Applied Nursing Research 27 (2014) 25–32

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Original Articles

Challenges and facilitators to nurse use of a guideline-based nursing information

system: Recommendations for nurse executives
Paulina S. Sockolow, DrPH, MBA a,⁎, Michelle Rogers, PhD b, Kathryn H. Bowles, RN, PhD c,
Kristin E. Hand, BSN, RN d, Jessie George, RN, MSN e
a
Drexel University College of Nursing and Health Professions, 245 N 15th St, Philadelphia, PA, USA
b
Drexel University College of Information Science and Technology, Philadelphia, PA, USA
c
University of Pennsylvania School of Nursing, Room 340 Fagin Hall 418 Curie Blvd. Philadelphia, PA, USA
d
University of Pennsylvania School of Nursing, Philadelphia, PA, USA
e
University of Pennsylvania Health System, Philadelphia, PA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Aims: The aims of this study were to develop empirical data on how nurses used an evidenced-based nursing
Received 25 February 2013 information system (NIS) and to identify challenges and facilitators to NIS adoption for nurse leaders.
Revised 17 July 2013 Background: The NIS was part of the electronic health record with 200 evidence-based, interdisciplinary
Accepted 28 October 2013 clinical practice guidelines from which clinicians selected to guide the patient's care.
Methods: A purposeful sample of 12 randomly selected nurses in three units across two hospitals participated
Keywords:
in scenario-testing. Sessions were audio-recorded, transcribed, content analyzed, and coded for themes.
Evaluation studies
Clinical information systems
Results: Major themes emerged: computer placement in patient rooms; difficulty using NIS; documentation
Evidence-based nursing completeness; efficiency; time spent at the bedside; team communication; training; unintended
Nursing informatics consequences of workflow changes; perceived NIS value as challenge to adoption.
Conclusions: Nurse executives' opportunities to improve adoption include enhancing communication to/from
front-line clinicians about the hospitals' goals, perceived NIS value at the bedside, and constructive feedback
especially for patient care/safety and software functionality.
© 2014 Elsevier Inc. All rights reserved.

Nursing information systems (NISs) are promoted as a technology chronologically order patient clinical information captured by
supporting collaboration and improving health care decision making systems. These include order entry and results reporting systems
at the point-of-care and ultimately health care outcomes. An NIS such as laboratory, pharmacy, and radiology, as well as medication
contains data collection and integration functionality for nurses and administration systems. While nurses are the end users of EHRs, very
could be used as a part of an electronic health record (EHR) or in little is known about how nurses are affected, and whether they
conjunction with an electronic medical record (EMR). NISs have the associate EHRs with quality care and patient safety (Kutney-Lee,
potential to improve the processes of obtaining patient history and 2011). Studies have shown that nurses are frustrated with the
care planning and to increase nursing documentation completeness, inconveniences of EHRs such as poor impact on nursing workflow
readability, and availability. NISs also provide the means to decrease (Stevenson, Nilsson, Petersson, & Johansson, 2010), increased work-
double documentation and assist with more precise compliance with load, and high frequency of irrelevant notifications or alerts (Sassen,
legal documentation requirements (Ammenwerth, Rauchegger, 2009; Sidebottom, Collins, Winden, Knutson, & Britt, 2012). As a result
Ehlers, Hirsch, & Schaubmayr, 2011). However, a recent systematic of such frustrations, nurses are less likely to use the EHR as intended
review found no evidence of measurable impact of nursing record (Sockolow, Lehmann, Bowles, & Weiner, 2009). To address this
systems on nursing practice and patient outcomes. The review knowledge gap, the study described in this article focused on a
included only two hospital studies of NIS: both assessed quality of hospital-based NIS, using a strong research design for the evaluation.
documentation (Urquhart, Currell, Grant Maria, & Hardiker Nicholas, Implementation of NIS is relatively new, and due to a lack of
2009). Due to the scarcity of hospital NIS studies, relatively little is evaluation studies, it is not well understood. This study focused on an
known about the impact of the increasing adoption and use of NISs in urban, non-profit, academic, health system that implemented an NIS
hospitals. There is a larger body of literature on EHRs. These systems in its hospitals in 2011. The health system's goal in implementing this
NIS was to promote patient safety and improve patient outcomes by:
(1) standardizing care and reducing variability in clinical practice
⁎ Corresponding author. Tel.: +1 9102 215 762 4694 (office); fax: +1 215 762 4080.
