CIN: Computers, Informatics, Nursing:
Capturing Nursing Care Workflow Disruptions: Comparison Between Nursing and Physician Workflows
LEE, SEONAH PhD, RN; MCELMURRY, BEVERLY EdD, FAAN
Author Affiliations: University of Illinois at Chicago, College of Nursing.
Disclaimer: Authors declare no conflict of interest.
Corresponding author: SeonAh Lee, PhD, RN, Room 1116 (M/C 802), 845 S Damen Ave, University of Illinois at Chicago, College of Nursing, Chicago, IL 60612 (firstname.lastname@example.org).
Clinical information systems implementation in healthcare delivery has changed clinical work patterns. Nursing practice is under pressure of the changes, which often lead to dysfunctional workflow. The purposes for this literature review were (1) to identify what has been examined about disruptions of nursing care workflow in using Clinical information systems and (2) to obtain a lesson for future research to investigate disruptions of nursing care workflow in using Clinical information systems. In reviewed studies, nursing workflow disruptions have limitedly been reported. Nursing care workflow has not been investigated sufficiently; thus, what happened to nursing care workflow by using a Clinical information system has not been fully known. Nurses have a need for the use of a Clinical information system in aspects of nursing perspective in patient care. Unless the use of Clinical information systems provides effective workflow of nursing care, it will result in confusion in nursing practice as well as poor quality of patient care. It is essential to capture disruptions and/or effectiveness in nursing care workflow from the perspectives of nurses. The required research approach to clinical settings is to identify all facets of adverse consequences triggered from the use of a Clinical information system by following the context of nursing care workflow.
Introduction of clinical information systems (CIS) in healthcare has led to new designs from paper-based systems to computer-based systems, promising quality of patient care and reduction of medical errors.1 The new designs require changes in existing workflows in patient care and communications among clinical staff2 because designing CISs outweighs the mere construction of technological artifacts.3,4 The changes often give rise to confusion and lead to inefficient and ineffective clinical practices.3 Within the healthcare system, nurses are responsible for integrating multiple sources of information and for coordinating services of multiple healthcare providers in the comprehensive daily management of patients.2 Without exception, introduction of a CIS requires changes in nursing practice.2 The changes are not unilateral3-5; they are negotiation between the changes required by the introduction of a CIS and the existing work practices in nursing care. The negotiation is possible only with the correct understanding of nursing practice.
A nursing perspective on patient care affects how a CIS is used and must be compatible with nursing care workflow.1 Nurses coordinate patient care activities, ensure that treatments are carried out on schedule through a three-shift system, and are faced with the distress of patients and relatives.6 Nurses make decisions based on patient needs as they become aware of them in familiar relationships with patients and their families, whereas physicians tend to make decisions based on aspects of pathology and treatments.7,8 Often, an on-call team of physicians is responsible for ward work on weekends and on public holidays.6 This different temporal-spatial organization of medical and nursing work creates different perspectives and priorities that are a source of strain.6 Different perspectives and priorities on patient care will give rise to different perspectives in the use of CISs.1
A nursing perspective on patient care shapes nurses' needs, interests, criteria, and expectations for nursing care in the use of CISs that are different from other healthcare providers' perspectives.1,2,9,10 An awareness of the differing demands of nursing care on technology can be gained by scrutinizing the influence of CISs on nursing care workflow.1,10 Factors of a CIS that conflict with the workflow of nursing activities will impose additional work tasks on already heavily burdened nurses.11 The adverse factors will never become apparent unless the speakers are nurses.
The purposes of this study are (1) to identify what has been examined about disruptions of nursing care workflow in using CISs and (2) to obtain a lesson for future research to capture nursing care workflow disruptions triggered from using CISs.
Definition of Nursing Care Workflow Disruptions
Nursing care workflow has not been defined, although examples using words of nursing workflow12 and nurse workflow do exist.13 Nursing care workflow disruptions by use of a CIS can be defined by "characteristics of poorly functioning nursing work."14,15 Nursing work is a set of clinical tasks a nurse performs for patient care.14 When a computational model does not reflect actual nursing practice in real-world clinical settings, a CIS highlights poorly functioning nursing work.15 Characteristics of poorly functioning nursing work include unnecessary pauses and rework, delays, established workarounds, gaps where steps are often omitted, and a process that nurses feel is overloading.14 For example, "a drug ordered three times a day had been discontinued, but one dose had already been given. The computer system would not allow the nurse to chart one dose because the system considered it an incomplete execution of the task."11(p108) To discontinue a drug, it might impose additional paper tasks on nurses.11 "During transfers between the emergency department and a patient ward, orders would not be transferred or new orders could not be entered in the system because the patient was not yet in the system. Once an order had been entered by a physician, that physician expected it to be carried out, but if the administrative data had not yet been entered, the physician's order might never be executed."11(p108) A poorly designed CIS might generate unnecessary delay in patient care and disrupt nursing care workflow.
