Neonatal Nurses Experience Unintended ...

FEATURE ARTICLE

Neonatal Nurses Experience Unintended Consequences and Risks to Patient Safety With Electronic Health Records Katherine M. Dudding, BSN, RNC-NIC, Sheila M. Gephart, PhD, RN, Jane M. Carrington, PhD, RN

In this article, we examine the unintended consequences of nurses' use of electronic health records. We define these as unforeseen events, change in workflow, or an unanticipated result of implementation and use of electronic health records. Unintended consequences experienced by nurses while using electronic health records have been well researched. However, few studies have focused on neonatal nurses, and it is unclear to what extent unintended consequences threaten patient safety. A new instrument called the Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire has been validated, and secondary analysis using the tool explored the phenomena among neonatal nurses (N = 40). The purposes of this study were to describe unintended consequences of use of electronic health records for neonatal nurses and to explore relationships between the phenomena and characteristics of the nurse and the electronic health record. The most frequent unintended consequences of electronic health record use were due to interruptions, followed by a heavier workload due to the electronic health record, changes to the workflow, and altered communication patterns. Neonatal nurses used workarounds most often with motivation to better assist patients. Teamwork was moderately related to higher unintended consequences including patient safety risks (r = 0.427, P = .007), system design (r = 0.419, P = .009), and technology barriers (r = 0.431, P = .007). Communication about patients was reduced when patient safety risks were high (r = −0.437, P = .003). By determining the frequency with which neonatal nurses experience unintended consequences of electronic health record use, future research can be targeted to improve electronic health record design through customization, integration, and refinement to support patient safety and better outcomes.

Author Affiliations: College of Nursing, The University of Arizona. This project was funded by the Lawrence B. Emmons Foundation from The University of Arizona. S.M.G. acknowledges research support from the Robert Wood Johnson Foundation Nurse Faculty Scholars Program and the Agency for Healthcare Research and Quality (K08HS022908). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the Robert Wood Johnson Foundation. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding Author: Katherine M. Dudding, BSN, RNC-NIC, College of Nursing, The University of Arizona, PO Box 210203, Tucson, AZ 85721 ([email protected]). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/CIN.0000000000000406

Volume 36 | Number 4

KEY WORDS: Electronic health record, Neonatal nurses, Nursing informatics, Risks to patient safety, Unintended consequences

n 1999, the Institute of Medicine (IOM) issued a report that revealed evidence of an unsafe healthcare system.1 It surmised that at least 44 000 and as many as 98 000 patients die each year due to preventable medical errors.1 The IOM then released a report suggesting that the use of technology could increase patient safety.2 Since then, the electronic health record (EHR) has been considered the solution, yet it too has fallen short of this goal.3–5 Despite comprehensive research, nurses' experience with EHRs has not been quantified, and little is known about the experiences of nurses who specialize in neonatal intensive care. This article presents the results of data analysis focused on the responses from the Unintended Consequences of EHR Questionnaire (UCE-Q).

I

BACKGROUND In 2009, as part of the American Recovery and Reinvestment Act, the Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted to prioritize health information technology to improve the quality of healthcare.1,6–8 The purpose of HITECH was to enhance the quality of patient care, reduce healthcare costs, promote wellness through disease prevention, encourage clinical research, reduce health disparities, and protect patient health records.6,7 Collectively, this resulted in a broader implementation of EHRs and emphasized the achievement of Meaningful Use goals in three stages over 5 years.6 To promote implementation of EHRs nationwide, healthcare systems were offered monetary incentives to adopt EHRs and demonstrate achievement of each stage of meaningful use by specified dates.8 Each stage of Meaningful Use centered on a specific goal. Briefly, Stage 1 focused on data collection and sharing, Stage 2 on the progression of effect of the EHR on clinical processes, and Stage 3 concentrated on enhanced patient outcomes and