E-mail addresses: pss44@drexel.edu (P.S. Sockolow), mlr92@drexel.edu (M. Rogers),
among the clinical disciplines with evidence-based clinical practice
bowles@nursing.upenn.edu (K.H. Bowles), heigoldk@nursing.upenn.edu (K.E. Hand), guidelines (CPGs), and (2) supporting nurse provision of patient-
Jessie.george@uphs.upenn.edu (J. George). centered care. Nursing leadership expected that the NIS would save

0897-1897/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.apnr.2013.10.005
26 P.S. Sockolow et al. / Applied Nursing Research 27 (2014) 25–32

time and improve the quality of care provided. The health system selected from among those working that day and were asked to
wanted to learn from the evaluation whether the NIS made a participate if they could spare 20 minutes away from their work.
difference in nurse practice and whether nurses were satisfied with Individually, a team member obtained the nurse's consent outside the
the NIS. The research question was, what were the challenges and conference room. To protect the nurses' identities in such as small
facilitators to NIS adoption? The purpose of this paper is to present sample, no demographic or identifying information was collected.
empirical data on how nurses used an evidenced-based NIS and, based
on the study findings, provide practical guidance about adoption of 1.4. Procedures
NIS designed to support clinical process and decision making.
The research team was composed of academic researchers and
1. Methods clinical nurses who conducted the evaluation from March to May of
2012. The team used scenario-based user testing, presented as a
The researchers conducted a qualitative study with staff nurses modified think-aloud protocol (Nielsen, 1993) which is a standard
using the NIS. The research team obtained approval from the methodology used to elicit data about cognitive reasoning that occurs
researchers' academic institutions' institutional review boards. The during a problem solving task. In a conference room with a computer,
study received strong backing from nurse leadership at the health the research team presented the previously prepared scenarios to the
system level as well as in the individual hospitals. nurses and simultaneously conducted follow-up interview questions
(shown in Fig. 1) while observing the nurses using the system. The
1.1. The intervention scenarios were designed by the investigators to have the nurses
interact with the major components of the NIS. For example, one
The NIS is a module within a nationally known electronic health scenario asked the nurse to document a patient fall. A different group
record (EHR) previously implemented throughout the hospital of randomly selected multiple scenarios was presented to each nurse,
system. The NIS provides approximately 200 evidence-based, inter- ensuring that all scenarios and questions were asked at least once for
disciplinary clinical practice guidelines (CPGs) from which clinicians each unit. The 20 minute sessions were audio recorded and
select to guide patient care. transcribed. Three researchers (i.e., PS, MR, KB), independently
Care plans, designed with information from CPGs, are further performed directed content analysis for challenges and facilitators
individualized by nurses for each patient. Content from the care plan to NIS adoption, analyzing the transcripts of the answers to the
populates throughout the assessment and education flowsheets scenarios and interview questions. The inter-rater agreement goal
producing a comprehensive and detailed assessment specific to the was 100% and discussion was held until it was reached. Similarly, the
chosen plan of care, prompting nurses to recognize important data were individually coded for themes. After the coding was
elements of the selected care plan. For example, for a patient admitted completed, the themes were mapped to the concepts and components
for chemotherapy, a nurse selects a chemotherapy CPG for the plan of within the Health Information Technology Reference-based Evalua-
care which incorporates or embeds chemotherapy specific assess- tion Framework (HITREF). The HITREF is a comprehensive framework
ment elements in the assessment and education flowsheets. These firmly grounded in research evidence that provides a comprehensive
embedded elements in the documentation fields are intended to list of 20 evaluation criteria related to HIT characteristics (Sockolow et
reduce variability in nursing care. The NIS is accessible on newly al., 2009). During the analysis process, questions that arose were
installed computers in each patient room. referred to the authors (i.e., KH,JG) who worked as nurses in the
hospitals. These authors provided validation as well as facilitated
1.2. Site member checking validation among their colleagues.
Following interpretation of the findings, the team developed
The study took place in two hospitals within a three-hospital solutions to the identified challenges to adoption. The team also
health system. The flagship hospital has 760 beds and the other has identified existing facilitators to adoption and proposed avenues to
300 beds. Nurses attended 8 hours of training in advance of the NIS support or enhance these facilitators. Health system nurse executives
implementation. They were instructed to document almost all received the team's final recommendations.
patient-related issues in the NIS including the admission assessment,
physical assessment, educational interventions, vital signs, intake and
2. Findings
output measurements, medication administration, assessment find-
ings, interventions completed, and significant event summaries. Two
Participants were 12 registered nurses. They were from two units
key benefits emphasized in the training were: (1) reduction of
of the flagship hospital and one unit of an acute care hospital—four
redundant questions addressed to patients by clinicians in various
nurses from each unit. To protect their anonymity no socio-
disciplines; and (2) support for patient-centered care. An example of
demographics were collected.
