3
(C
ontin
ued)
13652648, 2023, 1, Dow
nloaded from https://onlinelibrary.w
iley.com/doi/10.1111/jan.15484, W
iley Online L
ibrary on [14/05/2023]. See the Term
s and Conditions (https://onlinelibrary.w
iley.com/term
s-and-conditions) on Wiley O
nline Library for rules of use; O
A articles are governed by the applicable C
reative Com
mons L
icense
| 59FORDE-JOHNSTON et al.
Aut
hor,
year
& c
ount
ryStudyaim(s)/objective(s)
Studydesign&setting
Dat
a co
llect
ion
met
hods
& s
ampl
eKeyfindings:howdoesnurses'useofEHR
impa
ct o
n nu
rse–
patie
nt in
tera
ctio
ns?
Them
es
Gom
es e
t al.
(201
6) U
STo
und
erst
and
the
impa
ct
of E
HR
depl
oym
ent
on re
gist
ered
nur
ses'
time
spen
t in
dire
ct
prof
essi
onal
pat
ient
– ce
ntre
d nu
rsin
g ac
tiviti
es o
n m
edic
al-
surg
ical
uni
ts
Tim
e an
d m
otio
n st
udy
from
8 m
edic
al-
surg
ical
uni
ts, a
cros
s 4
hosp
itals
Att
itude
s an
d Be
liefs
Ass
essm
ent
Que
stio
nnai
re a
nd N
ursi
ng
Enga
gem
ent Q
uest
ionn
aire
to
dete
rmin
e nu
rses
' att
itude
s ab
out E
HR
Rapi
d M
odel
ling
Cor
pora
tion'
s pe
rson
al d
igita
l ass
ista
nts
(PD
A) f
or ti
me
and
mot
ion
data
col
lect
ion.
PD
A p
rom
pts
inqu
ired
whe
ther
the
nurs
e w
as e
ngag
ed in
a p
urpo
sefu
l in
tera
ctio
n w
ith th
e pa
tient
. Pu
rpos
eful
inte
ract
ions
de
fined
as
dedi
catin
g 5
min
of
uni
nter
rupt
ed p
erso
nal
inte
ract
ion
time
with
a p
atie
nt,
sitt
ing
dow
n an
d be
ing
at
eye
leve
l with
the
patie
nt,
and
lett
ing
the
inte
ract
ion
be p
atie
nt g
uide
d to
iden
tify
patie
nt- p
refe
rred
goa
ls. (
81
Nur
ses)
Con
clus
ion:
Nur
ses
attit
udes
abo
ut u
sing
EH
R w
ere
favo
urab
le. T
here
was
a s
igni
fican
t di
ffer
ence
in n
orm
ativ
e be
lief b
etw
een
nurs
es w
ith le
ss th
an 1
5 ye
ars'
expe
rienc
e an
d nu
rses
with
mor
e th
an 1
5 ye
ars'
expe
rienc
e (t2
1 =
2.7
, p =
.01)
. Dip
lom
a an
d as
soci
ate-
prep
ared
nur
ses
wer
e le
ss
posi
tive
than
bac
cala
urea
te- p
repa
red
nurs
es a
bout
EH
R us
eW
hile
nur
ses
spen
t les
s tim
e at
the
nurs
es'
stat
ion,
less
tim
e ch
artin
g, s
igni
fican
tly
mor
e tim
e in
pat
ient
s' ro
oms
and
in
purp
osef
ul in
tera
ctio
ns 6
mon
ths
post
– EH
R im
plem
enta
tion,
tim
e sp
ent i
n re
latio
nshi
p- ba
sed
carin
g be
havi
our
cate
gorie
s de
crea
sed
in m
ost c
ateg
orie
s,
exce
pt fo
r the
cat
egor
ies
of li
sten
ing
to th
e pa
tient
, bei
ng w
ith th
e pa
tient
, an
d pr
ovid
ing
spiri
tual
sup
port
. Oth
er
prof
essi
onal
nur
sing
act
ivity
cat
egor
ies
of
docu
men
tatio
n de
crea
sed
by 4
%, w
hile
ch
art r
evie
w d
ecre
ased
by
only
1%
pos
t EH
R im
plem
enta
tion.
