Measuring nursing benefits of an electronic medical record system: A scoping review

Jedwab, Rebecca M; Chalmers, Cheyne; Dobroff, Naomi; Redley, Bernice

doi:10.1016/j.colegn.2019.01.003

Cited by 30 publications

(36 citation statements)

References 130 publications

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“…Electronic documentation systems have been integrated within health care systems to provide a centralized repository and accessible source of clinical information for health care providers [ 10 ]. These same systems are intended to support clinical care practices among all health care providers while providing access to information, decision-support tools, and improved workflow [ 10 , 11 ]. Given their extended contact with patients and families, nurses tend to have the greatest interaction with electronic documentation systems relative to other health care providers [ 12 ].…”

Section: Introductionmentioning

confidence: 99%

Nurses’ Use of Personal Smartphone Technology in the Workplace: Scoping Review

Jong¹,

Donelle²,

Kerr³

2020

JMIR Mhealth Uhealth

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Background There has been an increase in the technological infrastructures of many health care organizations to support the practice of health care providers. However, many nurses are using their personal digital devices, such as smartphones, while at work for personal and professional purposes. Despite the proliferation of smartphone use in the health care setting, there is limited research on the clinical use of these devices by nurses. It is unclear as to what extent and for what reasons nurses are using their personal smartphones to support their practice. Objective This review aimed to understand the current breadth of research on nurses’ personal smartphone use in the workplace and to identify implications for research, practice, and education. Methods A scoping review using Arksey and O’Malley’s methodological framework was conducted, and the following databases were used in the literature search: CINAHL, PubMed, ProQuest Dissertations and Theses, Embase, MEDLINE, Nursing and Allied Health Database, Scopus, Web of Science, and Cochrane Reviews. Search terms used were Nurs* AND (personal digital technology OR smartphone OR cellphone OR mobile phone OR cellular phone). Inclusion criteria included research focused on nurses’ use of their own digital technologies, reported in English, and published between January 2010 and January 2020. Exclusion criteria were if the device or app was implemented for research purposes, if it was provided by the organization, if it focused on infection control, and if it was focused on nursing students or nursing education. Results A total of 22 out of 2606 articles met the inclusion criteria. Two main themes from the thematic analyses included personal smartphone use for patient care and implications of personal smartphone use. Nurses used their smartphones to locate information about medications, procedures, diagnoses, and laboratory tests. Downloaded apps were used by nurses to locate patient care–related information. Nurses reported improved communication among health team members and used their personal devices to communicate patient information via text messaging, calling, and picture and video functions. Nurses expressed insight into personal smartphone use and challenges related to distraction, information privacy, organizational policies, and patient perception. Conclusions Nurses view personal smartphones as an efficient method to gather patient care information and to communicate with the health care team. This review highlights knowledge gaps regarding nurses’ personal device use and information safety, patient care outcomes, and communication practices. This scoping review facilitates critical reflection on patient care practices within the digital context. We infer that nurses’ use of their personal devices to communicate among the health care team may demonstrate a technological “work-around” meant to reconcile health system demands for cost-efficiency with efforts to provide quality patient care. The current breadth of research is focused on acute care, with little research focus in other practices settings. Research initiatives are needed to explore personal device use across the continuum of health care settings.

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Section: Introductionmentioning

confidence: 99%

Nurses’ Use of Personal Smartphone Technology in the Workplace: Scoping Review

Jong¹,

Donelle²,

Kerr³

2020

JMIR Mhealth Uhealth

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“…As shown in Table 4 , the improvements can be evaluated with impact and effectiveness indicators. In this way, it is possible to measure [ 57 ] if each one of them responds efficiently to the actual needs of the users in relation with the overuse of attention in the Emergency Services of Chile. Impact is understood as the effect on the level of attention of each one of the actors that are interrelated in the process; and efectiveness, as the relationship that exists between the achieved results and the resources used, in terms of the expected and desired effect.…”

Section: Resultsmentioning

confidence: 99%

Overuse of Health Care in the Emergency Services in Chile

Alvial

Rojas

Carrasco

et al. 2021

IJERPH

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The Public Health Service in Chile consists of different levels of complexity and coverage depending on the severity and degree of specialization of the pathology to be treated. From primary to tertiary care, tertiary care is highly complex and has low coverage. This work focuses on an analysis of the public health system with emphasis on the healthcare network and tertiary care, whose objectives are designed to respond to the needs of each patient. A review of the literature and a field study of the problem of studying the perception of internal and external users is presented. This study intends to be a contribution in the detection of opportunities for the relevant actors and the processes involved through the performance of Triage. The main causes and limitations of the excessive use of emergency services in Chile are analyzed and concrete proposals are generated aiming to benefit clinical care in emergency services. Finally, improvements related to management are proposed and the main aspects are determined to improve decision-making in hospitals, which could be a contribution to public health policies.

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“…Omissions of patient-specific information, such as psychosocial assessment and the patient's experience of care were observed in this study, in both the digital and paper formats, are of concern. High-quality care is dependent on individualised care, 32 particularly for complex medical patients with multiple care needs. 33 Digital systems provide the opportunity to respond to the needs of this population by capturing the complexity of the nursing work needed to respond to changing risk profiles and specific needs of each hospitalised patient.…”

Section: Discussionmentioning

confidence: 99%

Documenting patient risk and nursing interventions: record audit

Bail¹,

Merrick²,

Bridge³

et al. 2021

AJAN

Self Cite

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Objective: The aim was to explore and compare documentation of the nursing process for patient safety in two nursing documentation systems: paper and digital records. Background:The 'nursing process' (assessment, planning, intervention, and evaluation) is recommended by professional nursing registration and health service accreditation bodies as a key component of understanding nurses' clinical reasoning. Nurses' responsibility for patient safety must be supported by comprehensive documentation practices. Study design and methods:A retrospective audit of twenty clinical care records (N = 20) randomly selected from a single acute medical ward at a tertiary hospital in Australia; ten from a digital trial that replicated selected paper forms and ten paper records as controls. The audit was conducted by two nurse researchers using a purpose built data extraction tool.Results: Patient age, gender and primary diagnoses were similar for the digital and paper care records. Documentation of the full nursing process was low in both record types, and comprehensiveness of nursing documentation was similar across the paper and digital records. Compared to the paper documents, the digital documents were more often rated as 'complete' (p<0.05). Documentation of risk to skin integrity (p<0.05) and evidence of completed nursing interventions to address risks were more frequent (p<0.05) in digital records. Discussion:The findings of this study highlight an important gap in comprehensive documentation of the nursing process that supports and informs the clinical reasoning of nurses for patient safety. Improvements in digital documents reflect future opportunity to enhance the quality of nurse documentation using technology specific strategies such as prompts, visualisation and nudge. Conclusion:This research identifies that both paper and digital systems of hospital documentation may fail to capture and communicate the clinical reasoning of nurses. Digital systems have the potential to improve capture of the clinical reasoning and nursing process. What is already known about the topic?• Professional registration and healthcare accreditation bodies recommend nurses' clinical decision making is underpinned by processes of assessment, planning, intervention and evaluation. • Poor capture of nurses' clinical decision making in their documentation has negative consequences for the continuity, quality and safety of care; including inadequate detection of deterioration and escalation of care.

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Measuring nursing benefits of an electronic medical record system: A scoping review

Cited by 30 publications

References 130 publications

Nurses’ Use of Personal Smartphone Technology in the Workplace: Scoping Review

Nurses’ Use of Personal Smartphone Technology in the Workplace: Scoping Review

Overuse of Health Care in the Emergency Services in Chile

Documenting patient risk and nursing interventions: record audit

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