CIN: Computers, Informatics, Nursing

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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FEATURE ARTICLE

engagement.6–10 Some healthcare organizations quickly implemented EHRs to qualify for incentives, but unfortunately, these systems did not meet all user needs. Electronic health record systems have evolved with much controversy surrounding meaningfulness and effectiveness.11,12 Electronic health record usability in general was poor and added to the workload of healthcare providers.10 In addition, EHRs have presented new challenges, such as a human-computer interface that prioritizes data entry over retrieval and has the potential to induce error.10 Although prevention of patient error is one of the main goals of EHR use, there are continued threats to patient safety.10,13 Despite efforts to prevent medical error, patient deaths occur as a result of EHR inadequacies.13,14 While unintended consequences of EHR use have been studied extensively among physicians, little research has focused on nurses in general or nurses in specialty practice such as neonatal intensive care.14–16 In 2015, Gephart et al14 conducted a systematic review to examine unintended consequences of EHR use among nurses; only five articles qualified for the review. Clearly, further research is needed to understand the breadth of this issue among nurses. Schoville17 studied nurse workarounds related to the implementation of computerized provider order entry. Five types of workarounds were identified, related to (1) changes in workflow, (2) communication changes, (3) system problems, (4) learning curve, and (5) patient safety; the findings suggested that nurses engaged in workarounds to increase patient care coordination. Similarly, Stevenson and Nilsson5 examined nurse perceptions of the EHR and the potential threats to patient safety related to a complex system design that required duplicate documentation in several areas of the EHR, difficulty with data retrieval, and issues with regular updates to medication changes. Carrington and Effken11,12 concentrated on nurse communication about clinical events, such as a change in the required level of care for a patient, through “handoff” reports and the corresponding documentation within the EHR. The report concluded that the EHR did not provide support for documentation of a clinical event.4,11 Furthermore, receiving nurses often found it difficult to locate the documentation that communicated the change in the level of care.11 Collins et al4 studied nurses using free-text documentation to record clinical events and its significance and discovered that (1) there was no linked support between the EHR flowsheet and free text documentation, and (2) text documentation was considered a nurse workaround because most of it was communication between healthcare providers. Other studies confirm that nurses' documentation needs within the EHR are not supported. Sockolow et al18 examined a Nursing Information System, part of the EHR designated to support nursing documentation and care plans for

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usability and effectiveness. Another study asked nurses to describe the unintended consequences of EHRs using a quantitative instrument.19 The authors defined an unintended consequence as an unforeseen event, change in workflow, or unanticipated result of implementation and use of EHRs.15 Study results indicated that unintended consequences of EHR use represented a threat to patient safety, increased workload, and made the coordination of care during staff or patient transitions more difficult.15 The frequency of unintended consequences related to hardware, technical interruptions, and copy-and-paste options within the EHR was low.15 In addition, if nurses worked in a positive environment, the likelihood of unintended consequences was reduced.15 Approximately one-third of the participants in this study were neonatal nurses, and this secondary analysis was undertaken to determine whether there were differences among specialized nurses, in particular neonatal nurses.15 Specific research aims were to (1) describe the unintended consequences of EHR use for neonatal nurses and (2) explore relationships among the phenomena and neonatal nurse and EHR characteristics.

METHODS Design A secondary analysis of data from a descriptive cross-sectional correlational study was conducted. The parent study's purpose was to validate and test the reliability of an instrument to measure EHR-related unintended consequences. The content, construct, and convergent validities of the instrument, the Carrington-Gephart UCE-Q (CG-UCE-Q), were confirmed to measure unintended consequences of EHR use.15 This study had a final usable sample size of 144 direct care and acute care nurses; results are reported elsewhere.15 The institutional review board at the University of Arizona provided oversight for the original study and the secondary analysis, although both were deemed exempt.

Setting and Sample In the parent study, RNs were recruited locally, regionally, and nationally and were eligible if they used an EHR daily, for at least 3 months, and worked at least 20 hours a week. They had to be able to read and write in English and be older than 18 years. For this analysis, data from neonatal nurses were separated from the larger data file and were analyzed separately.

Measures As the intent was to identify both the experience of nurses with the EHR and other factors that related to it, participants answered questions about both the technology and



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the work system. The survey included questions about the EHR vendor, professional practice environment, frequency of unintended consequences, use of workarounds, and nurse perceptions of threats to patient safety. Validated measures used in the study included the CG-UCE-Q, the Revised Professional Practice Environment (RPPE) scale,20 and Halbesleben's Workaround Tool,21 which are described below. Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire

Development of the CG-UCE-Q, based on qualitative studies, is described elsewhere.19 The final scale includes 36 items that are scored on the basis of how often a nurse experiences unintended consequences of EHRs, ranging from 0 (never) to 6 (multiple times per work shift). Exploratory factor analysis supported construct validity, with 66% of the variance explained by the tool across six subscales (patient safety, system design, workload issues, workarounds, technology barriers, and sociotechnical impact). Content validity was supported (content validity index = 0.96), and the instrument showed high internal consistency (Cronbach's α = .94, Intraclass Correlation Coefficient = 0.91) and strong item-to-total correlations (0.30–0.80) across items. Subscale reliabilities were adequate (α = .67–.96). Unfortunately, in the parent study, there was a major organizational change announced between the test and retest measurements that may have skewed views of participants and affected their response consistency. Median scores across the two testing points were highly similar for the group, but the individual responses changed. Workaround Tool