Adm
inis
trat
ive
beha
viou
rs in
crea
sed
from
9%
to 1
4%,
med
icat
ion
adm
inis
trat
ion
incr
ease
d fr
om
16%
to 2
1% a
nd c
omm
unic
atio
n in
crea
sed
from
8%
to 1
2%PD
A d
ata
reve
aled
that
nur
ses
spen
t 27%
of
thei
r tim
e in
the
patie
nt ro
om b
efor
e EH
R de
ploy
men
t, an
d 42
% o
f the
ir tim
e in
pat
ient
room
, 6 m
onth
s af
ter E
HR
impl
emen
tatio
n. N
urse
s al
so s
pent
less
tim
e at
the
nurs
es' s
tatio
n af
ter i
mpl
emen
tatio
n (3
8%) c
ompa
red
to b
efor
e (4
3%).
Tim
e sp
ent i
n pu
rpos
eful
inte
ract
ion
was
37%
pr
e EH
R- im
plem
enta
tion
and
incr
ease
d to
46
% p
ost-
impl
emen
tatio
n
Impa
ct o
n ty
pes
of
com
mun
icat
ion
patt
erns
Impa
cts
on ty
pes
of
com
mun
icat
ion
patt
erns
TAB
LE 3
(C
ontin
ued)
13652648, 2023, 1, Dow
nloaded from https://onlinelibrary.w
iley.com/doi/10.1111/jan.15484, W
iley Online L
ibrary on [14/05/2023]. See the Term
s and Conditions (https://onlinelibrary.w
iley.com/term
s-and-conditions) on Wiley O
nline Library for rules of use; O
A articles are governed by the applicable C
reative Com
mons L
icense
60 | FORDE-JOHNSTON et al.
TA B L E 4 Data collection methods during observations
Author, year and title of study Sample,layoutanddevice Observationaldatacollectionmethodsandsample
Gaudet (2016):Electronic Documentation and Nurse–
Patient Interaction
• 14 Nurses and 19 Patients observed• Stationary computer located adjacent
to the head of each patient's bed and a fixed object in the patient's room
• 24 × 1 h nurse– patient observations in hospital units over 3 months
• Limited to 1- h observation, once a day, per hospital unit
• Audiotaped observations and observer field notes• 22 out of 24 observations consisted of medication
administration• Narrative from audio tapes analysed using Nuance
Dragon NaturallySpeaking software
Rhodes et al. (2006):What Does the Use of a Computerized
Checklist Mean for Patient- Centred Care? The Example of a Routine Diabetes Review
• 25 Patients, 4 Doctors and 9 Nurses observed
• Static computer in primary care GP/clinic room
• 25 × primary care diabetes clinic consultations observed
• Videotaped observations for duration of consultation
• Narrative from video analysed using Conversations Analysis
Rhodes et al. (2008):Electronic Medical Records in Diabetes
Consultations: Participants' Gaze as an Interactional Resource
• 26 Patients, 4 Doctors and 9 Nurses observed
• Static computer in primary care GP/clinic room
• 26 × primary care diabetes clinic consultations observed
• 2 × primary care diabetes clinic consultations further analysed
• Videotaped observations for duration of consultation
• Used Conversation Analysis to examine nurses shift in gaze and body orientation between the computer screen and patient
Burridge et al. (2018):Person- centred care in a digital hospital:
observations and perspectives from a specialist rehabilitation setting
• 43 patients and 53 practitioners (3 medical, 37 nursing, 13 allied health practitioners) took part in mixed methods study
• Workstations on wheels or laptop computers and desktop or wall mounted computers
• 50 × practitioner- nurse observations in a Spinal Rehab Unit
• 17.5 h of observation conducted over 8 weeks• Majority of observations were conducted during
nurse in- patient handovers and medical outpatient consultations
• Observation tool developed by researchers to capture information
• Descriptive statistics and qualitative analysis of observations
Dowding et al. (2015):Nurses' use of an integrated electronic
health record: results of a case site analysis
• 13 Nurses observed• Computer cart on wheels and PC
stations located in various areas in each unit
• 14 × observations over 2 months across 2 hospital sites
• Total of 90 h 38 min of observation• Observations lasted an average of 6 h 27 min• Guided by observation protocol
Fore et al. (2019):Data collected by the electronic health
record are insufficient for estimating nursing costs: An observational study on acute care inpatient nursing units
• 63 Nurses observed• No details on EHR devices used
• Total of 250 h of observation across 63 units over 5 weeks
• Observations were 2– 4 h in duration• Descriptive tasks were recorded using time stamps
Walker et al. (2019):The impact of an integrated electronic
health record on nurse time at the bedside: A pre- post continuous time and motion study
• 51 Direct- care nurses observed• Computers mounted onto
workstations on wheels (referred to as ‘WOWs’) moved around bed areas
• Continuous observations took place in general wards over 18 months
• 51 Direct- care nurses were observed for duration of entire shift (33 shifts) or during medication round (19 medication rounds observed)
• Total of 6209 nursing activities observed• Care activities timed and coded into categories
using structured observation tool (direct care, indirect care, war- related activities, documentation, personal and miscellaneous activities) and additional elements that influence nursing care
• Time and motion outcomes measured• Descriptive statistics reported frequency,
percentages and median duration for care activities and pre/post- implementation differences
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iley.com/doi/10.1111/jan.15484, W
iley Online L
ibrary on [14/05/2023]. See the Term
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iley.com/term
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reative Com
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icense
| 61FORDE-JOHNSTON et al.