the latter is eliciting from the patient an individualized statement
Transcripts from the scenario testing sessions revealed the
indicating information about unique patient needs not readily
following themes. Further analysis and synthesis identified the
apparent from his or her diagnosis or CPGs. “Super-users” (nurses
challenges and facilitators to NIS adoption.
identified by managers to have advanced user skills) provided
ongoing support on each unit. 1. Hardware referred to placement of the computer in the patient
room. Nurses reported they tended to chart in the room
1.3. Participants especially for complex patients and were less likely to
document at the bedside for uncomplicated patients. As one
Nurses were selected purposefully to insure variety in the study nurse stated, “I find especially with my xxx patients, I really like
participants. The nurses worked on units that met the following it because they have so much going on, they have a-lines, they
criteria: (1) were representative of most units in the hospital (e.g., have chest tubes, they have epidurals, and it's easier to be like,
medical or surgical unit); (2) had a conference room with a computer ‘forgot to look at this’, and you can just peek at them real quick
where the study could be conducted; and (3) had a contact person on and finish your charting. And that part I do it in the room with
the unit known to a research team member (to facilitate introduction those patients, because I don't want to miss something. With
of the study to the staff). Eligible participants were registered nurses these patients back here [observation patients] I don't usually
who provided and documented direct patient care. Nurses were document at the bedside, cause it's pretty straightforward.”
 P.S. Sockolow et al. / Applied Nursing Research 27 (2014) 25–32 27

Fig. 1. Scenarios and questions interview guide for NIS scenario testing.

Nurses reported they documented medications, vital signs, the time requirement (e.g., 20 minutes), as one nurse stated, “I
giving blood, and hourly rounds in the room. Nurses also used think it's [in-room assessment documentation] fine, if the
the NIS in the room when reviewing information with the patient's okay with it, and you have time to do it. I wouldn't
patient. One respondent noted that having the computer in the want to stand there for 20 minutes documenting.” Some nurses
room enabled him or her to look at the patient while reported the patient or family talking to them while document-
documenting. However, a number of participants mentioned ing could distract them. For example, one nurse reported, “A lot
that they did not use the computer in the patient room for some of patients talk to you and interrupt your thought. And even if,
or all their documentation. Universally nurses reported they in the beginning we were really encouraged just to do it at the
did not document admission assessments in the room due to bedside no matter what, and to just remind the patients that
28 P.S. Sockolow et al. / Applied Nursing Research 27 (2014) 25–32

we were doing it. But some people just, they're bored, they bit, because it incorporates into my assessment sheet little
want to chat, or ask questions.” One participant said that he/she things that I should look for, so it's helpful in that sense.
did not like having her back to the patient when documenting, Especially some of the times we get surgeries I'm not familiar
indicating computer placement was an issue. The authors (KH, with.” Nurses also liked the “copy forward” functionality which
JG) and their colleagues concurred that some nurses do not allowed nurses to review the patient's previous admission
document the admission assessment in the room. However, assessment and copy any information that still applied. As one
some nurses do document in the room, and some begin the nurse said, “I do love the fact that when you have people that
admission assessment in the room and complete it on a come in again and again, that their admission sheet's already
computer outside the room. done. Copy forward is my favorite thing.”
An unintended consequence related to hardware placement Respondents highlighted functionality deficits, including the
was that computers in patient rooms and hallways were NIS's inability to summarize what happened on the shift for
designed for use while standing and did not offer users a each patient in a designated area, leaving it to the nurse to
chance to sit and have some respite. As a nurse described, “If write a narrative summary. Another functionality deficit was
you are standing there documenting for several minutes, you related to a key metric, patient falls. If a nurse missed
never get any reprieve, really…[get off your feet].” completing the fall risk assessment, there was no reminder to
2. Software Quality focused on software usability. Key topics were indicate that area of the assessment was incomplete. Further-
navigation and whether the screen flow matched the clinical more the NIS did not have a designated procedure for
workflow, as described more fully elsewhere (Rogers, Sock- communicating falls or other significant events. One respon-
olow, Bowles, Hand, & George, in review). Briefly, respondents dent suggested having a tab for significant events instead of the
reported the system was difficult to scroll through, required nurse needing to scroll back, or more likely, depend on the shift
much scrolling to look back at previous documentation (as one report to receive the information. In addition, one nurse
nurse stated, “you have to scroll, scroll, scroll”), and the screen mentioned that he or she tended to enter information using
flow skipped among screens. As one nurse said, “I'm always free text instead of the structured check boxes: “I free text a lot,
afraid I'm going to miss something, and [the system] tends to 'cause sometimes not everything is in there that you need. Or
jump around.” other times it's just easier to free text to write in something that
Respondents described situations where screen flow did not fits better, or makes more sense. 'Cause not everything is in the
sufficiently match clinical workflow such as where the NIS 20 check boxes….” Respondents suggested other functionality
caused changes in patient discharge workflow. The system improvements. Instead of looking in two places to find patients'
introduced one change perceived as increasing accountability height and weight entered by nursing assistants, information
and a second change that was viewed as introducing a delay in captured on one screen should also populate the same data
workflow. The former change forced nurses to document in a fields on other screens. Also, participants suggested additional
checklist that they reviewed discharge plans/education with functionality to alert the physician or nurse practitioner about
the patient. As one nurse explained, “we used to also review the significant events.