To determine the context of and processes in which nurses use workarounds during patient care activities, Halbesleben's 21 Workaround Tool was used with permission. Human factors researchers describe what we call “workarounds” as behaviors that promote adaptation and resilience to ineffective work systems.22 The instrument includes 20 items with responses on a 5-point Likert scale ranging from 5 (strongly agree) to 1 (strongly disagree). Process subscales addressed how participants perceived a block, worked around a block by altering a process, preference for following procedures, and motive for the workaround. Context subscales addressed workaround factors related to technology, equipment, policies and rules, people, and process design. The workaround tool yields both subscale and total scale scores across domains with established reliability and validity.21 Concurrent validity of the CG-UCE-Q with the workaround tool was modest. This may reflect differences in nurses' experience with workarounds.

that address features of the nursing unit and organization including perceptions about leadership and autonomy, nursephysician relationships, control over practice, communication about patients, teamwork, handling conflict, one's work motivation, and cultural sensitivity.20 High scores show a positive experience with the construct. Studies across different samples have consistently shown the RPPE to be valid and reliable (α = .80–.88 across subscales).20 However, the parent study found the RPPE to be less consistent than reported previously (α = .67–.85 across subscales).15 Historically, the RPPE had been used in samples from single organizations, but the parent study had nurses from diverse organizations and settings.

Procedures Recruitment and data collection procedures for the parent study are reported elsewhere.15 In short, nurses were recruited locally by e-mail and on e-mail discussion lists within two hospitals in the southwestern US, at the state level by announcing the survey on the Arizona Nurses Association Web site, and nationally through recruitment on the National Association of Neonatal Nursing e-mail discussion list. The survey was administered using SurveyMonkey (SurveyMonkey, San Mateo, CA). Local participants who completed the survey twice to assess test-retest reliability received a $5 gift card for their participation. Other participants received no incentive.

Analysis Quantitative data analysis applied descriptive statistics (frequencies, means, medians, and tests of normality), correlational statistics, and analysis of variance to examine differences based on nurse or EHR characteristics. Correlations are described using Pearson's r if normally distributed and Spearman's ρ if not normally distributed. Measures were scored using instructions from their authors.

RESULTS Sample Characteristics The parent study sample consisted of 144 nurses; the secondary analysis focused on responses only from neonatal intensive care nurses (n = 40). Most were female (97.5%) and practiced in the US North Central and Southwestern regions. Age varied, but most were older than 65 years (40.0%) and had practiced in neonatology for more than 20 years (70.0%). Half of the participants had earned at least a bachelor's degree (50%). The most frequently used EHR was from Epic (47.5%), followed by Cerner. Most nurses used one system (62.5%), although the remainder used at least two EHRs (37.5%) (Table 1).

Frequency of Experience With Unintended Consequences Revised Professional Practice Environment Scale

The RPPE, which comprises 42 items, was used to measure the practice environment.20 This tool includes eight subscales


The average frequency with which nurses dealt with unintended consequences of EHRs ranged from at least once a shift to very infrequently (Table 2). The most frequently



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experienced unintended consequences of EHRs were due to interruptions, either from another's request or remembering they had to do something else. Nurses reported these as occurring at least once a shift. Unintended consequences that took place approximately once a week were next in frequency. These included higher workload, changed workflow, altered communication patterns,

Table 1. Sample Characteristics (n = 40) Variable Age, years 65 Sex Female Male Region Northeast Southeast North Central South Central Northwest Southwest Years in practice 20 Highest earned degree Diploma in nursing Associates degree Associate degree in nursing/diploma (bachelor's degree in another field) Bachelor's degree Master's degree Currently in school for another nursing degree Yes No EHR used Epic Cerner Meditech Other No. of different systems used in your facility 1 2–4 5–6 Unsure

