Analysis of the relationship-based caring behavior categories indicate that during T1, nurses spent the most amount of time planning care for the patient (19%) and equal amounts of time being with the patient (12%) and making the patient a priority (12%). Listening to the patient (10%) and providing a caring environment (10%) were evenly matched. Nurses spent the least amount of time providing emotional support (4%), advocating for the patient (4%), and providing spiritual support (1%). Other professional nursing activities revealed that nurses spent most of their time in documentation (18%), followed by giving meds (16%), in chart review (8%), administrative tasks (9%), communication (8%), and conducting bedside procedures (5%).
During T2, 6 months after EHR implementation, nurses spent the majority of their time in the relationship-based caring behavior categories of listening to the patient (19%), being with the patient (12%), and making the patient a priority (9%), with the least amount of time spent providing a caring environment (4%), providing emotional support and advocating for the patient (3%), and providing spiritual support (2%). Other professional nursing activity category results in T2 include planning care for the patient and medication administration (21%), time spent in administrative tasks (14%), documentation (14%), communication (12%), chart review (7%), and conducting bedside procedures (5%).
An investigation was conducted to determine if there was a significant increase in the Registered Nurse Engagement Survey administered in 2010 and again in 2011 (preimplementation and postimplementation survey). There was a concern regarding the sampling unit of the department that resulted in a small sample of 11. However, research has shown that these small samples could be analyzed using the paired-sample t test with samples as small as five if the within-pair correlation is high.34
The researchers did not collect date of birth information from participants so they cannot conclude that nurses with diploma or ADN degrees and nurses with more experience were older and therefore less likely to be comfortable with computers and EHR use than younger, less experienced, and more educated nurses. However, the researchers believe that it was more likely the age and level of familiarity with computers than the degree level that was associated with attitudes and beliefs about EHR use. As increasing percentages of younger nurses enter the workforce, more nurses are likely to feel more normative toward using an EHR.
While nurses spent less time at the nurses' station and significantly more time in patients' rooms and in purposeful interactions 6 months post EHR implementation, time spent in relationship-based caring behavior categories actually decreased except for the categories of listening to the patient, being with the patient, and providing spiritual support. Other professional nursing activity categories of documentation decreased by 4%, while chart review decreased by only 1% post EHR implementation. Administrative behaviors increased from 9% to 14%, medication administration increased from 16% to 21%, and communication increased from 8% to 12%. It is likely that 6 months post EHR implementation, nurses adapted to using the EHR for documentation and for chart review, which freed up their time to engage in other activity category types. While it is likely that significant increases in time listening to the patient accounted for the largest rise in purposeful interaction, it is disappointing that increased time to focus on patients' concerns did not lead to increases in more time in relationship-based caring behavior categories. Also surprising was the lack of time spent by registered nurses in a faith-based health system giving spiritual support or providing emotional support. While all participants completed education sessions on the health system's Nursing Professional Practice Model, the THC, and the Relationship-Based Care Model, researchers did not determine how nurses defined giving spiritual support. Definitions of spiritual support may have been narrow and defined as only praying with the patient; nurses may have felt it was solely the chaplains' job to give spiritual support.
Although researchers were able to determine percentage of time nurses spent in the patient's room, they were not able to determine what nurses were doing in the room unless it involved activities that included the patient, such as listening to the patient and being with the patient. Medication administration required nurses to be both outside as well as inside the patient's room. Either computer workstations-on-wheels were in use or every patient room had a laptop computer mounted on a wall so nurses may have been documenting or performing chart review while they were in the room. This does not explain all the increase in time spent in patient rooms since overall time in documentation and chart review decreased after EHR implementation. Nurses being in the room with a patient does not necessarily equate to higher quality care if interactions are not patient centered.
Nursing staffing on all medical-surgical units was adequate. The health system participates in the Premier OperationsAdvisor database and benchmarks all medical-surgical nursing departments. Based on internal comparisons across hospitals and external in the National Database for Nurse Quality Indicators, the health system found the best outcomes when staffed between the 25th and 33rd percentile ranking. They did not find a substantial improvement in nurse-sensitive outcomes when staffed above the 50th percentile. Confirming that staffing was adequate ensured that nurses could choose to spend time in purposeful interactions and in the Caritas Processes.
While some units showed a slight increase in Gallop nursing engagement scores, overall scores slightly decreased after EHR implementation. While there are no direct questions on level of satisfaction with EHR use, questions solicited whether the nurse had enough materials and equipment to do their work right, had the opportunity to do their best every day, and had opportunities to learn and grow. Satisfaction scores were very high pre EHR implementation, which could explain for the lack of overall significant findings since the score range between pretest and posttest was narrow. Other issues besides EHR use may have been the cause of lower post-engagement scores on some units, especially units who were in-between managers.
Limitations for this study include the lack of consistent Wi-Fi capability across all hospitals at the time of this study so the researchers could not use RFID technology, which led to solely self-reported time nurses spent in activities. Although staff nurses' identities were carefully protected, nursing managers knew which of their units were participating in the study and it may have been obvious which nurses were participating due to the presence of PDAs in their hands. Nurses' knowledge that their managers knew about their participation may have biased their self-reports. In one of the four participating hospitals, none of the nurses participating during T1 data collection pre EHR deployment participated during T2 data collection 6 months post EHR deployment. While this may have skewed the results, there was only a 1% variation at T1 when data from the fourth hospital was removed from analysis. Because of this small variation, all data from all four hospitals were left in the final analysis of findings. In addition, not all nurses who participated in the study from the rest of the hospitals participated in T2 data collection; only about 50% of nurses participated in T2 overall. Asking nurses to self-report on PDAs for three consecutive scheduled shifts was burdensome as about 10% of the nurses were compliant with PDA responses only 2 out of the 3 days in T1 so the researchers averaged the data between consistent PDA responders and nonconsistent PDA responders. This may have biased results toward nurses who had more time or organizational skills to more consistently respond to PDA prompts.
While TPB has been used extensively to examine the impact of attitudes and beliefs and the primary investigator had extensive experience using TPB, the Attitudes and Beliefs Assessment was not independently tested for reliability or validity. Researchers relied on expert knowledge and experience for tool development. This may have biased survey findings.
Mixed-method studies are needed to determine factors related to EHR deployment, which creates shifts in nursing time spent across care categories. Simply capturing time spent in categories is not enough to determine which factors influenced time spent in activities across categories pre and post EHR deployment. While nurses may spend more time in the patient's room post EHR deployment, this does not guarantee that it is time well spent in individualizing care and in improving the overall patient care experience. More data are needed to determine what health systems can do to ensure that extra nursing time is well spent for the good of the patient. Reporting burden must be decreased to ensure that nurses who participated in baseline assessment data collection participate in end point data collection. Sample size should be increased to reduce chance of bias.
As health systems move toward data-driven systems and meaningful use, it is critical to not lose sight of the human beings we care for. Technology is a tool that should help frontline nurses deliver the highest-quality, safe, and patient-centered care achievable. It should never get in the way of treating patients as vulnerable human beings who need their healthcare givers to address their concerns as competently and as humanely as possible. To this end, further research needs to be conducted to determine factors that prevent nurses from spending enough time in relationship-based caring behaviors and technological processes that are likely to increase their time individualizing care.
The authors thank Diane Stager, Director, Marketing and Communications, Planning, Marketing and Communications, who helped with all the figures.
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