orders, the discharge orders, in the computer, and we can't 4. Documentation Quality included the completeness and timeli-
really do that: We have to wait until it prints out and then kind ness of the documentation. One nurse felt that documentation
of like review it there, and make sure everything's on it, so it's a quality improved due to wide system use saying, “I don't really
little more difficult…” The second change forced nurses to wait know if a lot has changed as far as how we give care, but we just
for the physician to “click the box” for the discharge order document it better now.” However, the documentation's
before the patient signature pages print and discharge richness and completeness may have been limited due to
education could begin. The unintended consequence of the how the system was used. Nurses reported they seldom
delay introduced in this workflow change could lead to rushed selected more than one CPG, because each additional CPG
discharge education. selected added more fields requiring documentation: “And
Participants noted the difficulty in finding their desired guideline. then when you do find it [CPG], there's like 17 pages of stuff.” In
Causes for difficulty included too many guidelines and too many addition, the use of ‘copy forward’ functionality may compro-
pages of documentation. One nurse explained, “there are so mise the correctness of the data. The concern is that nurses
many [CPGs], and the one that you want is so hard to find.” must carefully review the previous information to see if it was
Respondents also noted that guidelines were not sufficiently still accurate. For example, if a patient had a wound on the last
specific or not focused on frequent conditions, such as hyper- admission that is no longer present on the current admission
glycemia and hypoglycemia. Nurses described their solution as and a nurse copies all of the information forward without
choosing a more general guideline for pain, or for diabetes reading and editing, the current documentation would state
instead. This required them to spend more time searching the NIS that the wound was still present.
for the appropriate guideline. One nurse described the following 5. Clinician Satisfaction was found with the NIS. Observation
situation: “I've noticed that there aren't ones [guidelines] for indicated that all nurses who provided direct patient care used
hyperglycemia and hypoglycemia. I do see that a lot on the floor. the system. Overall, respondents reported being satisfied with
So then I'm like stuck between a rock and a hard place. I know the NIS. They were unanimous in their preference for
there's a diabetic one at least, so I'll use that one. I've used another documenting in the system rather than using paper records:
one before, too, and I can't remember which one I used. But I kind “I'm more comfortable with a computer, but I wouldn't want to
of go along with their main diagnosis and what they've come in go back to paper.”
with. My fallback is acute pain. I'll be honest, if I can't find 6. Efficiency focused on ease of use. Nurses reported that patient
anything else I choose acute pain.” education was easier and faster to document by using check-
3. Functionality related to the capabilities and features of the boxes. As one nurse stated, “it's [patient education] less time
software. Nurses appreciated specific functionality such as the consuming when you have that stuff at your fingertips…It's just
patient education functionality because it was easier to educate quicker, which in turn makes your patient care better, cause it's
the patient with the NIS in front of her/him. Another nurse more efficient.” However, nurses identified NIS-related changes
acknowledged the helpfulness of memory prompts in the that decreased their efficiency. As noted above, the system
presentation of the clinical guideline: “I guess it's helpful a little introduced a step in the clinical process—forcing a nurse to wait
 P.S. Sockolow et al. / Applied Nursing Research 27 (2014) 25–32 29

for the physician to finalize discharge orders before documenting point where we are spending so much more time documenting
the education of the patient. Nurses pointed out that this change than we are with our patients.”
