Qualitative Perspectives of Emergency Nurses on Electronic Health Record Behavioral Flags to Promote Workplace Safety

Abstract

ImportanceEmergency nurses experience high levels of workplace violence during patient interactions. Little is known about the efficacy of behavioral flags, which are notifications embedded within electronic health records (EHRs) as a tool to promote clinician safety.ObjectiveTo explore the perspectives of emergency nurses on EHR behavioral flags, workplace safety, and patient care.Design, Setting, and ParticipantsIn this qualitative study, semistructured interviews were conducted with emergency nurses at an academic, urban emergency department (ED) between February 8 and March 25, 2022. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. Data analysis was performed from April 2 to 13, 2022.Main Outcomes and MeasuresThemes and subthemes of nursing perspectives on EHR behavioral flags were identified.ResultsThis study included 25 registered emergency nurses at a large academic health system, with a mean (SD) tenure of 5 (6) years in the ED. Their mean (SD) age was 33 (7) years; 19 were women (76%) and 6 were men (24%). Participants self-reported their race as Asian (3 [12%]), Black (3 [12%]), White (15 [60%]), or multiple races (2 [8%]); 3 participants (12%) self-reported their ethnicity as Hispanic or Latinx. Five themes (with subthemes) were identified: (1) benefits of flags (useful advisory; prevents violence; engenders compassion), (2) issues with flags (administrative and process issues; unhelpful; unenforceable; bias; outdated), (3) patient transparency (patient accountability; damages patient-clinician relationship), (4) system improvements (process; built environment; human resources; zero-tolerance policies), and (5) difficulties of working in the ED (harassment and abuse; unmet mental health needs of patients; COVID-19–related strain and burnout).Conclusions and RelevanceIn this qualitative study, nursing perspectives on the utility and importance of EHR behavioral flags varied. For many, flags served as an important forewarning to approach patient interactions with more caution or use safety skills. However, nurses were skeptical of the ability of flags to prevent violence from occurring and noted concern for the unintended consequences of introducing bias into patient care. These findings suggest that changes to the deployment and utilization of flags, in concert with other safety interventions, are needed to create a safer work environment and mitigate bias.

Things We Do for No Reason™: Indiscriminate use of behavioral alerts

“…In some qualitative interviews, nurses and frontline staff note that BAs act as a useful advisory, provide reassurance of safety, and allow employees to take proactive preventive measures, such as involving security, removing objects with potential for harm, and communicating risk to other employees. [4][5][6][7] BAs in some contexts appear to be accurately predictive of violent behavior. In a retrospective case-control study, patients were screened on admission for a history of, or active display of, violence, threat, psychosis or cognitive impairment; patients with a positive screen were flagged with a "V" on their EMR, physical chart, and wristband.…”

“…7 Qualitative interviews highlight the lack of BA standardization and policy as a significant barrier to BA effectiveness. 6,7,10 In addition to the limited data supporting their effectiveness, there is emerging evidence that BAs may be harmful. In several studies, interviewed medical staff expressed concerns that BAs promote patient stigmatization, by labeling patients as violent for "one-off" situations, and limit patient care through denial of admission to skilled nursing facilities.…”

“…While BAs theoretically promote safety, staff note that they did not expect BAs to actually decrease the number of violent incidents, 4 as they do not provide the resources or procedures needed to prevent violence from occurring, 8 and describe BAs as unhelpful and unenforceable. 7 Qualitative interviews highlight the lack of BA standardization and policy as a significant barrier to BA effectiveness. 6,7,10 In addition to the limited data supporting their effectiveness, there is emerging evidence that BAs may be harmful.…”

“…Given the pervasiveness of violence against healthcare workers, 3 a system for communicating risk across encounters seems reasonable. In some qualitative interviews, nurses and frontline staff note that BAs act as a useful advisory, provide reassurance of safety, and allow employees to take proactive preventive measures, such as involving security, removing objects with potential for harm, and communicating risk to other employees 4–7 …”

“…While initial studies were promising, data to support BAs is limited. There have been a few published studies on BAs' usefulness, 1,4–14 including qualitative interviews with staff. Quantitative studies of effectiveness usually involve experiences at single centers and are without adequate control groups.…”