Recognizing the nature of clinical work and identifying the negative effects of workflow disruptions will be explored in the literature review section.
Nature of Clinical Work
The nature of clinical work is not simple.3-5,10 It is not easy to fit technological applications to clinical practice.10,16 The nature of clinical work is shaped by patient trajectories.17 The term trajectory refers not only to the pathophysiological unfolding of patient disease but also to healthcare providers' involvement in the process of patient care within a patient care context.10,17 The patient trajectory involves diverse actions and skills of healthcare providers and other resources.10 Patients have an evolving and unpredictable character; thus, their cues require continual readjustment and communication.10 Depending on the condition of the patient, the management of the trajectory evolves.10
The nature of clinical work shaped by a patient trajectory is a complex mixture of routine and exceptional events.1,18 Healthcare providers generally follow standards and prescribed plans of care, but they must also deal with exceptions on a daily basis.1 Clinical work is cooperative; decisions about patient care are the result of involvement of diverse healthcare providers, sometimes including the patient and his/her family.11,17-19 The clinical workflow is not a linear process with clear-cut inputs and outputs.18,20 In reality, it is not sharply demarcated,18 and technological application is thoroughly intertwined with the clinical practice in which it functions.3,4,9 The complex nature of clinical work would both add and hide the errors related to workflow disruptions.11,15
Clinical Workflow Disruptions
Clinical workflow disruptions caused by the use of CISs should be identified and addressed to prevent negative influences on patient outcomes and work effectiveness. (To avoid confusion in use of terms, the term clinical workflow was used because it was applicable to most of healthcare providers who work for patient care. Clinical workflow is not limited only to nursing care workflow or nurses.) Examples of this point are found in two studies21,22 that reported contradictory results in mortality rates of ICUs from the use of the same commercial computerized physician order entry (CPOE) system.20 Han et al21 analyzed mortality rates in 13 months before and 5 months after implementation of CPOE. After the use of the system, the mortality rate increased. Del Beccaro et al22 also analyzed the mortality rates 13 months before and 5 and 13 months after implementation of the same system at their site. No significant change in the mortality rate was found after CPOE implementation, and there was workflow effectiveness. Del Beccaro et al22 designed a CIS that matched their real work practices, using lessons learned from Han et al.21 As a result of meetings with administrative and clinical staff at the Del Beccaro et al22 study site over many months before the go-live date, almost all problems uncovered by Del Beccaro et al21 were addressed in the Del Beccaro CIS.21 A multidisciplinary team validated the functionality of the system application and end users were heavily involved in the design. Han et al found that21 workflow disruptions were the result of a mismatch between the functioning of a CIS and the real-life demands of clinical work. On the other hand, Del Beccaro et al22 showed the feasibility of preventing workflow disruptions from the implementation of a CIS by well-organized plans and actions, despite the complex nature of an ICU. Del Beccaro et al22 demonstrated the arguments of recent investigations that the causes of clinical workflow disruptions by the use of CISs lie in poorly designed CISs.16
MEDLINE and CINAHL were searched using the terms "electronic medical record, workflow," "electronic medical record, evaluation," "computerized physician order entry," and "nursing information systems." Only studies accessible in full text versions were selected to avoid misunderstanding of the original contents. To achieve the two purposes of this study, it was judged desirable to broadly retrieve studies relevant to improvements and/or disruptions of clinical workflow (including nursing care workflow) according to use of a CIS. It was also assumed that the literature would most likely report both disruptions and improvements. Inclusion criteria were studies that (1) examined positive and/or negative changes of clinical workflow triggered by use of a CIS; positive and/or negative changes of clinical workflow were based on the definition of characteristics of poorly functioning nursing work above; (2) that evaluated a CIS that fully operates in the environment of a real hospital information system combined with systems of various departments (eg, pharmacy or laboratory); studies that evaluated a CIS in the design stage and/or a controlled environment (eg, a laboratory) were excluded; and (3) that evaluated a CIS in acute inpatient settings; studies that evaluated a CIS in noninpatient settings (eg, home care settings and outpatient care settings) were excluded.