could lead to rushed discharge education. Another inefficiency An aspect of patient care, patient-centered care, was an
reported by nurses was documenting the same information in intended focus of the NIS. However, nurses reported they
two places in the system (e.g., goal section and discharge note). were frustrated having to spend time asking patients and
As a nurse explained, “When I review everything, then I do it in documenting questions in the admission assessment intended
the goal section, where we normally do our notes. I do like a to support patient-centered care, the purpose of which was
discharge note that says I reviewed everything with them, and unclear to them. For example, a question about the patient's
gave them all their prescriptions, answered all their question, pet, intended to identify a patient motivation for getting better,
and the patient left the unit at whatever time with whoever. So I was a puzzle to nurses: “Like the pets thing…Have you hurt
do it in both places.” your pets? Are your pets safe? What am I supposed to do, call
7. Impact on Patient Care is related to whether the NIS changed the the SPCA?”
process related to how clinicians provided care. Nurses 8. Team Communication is related to the quality and usefulness of
appreciated the availability of information relevant to patient NIS related to teamwork. Nurses described how using the NIS
care (e.g., key expert resources). As one nurse stated, “Another improved team communication and relations in variety of ways.
good thing is when you are giving out meds there is expert info, First, it was easier to find notes from other nurses and physical
you can right-click on that, and it tells you right in the room, therapists. Also, nurses could more easily follow what other
you can go over the side effects and everything. That's nice, and disciplines did. As one nurse noted, “So I think that's gotten
it would help promote quality care, standardized care.” better, I think we can follow much, much easier what's going on
However, another nurse described the resources as having from the other disciplines cause they are in there. They are
too many pages to be usable. Another information resource was putting little things into our assessment, like the notes sections
prior assessments, which one nurse reported was helpful to see that's going across, they would say they saw our patient, and we
if the patient's condition had changed. can see it really easy that they saw our patient, whereas before,
A second aspect of Impact on Patient Care was the memory we'd have to go back in, go into the chart, to see oh, yeah, they
prompt function in the system. Nurses acknowledged the came and they did this,…(before)…they had their own section,
benefits of reminders about completing items in the patient and half the time I couldn't even find their section, but now I
assessment, as one nurse stated, “[the CPG] kind of triggers think it's a lot easier.” A third point was that medical aides, by
what I tend to miss in an assessment. It triggers what I actually documenting in the NIS, were included in team communication:
should be looking for.” On the other hand, some nurses “[NIS] allows the aides to get involved. And they feel like they
reported they did not find the computerized CPGs useful as are more accountable because they have to enter documenta-
they provided clinical care. One nurse observed that he or she tion into the computer system: vitals and things like that.” A
chose a guideline only because it was required, not because it fourth point was that the use of the NIS made the physician's
was helpful. Another nurse explained that the NIS system did work easier which in turn made the nurses' work easier.
not provide new information for the clinical process: “I think However, nurses reported continued dependence on verbal
we already kind of had that, we had the [guidelines], which I communication. The NIS was not relied upon to relay important
think, at least I hope, we've already been doing, not giving events (e.g., at shift change or to report to physicians): “There's
ourselves credit for it. So I don't really know if a lot has changed also that physician communication note, but you're supposed to
as far as how we give care. But we just document it better now, I call the doc before you put that note in, so it's just documenting
think, cause you didn't have all those check boxes you filled out that you called the doc.” Also, nurses found it easier to talk to a
before.” A third nurse viewed the system as providing no input physical therapist when the person was nearby rather than
into the care process because the nurse did not incorporate the looking for a note: “What if I need to communicate with them
guideline into his or her care provision: “I kind of dictate my [physical therapy]? Well, not in the computer, I probably have
own care, and make [NIS] a part of it, I don't use [NIS] to dictate to call 'em… I wouldn't rely on the computer.”
my care.” In addition, nurses discussed their lack of critical In addition, respondents provided examples of the NIS not being
thinking as they quickly click through checkboxes when used sufficiently for team communication. One nurse reported
documenting patient education. As one nurse stated, “for all that patients complained they were being asked the same
this ‘education’ again you're clicking off, I can do it in my sleep questions repeatedly: “Sometimes, I'll go into a room and I'll ask
you know, sometimes, just 'cause I've been here for a while, you the person questions, and they'll say, I've already been asked
just go through it and sometimes, you don't read it—you know? that, a couple times.” Also, nurses expressed uncertainty and
Just, it's second nature, and I'm not sure who's looking at that doubt about whether other clinical disciplines looked at the
but literally you are just clicking off that you educated this nurse's documentation for information. However, validation
patient, which we do, but I think there should be a better way.” with a discharge planner revealed that discharge planners refer
A third aspect of Impact on Patient Care was the time spent at daily to the patient information (e.g., vital signs and clinical
the bedside. Two nurses pointed out the advantages of summary). Nurses also reported that physicians were not
accessing the NIS in the room. One nurse observed it was accessing the NIS, causing nurses to double document to enable
easier to educate patients with the NIS in front of him or her. physicians to more readily see the nursing documentation. As
Another nurse stated that documenting in the room resulted in one nurse described the situation: “…Everything was already
the nurse spending more time at the bedside while charting: “I done throughout the day, so that's how we were trained. And
probably spend more time at the bedside because of it, cause I then our doctors, our attendings, came in and said, ‘where are
sign out my meds at the bedside, and I'm able to actually do a the notes?’ …We request that our nurses still do a detailed note
little bit more charting, just on like rounding and stuff. Whereas because we are using them.” A challenge to clinicians using the
before I couldn't find the bedside chart or something, then I'd NIS for team communication was the existence of separate
forget about it, so it definitely makes it easier like that.” systems specific to various disciplines. For example, while
However, a different nurse described use of the NIS as time discharge planners reported they retrieved data from the NIS,
consuming such that nurses feel they spend more time with the they documented in another system that did not interface with
NIS than with their patients: “…It's still time consuming to the the NIS.