of nurses' use of EHR on nurse– patient interactions, ensuring that interactions were observed rather than reflected on. In contrast, Gomes et al. (2016) examined nurses' time and motion using Rapid Modelling Corporation's personal digital assistants (PDA) to deter-mine nurses' time spent on person- centred activities.
The number of hours spent in observation was recorded in several studies (Burridge et al., 2018; Dowding et al., 2015; Fore et al., 2019; Gaudet, 2016), ranging from 17.5 h of observation over 8 weeks in a Spinal Rehab Unit (Burridge et al., 2018), to 250 h across 63 hospital units over 5 weeks (Fore et al., 2019). Rather than pre-senting observation hours, two studies specified the number of observations, (Rhodes et al., 2006, 2008), and one study presented observed nursing care activities (Walker et al., 2019). Observation data collection methods across studies are presented in more detail in Table 4.
The recorded observations ranged from the durations of nurse– patient interactions (Burridge et al., 2018; Fore et al., 2019; Gaudet, 2016); average amounts of time to complete nursing tasks (Fore et al., 2019); and types of nurse– patient interactions (Gaudet, 2016; Rhodes et al., 2008). Gaudet (2016) found that the duration of nurse– patient interactions ranged from between 2 min, 23 s and 23 min, 50 s, and the average duration was 11 min, 14 s. Similarly, Burridge et al. (2018) found the length of clinician- patient encounters varied considerably from 1 to 66 min, while the mean time spent with patients was 21 min (Burridge et al., 2018). In comparison to the other studies, Fore et al. (2019) focused on the average time nurses spent on each nursing task and found that the average amount of time to complete anyone nursing task was less than 5 min. A total of 250 h of observation across 63 units over 5 weeks was conducted and observations were 2– 4 h in duration (Fore et al., 2019). Over 40 h of nurses' time, over the 250 h of total observation time, was spent on the activity of documentation/chart-ing in comparison to nearly 36 h spent on communication, about 5% of observed nursing time (10 h, 40 min) was spent doing ‘none nurs-ing’ tasks, and about 8.5% of the time the nurse was not performing productive work (Fore et al., 2019).
A range of EHR device types were used across studies, such as: static computers in GP clinic rooms (Rhodes et al., 2006, 2008); workstations on wheels moved into the vicinity of patients (Burridge et al., 2018; Dowding et al., 2015; Gomes et al., 2016; Walker et al., 2019); and wall mounted computers away from patient rooms (Burridge et al., 2018; Dowding et al., 2015). Some studies stated specifically where computers were located and being used by nurses, such as: adjacent to the head of each patient's bed (Gaudet, 2016); a laptop computer mounted on a wall (Gomes et al., 2016); or on a terminal in the medication room (Dowding et al., 2015).
4.2 | EHRimpedesonface-to-facecommunication
The impact of EHR use on face- to- face communication between the nurse and patient was observed in four studies (Burridge et al., 2018; Gaudet, 2016;Rhodes et al., 2006, 2008). Researchers observed that
this was due to the logistics of computer use, as most nurses' atten-tion was turned to the computer screen instead of towards the pa-tient (Gaudet, 2016; Rhodes et al., 2006). Gaudet (2016) termed this battling for nurse's attention a ‘game of tag’ between the computer and patient. Stationary computers challenged ‘the logistics of the exchange’ with continual interruptions to nurse– patient interactions noted during observations (Gaudet, 2016).