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n

%

8 2 3 11 16

20 5 7.5 27.5 40

39 1

97.5 2.5

8 6 9 4 4 9

20 15 22.5 10 10 22.5

1 3 6 2 28

2.5 7.5 15 5 70

6 2 1

15 5 2.5

20 11

50 27.5

6 34

15 85

19 14 4 3

47.5 35 10 7.5

25 13 1 1

62.5 32.5 2.5 2.5

and reliance on the EHR for clinical decision making. Frequently, documentation took longer as a result of repeated data entry in multiple places, and it kept nurses from other important parts of their work. Finally, data retrieval was a challenge when there was no nursing note to help them understand the current health status of the patient. On average from monthly to weekly, nurses reported challenges with information retrieval and slow system operations. Specifically, they could not document because computers were not working, systems were slow to respond during documentation, or they had to switch computer stations to document. They reported not being able to locate important patient information or having found that information was not enough to provide an accurate clinical picture. The most infrequently experienced unintended consequences occurred monthly to annually; however, these involved situations in which there was a perceived threat to patient safety. Examples include orders that were documented or ordered for the wrong patient, orders that were found to contain errors when reviewed (eg, “good catches”), or when medications had to be administered urgently. Nurses reported that at least once a year, on average, mistakes were made because the same patient information had to be entered in more than one place in the EHR.

Workarounds Neonatal nurses stated that when they used workarounds most often it was with motivation to follow rules and policies of work, use of equipment, and use of technology. They preferred to follow procedures, but when equipment, technology, or poorly designed work process became a barrier, a shortcut was taken if it was perceived to better assist patients (Table 3). However, nurses reported feeling neutral about having to alter their work process because of interruptions, or rules and policies, to better assist a patient. They remained impartial to changing work processes because of problems with technology, equipment, rules and policies keeping them from doing their jobs efficiently, and work processes that were poorly designed. In addition, they felt neutral about completing tasks to their satisfaction when work processes were barriers (eg, poorly designed processes, malfunctioning equipment and technology, or rules and policies). They disagreed that interruptions prevented them from completing tasks to their own satisfaction and that they had to alter work processes to accommodate rules or policies that kept them from doing their jobs efficiently.

Professional Practice Environment and Unintended Consequences of Electronic Health Records When comparing the practice environment to the unintended consequences of EHRs, relationships were identified



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Table 2. Frequency of NICU RN Experience With Unintended Consequences of EHRs Question Mean SD How often, when entering data into the EHR, do 5.43 1.11 you have to leave your computer before finishing because you get interrupted? How often, when entering data into the EHR, do you 5.05 1.11 have to leave your computer before finishing your task because you remembered you needed to do something and had to leave your computer? How often does using the EHR increase 4.40 2.01 your workload? When using EHRs, how often have you experienced 4.36 1.90 changes to your workflow? How often does documenting take too long so that 4.20 1.86 you cannot do important parts of your other work? How often, when entering data, do you enter the 4.15 2.23 same data repeatedly in different places? How often have you experienced differences in 4.03 1.86 communication patterns using the EHR vs other communication methods in your institution? How often when retrieving data from the EHR do you 4.00 1.81 find there is no nursing note to help you understand what is going on with the patient? How often is it difficult to locate significant 3.93 1.77 information (eg, changes in clinical status) about your patient in the EHR? How often, when you need to make a decision about 3.35 1.85 your patient, is there too little patient information documented for you to understand the clinical picture? How often do you have trouble documenting 3.35 1.88 because the system is slow? If one computer is not working, how often do you 3.00 1.55 use a different computer station? How often have you experienced power shifts while 2.95 1.97 using the EHR? How often, when you go back into the EHR to find 2.88 2.09 information you know you entered, is it difficult to find patient information you entered? How often have you seen patient safety issues 2.70 1.44 (eg, documenting or entering orders on the wrong patient) arise from using EHRs? How often, when attempting to use the EHR, do 2.68 1.59 the computers not work (eg, because they are not turned on or they have lost power)? All information systems require information 2.65 1.42 technology support to maintain the system. In your organization, how often is your work disrupted during hardware and software updates? Please indicate how often this EHR issue creates an 2.48 1.95 unsafe patient care situation: when you are reviewing orders. Please indicate how often this EHR issue creates 2.30 1.62 an unsafe patient care situation: when you need to administer a medication urgently.