30 P.S. Sockolow et al. / Applied Nursing Research 27 (2014) 25–32

9. Patient Rapport focused on NIS related to patient communica- 3. Discussion

tions. A nurse reported that he or she did not like documenting
in the NIS in the patient room because they perceived it was This is the first evaluation of a hospital point-of-care documenta-
impersonal to have your back toward the patient (as tion system designed for the interdisciplinary care team. The nurse
mentioned above in Hardware) or to not give the patient leadership of the health system requested feedback on the study
your full attention. As the nurse described his/her perception: results. Therefore, of special interest were themes that emerged
“I believe I should be giving my patient undivided attention, related to the institution's goals for the evaluation, standardizing care
exactly, and I want to look at the patient when I'm asking and supporting patient-centered care. Regarding the methods, the
questions. I want to see that facial [expression]—does he really scenario-based user testing process was enriched by the participation
have pain or is he just fluffing it off likes it's nothing? So I really of research team members who were knowledgeable, current users of
believe in watching the patient when I'm assessing him, taking the NIS to aid in question formation and interviewing.
time. And if I was doing it in the computer, then I don't get that. The study yielded themes related to the health system's evaluation
And I feel as though the patient feels that we are too busy doing goals including: (i) NIS impact on reducing variability in patient care
other things, than giving him the attention.” together with nurse use of NIS clinical educational resources, and (ii)
10. Training was focused on usefulness and NIS implementation. NIS effect on team communication. Nurses tended to use the NIS at the
Nurses described three types of training related issues. First, all point-of-care (i.e., in the patient room) for some of their documentation
the disciplines were supposed to participate in training. tasks. Nurses perceived NIS as a task-oriented documentation record
However, if the training is not completed by all NIS users, it is with limited impact on clinical decision making and quality of patient
frustrating for those who did complete the training. One nurse care. Infrequently nurses mentioned the benefits of the availability of
described the nurses showing a perturbed physician how to educational material or guideline memory prompts in clinical decision
access the flow sheets: “This is one of our big attendings, and he making. Some nurses perceived that use of point-of-care systems
was flipping out. We sat down and showed him the trending increased the time spent documenting, thereby decreasing the amount
sheets, and he got a little bit more comfortable with that….” of time for other patient care-related activities. Although not a direct
Second, nurses reported that NIS changes were introduced comparison, DesRoches' recent survey of nurses and EHRs (which were
during upgrades without sufficient communication or follow- described as at least minimally functional and may not have explicitly
up training. One nurse informed the researchers that he/she included interdisciplinary care documentation) found that EHR use did
was out for several weeks, but there was no update or not change nurse time allocation during their workday (DesRoches,
education to let him or her know about changes since the last Donelan, Buerhaus, Potter, & Zhonge, 2008).
login. Another nurse explained, “It just seems like every other The NIS implementation was intended to reduce team members'
week they come out with a new format for [NIS]. Like, first it repetitive questioning of patients by improving team communication.
was to do the care provider notes. Then it was, change it, do it However, nurses perceived that the NIS was not used to support cross
this way, do this. And sometimes they just added certain things. disciplinary communication because other disciplines did not use the
And you're like, where did that even come from? So, it just NIS. Furthermore, among nurses, as seen in studies of physicians
needs to be, if you are going to roll something out, at least let us (Coumou & Meijman, 2006), it was easier to ask the clinician at your
know what it is and tell us what we are supposed to be doing.” elbow than to look back through the documentation in the computer.