A total of 40 studies were retrieved. Of these, eight studies reporting stages of designing a CIS and two studies in outpatient settings were excluded. A total of 30 studies were included.
In Table 1, the 30 studies that met the inclusion criteria were arranged by three types: physician workflow, nursing care workflow, and others. Each type of workflow was divided by whether workflow was completely examined. Table 1 shows studies by methods for data collection used and elements measured. The 13 studies reported poorly functioning workflow triggered by use of a CIS (see the studies with a superscript "a" in Table 1).
In physician workflow in Table 1, the nine studies in detail examined changes in physician workflow. Seven of the nine studies reported physician workflow disruptions (from here on, they are called "the physician workflow-disruptions studies"). Details of the seven studies are provided in Table 2. The five studies in the other group reported improved results in use of CISs, but there were no measurements for other factors of a CIS that might influence physicians' workflow. Therefore, these five studies were grouped as studies that did not deal with details in workflow.
Table 1 shows there were no studies that examined in detail nursing care workflow disruptions. Charting completeness and quality, charting time, and medication errors were mainly investigated. Nurse attitude and acceptance were also examined. Five of the eight studies reported negative effects or no differences from use of CISs (from here on, they are called "the nursing care workflow-disruptions studies"). Details of the five studies are provided in Table 2.
In others in Table 1, Georgiou et al24 examined details of workflow disruptions in a laboratory department. Outcomes of the studies using chart review in the other group were associated with effectiveness and/or improvements in clinical workflow (including nursing care workflow and physician workflow), but there were no measurements or mention about other factors of a CIS that might influence clinical workflow. Therefore, these chart review studies were grouped as studies that did not completely examine workflow. Also, these chart review studies were classified as others because results of these studies could be applicable to interest of all types of healthcare providers who work for patients.
Table 2 provides details (ie, computer application, research sites, and methods for data collection) of the physician workflow-disruptions studies and nursing care workflow-disruptions studies from Table 1; results of these workflow-disruptions studies will be included and analyzed in the discussion section. In the physician workflow-disruptions studies, the computer application mostly examined was CPOE systems. Some of the studies included nurses as subjects. In nursing care workflow-disruptions studies, nursing documentation systems were examined, and only nurses were included in subjects of these studies. These studies compared selected nursing activities before and after use of nursing documentation systems. Different methods for data collection were used to measure different items. Research sites of the studies in Table 2 all were inpatient settings.
Table 3 is an example that compares the results between the physician workflow-disruptions studies and the nursing care workflow-disruptions studies. Nursing care workflow-disruptions studies showed negative and/or positive results in the same measurements. It makes clear beforehand that there was a sort of arbitrariness of the authors in combining and grouping the results of the physician workflow-disruptions studies, even though original groupings that were presented in each of the studies were considered as references.
In the discussion section, information in Tables 2 and 3 (ie, the physician workflow-disruptions studies and the nursing care workflow disruption-studies) will be analyzed for achieving the two purposes of this study (ie, to identify what has been examined about nursing care workflow disruptions and to obtain a lesson for future research to capture nursing care workflow disruptions triggered by using CISs. The study of Georgiou et al24 (Table 1) will also be included in the Discussion.
What Has Been Examined About Nursing Care Workflow Disruptions
The nursing care workflow-disruptions studies investigated the effects of CIS implementations on selected nursing activities (Table 2). Measurement of the selected nursing activities repeated a trend across all five studies. These studies did not trace all facets of adverse consequences that might be triggered by the use of CISs in the context of nursing care workflow (Table 3). The results of the nursing care workflow-disruptions studies were insufficient to fully explain nursing care workflow disruptions.
The physician workflow-disruptions studies highlighted mismatches between intended and actual workflow in real clinical settings. Scrutinizing physician workflow relevant to the use of CISs offered detailed information about dysfunctional workflow, from technological problems to incorrect uses of each individual and to socio-organizational problems in clinical practice (Table 3).