Findings from Burridge et al.'s (2018) facilitated group discussion of EHR work support Gaudet's (2016) findings that EHR impacts on face- to- face communication. Nurses were concerned about the intrusion of technology into patient encounters, and what this signified for their patients. One commented, ‘you're looking at the screen instead of looking at your patient’, and Burridge et al. (2018) highlighted nurses' concerns as ‘person- centredness seemed elusive, undermining the quality of the practitioner– patient relationship’. Most nurses' felt practitioners resorted to patients' records for informa-tion more readily than to patients themselves. As a result, some nurses opted for discretionary use of EHR on an Australian Spinal Injury Unit to maintain person- centredness (Burridge et al., 2018), for example, one nurse stated: “When [patients] are really upset be-cause they can't walk, I have to try and deal with this, so I just ignore the computer. Because you're a nurse, you're there for the patients; you're not there for the computer.” Similarly, a nurse interviewed in Gaudet's ((2016)) study recognized the time spent away from patients when using EHR, describing: “all the computer stuff that bogs you down,” and that: “We don't sit down, we don't talk to our patients, we are always very busy.”
There is evidence that use of a screen impedes on face- to- face communication. It is important to note that in the absence of a be-fore and after study, the perceptions of the participants cannot be verified. The further implications of this for the patient or nurse are not clear from the data. The effect of the screen might be differ-ent in different locations; for example, in clinical settings where the layout does not permit static computers to be taken to the patient. Some nurses are conscious of a potential barrier and choose to alter their behaviour in the light of this.
4.3 | EHRpromotesatendencytowardstask-orientated communication
In addition to the perceived effect on face- to- face communica-tion, four of the studies identified that task- orientated, checklist- focused communication dominated when nurses interacted with patients using EHR systems (Burridge et al., 2018; Gaudet, 2016; Rhodes et al., 2006, 2008). Nurses EHR use had the potential to create ‘automatic’ and ‘machine- like interactions’ between a nurse and patient (Gaudet, 2016) and was observed to disrupt informal communications and aspects of person- centred care, for example, 66% of nurses used EHR to conduct safety checks, focusing on checklists, rather than patients (Burridge et al., 2018).
Rhodes et al. (2006 and 2008) explored the contradictory fea-tures of ‘patient- centred practice’ and the ‘emphasis on biomedical
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nloaded from https://onlinelibrary.w
iley.com/doi/10.1111/jan.15484, W
iley Online L
ibrary on [14/05/2023]. See the Term
s and Conditions (https://onlinelibrary.w
iley.com/term
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nline Library for rules of use; O
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reative Com
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icense
62 | FORDE-JOHNSTON et al.
audit’, and achieving the former was found to be compromised by the demands of the latter (Rhodes et al., 2006, 2008). A common feature observed in Rhodes et al. (2006) study was that nurses' use of a computerized template forced a routine structure to the consultation and socialized ‘the patient into what is considered ac-ceptable behaviour’ (Rhodes et al., 2006). Once requisite patient data were obtained and entered on the EHR system, nurses would immediately move on to the next checklist item. This was a fea-ture of half of the primary care consultations undertaken by nurses (Rhodes et al., 2006). During consultations, Rhodes et al. (2006) observed that ‘digression from the checklist agenda was discouraged’ as the checklist templates imposed a routine of moving from one question to another, and the nurse did not invite the patient to express any concerns. Therefore, patients were treated as passive recipients of care, reflecting a task- orientated approach to care (Rhodes et al., 2006).
A shift towards a task allocation and a checklist approach is an unintended consequence of the use of EHR; again, this is perceived by the participants reflecting on their approach to care when EHR is used.
4.4 | EHRpromotesaformulaiccommunication style
Unsurprisingly, the lack of face- to- face communication and the ten-dency towards a task- oriented approach identified in the studies seemed to lead to a formulaic approach to the delivery of nursing care. Two studies specifically mentioned how nurses' use of EHR af-fected nurse– patient interaction and communication and promoted a formulaic communication style due to the algorithm promoting a set form of words, for example, positively promoting joint care planning (Dowding et al., 2015) or causing a communication bar-rier through reliance on EHR checklists (Burridge et al., 2018). In Burridge et al.'s (2018) study, the nurses' use of electronic checklists and complexity of EHR tasks, such as information retrieval, hindered informal communications between the nurse and patient. However, this did not always seem to be the case as in contrast, some nurses in Dowding et al. (2015) study were observed to be adept at using the computer screen to promote positive communications and shared patient care- planning in US hospital wards (Dowding et al., 2015). Furthermore, in interviews with nurses, Dowding et al. (2015) iden-tified that nurses perceived that use of EHR systems improved their ability to communicate with patients by providing up- to- date in-formation directly on the computer screen (Dowding et al., 2015). However, during interviews nurses from both case sites reflected on the constant problems they had between documenting care and meeting care demands from patients (Dowding et al., 2015). Therefore, it is evident that the formulaic communication style pro-moted by EHR influences nurse– patient communication; though not always negatively and these studies provide some guidance as to how good practice when using EHR might be developed.