Table 2. Frequency of NICU RN Experience With Unintended Consequences of EHRs, Continued Question Mean SD How often in your practice, as a result of needing 2.30 1.86 to enter the same patient information in more than one place, do you make mistakes documenting in the EHR? Please indicate how often this EHR issue creates an 1.88 1.76 unsafe patient care situation: when a patient is admitted to your setting. How often are you unable to access patient 1.78 1.46 information in the EHR because of problems with your password? Please indicate how often this EHR issue creates an 1.75 1.71 unsafe patient care situation: when your patient comes to the hospital in critical condition. Please indicate how often this EHR issue creates an 1.70 1.57 unsafe patient care situation: when a change in patient status occurs. Please indicate how often these EHR issues create 1.63 1.67 an unsafe patient care situation: when you need to coordinate care while your patient is on your unit. Please indicate how often these EHR issues create 1.58 1.52 an unsafe patient care situation: when a patient is transferred within the hospital. Please indicate how often EHR issues create an 1.58 1.66 unsafe patient care situation: when you are trying to assess risk for complications (eg, related to diagnosis, comorbidities). Please indicate how often this EHR issue creates an 1.53 1.62 unsafe patient care situation: when a patient is admitted to the hospital. Please indicate how often these EHR issues create 1.53 1.60 an unsafe patient care situation: when a patient is discharged to home. Do you experience strong emotions about using the 1.43 0.50 EHR? Please indicate how often these EHR issues create 1.33 1.44 an unsafe patient care situation: when a patient is transferred to your hospital from another setting. How often do you deal with a computer that does 1.30 1.38 not work by documenting on paper? Please indicate how often these EHR issues create 1.30 1.65 an unsafe patient care situation: when you need to teach your patients. Please indicate how often these EHR issues create 1.10 1.55 an unsafe patient care situation: when you need to coordinate care for your patient once they leave your unit. Please indicate how often these EHR issues create 1.00 1.36 an unsafe patient care situation: when a patient is transferred to another hospital or care setting (eg, long-term care) from your hospital. How often in your practice do you add to your 0.65 1.49 nursing note through the shift to edit for details but do not sign it each time?

(continues)


(continues)



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FEATURE ARTICLE Table 2. Frequency of NICU RN Experience With Unintended Consequences of EHRs, Continued Question Mean SD How often in your practice do you add to your 0.65 1.49 nursing note through the shift to edit for details but do not sign it each time? How often do you save the note without signing it 0.50 1.24 because of concerns that once signed it becomes a permanent part of the EHR? Most frequency to least frequency was determined on a 0- to 6-point scale, where 6 = multiple times a shift, 5 = once a shift, 4 = once a week, 3 = once a month, 2 = once every couple of months, 1 = once a year, and 0 = never.

across several subscales. The RPPE subscale for handling conflict was inversely associated with CG-UCE-Q subscales for patient safety risks (r = −0.495, P = .002), system design (r = −0.495, P = .002), and technology barriers (r = −0.414, P = .010). Teamwork was moderately related to higher unintended consequences including patient safety risks (r = 0.427, P = .007), system design (r = 0.419, P = .009), and technology barriers (r = 0.431, P = .007). Communication about patients was reduced when patient safety risks were high (r = −0.437, P = .003) (Table 4).

DISCUSSION Neonatal nurses reported frequent interruptions, higher workload, and altered workflow as unintended consequences of EHRs. Once per shift, interruptions occurred at a critical time in the nursing workflow (ie, during documentation). Nursing documentation includes assessments of critically ill neonates to communicate an accurate clinical picture of the neonate's current condition.23 If each of the 40 neonatal nurses experienced these interruptions two to three times a week (based on worked hours), that yields a rough estimate of 4160 to 6240 occurrences over the year that represent potential threats to patient safety. The need to document the same information in several different places in the EHR prolonged the charting process. One might argue that paper charting also requires duplicate information in several places, and this is not an EHR-specific problem.24 However, time spent charting in the EHR may be extended simply as a result of locating an available computer or slow system response when logging into patient charts. If nurses are interrupted, one could ask whether the data entered are of the highest quality and correct descriptions of care are communicated to the entire healthcare team. If nurses are unable to document assessments in “real time,” communication patterns among healthcare providers are altered, and data retrieval hindered.25,26 It is especially crucial in an emergency situation to have accurate and timely information about neonate status; missing data could