However, nursing care workflow disruptions were not a focus of the physician workflow-disruptions studies. Some of the studies in Table 2 included nurses as subjects of their study, but their focus was on disruptions of physicians' workflow. In the context of creating and processing physicians' orders, nurses coordinated and/or implemented the resources needed to ensure the orders are completed.11,15,25,29,48 Nursing roles and activities were obviously affected by physician orders, so any changes in the process of originating and implementing physician orders impacted on nursing roles, activities, and in turn nursing care workflow. But mediating and being affected by physician orders are part of nursing roles.49 Results of the physician workflow-disruptions studies did not systematically organize disruptions of nursing care workflow that could occur in other many facets of nursing roles and activities in a fast-flowing and dynamic work environment.49
Consequently, the physician workflow-disruptions studies reported details in disrupted workflows for physicians while rarely focusing on nursing care workflow disruptions. The nursing care workflow-disruptions studies did not also capture all domains of adverse consequences from use of CISs that could be derived from a nursing perspective on patient care, because they measured only selected nursing activities. For the first purpose of this study, nursing care workflow disruptions from use of a CIS have been examined with selected nursing activities and not fully investigated, so what happens to nursing care workflow has not been fully recognized.
Implications for Future Research to Fully Capture Nursing Care Workflow Disruptions
Clinical information systems have not yet reached full maturity in healthcare environments.11 Unintended adverse consequences in technological applications have been distributed in almost all CIS implementations in clinical settings.11,18,48 Also, adverse findings are rarely revealed until after the first encounter with the system in use.11 Therefore, adverse consequences in the use of CISs have to be captured from the context of clinical work.18,19 Otherwise, implementation of a CIS will not allow integration into clinical workflow of healthcare providers directly involved in patient care. Nursing care workflow should be examined thoroughly in the context of nursing care. Such an examination will facilitate the design of CISs that are supportive of nursing care as adverse findings are addressed.16,25,50 Unfortunately, such research is still lacking. There was also the limited discussion about qualities of a CIS to address the adverse consequences in nursing care workflow.
The physician workflow-disruptions studies are a good model, even though they did not focus on nursing care workflow disruptions. As shown in Table 3, the comparison indicated a large difference between the results from investigations of physician workflow disruptions and the results from investigations of nursing care workflow disruptions. These studies provided rich information about physicians' difficulties in the use of a CIS. Details about dysfunctional workflow provided actual ideas for quality improvement of a CIS to improve effectiveness of physician workflow (Table 3). This is a strong point of the physician workflow-disruptions studies.
The study of Georgiou et al24 (Table 1) is also a good model. The study provided an opportunity to appreciate needs and expectations of laboratory staff on the use of a CIS. Their adverse findings were new categories that were applicable to laboratory staff, which could not be recognized by healthcare providers in different departments (eg, confusion by nonmatch between specimen collection time and order entry time, difficulty of discriminating added test orders from original test orders). Georgiou et al24 pointed to the need for clear processes on renegotiation of work practices used in different departments to improve the workflow of laboratory staff.
For the other purpose of this study, implications for future research are to fully investigate disruptions and/or improvements in nursing care workflow according to use of CISs from nursing perspectives and in the context of nursing care, as demonstrated in the physician workflow-disruptions studies and the study of Georgiou et al.24
It is important to construct a technological application that fits into what healthcare providers actually do in their everyday practices.9,10 Adverse consequences from the use of CISs should be identified to eliminate workflow disruptions and to bring workflow effectiveness to nursing practice. The reviewed studies provided limited information about the compatibility of CISs on nursing care workflow. This study demonstrated that physician workflow disruptions have been examined in detail while report of nursing workflow disruptions has been limited in the existing literature. The compatibility of CISs on nursing care workflow, that is, nursing care workflow disruptions, needs to be fully captured. The required research approach to clinical settings is to identify all facets of adverse consequences triggered from the use of a CIS in the context of nursing care workflow. Nurses have a need for a CIS based on nursing perspective in patient care. Unless the use of CISs effectively captures the workflow of nursing care, it will result in confusion in nursing practice1 as well as poor quality of patient care.11 It is essential to carefully consider workflow perspective of nursing in the use of CISs.
The authors thank Dr Chang Gi Park, Dr Gail M. Keenan, Dr Mi Ja Kim, Dr Annette L. Valenta, and Dr Carrol Smith, University of Illinois at Chicago, for critical review of draft materials that resulted in this article.
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