4.5 | EHRimpactontypesofcommunication patterns
Five studies identified that EHR impacts on the types of commu-nication patterns, for example, changes in the time nurses spent on documentation and direct patient care activities/interactions (Fore et al., 2019; Gomes et al., 2016; Walker et al., 2019); and two studies identified communication patterns (Gaudet, 2016; Rhodes et al., 2008). Gomes et al. (2016), for example, found that most nurses in US medical- surgical units spent less time at the nurses' station, less time charting and significantly more time in patients' rooms in pur-poseful interactions 6 months post- EHR implementation. However, time spent in relationship- based caring behaviour categories de-creased, except for the categories of listening to the patient, being with the patient and providing spiritual support (Gomes et al., 2016). Time spent on other professional nursing activity categories such as communication increased from 8% to 12% post- EHR implementa-tion (Gomes et al., 2016). In contrast to Gomes et al. (2016), Walker et al. (2019) found the move from paper- based patient records to EHR in Australian medical- surgical units did not significantly change the amount of nurse time at the bedside, or for the preparation and administration of ordered medications. However, there was a clear and consistent trend of increased documentation time and activities following implementation of EHR (Walker et al., 2019).
Nurse– patient interactions were identified by researchers as ‘de-liberative’ or ‘automatic’ responses (Gaudet, 2016), or ‘bureaucratic’ or ‘participative or patient centred’ (Rhodes et al., 2008). Deliberative responses validated patients' replies, whereas automatic responses were characterized by limited exchange with a patient and a focus on the computer (Gaudet, 2016). Deliberative responses were evident on 12 occasions involving medication administration and automatic responses were present during 10 observations, when additional communication might have been warranted to ascertain the patient's need (Gaudet, 2016). Therefore, nurse– patient interactions reflect-ing automatic responses caused a barrier to open- ended questions and two- way communication, and patients' care needs may have been missed as nurse– patient conversations were concluded too early (Gaudet, 2016).
Two routine consultations in UK primary care diabetes clinics were deliberately compared to present two different styles of inter-action, where a nurse's gaze was either predominantly towards the computer screen or directed more towards the patient. Two styles of ‘bureaucratic’ or ‘participative or patient- centred’ nurse– patient in-teractions were presented through the examination of these two primary care consultations (Rhodes et al., 2008). When the nurse's gaze was primarily towards the computer screen and a checklist approach was used, it was viewed as a ‘bureaucratic’ style of inter-action. When the nurse's interactions were directed more towards the patient and the checklist agenda was suspended, it was deemed a ‘participative or patient- centred’ interaction (Rhodes et al., 2008). Although one nurse gave priority to the EHR, which hindered patient participation, Rhodes et al. (2008) suggest that this is not necessarily
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a consequence of the use of EHR, as the other nurse suspended the use of a checklist. Rhodes et al. (2008) suggest that the differences between each encounter may relate to the ‘active accomplishment of the nurse’ and their ability to shift their gaze and bodily orientation between a computer screen and a patient.
5 | DISCUSSION
We believe that this integrative review is the first to explore how nurses' use of EHR impacts on the quality of nurse– patient interac-tions and communication. The review provides evidence of signifi-cant unanticipated and unintended consequences when nurses use EHR. The use of EHR impedes on face- to- face communication, inter-action styles and ultimately a person- centred approach. Our review suggests that without careful planning, nurses' use of EHR check-list and scripts may promote formulaic interaction styles and ‘pas-sive’ patient engagement, as nurses' attention focuses on electronic checklists instead of the patient, and open nurse– patient conversa-tions may be inhibited when nurses adhere to EHR. This is clearly a negative unintended consequence of the use of EHR checklists. However, some nurses were able to adapt or be flexible with the system to achieve a dynamic, open nurse– patient communication, that reflected a person- centred care approach. Hence in addition to highlighting the disadvantages to the use of EPR, this review also points to some solutions.