In addition, the researchers observed and nurses reported an The assessment was intended to support patient-centered care by
inconsistency in standards across units that should have been capturing information pertinent to the patient's motivation to get
addressed with training. The team observed variation in how better. However, nurses did not perceive the value of these
many or what types of guidelines were required. One nurse questions, and instead found them puzzling. Other than these
stated, “People need to be on the same page as to how we're questions, it was not apparent whether or how the NIS supported
documenting each of our systems, what we are putting into patient-centered care. As Avgar, Litwin, and Pronovost (2012) note,
[NIS], and what certain things mean, like our falls prevention patient-centered care requires fundamental reorganization of work;
program, what does it mean to be multi pharmacy or you know successful HIT implementations leverage the HIT as a tool to
what I mean? They just weren't understanding some of the reinforce these work changes.
lingo in the [NIS], so to speak.” Nurses also reported training Themes related to challenges and facilitators to adoption also
issues involving lack of standards for documentation and emerged, which should be of particular interest to nurse decision
different interpretations of NIS terms. As one nurse observed, makers. All nurse participants expressed that they did not want to go
“There has to be a continuous ongoing training.” back to a paper medical record. Nurses said that it was easier to find
11. Patient Outcome was related to perceptions about NIS impact on patient information in the NIS compared to searching the patient's
the outcome of the process of providing care. As mentioned paper charts. They conveyed that, even though the system had
above, one nurse perceived the NIS had a positive impact on navigation and usability issues that reduced their efficiency, having
patient outcomes, because clinicians across disciplines used the the majority of the patients' information in one place, accessible from
system. This nurse also felt the NIS had a positive impact on any computer, was convenient. However, nurses also expressed
patient safety because clinical roles, such as medical aides, were dissatisfaction with NIS impact on workflow. Nurses experienced
now documenting in the system. usability issues that impeded their ability to document in a systematic
12. Perceived NIS Value related to overall impact of the NIS way. For example, the location of the detail to be documented was
implementation. Nurses were not aware of the value of the hidden beneath unexpanded headers forcing the clinician to search
NIS. As one nurse stated, “[documenting in the NIS is] just one further. A concern was that a less experienced clinician may forget to
more thing to do.” They viewed the NIS as a documentation go back and document the detail. Instead of saving time as intended,
system. For example, most respondents perceived that other navigation patterns that skipped important sections in the documen-
clinical disciplines did not view the NIS nursing documenta- tation added more time to the process and were confusing to the
tion, although a few nurses thought that physicians viewed nurse. In addition, nurses experienced unintended consequences that
it. Respondents identified one opportunity where the NIS disrupted workflow, benefited other groups (e.g., physicians), and did
could provide value: improve presentation of data by syn- not decrease their cognitive load. For example, the absence of
thesizing clinical information into a summary, such as an end functionality that synthesized and summarized information (Collins,
of shift summary. Bakken, Vawdrey, Coiera, & Currie, 2011) caused nurses to double
 P.S. Sockolow et al. / Applied Nursing Research 27 (2014) 25–32 31

document a summary in a location where a physician could readily Further communication opportunities include flowing information
view the information. from NIS to front-line clinicians to improve clinical process related to
In addition to usability issues, a challenge to adoption was that patient care and patient safety. An example is regular emails
nurses perceived their use of NIS as a task to be completed without informing nurses of issues that have been fixed in response to their
recognizing value in the process. Nurses did not know that other requests. Closing the communication loop would demonstrate that
disciplines (e.g., discharge planner) looked at their documentation nurses' concerns were being addressed and that the NIS was being
and did not perceive that documenting in the system provided value improved for their benefit. The intended result is that front line users
to the clinicians on the team, raising the nurses' visibility. In addition, may be more accepting of the system and more willing to
the value of the data collected was not demonstrated to the clinicians communicate their questions and issues. Another recommendation
due to the lack of feedback to clinicians providing direct patient care is to keep training up to date to create and sustain clinicians'
(e.g., quality indicators). As a result, nurses were unaware that enthusiasm for the potential of the NIS.
documenting via free text as compared to structured text negatively In addition, acknowledging that the NIS was a relatively new
impacts the availability of data for operational improvements and implementation, there is an opportunity to improve important NIS
research (Bowles et al., in review). functionality. Valuable patient information is collected in the NIS that
Significant challenges to adoption were problems with ongoing could trigger the initiation of consults or referrals, for example, for
training and support. Nurses described the need for continuous high risk patients (Bowles, Hanlon, Holland, Potashnik, & Topaz, In
ongoing training due to upgrades as well as prolonged staff absences. press). Also, while the outcome summary enables nurses to review
In addition, there was inconsistency in NIS use among the units and their day and possibly identify important events that were missed, the
the nurses, underscoring insufficient communication and training outcome summary's functionality could be enhanced. The NIS should
related to NIS functionality. be able to perform a lower-level synthesis for the clinician, such as
pull together what was done for the patient in one place where the
3.1. Limitations summary could be edited by the clinician. If decision makers do not
want clinicians relying on verbal communication, then output
During the interview process, the data collected were based solely summaries should also have a place to capture and flag information
on responses to the list of questions and scenarios. If anonymity can currently communicated via verbal report, such as significant events.