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Table 3. Workaround Tool Results (n = 39) Question Mean SD When possible, I follow rules and policies at work. 4.64 0.49 When possible, I follow procedures regarding use 4.51 0.51 of equipment. When possible, I follow procedures regarding use 4.41 0.64 of technology. When given the choice between following 4.18 0.68 procedures or taking a shortcut, I prefer to follow procedures. When I have to alter my work process because of 4.18 0.91 problems with equipment, I do so to better assist a patient. When I have to alter my work process because of 4.15 0.93 problems with technology, I do so to better assist a patient. When I have to alter my work process because my 4.00 0.83 work processes are not well designed, I do so to better assist a patient. When I have to alter my work process because other 3.97 0.84 people keep me from doing my job, I do so to better assist a patient. When I have to alter my work process because rules 3.94 1.02 or policies, I do so to better assist a patient. When possible, I follow intended work processes 3.79 0.77 even when they are poorly designed. I have to alter my work process because of problems 3.56 0.97 with technology. Poorly designed work processes prevent me from 3.49 1.14 completing tasks as well as I would like to. Problems with equipment prevent me from completing 3.38 1.07 tasks as well as I would like to. Problems with technology prevent me from completing 3.33 1.26 tasks as well as I would like to. I have to alter my work process because of problems 3.31 0.98 with equipment. I have to alter my work process because rules or 3.23 0.96 policies keep me from doing my job efficiently. I have to alter my work process because my work 3.08 1.11 processes are not well designed. Rules or policies prevent me from completing tasks 3.03 1.06 as well as I would like to. Other people prevent me from completing tasks as 2.87 1.13 well as I would like to. I have to alter my work process because rules or 2.79 1.00 policies keep me from doing my job efficiently. Frequency was determined on a 1- to 5-point scale, where 5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, and 1 = strongly disagree.

threaten patient safety. Other studies have found that when information retrieval is difficult nurses typically use free text comments to document changes in status.4 Weekly to monthly, malfunctioning computers or slow system operations hindered nurses when completing documentation. This was often resolved by switching computers. Slow systems take valuable time away from patient care and



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Table 4. Revised Professional Practice Environment Scale (n = 38) Question Mean SD 1. Leadership is supportive of my department/unit 2.79 0.99 staff. 2. My discipline controls its own practice. 2.79 0.78 3. I have freedom to make important patient 2.87 0.58 management and work decisions. 4. There is a lot of teamwork between unit/ 3.13 0.53 department staff and doctors. 5. I have adequate support services to allow me 2.63 0.67 to spend time with my patients. 6. I have enough time and opportunity to discuss 2.76 0.68 patient management problems with other staff. 7. There are enough staff to provide quality patient 2.58 0.76 care. 8. We have enough staff to get the work done. 2.63 0.71 9. There are opportunities to work on a highly 3.24 0.43 specialized patient care unit. 10. My unit/department head supports the staff 2.87 0.66 in decision making, even if the conflict is with a physician. 11. Physicians and staff have good working 3.10 0.51 relationships. 12. Information on the status of patients is 3.00 0.46 available when I need it. 13. I receive information quickly when a patient's 2.84 0.55 status changes. 14. There are needless delays in relaying 2.34 0.71 information about patient care. 15. My unit/department has constructive work 2.87 0.58 relationships with other groups in this hospital. 16. My unit/department does not receive the 2.18 0.61 cooperation it needs from other hospital units/departments. 17. Other hospital units/departments seem to have 1.89 0.65 a low opinion of my unit/department. 18. Inadequate working relationships with other 1.89 0.61 hospital groups limit the effectiveness of work on this unit. 19. When staff disagree, they ignore the issue, 2.32 0.70 pretending it will “go away.” 20. Most conflicts occur with members of my 2.44 0.64 own discipline. 21. Staff withdraw from conflict. 2.53 0.56 22. All points of view are carefully considered in 2.34 0.63 arriving at the best solution for the problem. 23. All staff work hard to arrive at the best possible 2.74 0.60 solution. 24. Staff involved in a disagreement or conflict do not 2.26 0.45 settle the dispute until all are satisfied with the decision. 25. All contribute from their experience and expertise 2.58 0.50 to produce a high-quality solution for a conflict. (continues)


Table 4. Revised Professional Practice Environment Scale (n = 38), Continued Question Mean SD 26. Disagreements between staff are ignored or 2.42 0.60 avoided. 27. Staff involved in a disagreement or conflict settle 2.42 0.50 the dispute by consensus. 28. My opinion of myself goes up when I work in this 2.89 0.56 unit/department. 29. I feel bad and unhappy when I discover that I 3.13 0.70 have performed less well than I should. 30. I feel a high degree of personal responsibility 3.82 0.39 for the work I do. 31. I feel a great sense of personal satisfaction 3.76 0.43 when I do my work well. 32. I have challenging work that motivates me to 3.71 0.46 do the best job I can. 33. Working in this unit/department gives me the 3.37 0.71 opportunity to gain new knowledge and skills. 34. I am motivated to do well because I am 3.05 0.73 empowered by my work environment. 35. Working in this environment increases my sense 3.11 0.65 of professional growth. 36. Staff have access to the necessary resources to 2.84 0.64 provide culturally competent care. 37. Staff are sensitive to the diverse patient 2.82 0.69 population for whom they care. 38. Staff respect the diversity of their healthcare 2.97 0.59 team. Frequency was determined on a 1- to 5-point scale, where 5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, and 1 = strongly disagree.