However, a tension clearly exists. The Person- centred Nursing Framework (McCormack & McCance, 2006) is a useful tool to ex-plore the tension between a task- based EHR system and a person- centred approach. It comprises four constructs: prerequisites, focusing on attributes of the nurse; the care environment, focusing on the context in which care is delivered; person- centred processes, focusing on delivering care through a range of activities; and ex-pected outcomes that are the results of effective person- centred nursing (McCormack & McCance, 2006). To reach the centre of the person- centred framework, a ‘necessary care environment for provid-ing effective care’ must be met, which includes a system that facili-tates shared decision- making and effective staff relationships, and the ‘sharing of power’ (McCormack & McCance, 2006).
Evidence from our review suggests that the current EHR sys-tems dominating healthcare impact on the extent to which nurses can provide ‘the necessary care environment’ conducive to person- centred communication and shared decision- making (McCormack & McCance, 2006). Instead, these systems can cause a barrier between the patient and nurse and impede on face- to- face communication, due to the logistics of computer use and the types of devices being used (Gaudet, 2016; Rhodes et al., 2006, 2008). While EHR systems have the potential to assist in achieving a necessary care environ-ment for positive nurse– patient interactions and communication to take place, this review suggests that this is not necessarily easily achieved, and nurses need to consciously change their behaviour for this to happen. The default situation seems to be that the use of EHR constrains a person- centred approach to care.
In practice, there is limited guidance on best practices when nurses use EHR to promote ‘shared power’, shared decision- making and patient involvement. The American Academy of Family Practice (Ventres et al., 2006) and Wuerth et al. (2014) offer practical tips that clinicians can use to promote a patient- centred approach, such as starting with the patient's concerns, encouraging patient's active participation in building their charts and screen sharing with patients but it is not clear that these are based on empirical evidence.
Voran et al. (2016) highlight a triangulated relationship between a healthcare provider, computer and patient, calling it a ‘Magic Triangle’; whereby the computer has become an essential part of a provider- patient interaction. How a healthcare provider interacts with a patient while using a computer may promote or hinder pa-tient participation (Voran et al., 2016). Directing the patient to the computer screen, for example, is suggested to be consistent with a patient- centred caring approach (Voran et al., 2016).
Kumarapeli and de Lusignan (2013) agree, suggesting that clini-cians should increase their awareness of posture and the layout of rooms when they are using the computer to promote screen shar-ing and move computers to promote patient engagement. Similarly, Chen et al. (2011) suggest that patients should be involved at every stage in what is happening behind the computer screen. However, both studies relate to medical consultant or exam rooms, indicating the need for more nursing research in this area.
We did not identify research that specifically explored nurses' adaptation to the use of EHR, however some nurses do adapt their communication style when using the EHR technology (Rhodes et al., 2008), whereas others seem less able to do so (Gaudet, 2016; Rhodes et al., 2006, 2008). Crampton et al.'s (2016) review of com-puter use in the clinical encounter concurs, suggesting that the strat-egies employed by clinicians, clinicians' styles and the layout of the room, will all have an impact on the clinician- patient encounter; ei-ther positively or negatively.
One explanation for this is the way in which the use of EHR affects the nurses' gaze and posture (Rhodes et al., 2008). Two case studies from routine consultations in primary care diabetes clinics identi-fied how nurses' gaze orientations reinforced their body orientations and led to different types of nurse– patient interactions, for example turning away from the patient towards the computer, systematically obstructing discussions and seemingly reluctant to engage with the patient's concerns (Rhodes et al., 2008). The nurse's body orienta-tion in Case 1 had legs and torso turned towards the computer and the nurse appeared reluctant to engage with the patient's concerns, systematically obstructing discussion. In comparison, the nurse's body orientation in Case 2 signalled full attention through contin-ued eye contact and by fully facing the patient, and the nurse en-couraged the patient to expand conversation (Rhodes et al., 2008). Although both nurses followed a computerized checklist, the second nurse did not allow its presence to dominate nurse– patient interac-tions, which suggests that not all nurses are detracted from face- to- face communication when using EHR systems. Similarly, Dowding et al. (2015) observed that many nurses across both case study sites developed a ‘sophisticated ability to juggle these competing demands’
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between the patient and the EHR system; documenting assessment information and vital signs immediately onto the EHR system by the patient's bedside (Dowding et al., 2015).