be assured, other factors that should be considered include nurses' The results of this study would help front-line clinicians'
age, length of employment within the hospital, and familiarity and application to practice in a number of ways. First, this study informs
frequency of computer use. These factors have been shown to these clinicians about the challenges and facilitators to NIS adoption
influence nurses' perceptions of usability, support, and ease of use identified at the study site. Clinicians can use this information to
with NIS (Seckman, Romano, Mills, Friedmann, & Johantgen, 2009). In inform decisions if they are involved in the selection or implemen-
addition to lack of participant demographic data, another limitation tation of an NIS. Second, clinicians can use the study findings post-
was that scenario testing produced descriptive results which may not implementation to inform their communication with NIS implemen-
be generalizable beyond early stage NIS implementations or academic tation decision makers, if a mechanism for feedback from front-line
medical centers. Also, study findings are not able to be generalized clinicians is available and functional. Using such a communication
because the results are applicable to the participants and not to the mechanism, clinicians could provide feedback on topics such as NIS
population as a whole. impact on workflow, as well as suggestions to improve presentation of
NIS information. In addition, our methods might be useful to others.
4. Recommendations Using scenarios to gain insights into how the system is used proved
valuable and rich for the researchers.
Our recommendations to nurse leaders have included responding
to opportunities to improve communication with front-line clinicians.
5. Conclusions
Fundamentally, nurses need to understand the goals of the system
and hear feedback about why the NIS is or should be providing value.
Opportunities for hospital leadership to improve NIS adoption
For example, replace the units' hand written posters on a bulletin
include enhancing two-way communication with front-line clinicians
board in a conference room illustrating trends of selected metrics with
about: (1) the hospitals' goals; (2) perceived NIS value at the bedside;
a display on the computer (e.g., a splash screen) showing trends
and (3) constructive feedback about design (e.g., functionality) and
generated from data captured in the NIS. We acknowledge the
implementation (e.g., training) especially about patient care/safety.
organizational challenges in using HIT strategically and analytically,
During NIS selection, design, and implementation, nurse leaders
yet doing so can help transform care delivery instead of merely
should also focus on the other highly problematic areas identified in
automating documentation (Avgar et al., 2012).
this study: software usability, implementation, and training. Areas not
Operationally, there is an opportunity to improve how the NIS is
identified as problematic warranted less investment while being
evaluated, that is, to promote constructive feedback from front line
carefully monitored. Clinicians were relatively satisfied with hard-
clinicians that is provided to those who can make decisions regarding
ware placement, completeness of documentation, clinician efficiency,
system design and implementation. Novak, Shilo, Gadd, and Lorenz
and appropriateness of patient care. Clinicians were neither satisfied
(2012) described clinicians who served as mediators of adoption by
nor dissatisfied with areas that included software functionality and
conducting on-going organizationally-sanctioned “work at the nexus
team communication. Addressing these opportunities may improve
of the institutional setting, the clinical users of information systems,
the value and usefulness of the system to clinicians, hopefully
and the IT infrastructure, including developers.” (p. 1043). Among the
realizing the implementation goals of supporting collaboration and
responsibilities ascribed to mediators are the following post-imple-
improving patient care outcomes.
mentation activities of: (i) problem resolution for new systems being
implemented, and (ii) ongoing support including identifying issues
that necessitate process and policy changes (Novak et al., 2012). An Acknowledgments
example is the continued reliance on verbal communication because
the NIS cannot be relied upon to relay important events. This process We thank Barbara Granger for her editorial assistance and Gioia
of mediation of adoption and use is a key strategy for mitigating Chilton for transcribing the recorded scenario testing sessions. We
unintended consequences of HIT implementation. also thank the clinicians who participated in the study and the health
32 P.S. Sockolow et al. / Applied Nursing Research 27 (2014) 25–32

system nursing leadership who enabled the team to conduct this Kutney-Lee, A. (2011). The effect of hospital electronic health record adoption on
nurse-assessed quality of care and patient safety. Journal of Nursing Administration,
research. 41(11).
Nielsen, J. (1993). Usability engineering. San Diego, CA: Academic Press.
Novak, L. L., Shilo, A., Gadd, C. S., & Lorenz, N. M. (2012). Mediation of adoption and use:
A key strategy for mitigating unintended consequences of health IT implementa-
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