limit the “user-friendliness” of a system to support data retrieval. Collectively, if each of the 40 nurses experienced one of these threats just every 6 months, this translates to 240 significant threats to safety that either required interception by the nurse or were carried through to affect the neonate. Monthly to yearly, unintended consequences of EHRs were identified as orders entered for the wrong patient, in correct orders that were caught on review (eg, “good catches”), or ordering issues that occurred when a medication had to be given urgently. This aligns with research on unintended consequences among physicians (although the frequency with which they occurred was not described).27 It is possible that a lack of population-specific customization (ie, templates and other tools tailored to the neonatal ICU [NICU]) leads to issues such as poor information retrieval and inconsistent fit of technology to workflow and that appropriate customization should be considered standard when a hospital has a NICU. Further customization of the EHR may not only alleviate risks to patient safety but also improve the professional practice environment. Strong managerial support and nurse autonomy and control over practice may influence the customization, implementation,



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and adoption process that appropriately tailors the EHR to workflow.28 Little has been done to customize EHRs to specific work areas, due in part to the 80/20 rule.28,29 While customization has the potential to make EHR use more meaningful through data entry and retrieval, it is costly.28,29 The impact of unintended consequences of EHRs on specialty nursing units, particularly neonatal intensive care, has not been studied. Despite problems with technology, equipment, or a poorly designed system, study results show that neonatal nurses used workarounds primarily to complete work tasks and with motives to improve patient care.4 Halbesleben et al21 does not define workarounds as deviant but as strategies nurses use to accomplish their work. Workarounds can be willfully defiant of existing systems and processes. However, that is contrary to the working hypothesis of Halbesleben and colleagues, or our team's working hypothesis about nursing use of workarounds as behaviors that promote adaptation and resilience to ineffective work systems.22 When neonatal nurses were presented with a choice how to complete a task, they typically followed policies and procedures. Collectively, the unintended consequences of the EHR, workarounds required to deal with them, and the professional practice environment within the NICU result in a busy, fast-paced environment where interruptions are constant, all while caring for critically ill neonates. To compound this problem, there are multiple charting requirements, which must be completed in real time to provide updated patient status. However, busy and potentially overworked nurses are often unable to update documentation in real time, leading to disrupted communication patterns and data retrieval problems among the healthcare team. Patient safety risks were high when communication among the healthcare team was low. Unintended consequences often require workarounds by nurses to address problems with workflow related to using the EHR.

(Table 5). Neonatal nurses reported more problems each week with data retrieval from the EHR, in particular nursing notes, to assist with patient care. There were more power shifts in the parent study once a month compared with the neonatal nurses. In addition, participants in the parent study reported that the EHR created unsafe patient care situations once every couple of months, such as when the patient was admitted to a particular setting or presented in critical condition, there was a change in patient status, coordination was needed while transferring a patient, assessing for complications (ie, comorbidities), and the patient was admitted to the hospital. There were also slight differences in results between the two studies, with unintended consequences of EHR use creating unsafe patient care situations more than once a year during patient discharges, transfers to another setting, and coordinating care once the patient left the unit. Finally, the parent study participants tended to add to a nursing note throughout the shift and edit for details without signing it each time more than once a year, compared to the neonatal nurses.

Strengths Overall, there was a highly educated, experienced, and mature neonatal nurse sample, participants who had previously documented on a paper-based health record and then transitioned to a computer-based EHR, rather than recent graduates who might have used only an EHR in practice. These participants have seen interruptions, workarounds, and threats to patient safety occurring in both types of documentation system. Nurses from nearly every US region (Northeast, Southeast, North Central, South Central, Northwest, and Southwest) were represented in the sample, and a variety of EHR systems were used, which eliminated potential bias from dissatisfaction with one specific EHR. Furthermore, we used psychometrically valid measures, including the CG-UCE-Q, to conduct the study and scored them using established criteria.15,19