These case studies indicate that there are ways in which nurses can adapt the EHR systems to promote nurse– patient interactions. Such adaptations require conscious action on the part of the nurse and the effectiveness of these adaptations requires further re-search. In addition, there have been calls in the UK for a more cen-tralized approach when purchasing EHR systems to promote further consideration of interoperability and standardization and to include nurses in the design (Warren et al., 2019). For example, some clinical areas promoted ‘Point- of- care’ (as defined by Kitson, 2018) patient assessment and documentation; moving workstations on wheels into the vicinity of the patient at the point at which care was under-taken (Dowding et al., 2015; Gomes et al., 2016; Walker et al., 2019). In contrast, Gaudet (2016) provided evidence that stationary com-puters interrupted nurse– patient interaction and workflow, as the nurses move ‘back and forth’ from the static computer and direct eye contact was sometimes obscured.
Healthcare providers have a responsibility to develop EHR systems, devices and layout of clinical areas that facilitate nurse– patient interaction. Consideration of whether computers are fixed to room walls or outside patient rooms, and proximity to the patient are important. Clearly, it is not conducive to quality nurse– patient interactions if a nurse has their back to the patient or must leave the room to enter information or ‘screen gazes’ rather than focussing on the patient.
A future evidence base evaluating best nursing practices when nurses use EHR is paramount to promoting person- centred care and quality nurse– patient interactions. Without this evidence- base we risk losing the art and person- centred nature of nursing; with pa-tients ending up as passive receivers of care.
There are several limitations to this review. Eight studies that met the inclusion criteria were undertaken in three countries and hence do not represent the global picture of nurse– patient inter-action when EPR is used. Capturing the essence of nurse– patient interaction and communication is inherently complex and none of the studies identified were able to assess communication and inter-action before the introduction of EHR. Therefore, a true comparison of nurse– patient interaction before and after the introduction of EHR is not possible.
5.1 | Implicationsfornurseeducationandpractice
This review has identified that EHR affects the way that nurses and patients interact. Different types of communication patterns were observed across studies (Burridge et al., 2018; Fore et al., 2019; Gaudet, 2016; Rhodes et al., 2008), and some nurses were able to provide more person- centred communications than others when using EHR electronic record systems (Dowding et al., 2015; Rhodes et al., 2008). Therefore, future research needs to understand what influences the types of communication patterns taking place when
nurses use EHR electronic records, and why some nurses can offer more person- centred communication when using EHR than others. Does it relate to a nurses' education, professional experiences and/or the values they hold?
There is evidence that some nurses may need to further de-velop their interpersonal, communication and technical skills to be able to involve patients when they use an EHR script and checklist. Therefore, nurse educators should promote patient involvement when teaching students about the use of EHR electronic records. Checklist- based EHR use may be mitigated if nurse training increases individual's self- awareness and nurses become more conscious of their positioning and practices when using EHR. Undergraduate and post- registration nurse education programmes need to acknowl-edge and support developing competencies to reflect a person- centred nursing framework when signing students and staff off as competent to use EHR electronic record scripts (McCormack & McCance, 2006). Competency- based proficiencies to assess nurses' EHR use should include behaviours, such as explaining what is being done while using EHR, facing the patient and involving the patient in their care plans to promote two- way conversation and shared decision- making.
Interestingly, there is evidence that physicians are promoting the need for EHR training to improve doctor– patient interactions and communication, using strategies such as repositioning themselves and screen sharing to improve patient experience (Voran et al., 2016). The nursing profession and nurse educators should follow suit, as nurses' style of communication and their approach towards patient communication when using EHR may affect patients' experiences.
5.2 | Implicationsforfutureresearch
The on- going development of EHR systems is likely to have far- reaching effects on the future of nursing practice in both profound and subtle ways. Healthcare employers and system developers need to consider the unintended impact of nurses' use of EHR on the qual-ity of nurse– patient interactions and communication. Technology companies and healthcare providers need to develop and support user- friendly EHR systems that promote, and not hinder, quality nurse– patient interactions and person- centred care. For example, devices that direct patients to their EHR care plan, may promote two- way communication and shared decision- making. However, we need to be mindful that not all patients can access this. Future stud-ies are needed to evaluate nurses' use of different EHR systems and identify systems which promote two- way communication, shared decision- making and a person- centred approach to care. There are indications that nurses can use strategies to minimize the effects of the checklist approach on nurse– patient interaction, but these strat-egies are not extensively evaluated.
It is evident that there is a need for more international multi- method research studies that explore how nurses EHR use influences the quality of nurse– patient communication, across a range of healthcare settings. Future research exploring nurses' use of EHR should include rigorous
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evaluation of the algorithms and other technology- mediated communi-cation systems being used that includes the perspective of both patients and nurses to achieve these goals. The environments in which EHR sys-tems are being used by nurses and the ergonomics surrounding their use must also be examined and taken account of when researching this area. This is important to ensure that nurses play an active role in the development of EHR and avoid being a passive recipient of technology.
6 | CONCLUSION
It is internationally accepted that the essence of nursing practice is underpinned by a compassionate, holistic and person- centred ap-proach to care. Globally, the importance of EHR to promote clini-cal safety standards is not disputed. However, there is evidence to suggest that compassionate, two- way nurse– patient interactions are hindered by the unreflective use of checklists underpinning EHR systems. Digital algorithms are dictating and changing contemporary nursing practice at a rapid rate, and we owe it to our future nurs-ing profession and patients to engage fully with the developments surrounding this to ensure that our profession is not reduced to checklists and changed beyond recognition. Healthcare employers and technology companies developing future systems must include nurses' and patients' perspectives when evaluating EHR systems and take account of the environments in which they work to pro-mote person- centred care and quality nurse– patient interactions.
AUTHORCONTRIBUTIONSAll authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE*): (1) substantial contributions to conception and design, acquisition of data or analy-sis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content. * http://www.icmje.org/recom menda tions/.
ACKNOWLEDGEMENTSSpecial thanks to Helen Walthall Director of Nursing Research and Innovation at the Oxford University Hospitals NHS Foundation Trust for supporting the early stages of PhD discussion.
FUNDINGINFORMATIONFunding for the review was provided by the NIHR Oxford Biomedical Research Centre, Oxford, England and the NIHR Thames Valley Comprehensive Local Research Network, Oxford, England. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the UK Department of Health.
CONFLICTOFINTERESTNo conflict of interest has been declared by the authors.
PEER RE VIE WThe peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15484.
DATAAVAILABILITYSTATEMENTThe data that support the findings of this study are available from the corresponding author upon reasonable request.
ORCIDCarol Forde- Johnston https://orcid.org/0000-0001-7266-5755 Dan Butcher https://orcid.org/0000-0002-6151-7738 Helen Aveyard https://orcid.org/0000-0001-5133-3356
T WIT TERCarol Forde- Johnston @@FordeJohnston Dan Butcher @@Dan_ButcherOBU Helen Aveyard @@AveyardH
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How to cite this article: Forde- Johnston, C., Butcher, D., & Aveyard, H. (2023). An integrative review exploring the impact of Electronic Health Records (EHR) on the quality of nurse– patient interactions and communication. Journal of Advanced Nursing, 79, 48–67. https://doi.org/10.1111/jan.15484
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- An integrative review exploring the impact of Electronic Health Records (EHR) on the quality of nurse–patient interactions and communication
- Abstract
- 1|INTRODUCTION
- 2|BACKGROUND
- 2.1|Nurse–patient interactions
- 2.2|Checklist approach
- 2.3|Practices and standards for EHR use
- 3|INTEGRATIVE REVIEW
- 3.1|Aim
- 3.2|Design
- 3.3|Methods
- 3.3.1|Literature search
- 3.4|Quality appraisal
- 3.5|Data extraction
- 3.6|Synthesis
- 4|RESULTS
- 4.1|Characteristics of included studies
- 4.2|EHR impedes on face-to-face communication
- 4.3|EHR promotes a tendency towards task-orientated communication
- 4.4|EHR promotes a formulaic communication style
- 4.5|EHR impact on types of communication patterns
- 5|DISCUSSION
- 5.1|Implications for nurse education and practice
- 5.2|Implications for future research
- 6|CONCLUSION
- AUTHOR CONTRIBUTIONS
- ACKNOWLEDGEMENTS
- FUNDING INFORMATION
- CONFLICT OF INTEREST
- PEER REVIEW
- DATA AVAILABILITY STATEMENT
- REFERENCES