Comparison of Neonatal Nurse and Parent Study Interestingly, comparing our study results to the parent study revealed some intriguing differences. For example, sample characteristics varied; average age of participants in the parent study was lower (65 years [40%]). There was more concentrated regional representation in the parent study (primarily Southwest [56.9%]) versus national distribution in the current study (Southwest and North Central [22.5%] and Northeast [20%]). There were also fewer nurses with more years of experience in the parent study (>20 years [47.9%]) versus the current study (>20 years [70%]).15 Differences in the frequency of unintended consequences were also noted between the parent and current studies

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Limitations While this study is useful to both the science and practice of informatics and neonatal nursing, we acknowledge a few important limitations. A convenience sample was used by the parent study, and this secondary analysis limits generalizability and overall rigor. Most participants were female and overall quite experienced, educated, and older than many nurses in practice. It is possible that participants in the parent study were more disgruntled than others who used the EHR but did not participate; the level of experience among the participants makes it difficult to generalize the results to younger, less experienced nurses. We did not ask about customization, version year, or use of clinical decision support within EHR systems, and perceptions



April 2018

Table 5. Frequency of NICU RN Experience With Unintended Consequences of EHR Comparison Between the Parent Study and Neonatal Nurses Question How often, when retrieving data from the EHR, do you find there is no nursing note to help you understand what is going on with the patient? How often have you experienced power shifts while using the EHR? Please indicate how often this EHR issue creates an unsafe patient care situation: when a patient is admitted to your setting. Please indicate how often this EHR issue creates an unsafe patient care situation: when your patient comes to the hospital in critical condition. Please indicate how often this EHR issue creates an unsafe patient care situation: when a change in patient status occurs. Please indicate how often these EHR issues create an unsafe patient care situation: when you need to coordinate care while your patient is on your unit. Please indicate how often these EHR issues create an unsafe patient care situation: when a patient is transferred within the hospital. Please indicate how often EHR issues create an unsafe patient care situation: when you are trying to assess risk for complications (eg, related to diagnosis, comorbidities). Please indicate how often this EHR issue creates an unsafe patient care situation: when a patient is admitted to the hospital. Please indicate how often these EHR issues create an unsafe patient care situation: when a patient is discharged to home. Please indicate how often these EHR issues create an unsafe patient care situation: when a patient is transferred to your hospital from another setting. Please indicate how often these EHR issues create an unsafe patient care situation: when you need to coordinate care for your patient once he/she leaves your unit. Please indicate how often these EHR issues create an unsafe patient care situation: when a patient is transferred to another hospital or care setting (eg, long-term care) from your hospital. How often in your practice do you add to your nursing note through the shift to edit for details but do not sign it each time?

Parent, Mean (SD)

Neonatal, Mean (SD)

3.72 (1.78)

4.00 (1.81)

3.40 (2.05) 2.23 (1.89)

2.95 (1.97) 1.88 (1.76)

2.24 (2.05)

1.75 (1.71)

2.41 (1.92)

1.70 (1.57)

2.15 (1.96)

1.63 (1.67)

2.24 (1.85)

1.58 (1.52)

2.21 (1.89)

1.58 (1.66)

2.04 (1.84)

1.53 (1.62)

1.93 (1.85)

1.53 (1.60)

1.93 (1.74)

1.33 (1.44)

1.74 (1.85)

1.10 (1.55)

1.56 (1.73)

1.00 (1.36)

1.54 (2.24)

0.65 (1.49)

Most frequency to least frequency was determined on a 0- to 6-point scale, where 6 = multiple times a shift, 5 = once a shift, 4 = once a week, 3 = once a month, 2 = once every couple of once every couple of months, 1 = once a year, and 0 = never. Parent refers to the parent study; neonatal refers to neonatal study. Parent study results obtained from Gephart et al.15

of patient safety risk were gathered by self-report, which may be affected by recall bias. Because of the small sample size and lack of data about EHR features and version, we could not ascertain with confidence whether threats to patient safety differed across EHR types. Frequent interruptions are part of the nature of nursing care, regardless of paper or electronic charting, but interruptions during electronic charting, which requires logging into a system to maintain patient confidentiality, retrieving a patient's record, and then finally charting in it, conceivably consume more time than paper charting. However, when charting on paper, one could argue that the chart was missing much more often than once a week and that the EHR resolved this issue. Nonetheless, electronic charting presents unique problems with workload, workflow, time spent charting, and duplicate charting. Furthermore, the results from questions exploring unsafe patient care situations indicated a low likelihood (